Diagnostic Algorithm for Constipation and Obstructed Defecation

Antidiarrheal agents

Antiparkinson drugs

Antiepileptics

Antispasmodics

Antihistamines

Calcium channel blockers

Antidepressants

Diuretics

Antipsychotics

Sympathomimetics

Antiacids with aluminum or calcium

NSAIDs

Table 24.2

Condition associated to constipation (Diamant et al. 1999)

Mechanical obstruction	Colorectal tumor, diverticulosis, strictures, ab-extrinseco compression, postsurgical abnormalities, volvulus
Pelvic – anal diseases	Levator ani syndrome, rectal prolapse, rectocele, anal abscess, anal fissure, hemorrhoids
Myopathies, neuropathies	Autonomic neuropathy, cerebrovascular disease, spinal cord disease, multiple sclerosis, Parkinson disease, systemic sclerosis
Metabolic conditions	Chronic renal failure, diabetes mellitus, electrolyte disorders, dysthyroidism, Porphyria
Psychiatric conditions	Cognitive impairment, anorexia, depression
Other conditions	Fluid depletion, low-fiber intake, immobilization, dehydration, cardiac disease

The term “primary constipation” itself hides different conditions, such as irritable bowel syndrome with constipation (IBS-C), functional constipation, functional defecation disorders, and rectal hyposensitivity (Bellini et al. 2015; Bharucha et al. 2006; Longstreth et al. 2006) (Tables 24.3 and 24.4).

Table 24.3

Rome III criteria for differential diagnosis between functional constipation and irritable bowel syndrome (Bharucha et al. 2006)

Functional constipation

Diagnostic criteria *

1. Must include two or more of the following:

Straining during at least 25 % of defecations

a. Lumpy or hard stools in at least 25 % of defecations

b. Sensation of incomplete evacuation for at least 25 % of defecations

c. Sensation of anorectal obstruction/blockage for at least 25 % of defecations

d. Manual maneuvers to facilitate at least 25 % of defecations (e.g., digital evacuation, support of the pelvic floor)

e. Fewer than three defecations per week

2. Loose stools are rarely present without the use of laxatives

3. Insufficient criteria for irritable bowel syndrome

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

Irritable bowel syndrome with constipation

Diagnostic criterion *

Recurrent abdominal pain or discomfort ** at least 3 days/month in the last 3 months associated

with two or more of the following:

1. Improvement with defecation

2. Onset associated with a change in frequency of stool

3. Onset associated with a change in form (appearance) of stool (hard or lumpy stools ≥25 % and loose or watery stools <25 % of bowel movements)

Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

** “Discomfort” means an uncomfortable sensation not described as pain

Table 24.4

Roma III diagnostic criteria for functional defecation disorders

Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis
The patient must satisfy diagnostic criteria for functional constipation During repeated attempts to defecate must have at least two of the following:
	Evidence of impaired evacuation, based on balloon expulsion test or imaging
	Inappropriate contraction of the pelvic floor muscles or less than 20 % Relaxation of basal resting sphincter pressure by manometry, imaging, or EMG
	Inadequate propulsive forces assessed by manometry or imaging

Particularly IBS-C is characterized by abdominal pain or discomfort improved by defecation, whereas functional constipation is a functional bowel disorder that presents as persistently difficult, infrequent, or incomplete defecation. Functional defecation disorders are characterized by paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defecation (dyssynergic defecation ) or inadequate propulsive forces during attempted defecation (inadequate defecatory propulsion) (Bharucha et al. 2006).

Rectal hyposensitivity is a relatively new disorder defined by Gladman (Gladman et al. 2003) as an elevation beyond the normal range in the perception of at least one of the sensory threshold volumes during anorectal manometry. There are as yet no specific criteria that can differentiate the subtypes of chronic constipation based on history (Bharucha et al. 2006). Also performing a full assessment of defecation using specific tests (e.g., anorectal manometry, colonic transit time, and defecography) may not distinguish these different conditions (Wong et al. 2010; Rey et al. 2014; Jones et al. 2007; Gambaccini et al. 2013). However, a careful attempt to understand the pathophysiological mechanisms underlying the constipation of each patient is mandatory in order to suggest an effective therapy. This should be strictly tailored to each individual patient and therefore different from one patient to another (Bellini et al. 2015).

Even if there are no specific criteria that can definitely distinguish among the different subtypes of chronic constipation, a careful medical history should always be collected. It is the first approach to the patient and is aimed to detect symptoms and events possibly linked to the onset of symptoms themselves (Bove et al. 2012).

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