Constipation Causes, Symptoms & Tratment

Figure 1

Many people think they are constipated when, in fact, their bowel movements are regular. For example, some people believe they are constipated, or irregular, if they do not have a bowel movement every day. However, there is no right number of daily or weekly bowel movements. Normal may be three times a day or three times a week depending on the person. In addition, some people naturally have firmer stools than others.

At one time or another almost everyone gets constipated. Poor diet and lack of exercise are usually the causes. In most cases, constipation is temporary and not serious. Understanding causes, prevention, and treatment will help most people find relief.

Constipation is the most common gastrointestinal complaint in the United States, resulting in about 2 million annual visits to the doctor. However, most people treat themselves without seeking medical help, as is evident from the $725 million Americans spend on laxatives each year.

The hard and dry stools of constipation occur when the colon absorbs too much water. This happens because the colon's muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly. Figure 2 lists the most common causes of constipation.

Figure 2

Common Constipation Causes Not enough fiber in diet Not enough liquids Lack of exercise Medications Irritable bowel syndrome Changes in life or routine such as pregnancy, older age, and travel Abuse of laxatives Ignoring the urge to have a bowel movement Specific diseases such as multiple sclerosis and lupus Problems with the colon and rectum Problems with intestinal function (Chronic idiopathic constipation).

Diet

Fiber--soluble and insoluble--is the part of fruits, vegetables, and grains that the body cannot digest. Soluble fiber dissolves easily in water and takes on a soft, gel-like texture in the intestines. Insoluble fiber passes almost unchanged through the intestines. The bulk and soft texture of fiber help prevent hard, dry stools that are difficult to pass.

On average, Americans eat about 5 to 20 grams of fiber daily, short of the 20 to 35 grams recommended by the American Dietetic Association. Both children and adults eat too many refined and processed foods in which the natural fiber is removed.

A low-fiber diet also plays a key role in constipation among older adults. They often lack interest in eating and may choose fast foods low in fiber. In addition, loss of teeth may force older people to eat soft foods that are processed and low in fiber.

Not Enough Liquids

Lack of Exercise

Medications

Irritable Bowel Syndrome (IBS)

Changes in Life or Routine

Abuse of Laxatives

Laxatives usually are not necessary and can be habit-forming. The colon begins to rely on laxatives to bring on bowel movements. Over time, laxatives can damage nerve cells in the colon and interfere with the colon's natural ability to contract. For the same reason, regular use of enemas can also lead to a loss of normal bowel function.

Ignoring the Urge to Have a Bowel Movement

Specific Diseases

Figure 3

Constipation Causes - Diseases Neurological disorders that may cause constipation include: Multiple sclerosis Parkinson's disease Chronic idiopathic intestinal pseudo-obstruction Stroke Spinal cord injuries. Metabolic and endocrine conditions include: Diabetes Underactive or overactive thyroid gland Uremia. Systemic disorders include: Amyloidosis Lupus Scleroderma.

Problems with the Colon and Rectum

Problems with Intestinal Function (Chronic Idiopathic Constipation)

Colonic inertia and delayed transit are two types of functional constipation caused by decreased muscle activity in the colon. These syndromes may affect the entire colon or may be confined to the left or lower (sigmoid) colon.

Functional constipation that stems from abnormalities in the structure of the anus and rectum is known as anorectal dysfunction, or anismus. These abnormalities result in an inability to relax the rectal and anal muscles that allow stool to exit.

Medical History

Physical Examination

Extensive testing usually is reserved for people with severe symptoms, for those with sudden changes in number and consistency of bowel movements or blood in the stool, and for older adults. Because of an increased risk of colorectal cancer in older adults, the doctor may use these tests to rule out a diagnosis of cancer:

• Barium enema x-ray
• Sigmoidoscopy or colonoscopy
• Colorectal transit study
• Anorectal function tests.

Barium Enema X-Ray

The night before the test, bowel cleansing, also called bowel prep, is necessary to clear the lower digestive tract. The patient drinks 8 ounces of a special liquid every 15 minutes for about 4 hours. This liquid flushes out the bowel. A clean bowel is important, because even a small amount of stool in the colon can hide details and result in an inaccurate exam.

Because the colon does not show up well on an x-ray, the doctor fills the organs with a barium enema, a chalky liquid to make the area visible. Once the mixture coats the organs, x-rays are taken that reveal their shape and condition. The patient may feel some abdominal cramping when the barium fills the colon, but usually feels little discomfort after the procedure. Stools may be a whitish color for a few days after the exam.

Sigmoidoscopy or Colonoscopy

The night before a sigmoidoscopy, the patient usually has a liquid dinner and takes an enema in the early morning. A light breakfast and a cleansing enema an hour before the test may also be necessary.

