Constipation II

ConstipationDescription:Irregularity of bowels, lack of regular bowel movements.ICD-9-CM: 564.0.A condition in which bowel movements are infrequent or incomplete.Constipation is defined as having a bowel movement fewer than three times per week. With constipation stools are usually hard, dry, small in size, and difficult to eliminate. Some people who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel.Constipation is one of the most common gastrointestinal complaints in the United States. More than 4 million Americans have frequent constipation, accounting for 2.5 million physician visits a year. Those reporting constipation most often are women and adults ages 65 and older. Pregnant women may have constipation, and it is a common problem following childbirth or surgery.Constipation is a symptom, not a disease. Almost everyone experiences constipation at some point in their life, and a poor diet typically is the cause. Most constipation is temporary and not serious. Understanding its causes, prevention, and treatment will help most people find relief.Many of us think "constipation" means stools that are not as soft as usual. This isn't quite true: stool consistency changes all the time, depending on what and when we eat and drink and when and how often we have bowel movements. Strictly speaking, "constipation" refers to infrequent or incomplete bowel movements. We also use the term to refer to stools that are hard or difficult to pass.When we eat, the food we eat is mixed with acids and some enzymes in the stomach (after we grind it up with our teeth), and the mixture -- which is a thin liquid -- passes into the small intestine where it is mixed with other enzymes and with bile (a liquid secreted by the liver, which contains chemicals that also help break down food and also contains waste products that the liver removes from your blood, including breakdown products of old red blood cells, some medicines that you may have taken, and many other things). The enzymes break down the food chemically, and the cells in the mucous membranes on the intestinal walls help absorb the nutrients from the liquid. More water is "sucked" into the liquid on the way through the intestines if it is needed to help with digestion, and the bacteria that normally live in the intestine also help to break the food down. (The bacteria also break down many of the substances that the liver secretes in the bile; this gives stool its characteristic colour and bouquet.) The undigested and indigestible residue passes from the end of the small intestine into the large intestine, or "colon", which stores the residue until you are ready to get rid of it. The colon walls absorb much of the excess water from the residue, leaving only semisolid waste (the stool).The more unabsorbed residue there is, the more water is retained in the stool and the larger the stool is. Many things, such as unabsorbed sugar and certain chemicals, can draw more water into the stool and make it more liquid, and viral or bacterial damage to the mucous membranes of the intestine can cause excess water to enter the stool, causing diarrhea. On the other hand, there are also many things including certain other chemicals that can, so to speak, push water out of the stool, making the stool harder. Also, if the residue is minimal to begin with, chances are that the resulting stool will be much smaller and harder.Stool frequency, like stool consistency, also changes with what and when we eat and drink. Some people have 3-4 bowel movements each day, while others have one bowel movement every 3-4 days. Every 3-4 days may be perfectly normal for the latter, but awfully uncomfortable for other people. In practice, a constipated patient is one who has fewer or harder bowel movements than usual and who is physically uncomfortable because of it. (Note, by the way, that the patient must be physically uncomfortable; whether the child's parents are uncomfortable with the child's stools is not relevant.) People who are very constipated may also develop anal fissures -- cracks in the side of the anus, which may or may not be visible from the outside -- leading to streaks of blood on the surface of the stool but not mixed in with the stool.ConstipationChildren who are "always" constipated present a different problem. Most often these kids have had painful bowel movements due to large, hard stool. Understandably, they are scared of having bowel movements because of the pain, so they withhold their stools. Unfortunately, the longer they withhold the larger and harder the stool gets, and so their next bowel movement hurts even more. (Strangely, many of these kids have slight diarrhea, because the thin liquid coming into the colon from the small intestine is all that can pass the large stool plugging up the plumbing.) The secret to treating this is to break the vicious cycle. My method is to use mineral oil, which is a fairly safe and relatively non-habit forming laxative. We give it in small doses at first, and increase the dose each day until the stool is so soft that the child can't possibly hold on to it -- potentially kind of messy, yes, but you only have to keep the stool that soft until your child has had enough painless bowel movements to be willing to go, after which you can back off gradually on the mineral oil. A newer laxative, which tastes better and has fewer side effects, consists of a large-molecule sugar-like chemical that is not absorbed by the body because of its molecular size and structure, but tends to draw water into the colon, thus softening the stool. There are potential risks to mineral oil and other laxatives, just as there are with any other medicine, and there are other possible approaches to the problem as well, so check with your doctor before trying this out at home.Again, chronic constipation can be the first sign of a more serious bowel problem. Some of the (fortunately rare) causes of chronic constipation include cystic fibrosis, hypothyroidism, lead poisoning, and intestinal aganglionosis, also known as Hirschsprung's disease, in which the nerves that control the bowel-wall muscles do not develop properly. Hirschsprung's is usually diagnosed at or even before birth, but occasionally a person is born with an "ultra-short" section of intestine without nerves (the segment without nerves always includes the part just above the rectum) and may not be diagnosed until their teens or even later. Another possible -- and more common -- cause of constipation is intolerance to cow's milk protein, which can cause constipation even though it usually produces constipation less often than soy milk formulas. If your child is often constipated, she should be seen by her doctor, who may run tests to find out if there is another (and otherwise treatable) cause.Sometimes constipation can lead to complications. These complications include hemorrhoids, caused by straining to have a bowel movement, or anal fissures (tears in the skin around the anus) caused when hard stool stretches the sphincter muscle. As a result, rectal bleeding may occur, appearing as bright red streaks on the surface of the stool.Characteristics of constipation include
  • Bloating.
