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| {{CMG}} | | __NOTOC__ |
| | {| class="infobox" style="float:right;" |
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| | | [[File:Siren.gif|link= Constipation resident survival guide|41x41px]]|| <br> || <br> |
| | | [[Constipation resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
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| | {{Constipation}} |
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| {{Editor Help}} | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| ==Overview==
| | {{CMG}}; '''Associate Editor-In-Chief:''' {{EG}} |
| {{DiseaseDisorder infobox | | |
| Name = Constipation |
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| ICD10 = {{ICD10|K|59|0|k|55}} |
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| ICD9 = {{ICD9|564.0}} |
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| ICDO = |
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| Image = |
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| Caption = |
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| OMIM = |
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| MedlinePlus = 003125 |
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| eMedicineSubj = med |
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| eMedicineTopic = 2833 |
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| DiseasesDB = 3080 |
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| {{SI}}
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| '''Constipation''' or '''irregularity''', is a condition of the [[digestive system]] where a person (or animal) experiences hard [[feces]] that are difficult to [[Defecation|egest]]. It may be extremely painful, and in severe cases (''fecal impaction'') lead to symptoms of [[bowel obstruction]]. The term '''obstipation''' is used for severe constipation. Causes of constipation may be [[diet (nutrition)|diet]]ary, [[hormone|hormonal]], anatomical, a side effect of [[medication]]s (e.g. some [[analgesic|painkillers]]), or an illness or disorder. Treatments consist of changes in dietary and [[exercise]] habits, the use of laxatives, and other medical interventions depending on the underlying cause. | |
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| ==Signs and symptoms==
| | {{SK}}Hard stool, Hard feces, Idiopathic constipation. |
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| <gallery>
| | ==[[Constipation overview|Overview]]== |
| Image:Bristol Stool Chart.png|Types 1 and 2 on the [[Bristol Stool Scale|Bristol Stool Chart]] indicate constipation
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| </gallery>
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| Constipation is one of the most common digestive complaints. It varies greatly between different people, as each person's bowel movements differ. Rate of defecation is not in itself a problem, as infrequent defecation without problems is not abnormal. Constipation is most common in children and older people, and affects women more than men. In children, constipation can lead to [[soiling]] ([[enuresis]] and [[encopresis]]).
| | ==[[Constipation historical perspective|Historical Perspective]]== |
| <ref>[http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=111§ionId=1 NHS direct] page on constipation.</ref>
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| In common constipation, the stool is hard and difficult and painful to pass. Usually, there is an infrequent urge to void. Straining to pass stool may cause [[hemorrhoid]]s and [[anal fissure]]s, which are themselves painful. In later stages of constipation, the abdomen may become distended and diffusely tender and [[cramp]]y, occasionally with enhanced [[borborygmus|bowel sounds]].
| | ==[[Constipation classification|Classification]]== |
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| The definition of constipation includes the following:<ref>[http://www.emedicine.com/med/topic2833.htm Emedicine], "constipation".</ref>
| | ==[[Constipation pathophysiology|Pathophysiology]]== |
| * infrequent bowel movements (typically 3 times or less per week)
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| * difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools), or
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| * the sensation of incomplete bowel evacuation.
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| Severe cases ("fecal impaction") may feature symptoms of bowel obstruction ([[vomiting]], very tender abdomen) and "paradoxical diarrhea", where soft stool from the small intestine bypasses the impacted matter in the [[colon (anatomy)|colon]].
| | ==[[Constipation causes|Causes]]== |
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| ==Diagnosis== | | ==[[Constipation differential diagnosis|Differentiating Constipation from Other Diseases]]== |
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| The diagnosis is essentially made from the patient's description of the symptoms. Bowel movements that are difficult to pass, very firm, or made up of small rabbit-like pellets qualify as constipation, even if they occur every day. Other symptoms related to constipation can include bloating, distention, abdominal pain, or a sense of incomplete emptying.
