Constipation

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What is constipation?

Constipation is a condition where or three or fewer bowel movements occur within a week, and with difficulty in passing stool. There may be an underlying cause that leads to constipation, although in some cases no cause can be found. 

Is constipation a medical emergency?

Constipation is not a medical emergency. 

Types of constipation

Based on the cause constipation may be of the following types:

  • Primary or Functional Constipation
  • Secondary Constipation
  • Congenital Constipation

Causes of constipation

Several conditions and factors can result in constipation, and they may be as follows:

  • Diet - Low fiber diet, low liquid intake, or dieting
  • Medications - Such as
    • Opioids
    • Diuretics
    • Antidepressants and Tricyclic antidepressants
    • Antihistamines
    • Beta-blockers
    • Calcium channel blockers
    • Antidiarrheals
  • Metabolic and Endocrine problems -
    • Hypothyroidism
    • Hyperparathyroidism
    • Hypopituitarism
    • Diabetes
    • Chronic kidney diseases
    • Hypercalcemia
    • Cystic fibrosis
    • Celiac disease
    • Pregnancy
  • Structural causes -
    • Bowel obstruction
    • Colorectal cancer
    • Strictures
    • Anal fissures
    • Rectoceles
    • Sphincter damage
    • Post-surgical complications
  • Neurologic causes -
    • Multiple sclerosis
    • Parkinson’s disease
    • Spinal cord injury
    • Stroke
    • Autonomic neuropathy
  • Muscular causes - Such as Anismus which is the failure of relaxation of the muscles of the pelvic floor during attempted defecation; weak pelvic muscles.
  • Psychological causes
  • Congenital causes - Such as Hirschsprung’s disease in which nerves are missing from the intestine.

Risk factors for constipation

The following are the risk factors for constipation:

  • Age - The elderly age group is more prone to constipation
  • Gender - Women are more prone to constipation
  • Dehydration
  • Sedentary Lifestyle
  • Low fiber diet
  • Mental health conditions such as depression or eating disorders
  • Certain Medications 

Signs & symptoms of constipation

The following are the signs and symptoms that are seen along with constipation:

  • Passing lesser than 3 bowel movements in a week
  • Passing hard and lumpy stool
  • Straining to pass stool
  • The sensation of blockage or obstruction of the rectum, that seems to prevent the passage of stool
  • The sensation of the incomplete passage of stool
  • Needing manual intervention to remove stool from the rectum

Some other complaints that may or may not always be present include:

  • Abdominal bloating
  • Pain on defecation
  • Bleeding from the rectum
  • Low back pain
  • Inability to pass gas
  • Vomiting

Investigations

The following investigations may be done to establish the underlying cause of constipation:

  • Laboratory tests -
    • CBP & ESR
    • Thyroid function tests
    • Serum Calcium levels
    • Renal Function tests
    • Fasting Blood Glucose
  • Imaging tests -
    • X-ray – Abdomen
  • Diagnostic procedures -
    • Colonoscopy
    • Flexible Sigmoidoscopy
    • Colonic Transit Study
    • Anorectal Manometry
    • Surface Anal Electromyography
    • Defecography -
      • X-ray Defecography
      • MRI Defecography
    • Balloon Expulsion testing 

Diagnosis

A diagnosis of the underlying cause of constipation is established based on the medical history, clinical evaluation, and results of the investigations done. 

Constipation treatment options

Management of constipation depends on identifying the underlying cause and then treating it. Diet and lifestyle changes are usually recommended in addition to management of the underlying cause if any. Surgical intervention may be required if there is no response to conservative management.

A. Medical management

Medical Management of constipation involves the use of the following depending on the underlying cause:

  • Bulk Forming Agents - Such as psyllium, for long term use
  • Emollient Stool Softeners - Such as docusate, for short term use as in post-surgery
  • Rapidly Acting Lubricants - Such as mineral oil, useful in acute constipation
  • Prokinetics - Useful in severe constipation associated symptoms
  • Stimulant Laxative - Such as Senna; should not be used for long durations

New medications such as the following are sometimes recommended:

  • 5HT-4 Receptor Agonists - Act by stimulating the movement of the colon
  • Lubiprostone - Useful in opioid-induced constipation, and Irritable Bowel Syndrome
  • Osmotic Laxatives - Such as Lactitol, useful in chronic constipation with no definitive cause
  • GC-C Agonists - Such as Linaclotide, Plecanatide; useful in chronic constipation with no identifiable cause, or Irritable Bowel Syndrome induced constipation.
  • PAMORA - Useful in opioid-induced constipation

B. Interventional including surgery and indications for surgery

Surgical Management of constipation is only indicated if:

  • There is no response to medical or conservative management
  • The constipation is caused by a bowel obstruction, strictures, rectocele, or other physical obstructions to the passage of stool

C. Role of diet/exercise/lifestyle changes/preventive measures

Some measure that can help with the management may include:

  • Eating a diet that is high in fiber
  • Exercising and avoiding a sedentary lifestyle
  • Paying attention to the urge for a bowel movement and not delaying responding to the urge
  • Biofeedback training and exercises to strengthen the pelvic muscles

Some measures that can help in the prevention may include:

  • Adding foods with high fiber content in regular meals
  • Avoiding processed foods, dairy, and meat products
  • Drinking plenty of fluids and staying hydrated
  • Creating a regular schedule for bowel movements
  • Managing stress
  • Immediately responding to the urge to pass stool without holding back

Complications

Some of the complications of constipation may include:

  • Fecal impaction - Stool gets accumulated in the intestines
  • Bowel obstruction
  • Volvulus
  • Megacolon
  • Anal fissures - Large hard stool can lead to tearing of skin around the anus
  • Hemorrhoids - Swollen veins around the anus may develop due to excessive straining while defecating
  • Rectal prolapse
  • Pelvic floor damage in women
  • Urinary retention
  • Ulceration or perforation

Prognosis

The prognosis for constipation is generally good, with most individuals responding well to diet and lifestyle changes, and some medical management. 

When to contact the doctor or hospital/how to identify the emergency or complications?

It is advisable to seek medical attention if the signs and symptoms are noticed and the changes in bowel habits persist for more than a week. 

Indications for hospitalization if required

Hospitalization is usually not required for constipation. It may only be required if there is an indication for surgical management of the condition.

Suggested clinical specialist/department to consult for this condition

Constipation will be attended by specialists from the department of gastroenterology.

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