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Constipation

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Constipation

Constipation in a young child as seen by X-ray. Circles represent areas of fecal matter (stool is opaque white surrounded by black bowel gas).
ICD-10	K59.0
ICD-9	564.0
DiseasesDB	3080
MedlinePlus	003125
eMedicine	med/2833
MeSH	D003248

Constipation, costiveness, or irregularity is a condition of the digestive system in which a person (or animal) experiences hard feces that are difficult to expel. This usually happens because the colon has absorbed too much water from the food due to the lack of water-holding capacity of the bowels' contents. If the food moves through the gastro-intestinal tract too slowly, the colon may absorb too much water, resulting in feces that are dry and hard. Defecation is often painful, and in severe cases (fecal impaction) may lead to symptoms of bowel obstruction. The term obstipation describes severe constipation which prevents passage of both stool and gas. Causes of constipation include dietary, hormonal, anatomical, a side effect of medications (e.g., some opiates), poisoning by heavy metals, or an illness or disorder. Treatments may include laxatives, enemas, changes in dietary and exercise habits, and other medical interventions depending on the underlying cause and urgency of needed relief.

Definition

Types 1 and 2 on the Bristol Stool Chart indicate constipation

In common constipation, the stool is hard, difficult, and painful to pass. Usually, there is an infrequent urge to void. Straining to pass stool may cause high intra-rectal pressure leading to hemorrhoids. In later stages of constipation, the abdomen may become distended, hard and diffusely tender and the patient may experience cramps and colicky symptoms, occasionally with enhanced bowel sounds.

The definition of constipation includes the following:

• infrequent bowel movements (typically three times or fewer per week)
• difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools), or
• the sensation of incomplete bowel evacuation.

Severe cases ("fecal impaction" or malignant constipation) may exhibit symptoms of bowel obstruction (vomiting, very tender abdomen) and "paradoxical diarrhea", where soft stool from the small intestine bypasses the mass of impacted fecal matter in the colon.

Children

The majority of infants with constipation do not present any alarming medical disorders. Constipation usually resolves with changes in diet, behavior and use of laxatives. Most home treatments for constipation in children have been shown to work.

After birth, most infants pass 4-5 soft liquid bowel movements (BM) a day. Breast-fed infants usually tend to have more BM compared to formula-fed infants. Some breast-fed infants have a BM after each feed, whereas others have only one BM every 2-3 days. Infants who are breast-fed rarely develop constipation.

The majority of formula-fed infants have fewer BM per day and this also depends on the type of formula. By the age of 2 years, a child will have 1-2 bowel movements per day and by 4 years of age, a child will have one BM per day. An infant who has a BM every 2-3 days is not constipated as long as the stools are soft and pass easily.

Constipation in infants usually occurs at three distinct points: after starting formula or processed foods, during toilet training and soon after starting school.

Causes

There are several reasons why constipation may occur, including poor intake of fluids, leading to dehydration; dysmotility; ignoring the urge to go to the bathroom, eventually resulting in desensitization of bowel; lack of fiber in the diet; sedentary lifestyle both in young and old individuals; irritable bowel syndrome (IBS); pregnancy; aging resulting in a more-inactive intestine; changes in daily life style routine (e.g., frequent long-distance travel); acute illness; increasing use of pain pills, especially opiate- and narcotic-based; abuse of laxatives which often leads to desensitization of the bowels motility; specific medical disorders, such as diabetes, multiple sclerosis, Parkinson's disease, strokes, and/or low thyroid activity; presence of an intestinal mass, tumor or colon cancer; use of such medications as water pills, drugs for treating Parkinson's disease, anti-depressants and anti-hypertensives; tearing in the anal canal and hemorrhoids which may cause spasms of the anal muscles, leading to constipation; injuries to the spinal cord resulting in paralysis, a common cause of constipation in young individuals.

However, in some cases, no one specific cause of constipation may be determined. For elderly individuals, it is important to remember that constipation may be caused by colon cancer. A significant cause of constipation in children is fear of using the toilet. Many older children often ignore the urge to have a bowel movement and later develop a lay bowel (See Encopresis).

