1. Constipation
Infrequent BM- <3/week
Hard stools
Straining during defecation
Sensation of incomplete bowel evacuation

2. Causes
 Inadequate fluid or
fiber intake
 Suppression of
defecatory urge
 IBS
 Impaired colonic motility
 Drugs- opioids, CCB,
Iron, calcium,
anticholenergics
 Structural disorders
 Rectal prolapse, stricture,
fissure, abscess
 Colonic mass, stricture
 Hirschsprung disease
 Systemic disease
 Hypothyroidism
 Hyperparathyroidism
 Hypokalemia
 Parkinson’s, paraplegia
 Autonomic neuropathy

3. Alarm symptoms or signs
 Hematochezia
 Weight loss
 Anemia
 Positive FOBT
 Mass
 F/H of colon cancer or IBD

4. Evaluation & management
 History- duration, bowel habits, dietary habits, mobility, drugs
 Examination- rectal examination
 Sigmoidoscopy/colonoscopy, if required
 Treatment-
 Adequate fiber & fluids
 Bulk laxative- Psyllium, Methylcellulose
 Stool softeners- Docusate
 Osmotic laxative- lactulose, sorbitol, polyethylene glycol
 Stimulant laxative- senna, Bisacodyl, Lubiprostone
 Enema
Treat underlying cause, if any

5. Diarrhea
3 or more loose or liquid
bowel movements per day
Dysentery- bloody loose stools

6. Classification
 Secretory- increased secretion or decreased
absorption of electrolytes
 Exudative- outpouring of cells & colloid
 Infectious
 Inflammatory
 Osmotic- nonabsorbable intraluminal
molecules
 Anatomical- decreased absorptive surface
 Motility- decreased contact time

7. Acute or chronic?
Acute- <2 weeks
Chronic- >2 weeks

8. Causes- acute
 Noninflammatory
 Rota/Norwalk virus
 Giardia
 Enterotoxin-
 Staph. aureus
 Bacillus cereus
 Clostridium perfringens
 ETEC
 Vibrio cholerae
 Inflammatory
 CMV
 Entamoeba histolytica
 Cytotoxin-
 EHEC
 Clostridium difficile
 Mucosal invasion
 Shigella
 Salmonella
 Campylobacter
 EIEC etc.

9. Acute diarrhea
 Mostly self-limited,
requiring rehydration (ORS) only
 Prompt medical evaluation required if-
 Fever
 Dysentery
 Abdominal pain/tenderness/peritonitis
 Profuse watery stools with dehydration
 Elderly & Immunocompromised
 Hospital acquired (>3 days after admission)
Consider empiric antibiotics

10. Causes- chronic
 Secretory- laxative abuse, endocrine tumors,
villous adenoma, bile salt malabsorption
 Infectious- Giardia, E. histolytica, CMV, MAC,
Cryptosporidium, Isospora
 Inflammatory- IBD, radiation, malignancy
 Osmotic- medication, lactose intolerance
 Anatomical- post-resection
 Motility- IBS, scleroderma, DM, hyperthyroidism
 Malabsorption- sprue, chronic pancreatitis, fistula

11. Chronic diarrhea- evaluation
 History- weight loss, nature of stool,
associated symptoms, lactose intolerance,
medication, surgery, systemic disease
 Examination- weight, nutritional deficiency
 Investigation- stool WBC/RBC/fat/osmolality,
sigmoido/colonoscopy with biopsy,
barium meal followthrough/enema
 Other- Hb., albumin, electrolytes etc.

12. Treatment
 Treat underlying cause
 Antidiarrheals-
 Loperamide
 Diphenoxylate with atropine
 Codeine
 Clonidine- secretory diarrhea, diabetes
 Octreotide- hormonal diarrhea
 Cholestyramine- bile salt induced diarrhea