  • Difficulty during elimination.
  • Sensation of incomplete elimination
  • Stools small in size.
  • Straining during bowel movement.
  • Dry stools.
  • Hard stools.
  • More than 3 days without a bowel movement.
  • Painful bowel movement.
  • Sensation of a full bowel.
Constipation may occur with cramping and pain in the rectum caused by the strain of trying to pass hard, dry stools. You may have some bloating and nausea. You may also have small amounts of bright red blood on the stool or on the toilet tissue, caused by bleeding hemorrhoids or a slight tearing of the anus (anal fissure) as the stool is pushed through the anus. This should stop when the constipation is controlled.Causes and Risk Factors:Some medications can cause constipation, including
  • Pain medications (especially narcotics)
  • Antacids that contain aluminum and calcium
  • Blood pressure medications (calcium channel blockers)
  • Antiparkinson drugs
  • Antispasmodics
  • Antidepressants.
  • Iron supplements.
  • Diuretics.
  • Anticonvulsants.
Two of the most common types of constipation are normal and slow transit (functional) constipation and outlet delay constipation.Lack of fiber is a common cause of functional constipation. Other causes include:
  • Irritable bowel syndrome.
  • Travel or other change in daily routine.
  • Lack of exercise.
  • Immobility caused by illness or aging.
  • Medicine use.
  • Overuse of laxatives.
  • Pregnancy.
Constipation is sometimes a sign of another health problem, such as diabetes, hypothyroidism, or hypercalcemia.Outlet delay constipation: Constipation is sometimes caused by poor muscle tone in the pelvic area (outlet delay). Excessive straining, needing manual pressure on the vaginal wall, or feelings of incomplete emptying may be a symptom of this type of constipation.Outlet delay constipation is caused by.
  • Physical disorders that cause loss of function, such as colon cancer, uterine prolapse or rectal prolapse, scarring (adhesions), or injury caused by physical or sexual abuse.
  • Nervous system diseases, such as Parkinson's disease, multiple sclerosis, or stroke.
  • Spinal cord injury.
  • Pain from hemorrhoids or anal fissures.
  • Delaying bowel movements because of convenience issues or because having a bowel movement causes pain.
Constipation is more common in people older than 65. People in this age group are more likely to have poor dietary habits and increased medicine use. Older adults also often have decreased muscular activity of the intestinal tract, which increases the time it takes for stool to move through the intestines. Physical problems, such as arthritis, may make sitting on the toilet uncomfortable or painful.
  • Constipation is also more common in rural areas, cold climates, and among the poor.
  • Psychological problems, such as severe anxiety, depression, eating disorders, or obsessive-compulsive disorder, also can cause constipation.
  • Women report problems with constipation more often than men.
  • If a stool becomes lodged in the rectum (impacted), mucus and fluid may leak out around the stool, sometimes leading to leakage of fecal material (fecal incontinence). You may experience this as constipation alternating with episodes of diarrhea.