Differential diagnosis

The main causes of constipation include:

• Hardening of the feces
  • Insufficient intake of dietary fiber
  • Dehydration from any cause or inadequate fluid intake
  • Medication, e.g., diuretics and those containing iron, calcium, aluminum
• Paralysis or slowed transit, where peristaltic action is diminished or absent, so that feces are not moved along
  • Hypothyroidism (underactive thyroid gland)
  • Hypokalemia
  • Injured anal sphincter (patulous anus)
  • Medications, such as loperamide, opioids (e.g., codeine and morphine) and certain tricyclic antidepressants
  • Severe illness due to other causes
  • Acute porphyria (a rare inherited condition)
  • Lead poisoning
  • Lactose Intolerance
  • Dyschezia (usually the result of suppressing defecation)
• Diverticula
  • Tumors, either of the bowel or surrounding tissues
• Obstructed defecation, due to:
  • Mechanical causes from morphological abnormalities of the anorectum including megarectum, rectal prolapse, rectocele, and enterocele
  • Functional causes from neurological disorders and dysfunction of the pelvic floor muscles or anorectal muscles, including anismus, descending perineum syndrome, and Hirschsprung's disease
  • Retained foreign body or a bezoar
• Psychosomatic constipation, based on anxiety or unfamiliarity with surroundings.
  • Functional constipation
  • Constipation-predominant irritable bowel syndrome, characterized by a combination of constipation and abdominal discomfort and/or pain
• Smoking cessation (nicotine has a laxative effect)
• Abdominal surgery, other types of surgery, childbirth
• Severe dehydration

Children

Constipation occurs in infants for many reasons. Some infants become apprehensive and because of fear that it may be painful, they withhold stools. Sometimes, small children feel shy and do not feel safe or comfortable having a bowel movement.

The most common medical disorder associated with constipation in infants is Hirschsprung's disease. Other medical disorders include abnormal development of the anus, spinal cord dysfunction and use of medications.

• Some causes are with particular respect to infants:
  • Switching from breast milk to bottle feeds, or to solid meals
  • Potty training anxiety
  • Hirschsprung's disease - a condition from birth where the child has a nerve cell defect that affects communication between the brain and bowels

Diagnostic approach

The diagnosis is essentially made from the patient's description of the symptoms. Bowel movements that are difficult to pass, very firm, or made up of small hard pellets (like those excreted by rabbits) qualify as constipation, even if they occur every day. Other symptoms related to constipation can include bloating, distension, abdominal pain, headaches, a feeling of fatigue and nervous exhaustion, or a sense of incomplete emptying.

Inquiring about dietary habits will often reveal a low intake of dietary fiber or inadequate amounts of fluids. Constipation as a result of poor ambulation or immobility should be considered in the elderly. Constipation may arise as a side effect of medications, including antidepressants, which can suppress acetylcholine and opiates, which can slow the movement of food through the intestines. Rarely, other symptoms suggestive of hypothyroidism may be elicited.

During physical examination, scybala (manually palpable lumps of stool) may be detected on palpation of the abdomen. Rectal examination gives an impression of the anal sphincter tone and whether the lower rectum contains any feces or not; if so, then suppositories or enemas may be considered. Otherwise, oral medication may be required. Rectal examination also gives information on the consistency of the stool, presence of hemorrhoids, admixture of blood and whether any tumors, polyps or abnormalities are present.

X-rays of the abdomen, generally only performed on hospitalized patients or if bowel obstruction is suspected, may reveal extensive impacted fecal matter in the colon, and confirm or rule out other causes of similar symptoms.

Chronic constipation (symptoms present for more than 3 months at least 3 days per month) associated with abdominal discomfort is often diagnosed as irritable bowel syndrome (IBS) when no obvious cause is found. Physicians caring for patients with chronic constipation are advised to rule out obvious causes through normal testing.

Colonic propagating pressure wave sequences (PSs) are responsible for discrete movements of the bowel contents and are vital for normal defecation. Deficiencies in PS frequency, amplitude and extent of propagation are all implicated in severe defecatory dysfunction (SDD). Mechanisms that can normalise these aberrant motor patterns may help rectify the problem. Recently the novel therapy of sacral nerve stimulation (SNS) has been utilized for the treatment of severe constipation.

Treatment

Current treatment options include: lifestyle changes (increasing water and dietary fiber intake; daily exercise), bulking agent laxatives (e.g. methylcellulose, psyllium), stool softening laxatives (e.g. docusate), osmotic laxatives (e.g. lactulose, polyethylene glycol), and stimulant laxatives (e.g. senna, bisacodyl). High levels of dissatisfaction have been reported (47%) for laxative medications and over-the-counter remedies, and for the majority (82%) this is due to lack of effectiveness. More recently, new therapies have become available which target the underlying pathophysiology.

