Constipation

CONSTIPATION

Being constipated means one’s bowel movements are tough or it happens less often than normal. Almost everyone experiences this at some point in life. Constipation is not usually serious, but one certainly feels much better when the body is back on the right track. The normal times between bowel movements varies widely between individuals. While some may have it once or twice a day others have them just a few times a week. Going longer than 3 or more days without defecating though, is considered too long, because after 3 days, the faeces gets harder and more difficult to pass.

TYPES OF CONSTIPATION

Chronic constipation can be divided into two categories:

Functional (primary) and Secondary.

• Functional constipation can be further divided into normal transit, slow transit, and outlet constipation.
• Secondary constipation is caused by medical conditions or medication use.

NORMAL TRANSIT CONSTIPATION

Normal transit constipation is defined as a perception of constipation on patient self-report; however, stool movement is normal throughout the colon. Other symptoms reported by patients with normal transit constipation include abdominal pain and bloating. Normal transit constipation has been associated with increased psychosocial stress. It usually responds to medical therapy, (e.g. fiber supplementation or laxatives.

SLOW TRANSIT CONSTIPATION

Slow transit constipation is defined as prolonged transit through the colon. This can be confirmed with radiopaque markers that are delayed on a motility study. A prolonged colonic transit time is defined as more than six markers still visible on a plain abdominal radiograph taken 120 hours after ingestion. Typical symptoms of slow transit constipation include an infrequent “call to stool,” bloating, and abdominal discomfort. Patients with this type of constipation tend not to respond to fiber supplementation or laxatives.

OUTLET CONSTIPATION

Outlet constipation, is also known as pelvic floor dysfunction. It is defined as the incoordination of the muscles of the pelvic floor during attempted defecation. This type of constipation is not caused by muscle or neurologic pathology. In patients with outlet constipation, stool is not expelled when it reaches the rectum. Common symptoms include prolonged or excessive straining, soft stools but which are difficult to pass, and discomfort in the rectum. In some cases, patients have required manual aid to evacuate stool from the rectum.

CAUSES

Constipation generally occurs when waste or stool, either moves too slowly through the digestive tract or cannot be eliminated effectively from the rectum. This may make the stool hard and dry. Chronic constipation has many possible causes.

The causes may include:

