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The lower digestive tract.
Who gets constipated?
What causes constipation?
What diagnostic tests are used
for constipation?
How is constipation treated?
Can constipation be serious?
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Constipation is the passage of small amounts of hard, dry bowel
movements, usually fewer than three times a week. People who are constipated
may find it difficult and painful to have a bowel movement. Other symptoms
of constipation include feeling bloated, uncomfortable and sluggish.
Many people think they are constipated when, in fact, their bowel movements
are regular. For example, some people believe they are constipated, or
irregular, if they do not have a bowel movement every day. However, there is
no right number of daily or weekly bowel movements. Normal may be three
times a day or three times a week depending on the person. Also, some people
naturally have firmer stools than others.
At one time or another, almost everyone gets constipated. Poor diet and lack
of exercise are usually the causes. In most cases, constipation is temporary
and not serious. Understanding its causes, prevention, and treatment will
help most people find relief.
It is still a good idea to try to train your bowel to get
rid of stuff every day! You will feel much better that way.
According to a National Health Interview Survey,
about 30 million people in the United States have frequent constipation.
Those reporting constipation most often are women and adults age 65 and
over. Pregnant women may have constipation, and it is a common problem
following childbirth or surgery.
Constipation is one of the most common gastrointestinal complaints. However,
most people treat themselves without seeking medical help, as is evident
from the millions of dollars Americans spend on laxatives each year.
To understand constipation, it helps to know how the colon
(large intestine) works. As food moves through the colon, it absorbs water
while forming waste products, or stool. Muscle contractions in the colon
push the stool toward the rectum. By the time stool reaches the rectum, it
is solid because most of the water has been absorbed.
The hard and dry stools of constipation occur when the colon absorbs too
much water or if the colon's muscle contractions are slow or sluggish,
causing the stool to move through the colon too slowly. Common causes of
constipation are:
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not enough liquids
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lack of exercise
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changes in life or routine such as pregnancy, older age,
and travel
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abuse of laxatives
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ignoring the urge to have a bowel movement
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not enough fiber in the diet
the most common cause of constipation is a diet low in fiber found in
vegetables, fruits, and whole grains and high in fats found in cheese,
eggs, and meats. People who eat plenty of high-fiber foods are less
likely to become constipated.
Fiber--both soluble and insoluble--is the part of fruits, vegetables,
and grains that the body cannot digest. Soluble fiber dissolves easily
in water and takes on a soft, gel-like texture in the intestines.
Insoluble fiber passes through the intestines almost unchanged. The bulk
and soft texture of fiber help prevent hard, dry stools that are
difficult to pass.
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Medications
Some medications can cause constipation. They include:
pain medications (especially narcotics)
antacids that contain aluminum and calcium
blood pressure medications (calcium channel blockers)
antiparkinson drugs
antispasmodics
antidepressants
iron supplements
diuretics
anticonvulsants
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Specific Diseases
Diseases that cause constipation include neurological disorders,
metabolic and endocrine disorders, and systemic conditions that affect
organ systems. These disorders can slow the movement of stool through
the colon, rectum, or anus.
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Several kinds of diseases can cause constipation:
Neurological disorders
multiple sclerosis
Parkinson's disease
chronic idiopathic intestinal pseudo-obstruction
stroke
spinal cord injuries
Metabolic and endocrine conditions
diabetes
underactive or overactive thyroid gland
uremia
hypercalcemia
Systemic disorders
amyloidosis
lupus
scleroderma
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Problems with the Colon and Rectum
Intestinal obstruction, scar tissue (adhesions), diverticulosis, tumors,
colorectal stricture, Hirschsprung's disease, or cancer can compress,
squeeze, or narrow the intestine and rectum and cause constipation.
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Problems with Intestinal Function (Chronic Idiopathic
Constipation)
Some people have chronic constipation that does not respond to standard
treatment. This rare condition, known as idiopathic (of unknown origin)
chronic constipation may be related to problems with intestinal function
such as problems with hormonal control or with nerves and muscles in the
colon, rectum, or anus. Functional constipation occurs in both children
and adults and is most common in women.
Colonic inertia and delayed transit are two types of functional
constipation caused by decreased muscle activity in the colon. These
syndromes may affect the entire colon or may be confined to the lower or
sigmoid colon.
Functional constipation that stems from abnormalities in the structure
of the anus and rectum is known as anorectal dysfunction, or anismus.
These abnormalities result in an inability to relax the rectal and anal
muscles that allow stool to exit.
Most people with constipation do not need extensive testing
and can be treated with changes in diet and exercise. For example, in young
people with mild symptoms, a medical history and physical examination may be
all the health care practitioner needs to suggest successful treatment. The
tests the health care practitioner
performs depend on the duration and severity of the constipation, the
person's age, and whether blood in stools, recent changes in bowel
movements, or weight loss have occurred.
The health care practitioner may ask a patient to describe his or her 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 or exercise will also help the doctor determine the cause
of constipation.
The clinical definition of constipation is any two of the following symptoms
for at least 12 weeks (not necessarily consecutive) in the previous 12
months:
straining during bowel movements
lumpy or hard stool
sensation of incomplete evacuation
sensation of anorectal blockage/obstruction
fewer than three bowel movements per week
Physical Examination
A physical exam may include a rectal exam with a gloved, lubricated finger
to evaluate the tone of the muscle that closes off the anus (anal sphincter)
and to detect tenderness, obstruction, or blood. In some cases, blood and
thyroid tests may be necessary to look for thyroid disease and serum calcium
or to rule out inflammatory, neoplastic, metabolic, and other systemic
disorders.
