|
 | Frequent straining |
| Hard, lumpy stools |
| Sense of incomplete evacuation |
| Frequent sense of rectal blockage |
| Use of manual procedures to facilitate defecation |
| Less than 3 stools per week. |
Epidemiology
Constipation accounts for 2.5 million physician visits each year.
Americans spend about a billion dollars each year on laxatives alone.
There is of course the additional cost of work-related absences, visits to
the physician office and emergency room, diagnostic tests and the
treatment undertaken. In many cases, fecal impaction is a significant
factor in the removal of senior citizens from their loved ones to nursing
homes.
Who gets it?
Constipation is more common among females. People of all ages can get
this condition; however the prevalence increases in both sexes with aging.
Physician visits for constipation as well as laxative use rise
dramatically after the age of 65 years.
Causes of constipation
No obvious cause can be identified in many patients. Constipation in
such cases is presumed to be due to any number of causes leading to a
sluggish movement of stool through the colon, the rectum or both.
The slowed movement may occur due to a variety of diseases including
diabetes mellitus, Parkinson's disease, multiple sclerosis, thyroid
disease, and scleroderma etc.
It may also occur as a side effect of many medications used for pain
(morphine, Demerol), seizures (phenytoin), Parkinson's disease (Sinemet),
depression (imipramine, desipramine), hypertension and heart disease (diltiazem,
verapamil), indigestion (Tums, sucralfate), anemia (iron), allergies
(antihistamines) and anxiety or psychological concerns (sedatives).
Evaluation
A detailed history with special attention to risk factors is important.
Maintaining a diary to record symptoms and food intake for several weeks
prior to a physician's visit is helpful. An unexplained recent alteration
in bowel habit or presence of anemia is cause for concern and call for
prompt investigation. Initial studies include complete blood counts, serum
chemistries including calcium level, and thyroid function tests.
Structural obstruction is excluded by a barium x-ray and/or endoscopy.
A radioopaque marker study may be performed for patients unresponsive
to conservative treatment. This is undertaken while on high fiber diet and
refraining from laxatives or enemas. This test identifies the part of
colon where the passage of stool is sluggish and helps in planning
management strategies. On the other hand, an x-ray evidence of timely
passage of markers in a patient complaining of infrequent defecation
suggests misconception or misrepresentation.
Barium defecography (x-rays while expelling barium from rectum) and
anorectal manometry (pressures in rectum and anal canal) may be evaluated
in selected cases.
Treatment
Patient education, reassurance, increased fluid intake and exercise
while trying to reduce laxative use help in uncomplicated cases. Initial
response may take several days, whereas resolution of constipation may
take several weeks.
Food intake stimulates the colon. Go to the toilet in the morning
especially after breakfast and after meals. Increased dietary fiber (wheat
bran is the most effective) and commercial bulk laxatives (Metamucil,
Fibercon) are safe and effective in the majority of cases. However, all
fibers are not created equal. Fiber contained in vegetables and fruits is
not a adequate substitute for bran.
Sorbitol and lactulose are poorly absorbed sugars and can cause
bloating and abdominal distention. Polyethylene glycol (Miralax) is very
effective and does not cause salt or fluid overload. Mineral oil softens
the stools, but the risk for aspiration pneumonia makes it an unattractive
option for oral administration.
Stimulant laxatives are frequently used when patients do not respond to
initial measures. Risk for "cathartic colon" has been overblown,
and they are usually safe if taken no more than 2-3 times per week under
physician supervision. Options include senna (Ex-Lax, Senokot), bisacodyl
(Dulcolax) and cascara. Melanosis coli (dark discoloration of colon) may
occur due to prolonged use of certain laxatives, but is harmless.
Self-administration of tap water enema every 3-4 days is helpful for
patients not responding to oral laxatives.
Treatment of severe cases
Habit training plus judicious use of laxatives is helpful. As a first
step, colon is cleansed out completely by twice daily enemas or 4-8 liters
of polyethylene glycol solution (GoLytely, CoLyte). Once colonic cleansing
has been accomplished, patient is started on a regular dose of laxatives,
titrated to achieve one stool per day. Enema is used if no bowel movement
occurs for two days. Once bowel movements have been regularized, laxatives
may be gradually weaned. Patients with anorectal dysfunction benefit from
biofeedback.
Bedridden patients or those with dementia and fecal impaction require
disimpaction followed by complete colonic cleansing. In contrast to the
otherwise healthy ambulatory adults, these patients should be on fiber
restricted diet along with a scheduled regimen of enemas (1-2 per week) or
polyethylene glycol laxative.
Surgery
Surgery is the treatment of choice in Hirschprung's disease (usually
seen in children and young adults). Surgery may also be helpful for
selected patients with severely sluggish colon or those with difficulty
expelling stool due to anorectal disorders.
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