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Constipation
Specialty	Gastroenterology

Constipation is a condition of the digestive system where a person (or other animal) experiences hard feces that is difficult to eliminate; it may be extremely painful, and in extreme cases (fecal impaction) lead to symptoms of bowel obstruction. Causes may be dietary, hormonal and anatomical. Treatment is with a change in dietary habits, laxatives, fiber therapy, enemas, and rarely surgery.

Signs and symptoms

In common constipation, the stool is hard and difficult to void. Straining may cause hemorrhoids and anal fissures. The abdomen may become distended and diffusely tender and crampy, occasionally with enhanced bowel sounds.

While many feel that one should have a bowel movement every day, it may be completely normal to defecate once a week as long as this does not cause any other symptoms. This depends on dietary habits, exercise and various other factors.

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

Diagnosis

The diagnosis is essentially made by the patient's description of the symptoms. Enquiring about dietary habits may reveal a low intake of dietary fiber or inadequate amounts of fluids. Constipation as a result of immobility or side effect of other medications should be considered in the elderly. Rarely other symptoms suggestive of hypothyroidism may be elicited.

During physical examination, scybala (manually palpable lumps of stool) may be detected. 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, else medication by mouth will be required. Rectal examination also gives information on the consistency of the stool, presence of hemorrhoids and whether any presence of tumors.

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

Causes

The main causes of constipation include:

• Hardening of the feces
  • Insufficient intake of dietary fiber
  • Dehydration
  • Medication, e.g. diuretics and those containing iron, calcium, aluminium
• Paralysis or slowed transit, where peristaltic action is diminished or absent, so that feces are not moved along
  • Hypothyroidism (slow-acting thyroid gland)
  • Hypokalemia
  • Injured anal sphincter (patulous anus)
  • Medications, such as loperamide, opioids (e.g. codeine & morphine) and certain antidepressants
  • Severe illness due to other causes
  • Acute porphyria (a very rare inherited condition)
• Dyschezia
• Constriction, where part of the intestine or rectum is narrowed or blocked, not allowing feces to pass
  • Strictures
  • Diverticula
  • Tumors, either of the bowel or surrounding tissues
• 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 (Caldarella, 2005)

Treatment

In people without medical problems, the main intervention is the increase of fluids (preferably water) and dietary fiber. The latter may be achieved by consuming more vegetables and fruit, whole meal bread and by adding linseeds to one's diet. The routine non-medical use of laxatives is to be discouraged as this may result in bowel action becoming dependant upon their use.

Laxatives may be necessary in people in whom dietary intervention is not effective or inappropriate. Stimulant laxatives (eg senna) are generally avoided, as they may worsen crampy sensations commonly experienced in constipation. In various conditions (such as the use of codeine or morphine), combinations of hydrating (eg lactulose or glycols), bulk-forming (eg psyllium) and stimulant agents may be necessary. Many of the products are widely available over-the-counter.

Enemas and Clysters are generally reserved for hospitalized patients in whom the constipation has proven to be severe, dangerous in other ways, or resistant to laxatives. Sorbitol, glycerin and arachis oil suppositories are used. Severe cases may require phosphate solutions introduced as enemas.

Irritable Bowel Syndrome constipation can respond to an IBS-specific diet. Having a foundation of high soluble fiber foods and soluble fiber supplements (acacia, methylcellulose), substituting soy or rice products for dairy, being careful with (but not avoiding) fresh fruits and vegetables that are high in insoluble fiber, and eating regular small amounts can all help to lessen the symptoms of IBS (Van Vorous 2000). Foods and beverages to be avoided or minimized include red meat, oily or fatty (and fried) products, dairy (even when there is no lactose intolerance), solid chocolate, coffee (regular and decaffeinated), alcohol, carbonated beverages (especialy those also containing sorbitol) and artificial sweeteners (Van Vorous 2000). Herbal remedies such as enteric coated peppermint oil capsules can also be helpful for IBS-constipation and associated abdominal pain.

Constipation that resists all the above measures requires physical intervention. Manual disimpaction (the physical removal of impacted stool) is done under sedation or a general anesthetic - this avoids pain and loosens the anal sphincter.

In alternative and traditional medicine, colonic irrigation, enemas, exercise, diet and herbs are used to treat constipation.

In art

Screamin' Jay Hawkins wrote and sang "Constipation Blues" while suffering a serious bout. The Bonzo Dog Band recorded "The Strain" on the same subject.

References

• Caldarella, M. Visceral Sensitivity and Symptoms in Patients with Constipation- or Diarrhea-predominant Irritable Bowel Syndrome (IBS). The American Journal of Gastroenterology, Volume 100 Issue 2 Page 383 - February 2005.
• Van Vorous, Heather. Eating for IBS. 2000. ISBN 1569246009. Excerpted with author's permission at Help for Irritable Bowel Syndrome (see IBS Diet Section)

External links

• American Gastroenterological Association
• International Foundation for Functional Gastrointestinal Disorders Inc. - Education and research organization for bowel disorders
• 09-129b. at Merck Manual of Diagnosis and Therapy Home Edition
• MedlinePlus Overview constipation

• General practice
• Gastroenterology