Constipation

DESCRIPTION

Definition of Constipation

Constipation refers to three or less bowel movements in a week. The stool may be hard, dry, and difficult to pass.

Causes and Risk Factors of Constipation

The risk factors for constipation include:

1. Age -- constipation is more common in older adults

2. Gender -- constipation occurs more frequently in women

3. Low intake of fiber in the diet can cause constipation -- Insoluble fiber cannot be digested by the body and adds bulk to the stools. This eases the passage of fecal material through the digestive tract. Soluble fiber retains water making stools softer.

4. Low intake of fluids (dehydration) will lead to hard stools and difficulty to pass them.

5. Less physical activity -- people who exercise daily are less likely to have constipation.

Other risk factors for constipation include conditions such as:

1. Diabetes mellitus

2. Thyroid disorders (like hypothyroidism)

3. Pregnancy

4. Low levels of potassium (hypokalemia) or high levels of calcium in blood (hypercalcemia)

5. Insufficient production of pituitary hormones

6. Tumor of the adrenal gland

7. Amyloidosis (buildup of amyloid in tissues and organs)

8. Spinal cord injury

9. Stroke

Certain medicines that may cause constipation include:

1. Paracetamol -- if more than seven tablets are taken in a week

2. Nonsteroidal anti-inflammatory drugs (NSAIDs) (for example, ibuprofen)

3. Iron and calcium supplements

4. Aluminum-containing antacids

5. Anticholinergic agents or medicines that oppose the actions of the neurotransmitter acetylcholine. These include drugs for Parkinson’s disease, depression, delusions, hallucinations, and muscular spasms.

6. Anticonvulsants (drugs used to treat seizures) such as carbamazepine, phenobarbital, and phenytoin.

7. Cancer drugs such as vinblastine, vincristine, vindesine, and vinorelbine

8. Calcium-channel blockers such as verapamil

9. Water pills (diuretics) such as furosemide

Signs and Symptoms of Constipation

Symptoms of constipation include:

1. Bloating

2. Hard stools

3. Reduced bowel movement -- less than three times a week.

4. Some people may find it difficult to evacuate stools completely or may need digital evacuation.

Investigations

The diagnosis of constipation depends largely on the patient’s history. The doctor will take:

1. Medical history

2. Dietary history -- intake of fiber and water

3. Symptoms history -- duration and severity

Physical examination of the following may be done:

1. The abdomen may be examined for distension. The enlarged or swollen bowel may point towards constipation.

2. Rectal examination may be done to look for scars, hemorrhoids, fistulas or fissures around the perineum, the area between anus and scrotum (in males) or vulva (in females).

Tests may be done to look for underlying conditions that cause constipation. These may include:

1. Blood tests for hemoglobin, thyroid stimulating hormone (TSH), calcium, and glucose.

2. CT scan or MRI of the colon (large intestine) to check the length and width of the colon or any lesion that may cause obstruction.

3. Barium enema study is an imaging study that uses x-rays along with an enema (containing barium) to detect abnormalities inside the colon. The contrast solution containing barium is injected into the rectum. Barium enema produces better images as compared to other imaging studies.

4. Colonic transit time may be measured to evaluate the time taken by food to travel through the colon.

5. Colonoscopy (endoscopy of the colon) -- a thin tube with a camera at one end is used to view the insides of the colon. It is recommended only in severe cases of constipation when it is accompanied with blood in the stools, fever, or rapid weight loss.

Treatments of Constipation

Treatment for constipation mainly includes lifestyle changes. However, medicines may also be prescribed for softening the stools or stimulating its movement through the colon.

Make the following lifestyle modifications:

1. Increase fiber in diet

2. Increase fluid intake

3. Avoid processed foods or fast

4. Increase physical activity

5. Follow a regular schedule for bowel movements

6. Maintain right posture while defecating

7. Reduce use of over-the-counter (OTC) drugs for constipation

8. Psychological support for depressive disorders

Medicines that may be prescribed to treat constipation include:

1. Emollients or stool softeners such as mineral oil and docusate sodium

2. Osmotic laxatives -- stimulate absorption of water from the body to make stools softer. These include magnesium hydroxide, magnesium sulfate, sodium phosphate, lactulose, or polyethylene glycol.

3. Stimulant laxatives work by stimulating the colon for bowel movements. Examples include castor oil, sodium picosulfate, and bisacodyl.

4. Enemas use a thin tube to inject a liquid or a gas into the rectum to expel its contents. Examples: Phosphate enema, mineral oil retention enema, and soapsuds enema.

5. Suppositories such as those containing glycerin or bisacodyl (dulcolax) are placed into the rectum.

6. Chloride channel activator such as Lubiprostone is used to treat chronic constipation.

Use medicines only if recommended by your doctor.

Biofeedback is used to treat chronic constipation. It involves training of pelvic floor muscles for passing stools by electronic monitoring.

Many natural products that may help in constipation are:

1. Psyllium husk or Isabgol

2. Methylcellulose

3. Calcium polycarbophil

4. Guar gum

5. Flax seeds

Home Remedies for Constipation

Try the following tips to relieve constipation:

1. Have two to three triphala tablets with warm water at bedtime.

2. Mix Isabgol with water and drink it once or twice a day.

3. Drink warm milk every day before going to bed.

4. Squeeze half a lemon into a glass of warm water and add honey or a pinch of salt and drink it every morning.

5. Soak flax seeds in water for 2 hours. Grind and drink a cup of warm milk at bedtime.

Yoga for Constipation

Yoga offers several poses that stimulate peristaltic action and increase blood flow to the gut. Matsyasana (fish pose), anjaneyasana (crescent pose), pavanamuktasana (wind-relieving pose), and balasana (child’s pose) aid in constipation. When done on a regular basis, yoga can help in regular bowel movements.

Complications and When Should You See a Doctor

Chronic constipation may cause:

1. Hemorrhoids -- swollen veins in the rectum and anus

2. Rectal prolapse -- a part of or the entire wall of rectum moves out of its place and protrudes out of the anus

3. Anal fissures -- tear in the anus that causes pain and bleeding

Consult a doctor if you have:

1. Less than three bowel movements in a week

2. Pain while passing stools

3. Rectal bleeding

Prognosis and Prevention

Mild constipation gets better with lifestyle modifications. However, severe constipation may require medications.

You can prevent constipation by:

1. Eating a high fiber diet comprising fruits, vegetables, and whole grains

2. Drinking plenty of water and other liquids

3. Avoiding processed foods made with refined flour

4. Getting enough exercise

References

AJ Lembo. Constipation. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap19.

AKS Rawat, Srivastava S, Ojha SK. Herbal Remedies for Management of Constipation and its Ayurvedic Perspectives. JIMSA: 2012(25).

Schrank KS. Constipation. In: Adams JG, eds. Emergency Medicine. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2013:chap 37.

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