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Constipation

Introduction

What should I know about Constipation?

Constipation is a common problem in clinical practice. It does not, however, have one consistently used definition. Because of the wide range of normal bowel habits, constipation is difficult to define precisely. Stool frequency is most often used to describe constipation, and has been defined as less than three stools per week. Frequency alone, however, is not sufficient criterion to describe constipation, as patients often complain not only about frequency, but also about stool size or consistency, straining, lower abdominal pain or fullness, and a sense of incomplete evacuation.

While constipation may be caused by numerous reasons, probably the most common reason, particularly in the United States, is due to lack of fiber in the diet. Often, cases are self-treated by the patient without consultation or advice from a health care practitioner. The large dollar volume spent each year on laxatives, advertising attention received, and shelf space allotted in retail stores is evidence that constipation is a common occurrence. Another reason for frequent laxative use may be misconceptions concerning normal bowel habits. Some people believe that if they do not have a daily bowel movement, that it is detrimental to their health because toxins will accumulate.

Constipation is not a disease, but a symptom of some underlying problem. Approaches to treatment of constipation should begin with attempts to determine its cause. Disorders of the GI tract (irritable bowel syndrome or diverticulitis), metabolic disorders (diabetes), or endocrine disorders (hypothyroidism) may be involved. (1)

Constipation is a frequent problem in the elderly, and may be caused by a lack of fiber in the diet or decreased fluid intake. Other factors to consider may include lack of physical activity or diminished abdominal muscle wall strength. However, the frequency of bowel movements is not decreased with normal aging. (2) Abdominal surgery, hospitalization, stress and anxiety, or chronic illnesses that lead to physical or mental impairment and result in physical immobility or inactivity may worsen constipation.

In a person who has a recent onset of constipation, the possibility of some type of obstruction of the colon should be sought. Such an obstruction may be due to a variety of things including diverticular disease, irritable bowel syndrome, foreign bodies, or anal strictures. Hemorrhoids, anal fissures, or ulcerative proctitis may all result in painful defecation and inhibit the desire to evacuate.

Neurologic disorders of the GI tract may also cause constipation. Hirschsprung’s disease, also called aganglionosis, is characterized by a congenital absence of neurons to terminal segments of the bowel. Most cases are diagnosed by six months of age; however, mild cases may not be detected until adulthood. In addition to peripheral neurologic disorders, central nervous system disorders may be responsible for constipation. The CNS plays an important part in GI regulation, rather through reflexes, or coordination of other organs. It also modifies GI function in response to conscious effort or emotional stimuli. In patients with multiple sclerosis, constipation may be associated with dysfunction of other organs. Similarly, CNS lesions caused by Parkinsonism or cerebrovascular accident may cause constipation.

Constipation is a frequent problem during pregnancy, possibly resulting from complex factors that include depressed gut motility, increased fluid absorption from the colon, decreased physical activity, and dietary changes. (3)

Drugs that may lead to constipation include opiates, various agents with anticholinergic properties, such as antidepressants and antipsychotics, antacids containing calcium or aluminum, iron supplements, sucralfate, and calcium channel blockers. Generally, the constipating effects of these drugs are dose related, with larger doses causing constipation more frequently. Opiates have effects on all segments of the bowel, but particularly the colon. The major mechanism of opiate action has been proposed to be prolongation of intestinal transit time by causing spastic, nonpropulsive contractions. (4)

In the large majority of patients with severe constipation, no obvious cause can be identified.

Statistic

National Digestive Diseases Information Clearing House, 1999.

    Prevalence of Constipation: 4.4 million people (1983-87) Mortality: 29 deaths (1982-85) Hospitalizations : 100,000 (1983-87) Physician office visits: 2 million (1985) Prescriptions: 1 million (1985) Disability: 13,000 people (1983-87)

National Health Interview Survey, 1996.

    About 3 million people in the United States have frequent constipation. Those reporting constipation most often are women and adults age 65 and over. Pregnant women also complain of constipation, and it is a common problem following childbirth or surgery. Constipation is the most common gastrointestinal complaint in the United States, resulting in about 2 million annual visits to the doctor. Most people treat themselves without seeking medical help, as is evident from the $725 million Americans spend on laxatives each year.

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

Some, or all, of the symptoms below may be present in a patient complaining of constipation:

    Bowel movements occurring less than three times per week Feeling as if bowel movement was incomplete Feeling of abdominal bloating or fullness
  • Hard stools
  • Excessive straining with bowel movement Stools are small or of insufficient size Difficulty or pain when passing a stool
Constipation may actually be a sign of the presence of another disease or problem. Seek medical attention if the symptoms last for more than three days.

