A detailed history and physical examination, including a digital rectal examination, is the first step in the evaluation of constipation.
Diagnostic evaluation may include a colonoscopy if indicated, colonic transit study, anorectal manometry, and a balloon expulsion study.
Initial treatment consists of lifestyle modification and laxatives.
Medical treatment should be tailored to the underlying etiology. Patients who do not respond to medical treatment may need specialized evaluation for pelvic floor dysfunction and biofeedback therapy. Surgery is only rarely indicated.
Chronic constipation is a polysymptomatic heterogeneous disorder. Patients define constipation on the basis of excessive straining, a sense of incomplete evacuation, failed or lengthy attempts to defecate, hard stools, and, less frequently, by the number of stools per week. The American College of Gastroenterology describes constipation as unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or defecation that is both infrequent and/or difficult.
History and exam
Key diagnostic factors
- infrequent stools
- difficult defecation
- sensation of incomplete evacuation
- excessive straining
Other diagnostic factors
- hard stools
- abdominal mass
- signs suggestive of underlying medical disorder
- anorectal lesions
- abnormality on digital rectal examination (DRE)
- female sex
- age >65 years
- African ancestry
- lower socioeconomic status
- family history
- sedentary lifestyle
- low fiber intake
- inadequate calorie intake
- inadequate fluid intake
- surgical procedures and childbirth
- medications that induce constipation
1st investigations to order
- complete blood count (CBC)
- thyroid function tests
- serum electrolytes, calcium, and magnesium
- blood glucose
- abdominal x-ray
- barium enema
Investigations to consider
- magnetic resonance defecography
- colonic transit study
- anorectal manometry
- balloon expulsion studies
- colonic manometry
symptoms <3 months
symptoms >3 months
refractory to laxatives
Satish Rao, MD, PhD, FRCP (Lon), FACG, AGAF
Professor of Medicine
Chief, Section of Gastroenterology and Hepatology
Director, Digestive Health Center and Neurogastroenterology and GI Motility
Medical College of Georgia
Georgia Regents University
SR serves on the advisory board for Smartpill Corporation, Greenwood Pharmaceuticals, Forest Research Institute, and Takeda Pharmaceuticals of North America. SR is an author of a reference cited in this topic.
Amol Sharma, MD, MS
Section of Gastroenterology & Hepatology
AS declares that he is on the advisory board for Ironwood Pharmaceuticals.
Dr Satish Rao and Dr Amol Sharma would like to gratefully acknowledge Dr Humberto Sifuentes and Dr Ashok Attaluri, previous contributors to this topic. HS declares that he has no competing interests. AA is an author of one reference cited in this topic.
Stefan Muller-Lissner, MD
Abteilung fur Innere Medizin
SML declares that he has no competing interests.
Eamonn M.M. Quigley, MD, FRCP, FACP, FACG, FRCPI
Professor of Medicine and Human Physiology
Department of Medicine
Clinical Sciences Building
Cork University Hospital
EMMQ has served as a consultant or on advisory boards for the following companies: Sucampo, Movetis, Norgine, Procter and Gamble, Boehringer Ingelheim, Reckitts Benckiser, Schering, Novartis, Salix, Ironwood, and McNeill Consumer Health and has been paid for his time involved. EMMQ is an author of several references cited in this topic.
Ned Snyder, MD
Chief of Gastroenterology and Hepatology
Adjunct Professor of Medicine
University of Texas Medical Branch
- Anal fissure
- Medication-induced constipation
- American Gastroenterology Association Institute Guideline on the medical management of opioid-induced constipation
- Clinical practice guideline for the evaluation and management of constipation
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