Constipation physical examination: Difference between revisions

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Latest revision as of 21:08, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Physical examination of patients with constipation is usually remarkable for anal fissure or palpable lumpy mass in abdomen (particularly in left quadrant). The presence of thrombosed external hemorrhoids, skin tags, rectal prolapse, anal fissure, anal warts, excoriation or evidence of pruritus ani due to fecal soiling on physical examination are suggestive of constipation. Patients with chronic constipation usually appear to be discomfort while sitting due to anal pain.

Physical Examination

Physical examination of patients with constipation is usually remarkable for anal fissure or palpable lumpy mass in abdomen (particularly in left quadrant).
The presence of thrombosed external hemorrhoids, skin tags, rectal prolapse, anal fissure, anal warts, excoriation or evidence of pruritus ani due to fecal soiling on physical examination are suggestive of constipation.^[1]

Appearance of the Patient

Patients with chronic constipation usually appear to be discomfort while sitting due to anal pain

Skin

Dry skin may be seen in systemic sclerosis

HEENT

Extra-ocular movements may be abnormal

Neck

Thyromegaly/thyroid nodules may be seen in hypothyroidism

Abdomen

Abdominal distention
Abdominal tenderness in the left lower abdominal quadrant
A palpable abdominal mass in the left lower abdominal quadrant

Neuromuscular

Altered mental status
Clonus may be present
Hyperreflexia
Positive (abnormal) Babinski
Muscle rigidity
Abnormal gait (Parkinsonian gait)
Unilateral/bilateral tremor (pill-rolling)

Digital rectal examination (DRE)

Method and findings of digital rectal examination include:^[2]

DRE steps respectively		Method	Findings
Inspection		Patient in left lateral decubitus, hips 90° flexed Looking to the perineal area under reasonable light	Skin excoriation Skin tags Anal fissure Scars Hemorrhoids
External sensation		Using a stick with cotton head Tapping and touching all 4 quadrants centripetally (anocutaneous reflex)	Slight contraction of the skin and the external anal sphincter (normal reflex) No contraction with cotton head but slight contraction with wooden head (decreased reflex) No contraction with either of heads (absent reflex)
Internal examination	Digital palpation	Inserting the index finger into the patient anus Palpating the parts, such as mucosa, muscle, bone, uterus, or prostate	Tenderness Mass Stricture Stool consistency
	Sphincter tonometry	Evaluating the resting tone of the anal sphincter	Normal Decreased Increased
	Squeeze maneuver	Evaluating the voluntary squeezing pressure of the anal sphincter Asking to hold up to 30 seconds	Normal Decreased Increased
	Defecation maneuver	Asking to push as if to defecate Evaluating the push effort with a hand on the abdomen	Push effort (Normal, decreased, excessive) Anal relaxation (normal, impaired, paradoxical contraction) Perineal descent (Normal, excessive, absent)

References

↑ Rao SS, Meduri K (2011). "What is necessary to diagnose constipation?". Best Pract Res Clin Gastroenterol. 25 (1): 127–40. doi:10.1016/j.bpg.2010.11.001. PMC 3063397. PMID 21382584.
↑ Tantiphlachiva K, Rao P, Attaluri A, Rao SS (2010). "Digital rectal examination is a useful tool for identifying patients with dyssynergia". Clin. Gastroenterol. Hepatol. 8 (11): 955–60. doi:10.1016/j.cgh.2010.06.031. PMID 20656061.

Template:WikiDoc Sources

[pmid21382584-1] Rao SS, Meduri K (2011). "What is necessary to diagnose constipation?". Best Pract Res Clin Gastroenterol. 25 (1): 127–40. doi:10.1016/j.bpg.2010.11.001. PMC 3063397. PMID 21382584.

[pmid20656061-2] Tantiphlachiva K, Rao P, Attaluri A, Rao SS (2010). "Digital rectal examination is a useful tool for identifying patients with dyssynergia". Clin. Gastroenterol. Hepatol. 8 (11): 955–60. doi:10.1016/j.cgh.2010.06.031. PMID 20656061.

[1]

[2]