Treatment Options

Conventional

Since constipation may vary from a minor discomfort in an otherwise healthy adult, to a symptom of colon cancer or other serious disease, treatment must be individualized and is highly dependent upon the severity and duration of constipation, as well as the possible contributing factors.

Initial therapy is usually dietary, with an emphasis on increasing daily fiber intake. Although it has not been proven that constipated individuals consume less dietary fiber than non-constipated individuals, it has been shown that most patients respond well to an increase in dietary fiber to between 20 and 30 grams daily. Fiber supplementation is inappropriate for patients with megacolon, megarectum, or colonic obstruction. Dietary sources of fiber include fruits, vegetables, and cereals. Bran is very high in fiber and often added to foods to increase the fiber content.

Medicinal products such as psyllium, methylcellulose, or polycarbophil have properties similar to dietary fiber and may be taken as tablets, powders, or granules.

Other lifestyle changes may be suggested as well. Moderate increases in physical activity, such as walking, are helpful. Increased fluid intake generally helps, although there is little objective evidence of benefit.

Emollient laxatives, such as the docusate salts, result in a softening of the stool within one to three days. Emollients are generally used to prevent, rather than treat constipation, particularly if a patient has a condition where straining should be avoided.

Mineral oil is a lubricant that coats stool to allow easier passage. Mineral oil may be given orally or rectally in a dose of 15-45ml. It softens stool by inhibiting colonic absorption of water, increasing stool weight, and decreasing colon transit time. It has been associated with many more adverse effects than the docusates; however, routine use should be avoided.

Stimulant laxatives, generally have strong effects that forcefully stimulate the bowel to evacuate, and generally produce results between 6-12 hours. The effective dose seems to vary among individuals, with some patients reporting no effect, while others report severe cramping and fluid evacuation when given the same dose. These products are not recommended for daily use. Their use is acceptable intermittently, or for bowel evacuation prior to diagnostic procedure.

One potential problem with stimulant laxatives is that they evacuate the bowel so completely that bowel movements may not occur normally until a few days later. Thus when a patient attempts to defecate on the following day with negative results, they assume they are constipated again and may take another dose of stimulant laxative.

Saline cathartics are composed of relatively poorly absorbed ions such as magnesium, sulfate, phosphate, and citrate, which produce their effects, primarily by osmotic action, to retain fluid in the GI tract. Magnesium has been shown to stimulate the secretion of cholecystokinin, a hormone that causes stimulation of bowel motility and fluid secretion. (5) Such agents may be used occasionally to treat constipation, but should not be used on a routine basis.

Castor oil has a strong purgative action, and works by conversion in the GI tract to ricinoleic acid. It usually results in bowel movements within three hours and is not recommended for routine treatment of constipation.

Glycerin is usually administered as a suppository and exerts its effect by osmotic action in the rectum. Onset is generally less than 30 minutes and is considered safe, although it may occasionally cause rectal irritation.

Tap water enemas may be used to treat simple constipation. The administration of 200ml often results in a bowel movement within one-half hour. Soapsuds are no longer recommended due to the possibility of proctitis or colitis.

Nutritional Suplementation


Lactobacillus acidophilus

Frequently, individuals with either constipation or diarrhea have disordered gastrointestinal bacterial microflora. (6) An important part of normalizing both the functional activity and bowel microflora consists of ingesting large doses of beneficial bacteria such as Lactobacillus acidophilus. Many practitioners suggest that patients consume from 10 to 15 billion cfu (colony forming units) twice daily with meals until normal intestinal activity resumes.


Flaxseed

Flaxseed oil acts as a lubricant in the gastrointestinal tract. Although flaxseed oil is not regarded as a primary therapeutic modality for constipation, its lubricating properties may help facilitate bowel movements. Since the diets of most people are deficient in omega-3 fatty acids, taking one tablespoonful of flaxseed oil daily may help to alleviate constipation and also improve overall health.


Fiber

Constipation is a major complaint of older adults and studies indicate that increasing the intake of dietary fiber can often help patients improve their bowel movement regularity. (7) Chronic constipation is also relatively common in children and a lack of fiber may play an important role in the etiology of chronic idiopathic constipation in children. (8)

Herbal Suplementation


Aloe Vera

Aloe, a genus with over 150 species, is mostly native to East and South Africa. Aloe is a succulent plant that has been used medicinally for centuries. Records of its use date back to 1750 BC. The plant has a variety of uses, including topically in wounds, burns, rashes, and internally as a laxative and cathartic. The mucilaginous gel from the aloe leaf is an effective wound healing agent and is now found in many commercial skin-care products, shampoos, and conditioners. (9) The bitter, yellow latex from the plant contains the bowel stimulant hydroxyanthracene derivatives, used commercially as a laxative.

