Diagnosis of constipation: fibrocolonoscopy, coprogramma

Constipation is characterized by difficult and infrequent bowel movements, hard stool consistency, and a feeling of incomplete emptying of the rectum.

Many people mistakenly believe that daily bowel movements are necessary and complain of stool retention when bowel movements are less frequent. Others are concerned about the appearance (size, shape, color) or consistency of stool. Sometimes the main complaint is dissatisfaction with the act of defecation. Stool retention can be the cause of many complaints (abdominal pain, nausea, fatigue, anorexia), which are actually signs of an underlying pathology (e.g. irritable bowel syndrome, depression). Patients should not assume that all symptoms will disappear with daily bowel movements.

Because of these problems, many people abuse laxatives, suppositories, and enemas. This can lead to somatic changes, including colonic atony (a “water pipe” sign with characteristic smoothing or absence of haustra, revealed by barium enema and resembling ulcerative colitis) and melanosis coli (brown pigment deposits in the mucosa, revealed by endoscopy and in colonic biopsy specimens).

Patients with obsessive-compulsive disorder often feel the need to rid their bodies of "dirty" waste daily. Depression may result from the lack of daily bowel movements. The condition may progress, with depression contributing to a decrease in bowel frequency and the lack of bowel movements worsening the depression. Such patients often spend a lot of time and effort on the toilet or become chronic users of laxatives.

Anamnesis

A lifetime history of stool frequency, consistency, and color should be obtained, including use of laxatives or enemas. Some patients deny a history of stool retention, but when asked specifically, admit to a 15-20 minute bowel movement. An attempt should be made to determine the underlying metabolic and neurological disorders. Use of prescription or over-the-counter medications should be ascertained.

Chronic stool retention with frequent use of laxatives suggests colonic atony. Chronic stool retention without a sensation of urgency suggests neurologic dysfunction. Chronic stool retention alternating with diarrhea and associated intermittent abdominal pain suggests irritable bowel syndrome. New-onset stool retention that persists for several weeks or develops periodically with increasing frequency and severity suggests a colonic tumor or other causes of partial obstruction. Decreased stool volume suggests an obstructive lesion of the distal colon or irritable bowel syndrome.

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Physical examination

General examination reveals manifestations of systemic disease, including fever and cachexia. Tension of the anterior abdominal wall, abdominal distension and tympanitis indicate mechanical obstruction. Abdominal masses are diagnosed by palpation, rectal examination allows assessment of sphincter tone; sensitivity; presence of fissure, stricture, blood and masses (including coprostasis).

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Study

Stool retention with an identified etiology (medications, trauma, prolonged bed rest) does not require further investigation and is treated symptomatically. Patients with signs of intestinal obstruction require horizontal and vertical abdominal X-rays and, if indicated, CT. Most patients with an unclear etiology should undergo sigmoidoscopy and colonoscopy, as well as laboratory testing (complete blood count, thyroid-stimulating hormone and fasting blood glucose levels, electrolytes and Ca).

Further evaluation is usually necessary in patients with an unexplained cause or failure of symptomatic therapy. If the patient's primary complaint is infrequent bowel movements, colonic transit time should be measured using a radiopaque transit time. If the primary complaint is of straining to pass stool, anorectal manometry is most appropriate.

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