Abnormalities in bowel or urination habits

Chapter 25 Abnormalities in bowel or urination habits



Case 25.1



1. What is the most likely diagnosis?

Physiological Ileus.


2. Is this an unusual situation? Why or why not?

It is a common occurrence following abdominal surgery, and is characterised by impaired muscle contraction in the bowel wall. It usually resolves within 3 days. If it does not resolve, it is known as ‘paralytic ileus’.


The proposed mechanism by which it occurs is described by Mukherjee.[1]


3. What are other possible causes of this disorder?

Intra-abdominal infection, electrolyte imbalances, drugs, trauma, myocardial infarction, head injuries, brain surgery and retroperitoneal bleeding.[1]



Case 25.2



1. What pertinent information must you seek from Ian in order to determine the cause of his problem?
• Detailed questioning about his diet, fluid intake and activity levels are essential.

• The nature of his constipation should also be explored, including consistency of his stools and frequency of defecation.

• Ask about any changes that have occurred over the years regarding this problem.

• Ask about any associated symptoms.

• Question his family’s medical history.

• Ask about Ian’s medical, surgical and treatment history (check for history of recurrent abdominal pain in childhood).

2. What are some of the more likely causes of his problem?
• Lack of fibre in his diet.

• Lack of fluid in his diet.

• Lack of physical activity.

• Inappropriate levels of dietary fats in his diet.

• Rarer causes include congenital conditions such as Hirschsprung’s disease.

3. For each of your answers in question 2, explain how each can result in constipation.
• A low fibre diet causes the stools to be smaller than normal, resulting in a diminished stimulus of the bowel wall.

• A low fluid intake causes the stools to be harder in consistency, thus making defecation more difficult.

• A lack of exercise decreases motility of the bowel.

• The role of dietary fats in the development of constipation is unclear, but it seems that either an excess of, or an insufficiency of, certain fats in the diet can cause constipation in some individuals.

• Hirschsprung’s disease causes constipation due to absence of parasympathetic ganglia in the bowel wall, causing lack of peristalsis.


Case 25.3



1. What is your differential diagnosis, based only on this information?

The episode 6 months ago was probably an episode of gastroenteritis. Clinical features at that time are typical of gastroenteritis.


The 6 month history of diarrhoea suggests that either the condition has become chronic or there is a new pathology


The type of diarrhoea described (watery and frothy) is characteristic of lactose intolerance.


2. What questions would be pertinent to ask?

The relationship between the ingestion of dairy products to the diarrhoea may help to give further evidence of lactose intolerance being a likely diagnosis. Lactose intolerance may be secondary to an episode of gastroenteritis.


Other areas to question include:


• Relationship to other foods (eg: wheat products).

• Does the diarrhoea alternate with episodes of constipation?

• Is there any mucus or blood?

• Can the diarrhoea occur day and night?

• Is there any abdominal pain? Is it relieved by defecation?

• Is there any weight loss?

• Are there any fevers or night sweats?

• Is there any change in appetite?

• Is there any nausea? Is there any vomiting?

3. Physical examination is normal. What investigations would be relevant?

Lactose tolerance test or the breath hydrogen test.


Other tests will need to be done if these results are inconclusive (eg: stool culture, barium meal and follow through, bowel biopsy etc.).



Case 25.4



1. What is your differential diagnosis?

Joan’s constipation, varicosities, dysmenorrhoea and menorrhagia are all fairly ‘new’ symptoms. This suggests the possibility that they may be related. However, assuming that they are connected, and not isolated occurrences, is a mistake that must be avoided.


• Differential diagnosis 1: if all symptoms are related, the likely diagnosis is the presence of uterine fibromyomas (fibroids).

• Differential diagnosis 2: varicosities are more common in individuals who are constipated, thus these symptoms may be related. As the constipation is not a ‘lifelong’ problem, it is unlikely that lifestyle factors (the most common causes of constipation) are involved. Investigation of her constipation would then be required. Her menstrual symptoms may be unrelated, and due to either excess prostaglandin production or a disorder such as endometriosis or adenomyosis.

2. What investigations should be done to confirm your diagnosis?

A pelvic ultrasound would be the investigation of first choice, as uterine fibroids are a common occurrence in this age group, and should be considered first. Pelvic ultrasound is also useful to detect other disorders of the reproductive organs. If this test does not confirm the presence of any reproductive tract disorder, the patient will need to be assessed to determine the cause of her constipation.


3. Explain the mechanisms by which your diagnosis may be causing her symptoms.

If the diagnosis is uterine fibromyomas:


• dysmenorrhoea: uterus contracts more due to the presence of the mass, plus there may be an increase in vascular congestion

• menorrhagia: there is an increase in surface area of endometrium due to protrusion of fibroids into lumen, thus more endometrium to thicken during cycle, therefore more to shed during menses

• constipation: a fibroid may be causing pressure on rectum

• abdominal bloating: either due to constipation, or the uterus may be very large from the presence of fibroids

• varicosities: the enlarged uterus may place pressure on pelvic veins, resulting in congestion in the lower limb veins and the formation of varicosities.


Case 25.5



1. What is the most likely diagnosis?

Acute pyelonephritis.


2. What investigations should be done to confirm this?

Mid-stream urine: microscopy, culture and sensitivity.


3. What is the usual cause of this disorder?

Ascending infection from the bladder is the most common cause, but haematogenous spread from another source may occur.[2]



Case 25.6



1. Using only this information, list your differential diagnoses for Bridget’s presentation. Justify your answer.


















Possible diagnosis Justification
Irritable bowel syndrome (IBS)
• 2-year history (ie: chronic condition)

• Diarrhoea, mucus and pain

• Relieving and precipitating factors are typical
Crohn’s disease
• 2-year history (ie: chronic condition)

• Diarrhoea, mucus and pain
Ulcerative colitis
• 2-year history (ie: chronic condition)

• Diarrhoea, mucus and pain
Colorectal carcinoma
• Unlikely diagnosis but needs to be considered due to family history. Clinical presentation is atypical for bowel cancer

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Abnormalities in bowel or urination habits

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