A 66 year old man presents to the clinic with history of difficulty passing stools since 1 month. Initially he has one bowel movement every two days with difficulty. Of late he has one bowel movement every week which is associated with extreme straining and blood streaking in the stools towards the end. He is not a diabetic or hypertensive. He does not take any medications and is otherwise in perfect physical fitness.

Which of the following statements about this man is false?

1. ^{This is a very common complaint in the elderly}
2. ^{It may be intermittent in nature}
3. ^{Malignancy has to be ruled out}
4. ^{Dietary factors play the least role in this age group}

Answer: The answer is (d). This patient has constipation. Constipation is defined as two or fewer bowel movements per week or excessive straining and difficulty at defecation. It is a common complaint in this age group. It may present either intermittently or chronically. The most common causes for it are diet, medications and immobility. Malignancy of the gastrointestinal tract especially the rectum and colon has to be ruled out.

What is true about fecal impaction?

1. ^{Occurs commonly in neurological disorders of the urinary bladder}
2. ^{Can cause urinary incontinence}
3. ^{It is uncommon among psychiatric patients}
4. ^{Can be treated with laxatives}

Answer: The answer is (b). Fecal impaction is common in the setting of severe psychiatric illness, prolonged bed rest, prolonged debility, neurological disorders of the colon and spinal cord diseases. Chronic impacted stools can cause urinary incontinence. The treatment of impacted feces is digital disruption and enema. Long term treatment includes keeping the stools soft and maintaining regular bowel movements.

Which of the following associated clinical feature is not common in this man?

1. ^{Loss of appetite}
2. ^{Nausea and vomiting}
3. ^{Periodic diarrhea}
4. ^{Unresponsive to medicines or enema}

Answer: The answer is (d). The common associated symptoms of constipation are decreased appetite, nausea, vomiting, abdominal pain, distension and paradoxical diarrhea. The garden variety constipation is usually responsive to laxatives and enema.

The following statements are all true except

1. ^{Hyperparathyroidism can present with constipation}
2. ^{Multiple sclerosis can manifest as colonic dysmotility and constipation}
3. ^{Among the infective causes of constipation the most common is typhoid fever.}
4. ^{Non steroidal anti inflammatory agents are used in the treatment of constipation}

Answer: The answer is (d). The endocrine causes of constipation include hypothyroidism, hyperparathyroidism and diabetes mellitus. Hypercalcemia, hypokalemia and porphyrias can cause constipation. Multiple sclerosis can present as colonic dysmotility and constipation. Among the infective causes for constipation the common ones are typhoid fever and tuberculosis. Non steroidal anti inflammatory agents can cause constipation and hence cannot be used in the treatment of the condition.

Which of the following is a condition of slow colonic transit?

1. ^{Hirschprung’s disease}
2. ^{Stricture colon due to Crohn’s disease}
3. ^{Chronic Intestinal Pseudo obstruction}
4. ^{Chagas disease}

Answer: The answer is (c). Hirschprung’s disease is a congenital defect in the nervous plexus of the colon and hence there is dysmotility. Crohn’s disease stricture of the colon is a structural defect. Chagas disease is an acquired form of neurological defect of the colon. Chronic intestinal pseudo obstruction is the condition of slow colonic transit.