Constipation

What is Constipation?

Constipation is defined as the difficulty or inability to have a normal bowel movement because the stools are dry and hard. Constipation happens when the contractions of the muscles from the colon muscles are slow or delayed, and there is an excess absorption of fluid that causes the stools to become waterless and hard, causing the movement of the stool from the colon to become very slow. Normal bowel movement is a relative measure that varies from one individual to another; there are people that defecate three times a day while others only three times per week. Constipation is not a disease per se, but it is a common symptom which is regularly related to other diseases. Constipation is often short-term and can be treated. A lot of people experience constipation, but it is more frequent in older women. Children that are having constipation is usually related to changes in their diet, particularly toddlers, when their diet is changed from formula to milk.

What Causes Constipation?

Common causes of constipation are dehydration or less water intake that makes the stool hard and dry. People with irritable bowel syndrome (IBS) often develop constipation. Constipation is frequent in pregnant women due to the change in hormones, compression of the intestine by the enlarged uterus and decrease in physical activity. Elderly people are often more prone to constipation because their metabolism is slow, resulting in less intestinal activity and muscle tone. In general, less fiber intake makes the stools pass through the intestine at a slower pace, which leads to constipation.

There are several other causes for constipation, such as: presence of neurological disease (spinal cord injuries, Parkinson's disease, multiple sclerosis), medications (antacid or medicines that contain calcium or aluminum, iron pills, pain medications, antidepressants), inadequate physical activity, colon and rectum problems, excessive laxative use, systemic disease (lupus, for example), milk or excessive intake of dairy products, traveling which can alter or disrupt regular bowel movements and diet, stress, eating problems, metabolic and endocrine problems (hypothyroidism, diabetes, hypercalcemia) and ignoring the urge to defecate.

Symptoms of Constipation

Symptoms of constipation include:

• Dry and hard stool
• Difficulty defecating
• Nausea and vomiting
• Straining during defecation
• Feeling of incomplete evacuation after defecating
• Abdominal bloating
• Pain in the abdomen and rectum
• Loss of appetite
• Bad breath

Regularly, constipation is not that serious but may lead to certain complications like:

• Rectal prolapse – inner lining of the rectum protrudes through the anus.
• Fecal impaction - cluster of hard stools are accumulated within the intestine which causes difficulty in eliminating  stools through a normal bowel movement.
• Melanosis coli - this is due to excessive and long term use of laxatives.
• Fissures or Hemorrhoids - the sphincter muscles in the anus are stretched out and scarred by a hard stool.

Diagnosis of Constipation

Various tests may be necessary to identify the source of constipation. Initially, the doctor will ask the patient to describe the patterns of bowel movement, the length and severity of symptoms, occurrence of blood in the stool, the texture of the stool and several questions will be made regarding daily living such as dietary habits and physical activity. A complete listing of current medications should be disclosed to the doctor. A complete physical examination will then be performed.

Several other diagnostic procedures may then be applied to determine the exact cause of constipation. These include:

Digital rectal examination – with a gloved finger, the doctor checks the anus and lower part of the rectum for any obstruction or irregularity in the intestinal lining.

Blood test - an increase in the number of white blood cells and a high erythrocyte sedimentation rate are signs of inflammation and infection, which might then guide to a further diagnosis of the causative agent. Also, red blood cell levels are checked to ensure that potential blood loss is not severely impacting the patient.

Stool exam - feces are checked for occult blood, viral and bacterial agents or parasites.

Thyroid test - to assess the level of the thyroid stimulating hormone.

Abdominal computed tomography (CT) scan is used to estimate the chance of an intra-abdominal abscess.

Defecography is performed when the obstruction is situated around the anus. This is done by using an X-ray and inserting a paste that has a similar texture of a stool. The patient is then asked to constrict the anus in order to force out the paste in order to simulate the act of defecating while the X-ray machine will capture images that doctor will check and assess for any anorectal problems.

Colonoscopy examines the entire colon and rectum. A colonoscope (flexible tube with a light and camera attached at the end) is inserted through the anus to view the entire colon. This procedure allows removal of a small tissue in the colon for biopsy if abnormalities are identified.