• Not enough water or fiber in diet - If one does not have enough fluid in their system or has not taken in adequate fluids, dehydration of the GI tract can occur, leading to hardening and difficulty passing the stools
• The overuse of laxatives - Some drugs cause constipation, (e.g. Laxatives if abused can lead to serious dysfunction of bowel motility.
• Changes to diet or activities - A drastic change in diet can lead to short-term discomfort (grinding headaches, leaden sluggishness, embarrassing bloating and constipation).
• Eating disorders - Constipation is one of the well-known physical complications of eating disorders like anorexia nervosa. Contributing to the constipation are an intestinal musculature weakened by starvation.
• Eating lots of dairy products - Dairy is known to be a major culprit of many digestive issues, like leaky gut syndrome, bloating, constipation, diarrhea, and IBS.
• Non activity : The bones may get weaker and lose some of its mineral content. The body’s metabolism may also be affected, and the body may have more trouble breaking down fats and sugars.
• Resisting or ignoring the urge to defecate - Ignoring an urge to have a bowel movement could lead to constipation if the delay is too long.
• Problems with the nerves and muscles in the digestive system - When stress activates responses in the central nervous system, it can affect the digestive system by causing the esophagus to go into spasms. This increases acid levels in the stomach, which results in indigestion.
• Stress - Stress can lead to constipation in several ways. Stress hormones directly influence bowel movements by affecting the body’s processes. When stressed, people are more likely to have a poor diet, drink too little water, and get less exercise
• Antacid that contain calcium or aluminum - Disturbances of the stretching and contractions of the muscles in the gastrointestinal (GI) tract occurs frequently under a high dose antacid regimen. Typical symptoms are diarrhea and constipation.
• Irritable bowel syndrome - IBS is a common disorder that affects the large intestine. Signs and symptoms include cramping, abdominal pain, bloating, gas, and diarrhea or constipation.
• Pregnancy - Constipation occur in pregnant women due to hormones that relax the intestinal muscle and by the pressure of the expanding uterus on the intestines. Relaxation of the intestinal muscle causes food and waste to move slower through the system.
• Colon cancer - The commonest symptom of colorectal cancer is a change of bowel habits. There may be constipation, or perhaps alternating bouts of constipation and diarrhea.
• Blockages in the colon or rectum - may slow or stop stool movement. This may be caused by;
• Narrowing of the colon (bowel stricture)
• Anal fissure (Tiny tears in the skin around the anus)
• Colon cancer
• Rectal cancer
• Bowel obstruction (A blockage in the intestines)
• Other abdominal cancers that presses on the colon
• Rectocele (Rectum bulge through the back wall of the vagina)
• Problems with the nerves around the colon and rectum
• Some neurological problems : These can affect the nerves that cause muscles in the colon and rectum to contract and move stool through the intestines. Causes include:
• Stroke - A stroke occurs when the blood supply to part of the brain is interrupted or reduced. This prevents brain tissue from getting oxygen and nutrients. Brain cells begin to die within minutes.
• Parkinson's disease - A brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination.
• Autonomic neuropathy (Damage to the nerves that control bodily functions) : A group of symptoms that occur when there is damage to the nerves that manage every day body functions.
• Multiple sclerosis - a potentially disabling disease of the brain and spinal cord. The immune system attacks the protective sheath that covers nerve fibers and causes communication problems between the brain and the rest of the body.
• Spinal cord injury - A spinal cord injury is damage to the spinal cord that causes temporary or permanent changes in its function.
• Problems with the pelvic muscles : Pelvic muscles that are involved in bowel movement may cause chronic constipation. The problems may include;
• Anismus - The inability to relax the pelvic muscles to allow for a bowel movement
• Dyssynergia - Pelvic muscles that do not coordinate relaxation and contraction correctly
• Pelvic floor dysfunction - The inability to correctly relax and coordinate the pelvic floor muscles to have a bowel movement.
• Hormone disorders - Hormones work slowly and affect body processes from head to toe. Hormone diseases also occur if the body does not respond to hormones. Diseases and conditions that upset the balance of hormones may lead to constipation, including:
• Pregnancy - also known as gestation, is the time during which one or more offspring develops inside a woman.
• Hypothyroidism (Underactive thyroid) - Hypothyroidism means that the thyroid gland cannot make enough thyroid hormone to keep the body running normally.
• Diabetes - diabetes, is a metabolic disease that causes high blood sugar.
• Hyperparathyroidism (Overactive parathyroid gland) - Hyperparathyroidism is a condition in which one or more of the parathyroid glands become overactive and secrete too much parathyroid hormone.

SYMPTOMS?

An individual may have:

• Hard or small stool - They mean stool is moving through the intestines at a slower pace than normal. While they may be small, these hard lumps of stool are often hard to pass.
• Belly bloating - Bloating is when the belly feels swollen after eating. It is usually caused by excess gas production or disturbances in the movement of the muscles of the digestive system.
• Few bowel movements : Few moments of defecation
• Trouble having a bowel movement (straining to go) : When one strains (struggle) to defecate
• A sense that everything did not come out : One may feel like he/she needs help to empty their bowels, such as pressing on the belly or using a finger to remove stool from their bottom.

WHEN TO SEE A DOCTOR

People should consult a healthcare provider if:

• They have severe pain with bowel movements.
• Their constipation has lasted more than three weeks.
• Constipation is a new problem.
• They see blood in their stool.
• They lose weight unintentionally.
• They have symptoms of outlet dysfunction constipation.

Constipation may be a temporary situation or a sign of a more serious condition. People should see their doctor if they notice changes in bowel pattern.