| | ==[[Constipation epidemiology and demographics|Epidemiology and Demographics]]== |
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| Inquiring about dietary habits may reveal a low intake of dietary fiber or inadequate amounts of fluids. Constipation as a result of poor ambulation or immobility should be considered in the elderly. Constipation may arise as a [[Adverse effect (medicine)|side effect]] of medications (especially [[antidepressants]] and [[opiates]]). Rarely, other symptoms suggestive of [[hypothyroidism]] may be elicited.
| | ==[[Constipation risk factors|Risk Factors]]== |
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| During [[physical examination]], ''scybala'' (manually palpable lumps of stool) may be detected on palpation of the abdomen. [[Rectal examination]] gives an impression of the anal sphincter tone and whether the lower rectum contains any feces or not; if so, then suppositories or [[enema]]s may be considered. Otherwise, oral medication may be required. Rectal examination also gives information on the consistency of the stool, presence of hemorrhoids, admixture of blood and whether any tumors or abnormalities are present.
| | ==[[Constipation screening|Screening]]== |
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| [[X-ray]]s of the abdomen, generally only performed on hospitalized patients or if bowel obstruction is suspected, may reveal impacted fecal matter in the colon, and confirm or rule out other causes of similar symptoms. | | ==[[Constipation natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| Chronic constipation (symptoms present for more than 3 months at least 3 days per month) associated with abdominal discomfort is often diagnosed as [[irritable bowel syndrome]] (IBS) when no obvious cause is found. Physicians caring for patients with chronic constipation are advised to rule out obvious causes through normal testing.<ref>{{cite journal |author=Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC |title=Functional bowel disorders |journal=Gastroenterology |volume=130 |issue=5 |pages=1480–91 |year=2006 |pmid=16678561 |doi=10.1053/j.gastro.2005.11.061}}</ref>
| | ==Diagnosis== |
| | | [[Constipation history and symptoms| History and Symptoms]] | [[Constipation physical examination | Physical Examination]] | [[Constipation laboratory findings|Laboratory Findings]] | [[Constipation abdominal x ray|Abdominal X Ray]] | [[Constipation CT|CT]] | [[Constipation MRI|MRI]] | [[Constipation ultrasound|Ultrasound]] | [[Constipation other imaging findings|Other Imaging Findings]] | [[Constipation other diagnostic studies|Other Diagnostic Studies]] |
| ==Causes==
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| The main causes of constipation include:
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| * Hardening of the feces
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| ** Improper [[mastication]] (chewing) of food
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| ** Insufficient intake of [[dietary fiber]]
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| ** [[Dehydration]] from any cause or inadequate fluid intake
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| ** Medication, e.g. [[diuretic]]s and those containing [[iron]], [[calcium]], [[aluminium]]
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| * Paralysis or slowed transit, where [[Peristalsis|peristaltic action]] is diminished or absent, so that feces are not moved along
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| ** [[Hypothyroidism]] (slow-acting [[thyroid gland]])
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| ** [[Hypokalemia]]
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| ** Injured [[Anus|anal sphincter]] (patulous [[anus]])
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| ** Medications, such as [[loperamide]], [[opioid]]s (e.g. [[codeine]] & [[morphine]]) and certain [[tricyclic antidepressant]]s
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| ** Severe illness due to other causes
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| ** Acute [[porphyria]] (a rare inherited condition)
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| ** [[Lead poisoning]]
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| * Dyschezia (usually the result of suppressing defecation)
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| * Constriction, where part of the [[intestine]] or [[rectum]] is narrowed or blocked, not allowing feces to pass
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| ** [[Stenosis]] (Strictures)
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| ** [[Diverticula]]
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| ** [[Tumor]]s, either of the bowel or surrounding tissues
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| ** Retained [[foreign body]] or a [[bezoar]]
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| * [[Psychosomatic]] constipation, based on anxiety or unfamiliarity with surroundings.
