When should I consider referring a patient with constipation for further investigation or specialist input?

When considering referring a patient with constipation for further investigation or specialist input, different criteria apply depending on the patient's age and presenting symptoms.

• For Adults:
  • Consider a suspected cancer pathway referral for colorectal cancer if the patient has a positive quantitative faecal immunochemical test (FIT) and meets specific age and symptom criteria, such as being aged 40 and over with unexplained weight loss and abdominal pain, or aged 50 and over with unexplained rectal bleeding, or aged 60 and over with iron deficiency anaemia or changes in bowel habit, or tests show occult blood in faeces NICE CKS.
  • Also consider a suspected cancer pathway referral if adults have a rectal or abdominal mass, or if they are aged under 50 with rectal bleeding and any unexplained symptoms like abdominal pain, change in bowel habits, weight loss, or iron-deficiency anaemia NICE CKS.
  • Refer if the diagnosis remains uncertain after a primary care assessment, especially if infection and other common causes of acute diarrhoea have been excluded and a chronic cause is suspected NICE CKS.
  • If symptoms do not respond to oral laxatives in primary care, consider a diagnosis of a defecatory disorder and seek specialist advice or arrange referral NICE CKS. Referral is also indicated for persistent or refractory symptoms NICE CKS.
  • If irritable bowel syndrome (IBS) symptoms are present, assess for 'red flag' indicators such as signs and symptoms of cancer or inflammatory markers for inflammatory bowel disease, and refer to secondary care for further investigation if any are present NICE CG61.
• For Children and Young People:
  • If the child is younger than 1 year of age and shows no response to laxatives after 4 weeks, refer urgently to a clinician competent to perform a digital rectal examination to exclude Hirschsprung's disease or other underlying pathology NICE CKS,NICE CG99.
  • If the child is older than 1 year of age and shows no response to laxatives after 3 months, refer to a practitioner with appropriate expertise, such as a paediatrician or specialist nurse-led children's continence service NICE CKS,NICE CG99.
  • An urgent referral is needed if a child has 'red flag' symptoms or signs, as further specialist tests may be required, such as rectal biopsy if Hirschsprung's disease is suspected NICE CKS. Do not perform a digital rectal examination in children or young people older than 1 year with a 'red flag' in the history-taking and/or physical examination that might indicate an underlying disorder; instead, refer them urgently to a healthcare professional competent to perform a digital rectal examination and interpret features of anatomical abnormalities or Hirschsprung's disease NICE CG99.
  • If a child has 'amber flag' symptoms or signs, or ongoing constipation that has not responded to optimal laxative treatment in primary care, specialist referral is needed to consider further tests for underlying conditions, such as coeliac disease and hypothyroidism NICE CKS.
  • Referral to child and adolescent mental health services may be of value if psychological distress relates to the symptoms of constipation or there are family difficulties that maintain or exacerbate constipation NICE CKS.
• In Palliative Care:
  • It is important to attempt to diagnose the cause of constipation, which includes an abdominal and rectal examination (avoiding rectal examination in people receiving chemotherapy) NICE CKS.
  • Exclude bowel obstruction, noting features such as known intra-abdominal tumour, absence of flatus, nausea, vomiting, colicky abdominal pain, abdominal distension, and altered bowel sounds NICE CKS.
  • Consider performing blood tests, including urea and electrolytes, serum calcium, and thyroid function tests, to exclude an underlying treatable condition NICE CKS.