Constipation

Constipation - What is Constipation?

Constipation is a condition characterized by inability to pass stools that become hard and more difficult to pass.

Bowel habits are unique to all individuals. For some passing stools once in two or three days may be normal while for others passing stools every day is normal.

Symptoms of constipation

Constipation affects all individuals at any age or at least once in their lifetime. Inability to empty the bowels completely also may lead to constipation.

Constipation can lead to hard, lumpy, large or small stools passage as well. Severity of the condition may vary from person to person.

While constipation may be resolved in a short duration in some individuals, with others it may take longer with pain and discomfort.

Prolonged periods of on and off constipation severely affects the quality of life of individuals.

Causes of constipation

The cause of constipation is difficult to identify but there are several risk factors that raise the likelihood of constipation. Some of the risk factors of constipation include:-

  • Lack or inadequacy of fibres and fluids in diet. Fibres are included in fruit, vegetables and cereals
  • Avoiding or delaying urge to pass stools
  • Certain medications may lead to constipation as a side effect
  • Mental ailments like anxiety disorders and depression
  • Elderly over the age of 55. Older people are five times more likely than younger adults to get constipated. This is due to slow bowel movements, use of multiple medications as well as a relatively sedentary life.
  • Infants and children
  • Pregnant women - Approximately 40% of pregnant women experience constipation during their pregnancy
  • Sedentary life and lack of exercise
  • Recent abdominal or pelvic surgery
  • Terminally ill patients
  • Travelling

Diagnosis and treatment of constipation

Diagnosis of constipation is based mainly on history of the condition. Criteria for constipation are included in the ROME criteria. This includes:-

  • Less than three bowel movements a week
  • Passage of hard stools in more than 25% of bowel motions
  • Sense of incomplete bowel movements in more than 25% of bowel motions
  • Excess straining in more than 25% of bowel motions
  • Necessitating  digital manipulation to facilitate passage of stools

Laxatives are medications that are prescribed to help empty the bowels. Treatment for constipation is effective but it may take weeks before there is a regular bowel pattern.

Prevention of constipation

Prevention of constipation involves making diet and lifestyle changes. This includes eating high-fibre foods, drinking plenty of fluids and regularly exercising.

Good toilet habits and giving time and privacy to pass stools comfortably without ignoring the urge to go to the toilet also helps in preventing constipation.

Constipation Diagnosis

Constipation affects people of all ages at least once in their life time. It is a common condition. Diagnosis usually involves detailed history of the condition from the patient about the signs and symptoms.

Tests and diagnostic procedures are usually not needed for diagnosis of constipation.

Diagnosis of constipation involves:-

Details of bowel habits

Patients should not be embarrassed or shy in describing their normal bowel habits and the changes experienced. Diagnosis is made from the significant change in the bowel habits. Details of ignoring urges to pass stool and inadequacy of time and privacy for passing stools are also asked.

Details of diet and lifestyle habits

The patient is asked to detail the amount of fibres (from fruits and vegetables and whole grains) that they get in their daily diet. Lack of fluids and increased amount of red meats, processed meats and canned foods also leads to increased risk of constipation

Details of medications and laxative use

Several medications may cause constipation as a side effect. Laxative abuse is also an important cause of constipation and needs to be detected while diagnosing constipation.

Constipation criteria

Criteria for constipation are included in the ROME criteria. This includes:-

  • Less than three bowel movements a week
  • Passage of hard stools in more than 25% of bowel motions
  • Sense of incomplete bowel movements in more than 25% of bowel motions
  • Excess straining in more than 25% of bowel motions
  • Necessitating  digital manipulation to facilitate passage of stools

Physical examination

Physical examination involves examination for fecal or stool impaction. Abdomen is examined for abnormalities as well.

Neurological disorders

Neurological disorders or spinal disorders are examined as they may lead to delay in bowel transit time and constipation. Spinal cord injury, multiple sclerosis, Parkinson’s disease etc. has to be ruled out.

Blood tests

Blood tests may be advised to rule out other conditions. If inflammatory bowel disease or bowel cancer is suspected a colonoscopy or sigmoidoscopy is advised.