To perform a sigmoidoscopy, the doctor uses a long, flexible tube with a light on the end called a sigmoidoscope to view the rectum and lower colon. First, the doctor examines the rectum with a gloved, lubricated finger. Then, the sigmoidoscope is inserted through the anus into the rectum and lower colon. The procedure may cause a mild sensation of wanting to move the bowels and abdominal pressure. Sometimes the doctor fills the organs with air to get a better view. The air may cause mild cramping.

To perform a colonoscopy, the doctor uses a flexible tube with a light on the end called a colonoscope to view the entire colon. This tube is longer than a sigmoidoscope. The same bowel cleansing used for the barium x-ray is needed to clear the bowel of waste. The patient is lightly sedated before the exam. During the exam, the patient lies on his or her side and the doctor inserts the tube through the anus and rectum into the colon. If an abnormality is seen, the doctor can use the colonoscope to remove a small piece of tissue for examination (biopsy). The patient may feel gassy and bloated after the procedure.

Colorectal Transit Study

Anorectal Function Tests

Defecography is an x-ray of the anorectal area that evaluates completeness of stool elimination, identifies anorectal abnormalities, and evaluates rectal muscle contractions and relaxation. During the exam, the doctor fills the rectum with a soft paste that is the same consistency as stool. The patient sits on a toilet positioned inside an x-ray machine and then relaxes and squeezes the anus and expels the solution. The doctor studies the x-rays for anorectal problems that occurred while the patient emptied the paste.

Treating Constipation

Diet

Lifestyle Changes

Laxatives

A doctor should determine when a patient needs a laxative and which form is best. Laxatives taken by mouth are available in liquid, tablet, gum, powder, and granule forms. They work in various ways:

• Bulk-forming laxatives generally are considered the safest but can interfere with absorption of some medicines. These laxatives, also known as fiber supplements, are taken with water. They absorb water in the intestine and make the stool softer. Brand names include Metamucil^®, Citrucel^®, Konsyl^®, and Serutan^®.

• Stimulants cause rhythmic muscle contractions in the intestines. Brand names include Correctol^®, Dulcolax^®, Purge^®, Feen-A-Mint^®, and Senokot^®. Studies suggest that phenolphthalein, an ingredient in some stimulant laxatives, might increase a person's risk for cancer. The Food and Drug Administration has proposed a ban on all over-the-counter products containing phenolphthalein. Most laxative makers have replaced or plan to replace phenolphthalein with a safer ingredient.

• Stool softeners provide moisture to the stool and prevent dehydration. These laxatives are often recommended after childbirth or surgery. Products include Colace^®, Dialose^®, and Surfak^®.

• Lubricants grease the stool enabling it to move through the intestine more easily. Mineral oil is the most common lubricant.

• Saline laxatives act like a sponge to draw water into the colon for easier passage of stool. Laxatives in this group include Milk of Magnesia^®, Citrate of Magnesia^®, and Haley's M-O^®.

Other Treatment

People with chronic constipation caused by anorectal dysfunction can use biofeedback to retrain the muscles that control release of bowel movements. Biofeedback involves using a sensor to monitor muscle activity that at the same time can be displayed on a computer screen allowing for an accurate assessment of body functions. A health care professional uses this information to help the patient learn how to use these muscles.

Surgical removal of the colon may be an option for people with severe symptoms caused by colonic inertia. However, the benefits of this surgery must be weighed against possible complications, which include abdominal pain and diarrhea.

Sometimes straining causes a small amount of intestinal lining to push out from the anal opening. This condition is known as rectal prolapse and may lead to secretion of mucus from the anus. Usually, eliminating the cause of the prolapse such as straining or coughing is the only treatment necessary. Severe or chronic prolapse requires surgery to strengthen and tighten the anal sphincter muscle or to repair the prolapsed lining.

Constipation may also cause hard stool to pack the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition, called fecal impaction, occurs most often in children and older adults. An impaction can be softened with mineral oil taken by mouth and an enema. After softening the impaction, the doctor may break up and remove part of the hardened stool by inserting one or two fingers in the anus.

1. Constipation affects almost everyone at one time or another.

2. Many people think they are constipated when, in fact, their bowel movements are regular.

3. The most common causes of constipation are poor diet and lack of exercise.

4. Additional causes of constipation include medications, irritable bowel syndrome, abuse of laxatives, and specific diseases.

5. A medical history and physical examination may be the only diagnostic tests needed before the doctor suggests treatment.

6. In most cases, following these simple tips will help relieve symptoms and prevent recurrence of constipation:
   • Eat a well-balanced, high-fiber diet that includes beans, bran, whole grains, fresh fruits, and vegetables.
   • Drink plenty of liquids.
   • Exercise regularly.
   • Set aside time after breakfast or dinner for undisturbed visits to the toilet.
   • Do not ignore the urge to have a bowel movement.
   • Understand that normal bowel habits vary.
   • Whenever a significant or prolonged change in bowel habits occurs, check with a doctor.

7. Most people with mild constipation do not need laxatives. However, doctors may recommend laxatives for a limited time for people with chronic constipation.

Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.

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