The main intervention is to increase the intake of water, and dietary fiber. The latter may be achieved by consuming more vegetables and whole grain bread. The routine use of laxatives is discouraged as this may result in bowel action becoming dependent upon their use. Enemas can be used to provide a form of mechanical stimulation. However, enemas are generally useful only for stool in the rectum, not in the intestinal tract. Exercise has been shown to stimulate bowel motility.

Laxatives

Laxatives may be necessary in people in whom dietary or other interventions are not effective or are inappropriate. Laxatives should be used with caution and only as necessary. The following sequence of laxative use is recommended: bulk forming, then stool softeners, then osmotic, then stimulants, then suppositories, and finally enemas (only as a last resort). The reason for this cautious use is because laxatives can lead to dependence, and like all medications they have side effects. Laxatives should not be used if there are signs and/or symptoms of a bowel obstruction.

The various types of laxatives on the market include lubricants (mineral oil), bisacodyl, stool softeners (Colace), fiber supplements (Metamucil), Osmotics (sorbitol), and saline (milk of magnesia). There are also prescription based laxatives like Amitiza and prucalopride which are used for people with specific disorders. Females who develop constipation during pregnancy should try to eat lots of fiber and whole grains.

Lactulose, a nonabsorbable synthetic sugar that keeps sodium and water inside the intestinal lumen, relieves constipation. It can be used for months together. Among the other safe remedies, fiber supplements, lactitiol, sorbitol, milk of magnesia, lubricants, etc., may be of value. Electrolyte imbalance, e.g., hyponatremia may occur in some cases especially in diabetics.

Prokinetics

In cases of severe chronic constipation prokinetics may be prescribed to improve gastrointestinal motility. Prucalopride is a selective, high affinity 5-HT₄ receptor agonist which targets the impaired motility associated with chronic constipation, thereby restoring normal bowel movements. Three large clinical trials have demonstrated the efficacy and tolerability of prucalopride: 12 weeks of treatment significantly improved bowel habits, constipation symptoms and patient quality of life.

Physical intervention

Constipation that resists all the above measures requires physical intervention. Manual disimpaction (the physical removal of impacted stool using the hands) is done to relieve rectal impactions.

Children

Lactulose and milk of magnesia has been compared to PEG (polyethylene glycol) in children. They had similar side effects but PEG was more effective at treating constipation. Osmotic laxatives are recommended over stimulant laxatives.

Prevention

Constipation is usually easier to prevent than to treat. The relief of constipation with osmotic agents, i.e., lactulose, polyethylene glycol (PEG), or magnesium salts, should immediately be followed with prevention using increased fibre (fruits, vegetables, and grains) and a nightly decreasing dose of osmotic laxative. With continuing narcotic use, for instance, nightly doses of osmotic agents can be given indefinitely (without harm) to cause a daily bowel movement.

Recent controlled studies have questioned the role of physical exercise in the prevention and management of chronic constipation, while exercise is often recommended by published materials on the subject.

Epidemiology

Depending on the definition employed, constipation occurs in 2% of the population; being more common in women, the elderly and children.

Constipation is most common in children and elderly individuals. In children constipation is often found to be associated with several medical problems including altered behavior. In adults constipation can be very distressing and can severely degrade the quality of life. Sometimes constipation in the elderly may be a harbinger of a serious illness like cancer.

The actual number of people who suffer from constipation is not known because millions treat themselves with over the counter laxatives and never see a physician. However, hospital data indicate that at least 14 percent of the USA population is affected by constipation. Nearly 20 million seek active treatment for this disorder on a daily basis. People spend close to $1 billion each year on laxatives and there are about 2.5 millions visits to health care workers each year. Constipation occurs in all races but is most frequent in African Americans and women. Constipation increases with age and the highest rates are found in individuals over the age of 60. Constipation also affects close to 3% of children less than 4 years and about 1 percent of school aged children. In children constipation is more common in boys. Constipation is one of the top reasons why children are seen in pediatric clinics and accounts for the majority of referrals to specialists.

In animals

Hibernating animals can experience tappens that are usually expelled in the spring. For example, bears eat many foods that create a "rectal plug" before hibernation.

Canines may also experience constipation, which they usually attempt to repair by ingesting grass and other plant materials.

References

External links

• 09-129b. at Merck Manual of Diagnosis and Therapy Home Edition
• Constipation - Introduction (UK NHS site)
• MedlinePlus Overview constipation
• Constipation Guideline - the World Gastroenterology Organisation (WGO)
• Relieving Severe Constipation - Constipation symptoms, treatment and prevention of this uncomfortable condition