Psychiatric evaluation

Psychiatric evaluation is made to detect underlying cause of constipation. Previous history of sexual abuse, violence, trauma, fear or unusual attitude towards bowel motions, depression and eating disorders have to be ruled out or detected.

Anorectal function tests

Anorectal function tests may be advised to detect increased muscle tone of the anus sphincter. Tests include Manometry for Hirschsprung’s disease and Electromyography for spastic pelvic floor dysfunction. Rectal mucosa may be taken for biopsy to examine for abnormalities.

Causes of Constipation

The exact cause of constipation is not clear. However, there are several factors that may lead to an increased risk of constipation.

Some of these are irreversible for example age, pregnancy status and post-operative constipation. Some of these, however, are preventable by adopting life style and dietary modifications.

Risk factors for constipation

Causes and risk factors associated with constipation include:-

  • Lack or inadequacy of fibres and fluids in diet. Fibres are included in fruit, vegetables and cereals
  • Avoiding or delaying urge to pass stools. Having limited privacy for passing stools and using a community toilet (in schools, hostels or dormitories etc.) could be a reason for exacerbation of constipation.
  • Certain medications may lead to constipation as a side effect. Some of the medications that may cause constipation as a side effect include aluminium containing antacids, antidepressants, antiepileptics, tranquillizers, opioids like codeine, morphine etc., antipsychotics used in schizophrenia and other mental health conditions, calcium and iron supplements, diuretics etc.
  • Mental ailments like anxiety disorders and depression. Psychiatric problems, such as ones that result from sexual abuse, violence or trauma may also lead to constipation in the short as well as long run. Mental retardation, Down’s syndrome and other congenital conditions that lead to mental retardation are also associated with constipation.
  • Elderly over the age of 55. Older people are five times more likely than younger adults to get constipated. This is due to slow bowel movements, use of multiple medications as well as a relatively sedentary life.
  • Pregnant women - Approximately 40% of pregnant women experience constipation during their pregnancy.
  • Sedentary life and lack of exercise. Regular activity and physical fitness is important for normal bowel motions.
  • Recent abdominal or pelvic surgery
  • Terminally ill patients
  • Being underweight or overweight is also a risk factor for constipation
  • Travelling involves change in dietary habits and this may lead to constipation
  • Abuse of Laxatives is a common cause of recurring constipation
  • Constipation may also result due to gastrointestinal conditions like inflammatory bowel disease, irritable bowel syndrome, colon or rectal cancer and anal fissure.
  • Diabetics, those with high blood calcium levels, underactive thyroid functions, muscular dystrophy, Parkinson’s disease, Alzheimer’s disease, multiple sclerosis or spinal cord injury may also develop constipation

Constipation in infants and children

Constipation is common among infants and young children. Possible causes include lack of fluids in diet, lack of fibres, over feeding, malnutrition etc.

Another problem is inadequate and faulty toilet training. The child should not feel stressed or pressured about using the toilet. Constantly intervening while the child is using the toilet interferes with passing stools and may lead to constipation.

Phobia of toilets and using the toilets also plays a role in childhood constipation. The fear may result from the pain when passing stools. This leads to poor bowel habits when the child ignores the urge to pass stools and withholds the stools for fear of experiencing pain and discomfort. This worsens the condition.

Some disease conditions also lead to constipation among which is Hirschsprung’s disease, anus and rectum deformities at birth and spinal cord abnormalities at birth and cystic fibrosis.

Constipation Treatments

Treatment for constipation is dependent on the cause of constipation, how long the condition has been present and the severity of the symptoms. However, basics of treatment are similar for most cases.

In a large majority of cases it is possible to relieve symptoms through dietary and lifestyle changes alone. Management of constipation involves the following steps and measures.

