suggest myxoedema. Any cause of hypercalcemia, e.g. hyperparathyroidism, and malignancy may cause constipation. The patient may also c/o abdominal pain, vomiting, nocturia, and mental symptoms associated with this condition. A neurolo-gical examination may detect signs of CVA, dementia, Parkinson’s disease, spinal cord disease, or multiple sclerosis
• Past history—A long history of bowel obsession§, abdominal surgery, radiation therapy, may suggest the cause of constipation.
• Physical examination—For weight, nutritio-nal status, thyroid, and abdomen (tender-ness, mass, distended bowel loops)
• PR—It is an important procedure because about one-forth of cancers are within reach of the examining finger. Lesions such as hemorrhoids, fissure, ulcer, impaction, growth, fecal occult blood are obvious
• Anal wink— Sensation of the perianal area and the ‘anal wink’ (a reflex constriction upon pinprick sensation of the perianal area;
mediated by S2, S3, S4) reflex should be tested in spinal cord disease or lumbosacral roots
• Constipation from infancy may be due to Hirschsprung’s disease. Occasionally symp-toms may present for the first time in adult life
• Lifelong constipation (severe refractory constipation) is sometimes due to megacolon.
RED FLAGS
• Alarm symptoms and signs in patients with constipation include:
Persistent anemia
Positive FOBT
Hematochezia
Significant weight loss
Therapy resistant constipation
New onset constipation in elderly without obvious cause
Family history of IBD
Family history of colon cancer.
• Intermittent colicky abdominal pain with distension and progressive constipation or obstipation is an urgent indication to evaluate the cause of intestinal obstruction
• Sexual abuse is a known cause of chronic constipation and needs to be excluded in patients especially with psychosexual problems.
SELECTIVE GLOSSARY
Hirschsprung’s disease (Congenital Mega-colon)—Abnormally large or dilated colon due to congenital absence of myenteric ganglion cells in a distal segment of the large bowel, and resultant loss of motor function in this segment causes massive hypertrophic dilatation of the normal proximal colon, appears soon after birth, is called “Hirschsprung’s disease”. Signs and symptoms (abdominal distension, vomiting, constipation, etc.), may vary with the severity of the condition. Sometimes they appear after birth; other times they may not be apparent until the child becomes a teenager or adult.
Pelvic floor dysfunction (PFD)—The pelvic floor muscles support the pelvic organs, bladder and rectum, and their function is critical to activities such as urinating, having bowel movements, and sexual intercourse. PFD has traditionally been described as resulting from laxity or poor tone of the pelvic floor musculature and/or ligaments. Damage of this nature usually results from aging, straining, or trauma, resulting in complaints such as poor urine stream, consti-pation, low back pain, pain with ejaculation or
§The older generation considers defecation every day a sign of good health.
Diagnosis: A Symptom-based Approach in Internal Medicine 62
vaginal penetration, pelvic pain or pressure, or urinary frequency and urgency.
REFERENCES
1. Camilleri M, et al. Clinical management of intrac-table constipation. Ann Intern Med 1994;
121(7):520-8. Full Text [PMID: 8067650: Abstract].
2. Herz MJ, et al. Constipation: A different entity for patients and doctors. Fam Pract. 1996;13(2):156-9. [PMID: 8732327: Free full text].
3. Chang L, et al. Gender, age, society, culture, and the patient’s perspective in the functional gastro-intestinal disorders.Gastroenterology. 2006;
130(5):1435-46. [PMID: 16678557: Abstract].
4. Ashraf W, et al. An examination of the reliability of reported stool frequency in the diagnosis of idiopathic constipation. Am J Gastroenterol 1996;
91(1):26-32. [PMID: 8561138: Abstract].
5. Marshall JB. Chronic constipation in adults. How far should evaluation and treatment go? Postgrad Med 1990;88(3):49-51,54,57-9,63. [PMID:
2169048: Abstract].
6. Locke GR, et al. American Gastroenterological Association Medical Position Statement: Guide-lines on constipation. Gastroenterology 2000;
119(6):1761-6[PMID: 11113098: Abstract].
7. Rantis PC Jr, et al. Chronic constipation—is the work-up worth the cost? Dis Colon Rectum. 1997;
40(3):280-6. [PMID: 9118741: Abstract].
SYNOPSIS
A convulsion is a violent spasm, or a series of involuntary contractions of the voluntary muscles, especially those affecting the face, trunk, or extremities. During convulsions, the person may cry out, fall to the floor unconscious, his or her body shaking rapidly and uncontrollably, drool, or even loose bladder control. Within minutes the attack is over, and the person regains consciousness, but is dazed, confused, and incoherent, or may be exhausted and asleep. This is the image most people have when they describe the symptoms of convulsions to physicians which is typical of tonic-clonic grand mal seizure (Table 10.1).
Table 10.1: Convulsions: common symptoms and signs
• Fits
• Body twitching
• Body spasm
• Head spasm
• Facial spasm
• Limbs jerking
• Loss of consciousness
• Limb paralysis
• Bladder incontinence
• Bowel incontinence
• Tongue bite
• Abnormal behavior
• Sleeping after fits
The term ‘convulsion’* is often used interchangeably with seizure,^ although there are many types of seizures. Seizures are attacks of cerebral origin consisting of sudden and transitory abnormal phenomena of a motor (convulsive jerking), sensory (light flashes, buzzing), autonomic (sweating, enuresis), automatic (abnormal behavior, memory lapse), or psychic nature (hallucinations), resulting from transient abnormal neuronal discharge of the brain, with or without loss of consciousness.