Sigmoidoscopy is similar to colonoscopy but a smaller tube is used allowing only the lower parts of the colon (sigmoid colon) to be visualized.

Anorectal manometry allows the doctor to assess and evaluate the muscle coordination while passing stool. Anorectal manometry is performed to ensure that the anus and rectum are functioning well. A flexible tube is inserted in the anus and up to the rectum. Attached to the inserted end of the tube is a small balloon that will be inflated.

Barium enema enables a clear observation of the colon, rectum and parts of the intestine to check if there is an obstruction or other abnormality that is causing constipation. A special barium dye is inserted through a tube and images are taken with the use of an X-ray.

Treatment of Constipation

The treatment of constipation will depend on the severity of the condition or the cause of constipation.

Usually, management can be performed with simple behaviors:

• Drinking adequate fluids (at least 8 glasses a day) - to soften the stool.
• Eating foods that are rich in fiber.
• Visit the toilet regularly and don't ignore the urge to defecate.
• Regular physical activity to help stimulate intestinal function.

There are several medications that might be used to manage constipation:

5-HT-4 agonists will decrease the time that feces spends in the colon and increase fluid secretion.

Opioid antagoniststo treat opioid-induced constipation.

Laxatives include:

Osmotic laxatives (sorbitol and lactulose, for example) that stimulate movement or permanence of liquid into the colon.

Chloride channel activators (ubiprostone) that increase the fluid in the intestine, resulting in softer stools.

Bulk laxatives or iber supplements (methylcellulose and psyllium) are considered the safest laxative and are taken with water.

Stimulant laxatives (bisacodyl, castor oil, cascara sagrada, etc.) promote contraction of the intestinal muscles that propel the stool.

Saline laxatives (magnesium salts) stimulate absorption of fluids into the colon, allowing stools to pass easily.

Stool softeners (docusate) to soften the stool are often recommended after surgery and childbirth.

Lubricant laxatives (mineral oil) allow easier defecation by making the stool greasy.

Surgery is recommended when there are serious complications from constipation or there are other underlying conditions leading to constipation, such as hemorrhoids or anal fissures.

Alternative Treatment

There are unconventional treatments that can help relieve constipation or its symptoms like homeopathic remedies that use naturally occurring laxatives made from plants. Sulfur is used for difficult and painful defecation and a herbal remedy called bryonia is recommended for stools that are hard. Acupuncture is thought to aid in relieving pain and stimulating the colon. On the other hand, a body massage that helps the body to relax, can aid in having a bowel movement.

Prognosis of Constipation

Many people with constipation recover well since most of the causes are not related to a serious disease. It is usually related to people's dietary and lifestyle habits, a condition that can be treated with behavioral changes, over-the-counter medication or natural remedies. However, for people who had complications or the cause of constipation is due to certain diseases, the recovery of the person will depend on the origin of the problem.

Preventing Constipation

Eating a healthy and balanced diet that includes vegetables, beans, fruits, oatmeal, cereals and whole-grains.

• Exercise at least 20 minutes per day
• Have regular bowel habits
• Drink about 8 glasses of water per day
• Avoid drinks that promote dehydration such as coffee, sodas and alcoholic beverages
• Avoid medications that can cause constipation
• Do not hold your bowel for a long period of time
• Use laxatives properly
• Avoid stress

Living with Constipation

People who frequently experience constipation should change their diets and have a healthy lifestyle. They should go to a doctor for a check up to be familiar with the causes of constipation and ask for ways to facilitate a normal bowel movement and relieve the symptoms of constipation.

You should seek medical treatment or advice if you notice:

• There is severe pain during defecation
• Blood in the stool
• Thin, pencil-like stools
• Constipation lasts more than two weeks
• First time you experience constipation
• Unexplained weight loss

Current Research of Constipation

There are researchers, supported by the Division of Digestive Diseases and Nutrition at the National Institute of Diabetes and Digestive and Kidney Diseases, conducting a clinical investigation about gastrointestinal conditions. They are trying to understand the motility of the rectoanal and its physiological and anatomical distinctiveness. They are trying to generate new behavioral techniques and medications that can help treat constipation such as biofeedback.