Lifestyle and dietary changes

Some of the major lifestyle changes advised are those suggested for prevention of constipation. These measures can prevent recurrence of constipation as well. They include:-

  • Including enough fibres in diet - Fibres are available in fruits, vegetables, whole grain rice, whole wheat bread, whole wheat pasta, seeds, nuts, oats, pulses etc. It is recommended that a person needs at least 18 to 30g of fibre a day. Some bulking agents like wheat bran may be added to the diet to increase the bulk of the stools and facilitate passage
  • Including enough fluids in diet - Fluids like water and fruit juices help prevent dehydration and help in softening the stools as well. Certain fluids like caffeine, alcohol and fizzy drinks are not good for bowel motions and excessive coffee or alcohol may precipitate constipation.
  • Being more physically active - Sedentary habits often precipitate constipation. Being active and mobile helps prevent constipation. Ideally around 150 minutes of moderate physical activity is recommended every week
  • Developing good toilet habits - The urge to go to the toilet should not be ignored. When delayed the urge usually passes away and this may raise the risk of constipation.  The best time for passing stools is first thing in the morning or around half an hour after a full meal. The toilet should be used with adequate time and privacy.

Laxatives

These are medications that help pass stools more comfortably. They lead to formation of soft formed stools after a couple of days of use and ease the process of passing stools.

There are three major classes of laxatives. These include:-

Bulk-forming laxatives – These agents increase the bulk of the stools formed and soften them to ease passage. They soften the stools by retaining the fluids within the stools. Softening the stools help in their passage and prevents stool impaction or fecal impaction. Commonly prescribed bulk-forming laxatives include ispaghula husk or psyllium, polycarbophill, methylcellulose and sterculia. These should be taken with plenty of water. These agents take around two to three days to be effective.

Osmotic laxatives – Osmotic laxatives work by drawing the water into the intestines and thus make the stools soft. These are prescribed if the bulk laxatives fail to work. Commonly prescribed osmotic laxatives include lactulose.

Stimulant laxatives – These laxatives are used if the other two agents have failed to cause softening and passage of stools. These agents stimulate the muscles of the gut to contract and expel the feces. The most commonly prescribed stimulant laxatives are senna, bisacodyl and sodium picosulphate. These agents take around 6 to 12 hours to work and should be used on short term basis only. They are also useful for clearing the bowel in patients who are to undergo surgery (especially abdominal surgery) or radiological investigations and imaging of the abdomen.

Treatment of fecal or stool impaction in severe cases

Fecal impaction or stool impaction occurs when stools become hard and dry and get stuck in the rectum. This may lead to severe pain and a lump like sensation.

Initially osmotic laxatives are tried and if there are no results, a stimulant purgative may be added.

If these fail a suppository (capsule containing bisacodyl or glycerol) is inserted into the anus and this helps in softening of the lump and easy passage.

When this fails an enema may be tried to cleanse the rectum. Agents used include docusate and sodium citrate.

Treating infants and children

Infants who are not yet weaned may be given water in between feeds to ease constipation. Gentle movement of the baby’s legs in a bicycle motion also helps the baby pass stools.

Babies who have begun solids may be given plenty of fluids like water or diluted fruit juice to prevent and treat mild constipation. They may be given fibres in diet in the form of fruits like apples, apricots, pears, peaches, grapes, plums, bananas, raspberries, strawberries etc. that are pureed or chopped.

In severe cases osmotic laxatives are prescribed. However, if this does not work, they can be prescribed a stimulant laxative. Bulk forming laxatives are not suitable for babies.

Children with constipation are treated almost similarly as adults with the condition by making lifestyle and dietary changes. In severe cases osmotic laxatives are prescribed. However, if this does not work, they can be prescribed a stimulant laxative. Bulk forming laxatives are not suitable for children.

Good toilet habits and toilet training and removal of fears associated with passing stools is important to prevent constipation in preschoolers.

Treating pregnant and breastfeeding mothers

Pregnant women are at a greater risk of constipation. The first method is to change the diet and lifestyle. Increased fibres and fluids in diet and more physical activity is advised.

If dietary and lifestyle changes do not work, a laxative may be prescribed. Laxatives that are safe to use during pregnancy include the osmotic laxatives lactulose and macrogols. When this fails a small dose of bisacodyl or senna may be prescribed. Senna is not advisable after 27 weeks of pregnancy (third trimester).