@@ Line 1: / Line 1: @@
-== Physical Examination ==
+__NOTOC__
-=== Abdomen ===
+{{Constipation}}
+{{CMG}}; {{AE}} {{EG}}
-* Examination of abdomen:
+==Overview==
-*:* Palpate for masses
+Physical examination of patients with constipation is usually remarkable for [[anal fissure]] or palpable lumpy [[mass]] in [[abdomen]] (particularly in left quadrant). The presence of [[thrombosed]] [[Hemorrhoid|external hemorrhoids]], [[skin tags]], [[rectal prolapse]], [[anal fissure]], [[Anal wart|anal warts]], [[excoriation]] or evidence of [[pruritus ani]] due to fecal soiling on [[physical examination]] are suggestive of constipation. Patients with chronic constipation usually appear to be discomfort while sitting due to [[anal pain]].
-*:* Surgical scars
-*:* [[Hernia]]s
-*:* [[Hepatosoplenomegaly]]
-*:*:* Examination results are usually normal
-=== Other ===
+== Physical Examination ==
+*Physical examination of patients with constipation is usually remarkable for [[anal fissure]] or palpable lumpy [[mass]] in [[abdomen]] (particularly in left quadrant).
+*The presence of [[thrombosed]] [[Hemorrhoid|external hemorrhoids]], [[skin tags]], [[rectal prolapse]], [[anal fissure]], [[Anal wart|anal warts]], [[excoriation]] or evidence of [[pruritus ani]] due to fecal soiling on [[physical examination]] are suggestive of constipation.<ref name="pmid21382584">{{cite journal| author=Rao SS, Meduri K| title=What is necessary to diagnose constipation? | journal=Best Pract Res Clin Gastroenterol | year= 2011 | volume= 25 | issue= 1 | pages= 127-40 | pmid=21382584 | doi=10.1016/j.bpg.2010.11.001 | pmc=3063397 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21382584  }}</ref>
+===Appearance of the Patient===
+*Patients with chronic constipation usually appear to be discomfort while sitting due to [[anal pain]]
+===Skin===
+*[[Dry skin]] may be seen in [[systemic sclerosis]]
-* Complete rectal examination with attention paid to:
+=== HEENT ===
-*:* Presence of [[stool]]
+*[[Extraocular muscle|Extra-ocular]] movements may be abnormal
-*:* Masses
+===Neck===
-*:* [[Fistula]]s
+*[[Thyromegaly]]/[[Thyroid nodule|thyroid nodules]] may be seen in [[hypothyroidism]]
-*:* [[Hemorrhoid]]s
+===Abdomen===
-*:* [[Abscess]]es
+*[[Abdominal distention]]
-*:* [[Fissure]]s
+*[[Abdominal tenderness]] in the left lower abdominal quadrant
-*:* Squeezing and resting of [[sphincter]] tone
+*A palpable [[abdominal mass]] in the left lower abdominal quadrant
-*:* Palpable relaxation of anal tone and perineal descents
+===Neuromuscular===
+*[[Altered mental status]]
+*[[Clonus]] may be present
+*[[Hyperreflexia]]
+*Positive (abnormal) [[Babinski's Reflex|Babinski]]
+*[[Muscle rigidity]]
+*[[Gait abnormality|Abnormal gait]] ([[Parkinsonian]] [[gait]])
+*Unilateral/bilateral [[tremor]] (pill-rolling)
+=== Digital rectal examination (DRE)===
+Method and findings of digital rectal examination include:<ref name="pmid20656061">{{cite journal |vauthors=Tantiphlachiva K, Rao P, Attaluri A, Rao SS |title=Digital rectal examination is a useful tool for identifying patients with dyssynergia |journal=Clin. Gastroenterol. Hepatol. |volume=8 |issue=11 |pages=955–60 |year=2010 |pmid=20656061 |doi=10.1016/j.cgh.2010.06.031 |url=}}</ref>
+{|
+! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |DRE steps respectively
+! style="background:#4479BA; color: #FFFFFF;" align="center" + |Method
+! style="background:#4479BA; color: #FFFFFF;" align="center" + |Findings
+|-
+| colspan="2" style="background:#DCDCDC;" align="center" + |'''''[[Inspection (medicine)|Inspection]]'''''
+| style="background:#F5F5F5;" + |
+* Patient in left lateral decubitus, hips 90° flexed
+* Looking to the [[Perineal|perineal area]] under reasonable light
+| style="background:#F5F5F5;" + |
+* Skin [[excoriation]]
+* [[Skin tags]]
+* [[Anal fissure]]
+* [[Scars]]
+* [[Hemorrhoids]]
+|-
+| colspan="2" style="background:#DCDCDC;" align="center" + |[[Sensation|'''''External sensation''''']]
+| style="background:#F5F5F5;" + |
+* Using a stick with cotton head
+* Tapping and touching all 4 quadrants centripetally (anocutaneous reflex)
+| style="background:#F5F5F5;" + |
+* Slight [[contraction]] of the [[skin]] and the [[external anal sphincter]] (normal reflex)
+* No [[contraction]] with cotton head but slight [[contraction]] with wooden head (decreased reflex)
+* No [[contraction]] with either of heads (absent reflex)
+|-
+| rowspan="4" style="background:#DCDCDC;" align="center" + |'''''Internal examination'''''
+| colspan="1" rowspan="1" style="background:#DCDCDC;" align="center" + |Digital palpation
+| style="background:#F5F5F5;" + |
+* Inserting the index finger into the patient [[anus]]
+* Palpating the parts, such as [[mucosa]], [[muscle]], [[bone]], [[uterus]], or [[prostate]]
+| style="background:#F5F5F5;" + |
+* [[Tenderness]]
+* [[Mass]]
+* [[Stricture]]
+* [[Stool]] consistency
+|-
+| style="background:#DCDCDC;" align="center" + |[[Sphincter]] tonometry
+| style="background:#F5F5F5;" + |
+* Evaluating the resting tone of the [[anal sphincter]]
+| style="background:#F5F5F5;" + |
+* Normal
+* Decreased
+* Increased
+|-
+| colspan="1" rowspan="1" style="background:#DCDCDC;" align="center" + |Squeeze maneuver
+| style="background:#F5F5F5;" + |
+* Evaluating the voluntary squeezing pressure of the [[anal sphincter]]
+* Asking to hold up to 30 seconds
+| style="background:#F5F5F5;" + |
+* Normal
+* Decreased
+* Increased
+|-
+| colspan="1" rowspan="1" style="background:#DCDCDC;" align="center" + |[[Defecation]] maneuver
+| style="background:#F5F5F5;" + |
+* Asking to push as if to defecate
+* Evaluating the push effort with a hand on the [[abdomen]]
+| style="background:#F5F5F5;" + |
+* Push effort (Normal, decreased, excessive)
+* [[Anal]] relaxation (normal, impaired, paradoxical contraction)
+* [[Perineal]] descent (Normal, excessive, absent)
+|}
+==References==
+{{reflist|2}}
+{{WikiDoc Help Menu}}
+{{WikiDoc Sources}}
+[[Category:Gastroenterology]]
+[[Category:Medicine]]
+[[Category:Up-To-Date]]
+[[Category:Emergency medicine]]