Physiological Factors Metabolic

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Measurement of serum electrolytes is an important diagnostic modality in evaluating patients who present with constipation. It is known that electrolyte abnormalities such as hypokalemia, hypo- and hypercalcemia, and metabolic derangements seen in uremia are associated with symptoms of constipation.20

Endocrine Disorders

Endocrine disorders are associated with gastrointestinal complications, for example, constipation. Among the endocrinopathies discussed here are diabetes mellitus, hypothyroidism and hyperparathyroidism, multiple endocrine neo-plasia type lib (MEN lib), and pregnancy.

The prevalence of gastrointestinal symptoms in individuals with diabetes mellitus is higher as compared to the general population.21 The impact of diabetes mellitus on gastrointestinal function and quality of life was assessed by Talley et al22 in a total of 1101 Australian diabetics. Among the gastrointestinal symptoms that were assessed, 24.5% of patients reported having constipation, which was the most prevalent symptom reported among all diabetics, both types 1 and 2. The authors concluded that gastrointestinal morbidity among diabetics is high and is associated with a significant impairment of quality of life. This finding was echoed in another study that concluded that diabetic auto-nomic neuropathy is a serious and common complication of diabetes, and constipation is the most common lower gastrointestinal symptom.23 Gastrointestinal function of individuals who have diabetes mellitus and constipation were assessed by scintigraphic colonic transit studies, anal sphincter vector manometry, balloon expulsion defecatory dynamics, and scintigraphic measurement of anorectal angles. Among diabetics with constipation, the study concluded that, compared with community controls, diabetics have a higher prevalence of abnormal evacuation and colonic motor abnormality as manifested by prolonged colonic transit.24

The prevalence of bowel dysfunction in hypothyroidism was assessed by a colon transit study among patients who manifested with clinical hypothyroidism. The authors found a significant delay in the whole-gut transit in this population. The authors concluded that hypothyroidism may clinically manifest as a decrease in bowel movements, and is improved by replacement with thyroid hormones.25 Constipation is a common symptom of hypercal-cemia, secondary to hyperparathyroidism.26

Delayed orocecal transit studies were reported in pregnancy.27 There is an increased incidence of constipation and symptomatic hemorrhoids, especially during the latter phases of pregnancy, either as a result of alterations in hormones or secondary to mechanical compression caused by an enlarging uterus.28

It is known that the syndrome of MEN IIb comprises mucosal ganglioneuromatosis, medullary thyroid carcinoma, pheochromocy-toma, and skeletal anomalies. In patients who were found to have ganglioneuromatosis of the alimentary tract, constipation was described as a clinical manifestation of the disorder; megacolon occurred in five of a series of 16 patients.29

Other less common endocrinopathies that have been associated with constipation include hyperparathyroidism,26 panhypopituitarism, pheochromocytoma,30 and glucagonoma.31,32

Drugs (Table 4.1)

The following pharmacotherapeutic agents are associated with constipation: analgesics, which include opiates and to a much lesser extent non-

Table 4.1. Constipating medications

Medication class

Common medications

Analgesics

Opiates, nonsteroidal antiinflammatory

drugs

Anticholinergic

Antispasmodics, antidepressants, and

medications

antiparkinsonism drugs

Antacids

Aluminum hydroxide and calcium carbonate

Antihypertensives

a-adrenergic agonists, beta-blockers,

calcium channel blocker, and diuretics

Others

Anticonvulsants, iron, bismuth

steroidal antiinflammatory drugs; anticholinergic medications that are commonly used as anti-spasmodics, antidepressants, and antiparkinsonism drugs; antacids that contain the elements aluminum and calcium; a-adrener-gic agonists, beta-blockers, calcium channel blockers, and diuretic antihypertensives; and other medications such as anticonvulsants, iron, and bismuth.

Neurologic

Neurohumoral integrity is essential for normal gastrointestinal motility, and this is subdivided into intrinsic and extrinsic components. The intrinsic component involves the enteric nervous system; the extrinsic component involves the vagus nerve and splanchnic nerves to the stomach and upper intestine, and the pelvic nerves that supply the distal intestinal seg-ments.33 In patients with neurologic diseases, colorectal dysfunction is caused by a combination of lesions of the central or peripheral nervous systems, immobility, altered dietary habits, or use of medications such as opioid analgesics and spasmolytics.34

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