Etiology and evaluation of chronic constipation in adults
- Arnold Wald, MD
Arnold Wald, MD
- Professor of Medicine
- University of Wisconsin School of Medicine and Public Health, Madison
Constipation is the most common digestive complaint in the general population, and is associated with substantial economic costs [1-3]. The causes of chronic constipation are varied (table 1). Infrequently, constipation is the first manifestation of metabolic (diabetes mellitus, hypothyroidism, hypercalcemia, heavy metal intoxication), neurologic, or obstructive intestinal disease; more often, it occurs as a side effect of commonly used drugs (table 2).
The definition, etiology, and evaluation of chronic constipation will be reviewed here. Treatment of this disorder is discussed separately. The recommendations in this topic are largely consistent with guidelines from the American Gastroenterological Association (AGA) and American Society for Gastrointestinal Endoscopy [4,5]. (See "Management of chronic constipation in adults".)
DEFINITION OF CONSTIPATION
Constipation is often treated on the basis of a patient's impression that there is a disturbance in bowel function. However, the term constipation has varied meanings for different people. Stools may be too hard or too small for some, while for others defecation is too difficult or infrequent. The first three complaints are difficult to quantify in clinical practice; the last can be measured and compared to the general population.
Constipation has been defined as a stool frequency of less than three per week based upon epidemiological studies in the United States and the United Kingdom. However, this definition is not universally applicable. One complicating factor is that the frequency of bowel movements is usually underestimated . This has led some investigators to propose that only the use of daily diaries can define constipation adequately. Another problem is that up to 60 percent of patients in one survey who reported themselves to be constipated had daily bowel movements . These individuals most often complained of defecatory straining or a sense of incomplete defecation.
These observations have led to the use of more expansive criteria of functional constipation. An international working committee recommended diagnostic criteria (Rome IV) for functional constipation [7,8]. The diagnosis should be based upon the presence of the following for at least three months (with symptom onset at least six months prior to diagnosis).
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- DEFINITION OF CONSTIPATION
- ETIOLOGY AND PATHOPHYSIOLOGY
- Secondary causes of chronic constipation
- Severe idiopathic chronic constipation
- - Normal colonic transit
- - Colonic inertia
- - Outlet delay
- Dyssynergic defecation
- Megacolon and megarectum
- Physical examination
- Laboratory data
- Colon transit studies
- - Radiopaque marker study
- - Wireless motility capsule
- Motility studies
- - Anorectal manometry
- - Colonic manometry
- - Balloon expulsion
- Other tests
- - Rectal barostat test
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS