Is constipation really what we think it is?

Dr Megan Rossi in a lab looking through a microscope

Around 14% of the general population in the UK report suffering from chronic constipation, with many saying the symptoms have a profound effect in their daily lives. But what exactly is this disorder?

There are formal diagnostic criteria for chronic constipation (called the Rome IV criteria), according to which someone has to experience at least two of the six symptoms listed below for at least ¼ of their bowel movements in the past three months:

  • straining

  • hard or lumpy stools

  • a sense you have not completely emptied your bowels after a bowel movement

  • a sense there may be something blocking or obstructing your stool from being passed

  • using your fingers to pass a stool

  • having less than 3 bowel movements per week.

However, recent research by my team at King’s College London showed that the public and doctors disagree with the formal diagnostic criteria on what constipation is (or isn’t!).

What was the study?

We undertook a large national survey and collected data from 2,557 members of the public (of which 934 reported having reported constipation), 411 general practitioners (GPs) and 365 gastroenterology specialists.

What were the key findings?

  1. Firstly, there was a disagreement in perceptions of constipation diagnosis among people with constipation, doctors and the formal diagnostic criteria used in clinical practice (Rome IV). For example, infrequent bowel movements was perceived as important for diagnosing constipation by less than a third of the constipated general population, compared to 41% of GPs and as many as 65% of specialist doctors!

  2. Secondly, 94% of those who self-reported constipation met the formal diagnostic criteria (Rome IV). Surprisingly, however, 29% of the 1,623 who did not self-report constipation actually met these criteria too. Therefore, about 1 in 3 “healthy” people were clinically constipated but didn’t recognise it. This may be explained by the fact that, although they experience some of the symptoms assessed in the Rome IV criteria (and therefore they are clinically diagnosed with constipation), they may not actually see these as indicating constipation or bothersome enough for them to believe they suffer from constipation.

  3. Thirdly, using a series of case studies, the rates of correct diagnosis of constipation among the participants ranged from 99% down to 39%.

  4. We also identified six key symptom clusters, which were commonly agreed as important for a diagnosis: abdominal discomfort; rectal discomfort; infrequent bowel movements and hard stools; sensory dysfunction; flatulence and bloating; faecal incontinence.

Why are these findings important?

The differences in perceptions of constipation may mean that, in some cases, people with symptoms of constipation may not always have these recognised, diagnosed or managed as such.

These findings highlight there may be a need to refine the current diagnostic criteria, so they reflect what both patients and doctors perceive as being important for a diagnosis.

Healthcare professionals need to know what symptoms patients think are important for a diagnosis as this will allow healthcare professionals to examine and address these symptoms during their appointment.

This is also an opportunity to clarify whether symptoms that patients may be worried about are in fact “normal” – for example, someone may think that having 6 bowel movements per week instead of 7 is abnormal, but in the absence of any other symptoms or conditions, this is actually considered a normal stool frequency. As always, open communication and education between patients and their healthcare professionals are key!

If you think you may suffer from symptoms of constipation, always have a chat with your GP first. For diet and lifestyle management, our team at The Gut Health Clinic, are here to help, so please get in touch if you want to find out more about our dietitians and consider an appointment.

References:

Dimidi et al, Am J Gastroenterol 2019(114):1116-29

Lacy et al, Gastroenterology 2016(6):1393-1407

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