Constipation: When to Consider a Colonoscopy - Gastroenterology and Hepatology

Bowel issues

I have been experiencing constipation issues, having bowel movements every 3 to 5 days.
During college, I had bleeding during bowel movements and consulted a doctor who diagnosed me with anal fissures.
I also had a history of internal hemorrhoids.
Recently, I visited a traditional Chinese medicine practitioner, and my constipation improved to having bowel movements every 1 to 2 days.
However, lately, I often feel that my stools are a bit hard and require some effort to pass, accompanied by a slight tearing pain in the anus.
After bowel movements, I notice bright red blood on the toilet paper, and there is also a small amount of bright red blood at the end of the stool.
The color of my stool is brown, and its shape is mostly normal but occasionally lumpy.
Almost two years ago, I underwent cancer marker screening, and my CEA level was 0.66.
Recently, I occasionally feel the presence of stool at the anal opening, but I do not have an urgent need to use the restroom.
I find that when I sit on the toilet and push, I pass harder stools that stick together in lumps, and the amount is not significant.
I am feeling quite anxious and would like to ask the doctor if I need to undergo a colonoscopy.

S, 20~29 year old female. Ask Date: 2022/03/11

Dr. Chen Shidian reply Gastroenterology and Hepatology

Increase the intake of soft foods, and if necessary, use medication for adjustment; observation may also be employed.

Reply Date: 2022/03/11

More Info

When considering whether to undergo a colonoscopy for constipation, especially in the context of your symptoms and medical history, several factors need to be taken into account. Constipation can be a common issue, but when it is accompanied by symptoms such as rectal bleeding, pain, and changes in bowel habits, it may warrant further investigation.

Understanding Your Symptoms
1. History of Anal Fissures and Hemorrhoids: You mentioned having a history of anal fissures and internal hemorrhoids, which can certainly contribute to discomfort during bowel movements and may explain the presence of fresh red blood on the toilet paper and on the stool. Anal fissures can cause sharp pain during and after bowel movements, leading to a cycle of avoidance that can exacerbate constipation.

2. Changes in Bowel Habits: You noted that your bowel movements have improved from every 3-5 days to 1-2 days, which is a positive change. However, the fact that you are experiencing hard stools and straining indicates that your bowel habits are not yet optimal. The presence of hard stools can lead to further complications, including exacerbation of fissures and hemorrhoids.

3. Rectal Bleeding: The fresh red blood you observe can be alarming. While it is often associated with hemorrhoids or fissures, it is crucial to rule out other potential causes, especially if the bleeding persists or worsens.
4. Concerns About Colorectal Health: Given your previous screening for cancer markers (CEA) was normal, this is reassuring, but it does not completely rule out the possibility of other gastrointestinal issues. The fact that you are experiencing anxiety about your symptoms is also important to address, as stress can further complicate gastrointestinal function.

When to Consider a Colonoscopy
A colonoscopy is typically recommended in the following scenarios:
- Persistent Symptoms: If your constipation persists despite dietary changes, increased fluid intake, and possibly the use of laxatives, a colonoscopy may be warranted to rule out any underlying structural issues or diseases.

- Rectal Bleeding: Since you are experiencing rectal bleeding, especially if it is recurrent, it is advisable to have a colonoscopy to ensure there are no serious conditions such as polyps, diverticular disease, or other pathologies.

- Age and Family History: If you are over the age of 45 or have a family history of colorectal cancer or polyps, screening becomes even more critical.

- Change in Bowel Habits: Any significant change in bowel habits, particularly if accompanied by weight loss, abdominal pain, or other systemic symptoms, should prompt further evaluation.

Conclusion and Recommendations
Given your symptoms of hard stools, rectal bleeding, and the history of anal fissures and hemorrhoids, it would be prudent to discuss the possibility of a colonoscopy with your healthcare provider. They can evaluate your symptoms in the context of your overall health and history, and determine if a colonoscopy is necessary.

In the meantime, consider maintaining a high-fiber diet, staying well-hydrated, and possibly using stool softeners or laxatives as recommended by your doctor to manage your constipation. Addressing your anxiety about these symptoms is also important; consider discussing your concerns with a healthcare professional who can provide support and guidance.

Ultimately, your health and peace of mind are paramount, and taking proactive steps to investigate your symptoms is a wise decision.

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