Symptoms and signs of Constipation
As we have discussed earlier as constipation is itself a symptom. There is an underlying cause which cause the constipation. So depending upon the underlying cause the features associated with constipation vary. Let us discuss here how the features of constipation will vary with underlying cause.
Initial presentation
Patients of constipation show symptoms and signs on initial presentation
- Constipation can be a sole complain or patient may present with other symptoms and the constipation is revealed after probing the bowel habit history.
- Patients or in case of children the parents complain of pain while passing stool.
- The frequency of passing stool is reduced.
- In some cases contrarily the frequency of passing stool may be increased as patients especially children try to defecate but when they try there is pain so they try to hold. They may pass small quantity of hard stool multiple times a day.
- Sometimes the blood which may be typically bright red in color is seen with stool.
- The stool is generally hard like stone and very painful to excrete.
- Some patients also feel the abdominal cramps before passing stool.
- With past experience of severe pain patient is very afraid when he/she gets urge to pass the stool.
- In case of toddlers they may develop toilet phobias because of pain or the toilet phobia can lead to the constipation.
- In extreme cases where this hard stool leads to intestinal obstruction patient can present with signs and symptoms of intestinal obstruction which include vomiting and severe abdominal cramps.
- With repeated loss of blood patient may develop anemia and show signs and symptoms of anemia like fatigue, weakness.
- Some patients may complain of reduced appetite to the extent they may show weight loss or in case of children failure to gain the weight.
- School going children may report absence from the daily school and academic activities because of the abdominal cramps.
- Adults may complain absence from the work because of the severity of the complains.
- The abdominal cramps can be severe enough to disturb the sleep of the patients.
- Some patients may complain of the pain while passing urine as stool retention in rectum can lead to urine retention and difficulty in passing urine, which may lead to urinary tract infection and pain.
- With all these complains it is clear that patient is suffering from constipation. With all this data and associated symptoms, the diagnosis is concluded.
- In case functional constipation patients do not have other anatomical, physiological or hormonal disease. Constipation is sole complain. On history such patients usually have poor dietary habits and some psychosomatic disorders. The patients may come with acute complains or may be having constipation as a sole complain chronically for a prolonged period of time.
- Malnutrition: Malnutrition in children and adults alike can cause constipation. In malnutrition the gut mucosa changes in characteristics. In malnutrition motility of the gut too changes. Malnutrition includes both under weight and overweight people and children. This group of patients often have poor dietary habits. They also have other features of malnutrition and deficiency of other food vitamins and proteins. Obese people also have apathy and sleeplessness along with other complains. Children with malnutrition can present with delay in growth and physical and developmental milestones. Constipation itself can cause reduced intake of food can precipitate the malnutrition.
- Excessive intake of cow milk is another important cause of constipation. Cow milk is good in providing proteins but it lacks dietary fibers. Additionally high calcium contains of animal milk combines with iron in food and cause iron deficiency anemia. Children and people with excess intake of cow milk has tendency to become obese. They also suffer constipation very frequently. The can cause cow milk protein allergy also. The patient is usually normal weight and good weight and gives history of excess of cow milk daily.
- Lack of dietary fibers: Food faddism and increased intake of industry made junk food has altered the diet habits of the people in recent decades. On history of patients with constipation there is lack of fruits and green leafy vegetables in diet.
- Patient may have other underlying illness for which he/she may be using drugs in fact many over the counter drugs causing constipation as a side effects. Patients of chronic cough using codeine, terbutaline, may complain of constipation. Patients suffering from allergy and rhinitis may be using anti-histaminics which may cause constipation. Patients may have psychological problem for which he may be on anti-depressants that may cause constipation. Patients using dietary supplements without medical advise may suffer constipation.
- In motility disorder like Hirschprung’s disease presents from birth or after few weeks of birth. Rarely it may present later in toddler age. Patients typically have delay passing first motion. The infant presents with complains of constipation followed by lose motion alternately. Patients usually need surgical intervention.
- Neurological problems like mental retardation, spina-bifida, cerebral palsy, meningomyelocoele present in young age with complains and findings of underlying problem.
- Collagen disorders like scleroderma and SLE presents with other complains rather than constipation. The constipation is evident on history.
- Hypothyroidism presents with constipation and other features like feeling of excess cold, loss of appetite, feeling of low in energy, skin dryness and some other features.
- Hyperparathyroidism may present with weight loss, dry skin, excess sweating and hypercalcemia.
- In pregnancy constipation is common complain.
- Diabetes mallitus can present with increased frequency of urine, excess appetite and excess water intake
On physical examination:
Symptoms and signs of constipation on physical examination includes.
- Physical exam is done to confirm the finding on history.
- According to the underlying condition patient may be well nourished or malnourished, sometimes overweight and obese.
- Assessment of the pallor, edema, lymphadenopathy, icterus, cynosis should be done as it helps to add the additional input in diagnosing the underlying problem or complications of the constipation.
- Assessment of height and weight is essential for the assessment of the physical growth of the child and assessment of the obesity or malnutrition in older children and adults.
- Assessment of the milestones is essential to check for the developmental milestones in children.
- Assessment of mental status and higher mental function is needed is needed to rule out the causes like psychological problems and mental illnesses.
- On gross examination in children anomalies like ano-rectal malformation and spina – bifida, meningo-myelocele can be detected.
- Patient may have features of hypothyroidism like decreased pulse rate, dry skin.
- Patients suffering from scleroderma and SLE may have features of underlying disease those can be diagnostic.
- Renal tubular acidosis usually presents in young age usually with features of growth failure. On further investigations renal tubular acidosis is detected.
- Patients with constipation usually have localized abdominal swelling which may look like lump. On palpation it feels like a hard sometimes compressible lump which may change in location in abdomen and may be reduced after patient pass motion.
- On physical examination may reveal the local injury due to the hard motions. Anal fissures can be found which may need surgical intervention.
- Physical examination reveals increased tone and hypertrophy of the external anal sphincter.
- Per rectal examination can detect local tumor or ulcer in the anus.
- Grossly visible ano-rectal malformations can be revealed on local examination.
- In physical examination anomalies like spina-bifida and meningomyelocele can be checked.
- Assessment of the lower limb power and deep tendon reflexes and senses is needed to rule out paraplegia.
- Assessment of the touch sensation in sacral area is needed to be done to check for spinal cord section S-4 level as this plays important role in mechanism of defecation.
- Patients with cerebral palsy can have other findings like hypertonia and seizures, mental impairment, feeding difficulty with or without history of birth complications.
Here we tried to explains symptoms and signs of constipation.