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What is necessary to diagnose constipation?

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Constipation is a common ailment with multiple symptoms and diverse etiology. Understanding the pathophysiology is important to guide optimal management. During the past few years, there have been remarkable developments in the diagnosis of constipation and defecation disorders. Several innovative manometric, neurophysiologic, and radiologic techniques have been discovered, which have improved the accuracy of identifying the neuromuscular mechanisms of chronic constipation. These include use of digital rectal examination, Bristol stool scale, colonic scintigraphy, wireless motility capsule for assessment of colonic and whole gut transit, high resolution anorectal manometry, and colonic manometry. These tests provide a better definition of the underlying mechanism(s), which in turn can lead to improved management of this condition. In this review, we summarize the recent advances in diagnostic testing with a particular emphasis on when and why to test, and discuss the utility of diagnostic tests for chronic constipation.

Introduction

Constipation is a symptom based disorder that is caused by multiple mechanisms. Primary constipation involves three pathophysiologic subtypes *[1], [2]. Slow Transit Constipation is characterized by prolonged delay of stool transit through the colon. Dyssynergic Defecation is characterized by either difficulty or inability to evacuate stool from the rectum. Constipation-predominant irritable bowel syndrome is characterized by symptoms of constipation with discomfort or pain as a prominent feature [3]. Secondary constipation is caused by a myriad of factors such as diet, drugs, behavioral, lifestyle, endocrine, metabolic, neurological, psychiatric, and other disorders [4].

Although a diagnosis of constipation is usually made on the basis of symptoms, a more precise and accurate characterization of the underlying mechanism(s) requires physiologic tests of colorectal function especially in patients who are not responding to simple measures such as fiber supplements and over the counter laxatives [5].

In this review, we discuss the role of diagnostic tests for constipation and when to order these tests and what do they provide.

Section snippets

History

A detailed medical, surgical, dietary and drug history can facilitate the recognition of common constipation (Table 1). Patients and physicians have a different perception regarding the symptoms as constipation [6]. Hence, consensus criteria have been proposed by experts to improve the diagnosis of constipation such as the Rome III Criteria for constipation [3], [7] and the American College of Gastroenterology Chronic Constipation Task Force. The latter recommends a broader definition of

Diagnostic tests

A complete blood count, biochemical profile, serum calcium, glucose levels and thyroid function tests are usually sufficient for screening purposes to exclude an underlying metabolic or pathological disorder. If there is a high index of suspicion, serum protein electrophoresis, urine porphyrins, serum parathyroid hormone and serum cortisol levels may be requested. However there are no studies done to assess the clinical value of the routine use of blood tests alone and hence there is no

Conclusions

In conclusion, a careful history and stool diary is the initial step in the diagnosis of constipation. DRE can provide useful information on sphincter pressure, presence of dyssynergia and fecal impaction. There is little evidence to support the use of routine blood tests or endoscopy in constipated patients without alarm features. Though colonic transit studies are not standardized, there is good evidence to show its benefits. Anorectal manometry is the preferred method for diagnosis of

Conflict of interest

Dr. Rao serves on the advisory board for SmartPill Corporation and has received research support.

Acknowledgement

Dr Rao’s effort is supported in part by grant R01DK 57100-03 National Institute of Health. The authors also acknowledge the excellent secretarial support of Mrs Sara Allen.

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