It has long been recognized that the latex from aloe is an anthranoid stimulant laxative. Studies have reported the effects of aloe as a laxative, with the 1,8-dihydroxyanthracene derivatives (aloe-emodin, aloins). (10)


Cascara Sagrada

Northern California Native Americans introduced this herb, which they called sacred bark, to sixteenth-century Spanish explorers. Being much milder in its laxative action than the herb buckthorn, cascara became popular in Europe as a treatment for constipation and has been part of the U.S. Pharmacopoeia since 1890. (11) Cascara traditionally has been used to treat a sluggish gallbladder, digestive problems, hemorrhoids, skin problems, intestinal parasites, jaundice, and colitis. (12)


Psyllium Seed

An estimated 4 million Americans use psyllium products daily. (13) Psyllium is rich in dietary fiber, which is the most satisfactory prophylactic and treatment for functional constipation. (14) Dietary fiber increases the mass of stools, their water content, and the rate of colonic transit. Psyllium has traditionally been used as a bulk-forming laxative; however, recent research points to other uses including hypercholesterolemia, irritable bowel syndrome, and ulcerative colitis. (15) , (16) In February, 1998, the FDA gave permission to allow food manufactures to make a health claim on the packaging of food products regarding psyllium. The claim reads: “Eating soluble fiber from foods such as psyllium as part of a diet low in saturated fat and cholesterol may reduce the risk of heart disease."

References

  1. Longe RL, DiPiro JT. Diarrhea and Constipation. In: DiPiro JT, et al, eds. Pharmacotherapy, A Pathophysiologic Approach, 4th ed. Stamford, CT: Appleton & Lange; 1999:606-612.
  2. View Abstract: Romero Y, Fleming KC, Phillips SF. Constipation and fecal incontinence in the elderly population. Mayo Clin Proc. 1996;71:81-92.
  3. View Abstract: Clausen MR, Mortensen PB. Lactulose, disaccharides and colonic flora. Clinical consequences. Drugs. 1997;53:930-942.
  4. View Abstract: Sadick NS. Current aspects of bacterial infections of the skin. Dermatol Clin. 1997;15:341-349.
  5. View Abstract: Rodrigues-Fisher L, et al. Dietary fiber nursing intervention: prevention of constipation in older adults. Clin Nurs Res. Nov1993;2(4):464-77.
  6. View Abstract: Dunne C. Adaptation of bacteria to the intestinal niche: probiotics and gut disorder. Inflamm Bowel Dis. May2001;7(2):136-45.
  7. View Abstract: Rodrigues-Fisher L, et al. Dietary fiber nursing intervention: prevention of constipation in older adults. Clin Nurs Res. Nov1993;2(4):464-77.
  8. View Abstract: Roma E, et al. Diet and chronic constipation in children: the role of fiber. J Pediatr Gastroenterol Nutr. Feb1999;28(2):169-74.
  9. Salcido R. Complementary and alternative medicine in wound healing. Adv Wound Care. Nov1999;12(9):438.
  10. View Abstract: Ishii Y, et al. Studies of aloe. III. Mechanism of cathartic effect. (2). Chem Pharm Bull (Tokyo). Jan1990;38(1):197-200.
  11. Leung A, et al. Encylopedia of Common Natural Ingredients Used in Foods, Drugs, and Cosmetics. New York: Wiley-Interscience Publication; 1996:128-130.
  12. Newall CA, et al. Herbal Medicines: A Guide for Health Care Professionals. London: The Pharmaceutical Press; 1996:62.
  13. View Abstract: Freeman GL. Psyllium hypersensitivity. Ann Allergy. Dec1994;73(6):490-2.
  14. View Abstract: Wong PW, et al. How to deal with chronic constipation. A stepwise method of establishing and treating the source of the problem.Postgrad Med. Nov1999;106(6):199-200, 203-4, 207-10.
  15. View Abstract: Tomas-Ridocci M, et al. The efficacy of Plantago ovata as a regulator of intestinal transit. A double-blind study compared to placebo. Rev Esp Enferm Dig. Jul1992;82(1):17-22.
  16. View Abstract: Mac Mahon M, et al. Ispaghula husk in the treatment of hypercholesterolaemia: a double-blind controlled study. J Cardiovasc Risk. Jun1998;5(3):167-72.