MRCP PACES Approaches Approach to Constipation

Differential diagnosis

  • Hypercalcaemia
    • Primary hyperparathyroidism
      • MEN-1: pituitary adenoma, parathyroid adenoma, pancreatic tumours
    • Tertiary hyperparathyroidism
  • Endocrine
    • Hypothyroidism
  • Obstruction
    • Malignancy
    • Herniae
    • Adhesions (previous surgery)
    • Stricture
  • Crohn’s disease with stricturing
  • IBS
  • Dietary
  • Autonomic dysfunction
  • Drugs
    • Iron tablet
    • Opiates
  • Pregnancy
  • Psychogenic
    • Anorexia
    • Inability to relax (40% have previous sexual abuse)
  • Hirschsprung’s

Relevant points in the history

  • Constipation
    • When did you first notice it?
    • What is your normal bowel habit?
    • How often are you going to the toilet now?
    • Are you straining when you go to the toilet?
    • Have you noticed any blood in your stool?
    • Is it getting worse?
    • When you finish, does it feel like you have not emptied your bowels completely?
    • Are you still able to pass wind?
  • Hypercalcaemia
    • Do you feel thirsty?
    • Do you feel like you have to go to the toilet a lot?
    • Do you ever get any tummy pain?
      • Does this get better or worse with meals (peptic ulcer)?
      • Does it go from your back to your groin (renal colic)?
    • Do you have any aches and pains?
    • Do you feel like you are bumping into things more than usual?
    • When soaping yourself, have you noticed any unusual bumps in your skin?
  • Hypothyroidism
    • Have you noticed that you are unusually intolerant of the cold?
    • Have you noticed a change in your voice?
    • Have you noticed a change in the texture of your skin or hair?
    • Have you gained any weight?
  • Malignancy and obstruction
    • Have you lost any weight?
    • Do you feel like you have no appetite?
    • Have you noticed any fever?
    • Are you still able to pass wind?
    • Have you noticed any episodes where your eyes or skin have turned yellow?
  • Strictures
    • Have you had any operations before?
    • Have you ever had any bowel problems such as uncontrollable diarrhoea?
  • Dysautonomia
    • Do you feel dizzy when you stand up?
    • Do you have any problems with your urine?
    • Do you feel unusually full early in a meal?
  • Drugs
    • Are you on any medication?
    • Have you tried any over-the-counter medicines, such as cough medicines?
    • Have you ever required iron tablets?
  • Psychogenic
    • How has your mood been?

Examination

  • General
    • Cachexia
    • Pallor
    • Coarse facies, loss of outer 1/3rd of eyebrow
  • Hypercalcaemia
    • Parathyroid masses
    • Visual fields
    • Scars of previous pancreatic surgery
  • Thyroid status
    • Pulse – bradycardia
    • Goitre
    • Proximal myopathy
  • Malignancy
    • Abdominal masses
    • Hepatomegaly
    • Lymphadenopathy
  • Offer digital rectal examination

Investigations

  • Full blood count looking for anaemia
  • Renal function as can cause tertiary hyperparathyroidism in late stages
  • Liver function tests as malignancy may spread to liver
  • Calcium and phosphate, PTH to look for parathyroid adenoma
    • PTHrP if calcium elevated and PTH suppressed
    • Consider MRI brain and pancreatic imaging if family history suggestive of MEN-1
  • Thyroid function tests, consider thyroid auto-antibodies if deranged
  • Colonoscopy to rule out colonic lesion

Management

  • Laxatives
  • Treat underlying cause
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