Extensive testing usually is reserved for people with severe symptoms, for
those with sudden changes in number and consistency of bowel movements or
blood in the stool, and for older adults. Additional tests that may be used
to evaluate constipation include
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colorectal transit study
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anorectal function tests
Because of an increased risk of colorectal cancer in older adults, the
doctor may use tests to rule out a diagnosis of cancer, including
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Colorectal transit study. This test, reserved for those
with chronic constipation, shows how well food moves through the colon.
The patient swallows capsules containing small markers that are visible
on an x ray. The movement of the markers through the colon is monitored
with abdominal x rays taken several times 3 to 7 days after the capsule
is swallowed. The patient follows a high-fiber diet during the course of
this test.
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Anorectal function tests. These tests diagnose
constipation caused by abnormal functioning of the anus or rectum
(anorectal function). Anorectal manometry evaluates anal sphincter
muscle function. For this test, a catheter or air-filled balloon
inserted into the anus is slowly pulled back through the sphincter
muscle to measure muscle tone and contractions.
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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.
During the exam, the doctor fills the rectum with a soft paste that is
the same consistency as stool. The patient sits on a toilet positioned
inside an x ray machine and then relaxes and squeezes the anus to expel
the paste. The doctor studies the x rays for anorectal problems that
occurred as the paste was expelled.
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Barium enema x ray.This exam involves viewing the
rectum, colon, and lower part of the small intestine to locate any
problems. This part of the digestive tract is known as the bowel. This
test may show intestinal obstruction and Hirschsprung's disease, a lack
of nerves within the colon.
The night before the test, bowel cleansing, also called bowel prep, is
necessary to clear the lower digestive tract. The patient drinks a
special liquid to flush out the bowel. A clean bowel is important,
because even a small amount of stool in the colon can hide details and
result in an incomplete exam.
Because the colon does not show up well on x rays, the doctor fills it
with barium, a chalky liquid that makes the area visible. Once the
mixture coats the inside of colon and rectum, x rays are taken that
reveal their shape and condition. The patient may feel some abdominal
cramping when the barium fills the colon, but usually feels little
discomfort after the procedure. Stools may be a whitish color for a few
days after the exam.
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Sigmoidoscopy or colonoscopy. An examination of the
rectum and lower (sigmoid) colon is called a sigmoidoscopy. An
examination of the rectum and entire colon is called a colonoscopy.
The patient usually has a liquid dinner the night before a sigmoidoscopy
and takes an enema early the next morning. A light breakfast and a
cleansing enema an hour before the test may also be necessary.
To perform a sigmoidoscopy, the doctor uses a long, flexible tube with a
light on the end called a sigmoidoscope to view the rectum and lower
colon. First, the doctor examines the rectum with a gloved, lubricated
finger. Then, the sigmoidoscope is inserted through the anus into the
rectum and lower colon. The procedure may cause a mild sensation of
wanting to move the bowels and abdominal pressure. Sometimes the doctor
fills the colon with air to get a better view. The air may cause mild
cramping.
To perform a colonoscopy, the doctor uses a flexible tube with a light
on the end called a colonoscope to view the entire colon. This tube is
longer than a sigmoidoscope. The same bowel cleansing used for the
barium x ray is needed to clear the bowel of waste. The patient is
lightly sedated before the exam. During the exam, the patient lies on
his or her side and the doctor inserts the tube through the anus and
rectum into the colon. If an abnormality is seen, the doctor can use the
colonoscope to remove a small piece of tissue for examination (biopsy).
The patient may feel gassy and bloated after the procedure.
Although treatment depends on the cause, severity, and
duration, in most cases dietary and lifestyle changes will help relieve
symptoms of constipation and help prevent it.
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Diet
A diet with enough fiber (20 to 35 grams each day) helps 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. A high fiber supplement
can also be helpful for busy people. 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.
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Lifestyle Changes
Other changes that can help treat and prevent constipation include
drinking enough water and other liquids such as fruit and vegetable
juices and clear soups, 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.
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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, health care professionals 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, also helps prevent constipation. A
alternative would be oxy-powder as it is
gentle and non-habit forming.
People who are dependent on laxatives need to slowly stop using them. A
health care practitioner can assist in this process. In most people, this restores the
colon's natural ability to contract.
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Other Treatments
Treatment may be directed at a specific cause.
Colonics can be helpful
to re-establish good bowl habits.
A doctor may recommend discontinuing medication or performing surgery to
correct an anorectal problem such as rectal prolapse (try to avoid
surgery at all cost, only if you have exhausted all other alternatives
and you are sure that it is what YOU want)
Can constipation be serious?
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.
Sometimes straining causes a small amount of intestinal lining to push out
from the anal opening. This condition, known as rectal prolapse, may lead to
secretion of mucus from the anus. Usually eliminating the cause of the
prolapse, such as straining or coughing, is the only treatment necessary.
Severe or chronic prolapse requires surgery to strengthen and tighten the
anal sphincter muscle or to repair the prolapsed lining.
Constipation may also cause hard stool to pack the intestine and rectum so
tightly that the normal pushing action of the colon is not enough to expel
the stool. This condition, called fecal impaction, occurs most often in
children and older adults. An impaction can be softened with mineral oil
taken by mouth and by an enema or
a Colonic. After softening the impaction, the doctor
may break up and remove part of the hardened stool by inserting one or two
fingers into the anus.
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