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| ** [[Functional constipation]]
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| ** Constipation-predominant [[irritable bowel syndrome]], characterized by a combination of constipation and abdominal discomfort and/or pain<ref>{{cite journal |author=Caldarella MP, Milano A, Laterza F, ''et al'' |title=Visceral sensitivity and symptoms in patients with constipation- or diarrhea-predominant irritable bowel syndrome (IBS): effect of a low-fat intraduodenal infusion |journal=Am. J. Gastroenterol. |volume=100 |issue=2 |pages=383–9 |year=2005 |pmid=15667496 |doi=10.1111/j.1572-0241.2005.40100.x}}</ref>
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| * [[Smoking cessation]] ([[tobacco smoking]] has a [[laxative]] effect)<ref> {{cite web|url=http://www.helpwithsmoking.com/nicotine-withdrawal.php#constipation |title=Nicotine withdrawal symptoms:Constipation |accessdate=2007-06-29 |date=2005 |publisher=helpwithsmoking.com }}</ref>
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| * Abdominal surgery, other types of surgery, childbirth
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| == Complete List of Differential Diagnoses ==
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| In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
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| === Endocrine and Metabolic ===
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| * [[Conn's Syndrome]] ([[primary aldosteronism]])
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| * [[Glucagonoma]]
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| * [[Hypercalcemia]]
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| * [[Hypokalemia]]
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| * [[Hypothyroidism]]
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| * [[Myxedema]]
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| * [[Panhypopituitarism]]
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| * [[Pheochromocytoma]]
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| * [[Porphyria]]
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| * [[Pseudohypoparathyroidism]]
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| * [[Uremia]]
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| === Gastrointestinal ===
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| * [[Adhesion]]
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| * [[Anal atresia]], [[malformation]], [[stenosis]]
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| * [[Ascites]]
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| * Benign colonic [[tumor]]s
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| * Chronic [[amebiasis]]]
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| * Chronic [[ulcerative colitis]]
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| * Colonic stricture
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| * [[Colorectal Cancer]]
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| * Corrosive enemas
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| * Descending perineum syndrome
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| * Diverticular stricture
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| * [[Diverticulitis]]
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| * [[Endometriosis]]
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| * Eosinophilic colitis
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| * Extrinsic compression
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| * Fissures
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| * [[Ddx:Anal Fistula|Fistulas]]
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| * [[Ddx:Hemorrhoids|Hemorrhoids]]
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| * Hereditary internal anal sphincter [[myopathy]]
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| * [[Hernia]]
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| * [[Inflammatory Bowel Syndrome]]
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| * Intraabdominal/pelvic tumors
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| * [[Intussusception]]
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| * [[Irritable Bowel Syndrome]]
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| * Ischemic colitis
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| * [[Lymphogranuloma venereum]]
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| * [[Paralytic ileus]]
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| * [[Perianal abscess]]
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| * Postoperative disorder
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| * [[Proctitis]] (ulcerative)
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| * Rectal, [[anal carcinoma]]
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| * [[Rectal prolapse]]
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| * Rectal ulcer
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| * [[Rectocele]], enterocele
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| * Senility
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| * Spinal cord injury
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| * [[Syphilis]]
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| * Torsion
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| * [[Tuberculosis]]
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| * Urogenital tumors
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| * [[Volvulus]]
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| === Medications ===
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| * [[Aluminum hydroxide]] in [[antacid]]s
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| * [[Analgesics]]
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| * [[Anticholinergics]]
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| * [[Anticonvulsants]]
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| * [[Antihypertensives]]
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| * [[Antiparkinsonian]]
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| * [[Antipsychotics]]
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| * [[Antispasmodics]]
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| * [[Atropine]]
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| * [[Barium sulfate]]
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| * [[Benzodiazepines]]
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| * [[Bismuth]]
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| * [[Calcium carbonate]] in [[antacids]]
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| * [[Calcium channel blockers]]
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| * [[Calcium supplements]]
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| * Cation-containing agents
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| * [[Cholestyramine]]
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| * [[Codeine phosphate]]
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| * [[Diuretics]]
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| * [[Ferrous sulfate]]
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| * [[Ganglionic blocker]]s
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| * Heavy metal poisoning
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| * Ion-exchange resins
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| * [[Iron]] supplements
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| * [[Laxative]] abuse
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| * [[MAO inhibitor]]s
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| * [[Morphine]]
