Constipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation. Severe constipation includes obstipation (failure to pass stools or gas) and fecal impaction, which can progress to bowel obstruction and become life-threatening.
Constipation is a symptom with many causes. These causes are of two types: obstructed defecation and colonic slow transit (or hypomobility). About 50 percent of people evaluated for constipation at tertiary referral hospitals have obstructed defecation. This type of constipation has mechanical and functional causes. Causes of colonic slow transit constipation include diet, hormonal disorders such as hypothyroidism, side effects of medications, and rarely heavy metal toxicity. Because constipation is a symptom, not a disease, effective treatment of constipation may require first determining the cause. Treatments include changes in dietary habits, laxatives, enemas, biofeedback, and in particular situations surgery may be required.
Constipation is common; in the general population rates of constipation varies from 2-30 percent. In elderly people living in care homes the rate of constipation is 50-75 percent. In the United States expenditures on medications for constipation are greater than US$250 million per year.
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Definition
Constipation is a symptom, not a disease. Most commonly, constipation is thought of as infrequent bowel movements, usually less than 3 stools per week. However, people may have other complaints as well including:
- Straining with bowel movements
- Excessive time needed to pass a bowel movement
- Hard stools
- Pain with bowel movements secondary to straining
- Abdominal pain
- Abdominal bloating.
- the sensation of incomplete bowel evacuation.
The Rome Criteria, discussed in further detail below have also been used to define constipation.
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Causes
The causes of constipation can be divided into congenital, primary, and secondary. The most common cause is primary and not life-threatening. In the elderly, causes include: insufficient dietary fiber intake, inadequate fluid intake, decreased physical activity, side effects of medications, hypothyroidism, and obstruction by colorectal cancer. It can also be divided by the age group affected.
Constipation is a common complaint that can hamper quality of life, but there are a limited number of causes that require urgent medical intervention or result in severe consequences.
Primary
Primary or functional constipation is defined by ongoing symptoms for greater than six months not due to an underlying cause such as medication side effects or an underlying medical condition. It is not associated with abdominal pain, thus distinguishing it from irritable bowel syndrome. It is the most common cause of constipation, and is often multifactorial. In adults, such primary causes include: dietary choices such as insufficient dietary fiber or fluid intake, or behavioral causes such as decreased physical activity.
Diet
Constipation can be caused or exacerbated by a low-fiber diet, low liquid intake, or dieting. Dietary fiber helps to decrease colonic transport time, increases stool bulk but simultaneously softens stool. Therefore, diets low in fiber can lead to primary constipation.
Secondary
Secondary causes include side effects of medications, hypothyroidism, and obstruction by organic causes, such as colorectal cancer.
Medication
Many medications have constipation as a side effect. Some include (but are not limited to) opioids, diuretics, antidepressants, antihistamines, antispasmodics, anticonvulsants, and aluminum antacids. Certain calcium channel blockers such as nifedipine and verapamil can cause severe constipation due to dysfunction of motility in the rectosigmoid colon.
Metabolic and muscular
Metabolic and endocrine problems which may lead to constipation include: hypercalcemia, hypothyroidism, diabetes mellitus, cystic fibrosis, and celiac disease. Constipation is also common in individuals with muscular and myotonic dystrophy.
Structural and functional abnormalities
Constipation has a number of structural (mechanical, morphological, anatomical) causes, including: spinal cord lesions, Parkinsons, colon cancer, anal fissures, proctitis, and pelvic floor dysfunction.
Constipation also has functional (neurological) causes, including anismus, descending perineum syndrome, and Hirschsprung's disease. In infants, Hirschsprung's disease is the most common medical disorder associated with constipation. Anismus occurs in a small minority of persons with chronic constipation or obstructed defecation.
Psychological
Voluntary withholding of the stool is a common cause of constipation. The choice to withhold can be due to factors such as fear of pain, fear of public restrooms, or laziness. When a child holds in the stool a combination of encouragement, fluids, fiber, and laxatives may be useful to overcome the problem.
Diagnosis
The diagnosis is typically made based on a person'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.
Description
Distinguish between acute (days to weeks) or chronic (months to years) onset of constipation because this information changes the differential diagnosis. This in the context of accompanied symptoms help physicians discover the cause of constipation. People often describe their constipation as bowel movements that are difficult to pass, firm stool with lumpy or hard consistency, and excessive straining during bowel movements. Bloating, abdominal distension, and abdominal pain often accompany constipation.
Dietary habits, previous abdominal surgeries, and past medical history may be helpful. Diseases associated with constipation include hypothyroidism, certain types of cancer, and irritable bowel syndrome. Low fiber intake, inadequate amounts of fluids, poor ambulation or immobility, or medications can contribute to constipation.
Separating non-life-threatening from serious causes may be partly based on red flag symptoms. For example, colon cancer may be suspected if a person has a family history of colon cancer, fever, weight loss, and rectal bleeding. Other alarming signs and symptoms include family or personal history of inflammatory bowel disease, age of onset over 50, change in stool caliber, nausea, vomiting, and neurological symptoms like weakness, numbness and difficulty urinating.
Examination
During physical examination, 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. Rectal examination also gives information on the consistency of the stool, the presence of hemorrhoids, admixture of blood and whether any tumors, polyps or abnormalities are present. Physical examination may be done manually by the physician, or by using a colonoscope. X-rays of the abdomen, generally only performed 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 at least three days per month for more than three months) associated with abdominal discomfort is often diagnosed as irritable bowel syndrome (IBS) when no obvious cause is found.