RISK FACTORS

Factors that may increase the risk of chronic constipation include:

• Eating a low fiber diet
• Being dehydrated
• Being an older adult
• Being a woman
• Engaging in little or no physical activity
• Taking certain medications (e.g. sedatives, opioid pain medications, some antidepressants or medications to lower blood pressure)
• Having a mental health condition (e.g. depression or an eating disorder

DIAGNOSIS

Many people affected by constipation choose to treat themselves by changing their diets, increasing exercise, or using over-the-counter laxatives. However, laxatives must not be used for more than two weeks without consulting with a physician. This is because the body can become dependent on them for colon function.

Patients should talk to their primary care provider if:

• They have had constipation for more than three weeks
• They have blood in their stool
• They have abdominal pain
• They are experiencing pain during bowel movements
• They are losing weight
• They experience sudden changes in bowel movements

Doctors will normally ask questions about symptoms, medical history, and any medications or underlying conditions.

A physical examination may include a rectal exam and blood tests to check blood count, electrolytes, and thyroid function.

In severe cases, additional tests may be required to identify the cause of symptoms. Tests may include the following:

Marker study - Also called a colorectal transit study, it is used to test how food is moving through the colon. For this test, the patient will need to swallow a pill that contains tiny markers that will show up on an X-ray. Abdominal X-rays will be taken over a few days so the doctor can visualize how the food is moving through the colon and how well the intestinal muscles are working.

Anorectal manometry : This test is used to evaluate anal sphincter muscle function. For this, the doctor will insert a thin tube with a balloon tip into the patient’s anus. With the tube is inside, the doctor will proceed to inflate the balloon and slowly pull it out. This test allows them to measure the anal sphincter’s muscle strength and see if the muscles are contracting as it should.

Barium enema X-ray : This type of X-ray is one that is used to examine the colon. The patient will be made to drink a special liquid the night before the test to clean out the bowel. The actual test will involve the insertion of a dye called barium into the rectum, with the help of a lubricated tube. The barium highlights the rectum and colon area, which allows the doctor a better view on an X-ray.

Colonoscopy - Another type of test that doctors use to examine the colon. In this, the doctor will examine the colon using a tube that has a camera and light source (colonoscope) fitted to one end.  A sedative and pain medication is often given, so that one might not even remember the examination and should feel no pain. To prepare for this test, the patient will be on a liquid-only diet for 1 to 3 days, and may have to take a laxative or enema the night before the test to clean out the bowel.

TREATMENT

Self-care

Most cases of mild to moderate constipation can be managed at home. This effort will begin by taking an inventory of one’s diet and drinks, and then make changes.

Some recommendations for the relief of constipation include:

• Drink two to four extra glasses of water a day. Meanwhile avoid caffeine-containing drinks and alcohol, these can cause dehydration.
• Fruits, vegetables whole grains and other high-fiber foods should be added to diets. People should eat fewer high-fat foods, like meat, eggs and cheese.
• Get moving, exercise. There are many ways to get moving and exercise. Keep trying new exercises until something more fun is found.

It might be necessary to take a very mild over-the-counter stool softener or laxative (such as docusate or Milk of Magnesia. There are many laxative choices. The pharmacist or doctor can help in making a choice. Overuse of laxatives can worsen the symptoms, as such laxatives must not be used for more than two weeks.

Medication/supplement review

The doctor will in addition to self-care methods review medications and supplements. Some of these medications can cause constipation. If they do, the doctor may choose between changing the dose, switch to another drug and/or ask for the patient to stop taking the supplement.

Prescription medications

A few prescription drugs are available to treat constipation. These include lubiprostone, prucalopride, plecanatide, lactulose, and linaclotide. The doctor will pick the drug that might work best for based on the results of the tests conducted.