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| * [[Narcotic analgesic]]s
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| * [[Opiate]]s
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| * [[Phenothiazines]]
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| * [[Sucralfate]]
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| * [[Tricyclic antidepressants]]
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| * [[Vinca alkaloid]]s
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| === Neurological ===
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| * [[Amyloidosis]]
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| * [[Ddx:Cerebrovascular Accident|Cerebrovascular accident]]
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| * [[Chagas Disease]]
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| * [[Dermatomyositis]]
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| * [[Diabetes Mellitus]]
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| * [[Hirschsprung's Disease]]
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| * Intestinal pseduoobstruction
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| * [[Meningocele]]
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| * [[Multiple endocrine neoplasia]] (MEN 2b)
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| * [[Multiple Sclerosis]]
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| * Muscular dystrophies
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| * [[Neurofibromatosis]]
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| * [[Paraplegia]]
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| * [[Parkinson's Disease]]
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| * [[Scleroderma]]
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| * [[Ddx:Dementia|Senile dementia]]
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| * Spinal lesions
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| * [[Tabes Dorsalis]]
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| === Miscellaneous ===
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| * [[Ddx:Anxiety|Anxiety]]/Depression
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| * Change of environment
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| * Dietary changes:
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| *:* Chronic laxative/enema usage
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| *:* Fasting, reduced food intake
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| *:* Lack of fiber
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| *:* Low fluid intake
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| *:* Low-residue diet
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| *:* Starvation
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| * Eating disorder
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| * Emotional stress
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| * Extended bed rest
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| * Fecal impaction
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| * Generalized disease
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| * Idiopathic obstipation
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| * Obsessive/compulsive disorder
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| * Psychosis
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| * Repressed urge to defecate
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| * Travel constipation
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| == Physical Examination ==
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| * Complete physical examination including thyroid examination
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| === Abdomen ===
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| * Examination of abdomen:
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| *:* Palpate for masses
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| *:* Surgical scars
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| *:* [[Hernia]]s
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| *:* Hepatosoplenomegaly
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| *:*:* Examination results are usually normal
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| === Other ===
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| * Complete rectal examination with attention paid to:
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| *:* Presence of stool
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| *:* Masses
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| *:* [[Fistula]]s
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| *:* [[Hemorrhoid]]s
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| *:* [[Abscess]]es
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| *:* [[Fissure]]s
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| *:* Squeezing and resting of sphincter tone
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| *:* Palpable relaxation of anal tone and perineal descents
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| == Laboratory Findings ==
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| * [[Complete blood count]] ([[CBC]])
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| * [[Blood urea nitrogen]] ([[BUN]]) / [[creatinine]]
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| * [[Phosphate]]
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| * [[Glucose]]
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| * [[Liver function test]]s ([[LFT]]s)
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| * Fecal occult blood test
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| * [[Thyroid function test]]s
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| * [[Calcium]]
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| === Echocardiography or Ultrasound ===
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| * [[Ultrasound]] may be used to detect [[tumor]]s, [[fibroid]]s, [[ovarian cyst]]s or [[pregnancy]]
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| === Other Diagnostic Studies ===
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| * Colonoscopy for patients:
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| *:* Greater than 50 years old
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| *:* Present with constipation with no apparent cause
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| *:* Presence of blood in the stool
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| * Sigmoidoscopy for all other patients
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| * To rule out ova and parasites, a stool examination should be considered
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| ==Treatment== | | ==Treatment== |
| | [[Constipation medical therapy|Medical Therapy]] | [[Constipation surgery|Surgery]] | [[Constipation primary prevention|Primary Prevention]] | [[Constipation secondary prevention|Secondary Prevention]] | [[Constipation cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Constipation future or investigational therapies|Future or Investigational Therapies]] |
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| In people without medical problems, the main intervention is to increase the intake of fluids (preferably [[water]]) and [[dietary fiber]]. The latter may be achieved by consuming more vegetables and fruit and whole meal bread, and by adding linseeds to one's diet. The routine non-medical use of laxatives is to be discouraged as this may result in bowel action becoming dependent upon their use. Enemas can be used to provide a form of mechanical stimulation.