Thus, paroxysmal changes in consciousness, sensation, emotion, or thought processes may all be the manifestations of a seizure disorder without its motor component of convulsions, which are termed as nonepileptic seizures (i.e. NES:
Table 10.2), especially those subclassified as psychogenic origin, i.e. psychogenic nonepileptic seizure (PNES).1
*The special problems posed by children with convulsions are not addressed.
^‘Seizure’ is a sudden act, action, or attack of seizing something (as of disease), especially the physical mani-festations as convulsions; and the clinician should certainly refrain from diagnosing a first seizure as epilepsy.
Convulsions
10
CHAPTER
64
Epilepsy‡ is a symptom complex in which there is a tendency to have repeated (two or more), unprovoked seizures, requiring definitive diagnosis and treatment. Not everyone who has seizures has epilepsy, but everyone who has epilepsy has seizures.
Neither convulsions, seizures, nor epilepsy are a final diagnosis, but are symptom complexes requiring a search for underlying etiologic factors. Further, it is extremely important to differentiate epileptic seizures, including various simple partial seizures, complex partial seizures, typical and atypical absence seizures from NES, because misdiagnosis leads to inappropriate treatment with antiepileptic drugs, leading to toxic side effects, causing additional disability and frustration.
DIFFERENTIAL DIAGNOSIS Common
• Syncope (vasovagal, orthostatic hypoten-sion, cardiac arrhythmia)
• CNS infection (bacterial, TB, viral-HIV, cerebral malaria, cysticercosis)
• Seizures (generalized tonic-clonic, partial-simple, status epilepticus)
• Cerebrovascular accident (TIA, stroke)
• Head injury (early or late)
• Hypoglycemia
• Malignant hypertension (hypertensive encephalopathy)
• Toxemia of pregnancy.
Occasional
• Migraine (complicated)
• Alcoholism/withdrawal (rum fits)
• Metabolic (electrolyte imbalance, hypo-calcemic, DKA, uremia, hepatic encephalo-pathy, cardiac arrest)
• Drug toxicity (aminophylline, theophylline, ephedrine, terbutaline, bupropion, penicillin, insulin, metronidazole, pentazocine, lidocaine)
• Substance abuse (amphetamines, ‘ecstasy’, antidepressants, antipsychotics, cocaine).
Rare
• Pseudoseizure§ (i.e. PNES)
• Infections (tetanus, rabies)
• Brain tumors (primary/secondary)
• Degenerative disorders (dementia, multiple sclerosis)
• Sleep disorders (parasomnias)
• Poisoning (organophosphate insecticides, cyanide, strychnine).
INVESTIGATIONS—GENERAL CBC
• Leukocytosis may suggest CNS infections.
• Erythrocytes may show sickled cells.
• Polycythemia with elevated hematocrit in hypercoagulable states.
Table 10.2: Nonepileptic seizures (NES): Differentiation Two major types of NES are recognized; their differen-tiating features being as follows:
• Psychogenic NESs are symptoms of an underlying psychiatric disorder, without a physiologic basis, e.g. conversion disorder, anxiety disorder, PTSD, psy-chotic disorder, factitious disorder.
• Physiologic NESs are caused by physiologic dys-function, such as cardiac arrhythmias, hypotensive episodes, cerebrovascular disease, complicated mig-raine, parasomnias, tics, and spasms. Such conditions may result in loss of consciousness, with or without associated motor manifestations. A detailed history and appropriate investigations (e.g. Holter moni-toring, noninvasive carotid artery studies, or tilt-table testing) will usually reveal the true diagnosis.
Note: Most of the discussion in this article pertains to psychogenic NESs, i.e. PNES.
‡The word ‘epilepsy’ is derived from the Greek word for
‘attack’, (presently meaning seizure). People once thought that those with epilepsy were being ‘attacked’ by demons or Gods. However, in 400 BC Hippocrates suggested that epilepsy was a disorder of brain.
§ The term nonepileptic seizure is preferred to pseudoseizure, because the former term is nonjudgemental, and describes problem without implying causation.
65
Blood Glucose
• In diabetics and DKA.
Serum Electrolytes
• Hyponatremia, hypokalemia, hypomagne-semia, hypoglycemia, and hypocalcemia can precipitate seizures.
ECG
• To identify cardiac rhythm, detect possible cardiac ischemia, and measure QT-interval.
Prolonged QT syndrome often presents with simple or convulsive syncope.
Neuroimaging
• CT head is indicated in an emergency, e.g.
when seizures are due to head trauma, decreased level of consciousness, or a new neurologic deficit is evident. Otherwise, waiting for a more definitive imaging with MRI (for mass lesion, vascular malformation, stroke, cysticercosis, and multiple sclerosis) should be considered.
Biochemistry Panel
• LFTs, urea, creatinine, and VDRL as indicated.
INVESTIGATIONS—SPECIFIC