Red Flag Symptoms: Constipation

Check for serious pathology when treating this common problem.

Constipation is an extremely common problem seen by GPs. The danger is that it can be branded as trivial and serious pathology missed.

A UK GP will see an average of one case of colorectal cancer per year and will be caring for a patient dying from the condition every 18 months.1

Double contrast X-ray: colonic spasm can result in constipation (CNRI / SCIENCE PHOTO LIBRARY)

It is important to establish what a patient means by 'constipation'. Not everybody needs a daily bowel movement, but with true constipation the symptoms are distressing.

There may be hard stools, painful to pass associated with tenesmus and rectal bleeding. The colour of the blood and where it is in relation to the stool and toilet paper gives helpful clues as to its origin.

This is difficult with young children who are unable to give a clear history.

A drug history is important, including both prescribed and OTC medications. Opioid-containing analgesia are a common culprit, especially in the elderly.

Dietary history will reveal eating habits, especially fibre and water intake.

Perform a thorough examination. In children, are they progressing on the centile charts? Check the conjunctiva for anaemia and the sclera for jaundice.

Red flag symptoms
  • New onset in elderly patient
  • Unexplained anaemia
  • Rectal bleeding
  • Positive faecal occult blood test
  • Family history of bowel cancer or inflammatory bowel disease
  • Tenesmus
  • Weight loss

Palpate the abdomen for pain, masses or organomegaly. Faecal rocks are commonly felt and are indentable, but can mimic cancer. An irregular liver is a sinister sign.

A rectal exam is mandatory in adults to exclude carcinoma. Proctoscopy will also reveal fissures and haemorrhoids.

Treatments for constipation are stepwise. Laxative therapy is not given as a long-term treatment. Elderly patients with immobility and constipation may require long-term treatment. It is important the patient drinks at least two litres of water a day as this helps the laxative work.

Any patient with unexplained anaemia, weight loss or persisting rectal bleeding (>4 weeks) or altered bowel habit (>6 weeks) with the possibility of an abdominal mass should be referred urgently for assessment to exclude malignancy. Clinical suspicion is important.

  • Dr Croton is a salaried GP in Birmingham

Resources

1. Hobbs F D R. ABC of colorectal cancer: The role of primary care BMJ 2000; 321: 1,068-70

Possible causes

  • Functional constipation - poor diet, poor fluid intake, sedentary lifestyle.
  • Constipation prominent IBS.
  • Colorectal cancer.
  • Painful rectal conditions, e.g. anal fissure.
  • Drug related - opioids.
  • Hirschprung's disease - a rare cause in children.

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