Constipation is a very distressing condition and a common symptom mainly among elderly people and women. But it can affect all age groups. The definition for constipation used in Rome IV criteria research is having 2 or more of the following criteria for at least 3 months.
Signs & Symptoms
- Infrequent passage of stools(<3 times per week)
- Straining >25% of time
- Passage of hard stools in >25% defecations(Bristol stool chart form 1-2)
- Incomplete evacuation and sensation of anorectal blockage in >25% defecations
- manual maneuvers to facilitate>25% defecations( digital evacuation, support the pelvic floor)
Some other symptoms associated with constipation like abdominal bloating, discomfort, and local and perianal pain. To diagnose the condition a detailed history obtained from the patient is very important.
There are various etiologies for constipation.
Causes for Constipation
- Inadequate dietary fiber intake
- Inadequate water intake
- Immobility
- Endocrine diseases like diabetes mellitus
- Hypothyroidism
- Hypercalcemia
- Porphyria
- Functional disorders like irritable bowel syndrome
- Idiopathic slow transit
- Drugs like opiates
- Antimuscarinics
- Calcium channel blockers
- Antidepressants
- Psychological causes like depression
- Anorexia nervosa
- Repressed urge to defecate
- Neurological diseases like spinal cord lesions
- Parkinson’s disease
- Gastrointestinal diseases like colonic diseases
- Painful anal conditions(anal fissures), intestinal obstruction, defecatory disorders like rectal prolapse
Categories of Constipation
- Normal transit constipation
- Defecatory disorders
- Slow transit constipation
In normal transit, constipation stool transverses the colon at a normal rate but the patient feels that they are constipated. The frequency of defecation is normal. The condition may be associated with abdominal pain and bloating. Constipation due to defecatory disorders is mainly due to dysfunction of the anal sphincter and pelvic floor. Patients with defecatory disorders may need surgeries to repair the deficit and should be referred to specialist care. Slow transit constipation is due to infrequent bowel movements. It associates with the infrequent urge to defecate, bloating, abdominal pain, and discomfort. This type of constipation mainly affects young women. This usually starts at puberty and some patients may have coexisting small intestinal motility disorders.
Management of Constipation
In the management of constipation treating the underlying cause is very important and it should be treated. The fiber content of the diet can be increased mainly in normal or slow transit constipation. Increasing fluid intake is also a main part of the management. Laxatives and enemas can be used but they are restricted to cases where the patient’s quality of life is affected. There are a few types of laxatives and enemas.
- Bulk forming laxatives-Dietary fiber, wheat bran, methylcellulose, mucilaginous gums (sterculia),mucilaginous seeds and seed coats(ispaghula husk)
- Stimulant laxatives-Phenolphthalein, Bisacodyl, anthraquinones, docusate sodium, sodium picosulfate
- Osmotic laxatives-Magnesium sulphate, Lactulose, Macrogols
- Suppositories-Bisacodyl, Glycerol
- Enemas-Arachis oil, Docusate sodium, Hypertonic phosphate, Sodium citrate
When there is a recent change in bowel habits with other alarming symptoms like rectal bleeding, or a vague sense of evacuation a colonoscopy or a CT of the pneumococci is indicated.
References
- Kumar and Clerk’s Clinical Medicine -8th Edition- Parveen Kumar, Michael Clark
- Oxford Handbook of Clinical Medicine – 10th Edition