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 normalize 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.
Criteria
The Rome II Criteria for constipation require at least two of the following symptoms for 12 weeks or more over the period of a year:
- Straining with more than one-fourth of defecations
- Hard stool with more than one-fourth of defecations
- Feeling of incomplete evacuation with more than one-fourth of defecations
- Sensation of anorectal obstruction with more than one-fourth of defecations
- Manual maneuvers to facilitate more than one-fourth of defecations
- Fewer than three bowel movements per week
- Insufficient criteria for irritable bowel syndrome
Prevention
Constipation is usually easier to prevent than to treat. Following the relief of constipation, maintenance with adequate exercise, fluid intake, and high-fiber diet is recommended. Children benefit from scheduled toilet breaks, once early in the morning and 30 minutes after meals.
Treatment
The treatment of constipation should focus on the underlying cause if known. The National Institute of Health and Care Excellence (NICE) break constipation in adults into two categories - chronic constipation of unknown cause and constipation due to opiates.
In chronic constipation of unknown cause, the main treatment involves the increased intake of water and fiber (either dietary or as supplements). The routine use of laxatives is discouraged, as having bowel movements may come to be 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.
Laxatives
If laxatives are used, milk of magnesia or polyethylene glycol are recommended as first-line agents due to their low cost and safety. Stimulants should only be used if this is not effective. In cases of chronic constipation, polyethylene glycol appears superior to lactulose. Prokinetics may be used to improve gastrointestinal motility. A number of new agents have shown positive outcomes in chronic constipation; these include prucalopride and lubiprostone.
Physical intervention
Constipation that resists the above measures may require physical intervention such as manual disimpaction (the physical removal of impacted stool using the hands; see fecal impaction). Regular exercise can help improve chronic constipation.
Children
Lactulose and milk of magnesia have been compared with polyethylene glycol (PEG) in children. All had similar side effects, but PEG was more effective at treating constipation. Osmotic laxatives are recommended over stimulant laxatives.
Prognosis
Complications that can arise from constipation include hemorrhoids, anal fissures, rectal prolapse, and fecal impaction. Straining to pass stool may lead to hemorrhoids. In later stages of constipation, the abdomen may become distended, hard and diffusely tender. Severe cases ("fecal impaction" or malignant constipation) may exhibit symptoms of bowel obstruction (vomiting, very tender abdomen) and encopresis, where soft stool from the small intestine bypasses the mass of impacted fecal matter in the colon.
Epidemiology
Constipation is the most common digestive complaint in the United States as per survey data. Depending on the definition employed, it occurs in 2% to 20% of the population. It is more common in women, the elderly and children. Specifically constipation with no known cause affects females more often affected than males. The reasons it occurs more frequently in the elderly is felt to be due to an increasing number of health problems as humans age and decreased physical activity.
- 12% of the population worldwide reports having constipation.
- Chronic constipation accounts for 3% of all visits annually to pediatric outpatient clinics.
- Constipation-related health care costs total $6.9 billion in the US annually.
- More than four million Americans have frequent constipation, accounting for 2.5 million physician visits a year.
- Around $725 million is spent on laxative products each year in America.
Children
Approximately 3% of children have constipation, with girls and boys being equally affected. With constipation accounting for approximately 5% of general pediatrician visits and 25% of pediatric gastroenterologist visits, the symptom carries a significant financial impact upon our healthcare system. While it is difficult to assess an exact age at which constipation most commonly arises, children frequently suffer from constipation in conjunction with life-changes. Examples include: toilet training, starting or transferring to a new school, and changes in diet. Especially in infants, changes in formula or transitioning from breast milk to formula can cause constipation. Fortunately, the majority of constipation cases are not tied to a medical disease, and treatment can be focused on simply relieving the symptoms.
Children have different bowel movement patterns than adults. In addition, there is a wide spectrum of normalcy when considering children's bowel habits. On average, infants have 3-4 bowel movements/day, and toddlers have 2-3 bowel movements per day. At around age 4, children develop an adult-like pattern of bowel movements (1-2 stools/day). The Rome III Criteria for constipation in children helps to define constipation for various age groups.
Rome III criteria
Less than 4 years old: The child must have 2 or more of the following complaints. These complaints must be present for at least 1 month.
- 2 or fewer bowel movements per week
- Passing large bowel movements
- On physical exam, a doctor may find large amounts of feces within the child's rectum.
- A child who is already toilet trained has at least 1 accident per week involving a bowel movement.
- Child demonstrates withholding behavior in which he or she actively tries not to pass a bowel movement.
- Hard stools
- Pain with defecation.
More than 4 years old: The child must have 2 or more of the following complaints. These complaints must be present for at least 2 months
- 2 or fewer bowel movements per week
- Passing large bowel movements
- On physical exam, a doctor may find large amounts of feces within the child's rectum.
- A child who is already toilet trained has at least 1 accident per week involving a bowel movement.
- Child demonstrates withholding behavior in which he or she actively tries not to pass a bowel movement.
- Hard stools
- Pain with defecation.
Postpartum women
The six-week period after pregnancy is called the postpartum stage. During this time, women are at increased risk of being constipated. Constipation can cause discomfort for women, as they are still recovering from the delivery process especially if they have had a perineal tear or underwent a episiotomy. Hemorrhoids are common in pregnancy and also may get exacerbated when constipated. Women sometimes get enemas during labor that can also alter bowel movements in the days after having given birth. However, there is insufficient evidence to make conclusions about the effectiveness and safety of laxatives in this group of people.
Source of the article : Wikipedia
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