Diagnosis:Doctors perform a complete physical examination in order to identify possible causes of constipation. Most people with constipation do not need extensive testing and can be treated with changes in diet and exercise. However, the tests depend on the duration and severity of the constipation, patient age, and whether blood in stools, recent changes in bowel habits, or weight loss have occurred. It's recommended that you first see your family doctor for constipation, and then you may be referred to a GI specialist, radiologist, or colorectal surgeon if necessary.Clinical definition: The clinical definition of constipation requires that patients exhibit two of the following symptoms for at least 12 weeks (not necessarily consecutive) within the previous 12 months:
  • Fewer than three bowel movements per week.
  • Lumpy or hard stool.
  • Straining during bowel movements.
  • Sensation of incomplete evacuation.
  • Sensation of anal or rectal blockage or obstruction.
Medical history: Your doctor will ask you to constipation, including duration of symptoms, frequency of bowel movements, consistency of stools, presence of blood in the stool, and toilet habits-how often and where one has bowel movements. A record of eating habits, medication, and level of physical activity will also help the doctor determine the cause of constipation.Physical examination: A physical exam may include a digital rectal exam. During a rectal examination, the doctor inserts a gloved, lubricated finger into the anus to evaluate the tone of the muscle that closes off the anus (the sphincter) and to detect tenderness, obstruction, or blood. Depending on the results of the medical history and physical examination, a doctor may recommend a variety of tests help rule out structural or organic causes.Blood and thyroid tests: In some cases, blood and thyroid tests may be necessary to look for thyroid disease and serum calcium or to rule out inflammatory, metabolic, and other disorders.Extensive testing: The doctor may also order one or more tests if a serious problem is suspected as the cause of constipation. Extensive testing usually is reserved for people with severe symptoms, for those with sudden changes in the number and consistency of bowel movements or blood in the stool, and older adults. Doctors also use additional tests to rule out a diagnosis of cancer. Additional tests used to evaluate constipation include:Anorectal function tests - These tests diagnose constipation caused by abnormal functioning of the anus or rectum-also called anorectal function. Generally, the doctor inserts a small balloon into the anus to analyze sphincter muscle function. Anorectal manometry evaluates anal sphincter muscle function. For this test, a catheter or air-filled balloon is inserted into the anus and slowly pulled back through the sphincter muscle to measure muscle tone and contractions. Balloon expulsion tests consist of filling a balloon with varying amounts of water after it has been rectally inserted. Then the patient is asked to expel the balloon. The inability to expel a balloon filled with less than 150 mL of water may indicate a decrease in bowel function. Barium enema x ray - This exam involves viewing the bowel to locate problems (the rectum, colon, and lower part of the small intestine).Colonoscopy - You receive medicine to help you sleep during a colonoscopy. During the exam, you lie on your side, and the doctor inserts the tube through the anus and rectum into the colon. The doctor then views the entire large intestine with a long, flexible tube with a camera attached to the end. If an abnormality is seen, the doctor can use the colonoscope to remove a small piece of tissue for examination (biopsy). You may feel gassy and bloated after this procedure.Colorectal transit study - This test shows how well food moves through the colon. During a colorectal study, you swallow small capsules that can be seen on an x ray as they move through the large intestine and anus. The movement of the markers through the colon is monitored by abdominal x rays taken several times 3 to 7 days after the capsule is swallowed.Sigmoidoscopy - During a sigmoidoscopy, the doctor inserts a thin, flexible tube called a sigmoidoscope into the rectum after light sedation. This scope can show the last third of your large intestine. Doctors usually recommend a liquid dinner the night before a sigmoidoscopy and an enema early the next morning. An enema an hour before the test may also be necessary. The procedure may cause abdominal pressure and a mild sensation of wanting to move the bowels. The doctor may fill the colon with air to get a better view, which can cause mild cramping.Defecography test - 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. The doctor inserts a soft paste into the rectum. The doctor asks you to push out the paste while an x-ray machine takes pictures of the rectum and anus. The doctor then studies the x rays for anorectal problems that occurred as the paste was expelled.Treatment Options:If you're constipated eating more fiber and taking regular exercise is likely to help. You could also try drinking more fluids, although there's less research to show this is beneficial. Here's what we know.
  • Fibre makes stools bulkier and softer. High-fibre foods include bran, root vegetables, nuts, fresh or dried fruit, and whole meal cereals, bread and pasta. In one study, women who ate high-fibre rye bread were much less constipated after three weeks. In another study, women who generally ate more fibre were less likely to be constipated.