| | ==Case Studies== |
| | | [[Constipation case study one|Case #1]] |
| In alternative and traditional medicine, [[Enema|colonic irrigation]], enemas, exercise, diet and herbs are used to treat constipation.
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| ===Laxatives===
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| {{main|laxative}}
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| [[Laxative]]s may be necessary in people in whom dietary intervention is not effective or is inappropriate. Most laxatives can be safely used long-term, although some are associated with cramping and bloatedness and can cause the phenomenon of [[melanosis coli]].
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| ===Physical intervention===
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| Constipation that resists all the above measures requires physical intervention. ''Manual disimpaction'' (the physical removal of impacted stool) is done by patients who have lost control of their bowels secondary to spinal injuries. Manual disimpaction is also used by physicians and nurses to relieve rectal impactions. Finally, manual disimpaction can occasionally be done under [[sedation]] or a [[General anaesthetic|general anesthetic]]—this avoids pain and loosens the anal sphincter. | |
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| Many of the products are widely available [[over-the-counter drug|over-the-counter]]. [[Enema]]s and [[clyster]]s are a remedy occasionally used for hospitalized patients in whom the constipation has proven to be severe, dangerous in other ways, or resistant to laxatives. [[Sorbitol]], [[Glycerol|glycerin]] and [[Peanut oil|arachis oil]] [[Suppository|suppositories]] can be used. Severe cases may require [[phosphate]] solutions introduced as enemas.
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| ==Prevention==
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| Constipation is usually easier to prevent than to treat. The relief of constipation with osmotic agents, i.e. lactulose, [[polyethylene glycol]] (PEG), or magnesium salts, should immediately be followed with prevention using increased fiber (fruits, vegetables, and grains) and a nightly decreasing dose of osmotic laxative. With continuing narcotic use, for instance, nightly doses of osmotic agents can be given indefinitely (without harm) to cause a daily bowel movement.
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| Recent controlled studies have questioned the role of physical exercise in the prevention and management of chronic constipation, while exercise is often recommended by published materials on the subject.
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| In various conditions (such as the use of [[codeine]] or [[morphine]]), combinations of hydrating (e.g. [[lactulose]] or [[Diol|glycols]]), bulk-forming (e.g. [[psyllium]]) and stimulant agents may be necessary to prevent constipation.
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| ==Epidemiology==
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| Depending on the definition employed, constipation occurs in 2% of the population; it is more common in women, the elderly and children <ref>{{cite journal |author=Sonnenberg A, Koch TR |title=Epidemiology of constipation in the United States |journal=Dis. Colon Rectum |volume=32 |issue=1 |pages=1–8 |year=1989 |pmid=2910654 |doi=}}</ref>
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| ==In animals==
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| [[Hibernation|Hibernating]] animals can experience [[tappen]]s that are usually expelled in the spring. For example, bears eat many foods that create a "rectal plug" before hibernation.
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| ==See also==
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| * [[Diarrhea]]
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| * [[Feces]]
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| ==References==
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| <div class="references-small"><references/></div>
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| ==External links==
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| * {{MerckHome|09|129|b}}
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| * {{MedlinePlusOverview|constipation}}
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| {{SIB}}
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