Surgery

Surgery is rarely needed to treat constipation. The doctor may, however, recommend surgery if constipation is caused by a structural problem in the colon. Structural problems may include intestinal obstruction (a blockage in the colon), intestinal stricture (a narrowing in a portion of the intestine), anal fissure (tear in the anus) or rectal prolapse (the collapse of part of the rectum into the vagina). Surgery may also be needed if cancer was found in the colon, rectum or anus

COMPLICATIONS

Complications of chronic constipation include:

• Rectal prolapse (Intestine that protrudes from the anus) : Should one strains too hard to defecate, it can cause a small amount of the rectum to stretch and even protrude from the anus.
• Fecal impaction (Stool that cannot be expelled) - Constipation that persists may cause an accumulation of hardened stool that gets stuck in the intestines.
• Hemorrhoids (Swollen veins in the anus) - Straining to defecate may cause swelling in the veins in and around the anus.
• Anal fissure (Torn skin in the anus) - Large and/or hard stool can cause tiny tears in the anus.

HOME REMEDIES TO RELIEVE CONSTIPATION

Drink more water - Being dehydrated regularly can make an individual become constipated. To prevent this, it becomes imperative to drink enough water and stay hydrated. When one is constipated, he/she could try finding relief by drinking some carbonated (sparkling) water to help rehydrate the body. Certain studies have found sparkling water as more effective than tap water at relieving constipation.  However, more carbonated drinks like sugary soda are a bad choice for health and may make the constipation worse.

Eat more fiber - Especially people who are constipated are often told to increase their fiber intake. Fiber intake is thought to increase the consistency of bowel movements, making them easier to pass. However, it has also been established that increasing fiber intake can actually make the problem worse. Yet another study found that while dietary fiber can increase the frequency of bowel movements, it does not necessarily help with other symptoms of constipation  (e.g. stool consistency, pain, bloating and gas). The type of dietary fiber that one adds to their diet is important.

Generally, dietary fiber falls into two categories;

• Insoluble fibers -. They add bulk to stools and are thought to help them pass more quickly and easily through the digestive system. (They are found in wheat bran, vegetables and whole grains).
• Soluble fibers - They absorb water and form a gel-like paste, which softens stools and improves the consistency. (They can be found in oat bran, barley, nuts, seeds, beans, lentils and peas, as well as some fruits and vegetables). Studies examining the effects of insoluble fiber as treatment for constipation have been inconclusive. To prevent constipation, one should aim at consuming a mix of soluble and insoluble fibers.
• Exercise more - Studies on the effect of exercise on constipation have shown mixed results. In fact, many studies have shown that exercise does not affect the frequency of bowel movements. While many studies have found that exercise does not affect the number of times people defecate, it seems to reduce some symptoms of constipation.
• Drink especially caffeinated coffee - Coffee stimulates the muscles in the human digestive system. For that reason, coffee can increase the urge to go to the bathroom. In fact, according to research, caffeinated coffee can stimulate the gut in the same way that a meal can. Coffee may also contain small amounts of soluble fibers that help prevent constipation by improving the balance of gut bacteria.
• Take Senna (an herbal laxative) - Senna is commonly used to relieve constipation. It is available over-the-counter and can be taken orally or rectally. Senna contains a number of plant compounds called glycosides. This stimulates the nerves in the gut and speed up bowel movements. It is usually considered as a safe laxative for adults to use for short periods. It may not be recommended for people who are pregnant, breastfeeding or have certain health conditions, such as inflammatory bowel disease.

PREVENTION

The same home-based methods that are used to treat constipation can also be used to prevent constipation becoming a chronic problem;

Well-balanced diet with plenty of fiber : Fruits are good sources of fiber, vegetables, and legumes. Fiber and water help the colon pass stool. Most of the fiber in fruits is found in the skins, such as in apples. Fruits with edible seeds, like strawberries, have the most fiber. People with constipation should eat between 18 and 30 grams of fiber every day.

Drink eight 8-ounce glasses of water a day - Liquids that contain caffeine, such as coffee and soft drinks, are dehydrating, there may be the need to stop drinking these products until the bowel habits return to normal. Plain water will suffice.

Exercise regularly : There are many ways to get moving and exercise. Keep trying new exercises until something more fun is found.

Do not wait or hesitate. Patients must move the bowels when they feel the urge.