  • A small or moderate amount of exercise, such as a daily walk or run, has been shown to help constipation. In some studies, women who took more exercise were less likely to be constipated.
  • Drinking more fluids should make your stools heavier and more slippery. This might make going to the toilet easier. Drinking more fluids while eating more fibre has been shown to work better than just eating more fibre.
If these changes to your lifestyle don't help, then you may need to take some laxatives. You can buy these from a pharmacy without a prescription. But see your doctor if you need to take them for longer than two weeks. The laxative that research shows works best is one called polyethylene glycol (brand names Idrolax and Movicol). Seven in 10 people who had constipation for a long time found that polyethylene glycol helped after they'd taken it for four weeks. It doesn't seem to cause any side effects.Other laxatives that work well are ispaghula husk and lactulose. Ispaghula husk is a fibre supplement that comes as granules or a powder that you mix with water. Some brand names include Fibrelief, Fybogel, Isogel and Regulan. You need to drink plenty of fluids while you're taking ispaghula husk. If you don not, your bowels could get blocked. Also, you shouldn't take this treatment just before going to bed.You usually take lactulose as a liquid or you can mix it with a drink. Some brand names for lactulose are Duphalac, Lactugal and Regulose. You may get bloating, cramping and wind from ispaghula husk and lactulose. There are many different types of laxatives. We can't say if other laxatives work, because there hasn't been enough good research.Most constipation lasts for just a few days. It rarely becomes serious. But occasionally constipation can go on and on. If this isn't treated properly, it can get worse.In most cases dietary and lifestyle changes will help relieve symptoms and help prevent them from recurring.Diet: A diet with enough fiber (20 to 35 grams each day) helps the body form soft, bulky stool. A doctor or dietitian can help plan an appropriate diet. High-fiber foods include beans, whole grains and bran cereals, fresh fruits, and vegetables such as asparagus, Brussels sprouts, cabbage, and carrots. For people prone to constipation, limiting foods that have little or no fiber, such as ice cream, cheese, meat, and processed foods, is also important.Lifestyle Changes: Other changes that may help treat and prevent constipation include drinking enough water and other liquids, such as fruit and vegetable juices and clear soups, so as not to become dehydrated, engaging in daily exercise, and reserving enough time to have a bowel movement. In addition, the urge to have a bowel movement should not be ignored.Laxatives: Most people who are mildly constipated do not need laxatives. However, for those who have made diet and lifestyle changes and are still constipated, a doctor may recommend laxatives or enemas for a limited time. These treatments can help retrain a chronically sluggish bowel. For children, short-term treatment with laxatives, along with retraining to establish regular bowel habits, helps prevent constipation.Other Treatments: Treatment for constipation may be directed at a specific cause. For example, the doctor may recommend discontinuing medication or performing surgery to correct an anorectal problem such as rectal prolapse, a condition in which the lower portion of the colon turns inside out.People with chronic constipation caused by anorectal dysfunction can use biofeedback to retrain the muscles that control bowel movements. Biofeedback involves using a sensor to monitor muscle activity, which is 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 retrain 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.Commonly used constipation medications include
  • Milk of magnesia: contains magnesium hydroxide, an osmotic laxative with a chalky tasting that is not tolerated by all children. It may be helpful to mix with 1-2 teaspoons of Tang or Nestle Quick. Or mix into a milk shake.
  • Mineral Oil: a lubricant that you can mix with orange juice. May cause leakage and staining of underwear.
  • Docusate: available as Colace and Surfak, and is a lubricating laxative. Also available with a stimulant laxative in the combination medicine Peri-Colace.
  • Malt Soup Extract: or Maltsupex, it has an unpleasant odor, but is easily mixed with formula for younger infants.
  • Senokot: a stimulant laxative.
  • Bisacodyl: a stimulant laxative available as Correctol and Dulcolax.
Other medications that are available by prescription include:
  • Lactulose: an osmotic laxative.
  • Miralax: a tasteless, osmotic laxative that contains polyethylene glycol and is usually used for two weeks or less at a time.
Researchers are studying the anatomical and physiological characteristics of rectoanal motility and the use of new medications and behavioral techniques, such as biofeedback, to treat constipation.Note: The following drugs and medications are in some way related to, or used in the treatment. This service should be used as a supplement to, and NOT a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners.DISCLAIMER: This information should not substitute for seeking responsible, professional medical care. 

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