Diagnosis of Chronic Constipation

Symptoms of constipation

Physical Examination

Palpation of the left side of abdomen, especially the lower part (in children in lower-mid part) may reveal lumps of stool. In children inspection of anal area may reveal skin tears - anal fissure or fistulae, hemorrhoids, rectal prolapse. Causes of constipation in children. Digital rectal examination gives an impression of the anal sphincter tone, anal stenosis and presence of feces in the rectum. In women posterior vaginal wall palpation may give evidence of internal rectal prolapse or rectocele.

Laboratory Findings

CBC - Complete blood count (low red cells may indicate occult bleeding, raised leukocytes may show inflammation). Blood glucose is increased in diabetes, electrolyte levels may be deranged in renal disease. Fecal occult blood test may be done in chronically obstipated patients after age of 50 (eventual colon cancer).

Imaging

X-ray of the chest and abdomen may reveal a free air in abdominal cavity from bowel perforation. Air in distended proximal colon suggests obstruction. Double contrast X-ray with barium enema or gastrografin enema may reveal intestinal diverticula or tumor. Abdominal CT may reveal abdominal mass.
Colonoscopy with biopsy is needed to confirm tumors, inflammation or Hirschsprung disease.

Anal ultrasound may reveal damage of anal sphincters or processes in adjacent tissues. Investigation takes 5-10 minutes as an outpatient.

Functional Tests

Functional tests are made only if constipation does not respond to any treatment.

At defecography, rectosigmoid colon is filled with barium paste and act of defecation is observed with fluoroscope (a kind of X-ray video). Obstruction in the anal canal may be found this way. Dynamic MRI defecography shows anatomy of rectum and pelvic floor.

Bowel transit time is evaluated on the basis of passage of radioopaque capsules by x-ray 120 hours after ingestion.

Anorectal manometry reveals internal and external anal sphincter function. Electromyography of anal sphincter and pubic muscles may be needed.

At balloon expulsion test a balloon filled with water is inserted in the rectum. Decreased ability to expel a balloon suggests decreased ability to defecate.

Treatment of Chronic Constipation

In the acute constipation where the obvious cause is some food incident, no doctor help is needed. In chronic cases dietary and life changes should be considered first. Causes of constipation

Natural Laxatives

Foods that Act as Natural Laxatives

Dietary Fibres

Fibers improve peristalsis only when a cause is low fibre diet, additional fluid will help only in people who hadn’t had drunk enough before, activity will help only in non-active persons etc. All measures will hardly help, if exact cause of constipation is not found and removed.

Laxatives as Drugs

Laxatives are drugs which promote bowel evacuation and they should normally be confined only to patients who need to avoid straining (e.g. danger of stroke or heart attack), those with painful anal conditions (like anal fissure), before gut investigation or surgery and in bedridden patients.

Laxatives for use by mouth may be in the form of powder, granules, husk, tablets, capsules or liquids; for rectal use there are suppositories or enemas.

Laxative choice depends on type of constipation, hardness and the site of the stool, how quickly an effect is needed, eventual disease and cost. Once effect is achieved, the dose should be lowered and laxative withdrawn totally in time. Rectally inserted laxatives - suppositories - have much quicker effect (minutes) then orally taken (hours, days). Enemas and suppositories should not be used in hemorrhoids or anal fissura and in children, unless absolutely needed. Enemas are recommended for occasional rather than regular use, but may need to be repeated several times to clear impacted faeces, mostly at bedridden patients.

Fiber Supplements

Bulk-forming laxatives or fiber supplements, like bran and psyllium (Metamucil) attract water and make stool bulky and soft. They are good for people with small hard stools. Due to their delayed onset of action (few days), they are mostly used in chronic constipation and are not appropriate for acute relief. They may be used if regular high-fibre diet doesn’t work. They are mostly sold as powder and they need to be taken with a plenty of fluid and during the meal. Small amounts should be tried first to avoid bloating and then increased until regularity is achieved.

Contraindications: impaired swallowing, intestinal obstruction, colonic atony, faecal impaction or severe dehydration.

Side effects: bloating, which may vary a lot on a particular product, in general it improves with continued use; fecal impaction, if taken without fluid.

Stool Softeners

Stool softeners like docusate, e.g. Colace, increase amount of water that the stool can hold. They are recommended for temporary use after childbirth and surgery or at hemorrhoids when straining need to be avoided. They are used for prevention, not treatment of constipation. They should not be used in combination with mineral oil, since they increase its absorption leading to inflammation of liver, spleen and lymph glands.

Constipation may also result from the administration of some diet pill on a regular basis. The phenomenon is more common among the individuals who aim at fast weight loss and sustain their bodies on very little amounts of food. Unlike any other weight loss product, diets with adequate fiber, such an abs diet, help prevent the constipation and provides the fitness benefit at the same time.

Contraindications: intestinal obstruction.

Side effects: throat irritation, nausea, abdominal cramps, diarrhea, liquid paraffin can cause anal irritation, malabsorption of lipid-soluble vitamins, and lipoid pneumonia (rarely, on aspiration).

Lubricants

Lubricants, like mineral oils (Fleet), grease the stool. Like stool softeners, they are used by patients who need to avoid straining. They work within 8 hours. They should not be used in pregnancy since they slow down vitamin absorption. In people with swallowing disorders they may cause aspiration pneumonia.

Osmotics

Osmotics, like lactulose or sorbitol, attract water from the blood. They should be tried only if other laxatives fail. They act in the small and large bowel. Lactulose works within 48 hours. Saline laxatives, like Milk of Magnesia, draw water into the colon; they are used in acute constipation. They work within 3 h if taken by mouth, in 15 min if administered rectally. Macrogols polyethylene glycols, like Movicol - have an initial effect within an hour. Magnesium and phosphate based products work within 3 h; they are mainly used to clear stool before X-ray bowel investigation or colonoscopy. Phosphate and Arachis oil enemas are also suitable in fecal impaction.

Contraindications: heart and kidney disease, gastrointestinal obstruction, inflammatory bowel disease (Crohn), heart or kidney failure.

Side effects: diarrhea, abdominal cramps, bloating, feeling sick, electrolyte imbalance after long term use.

Stimulants

Stimulants, like senna products (Senokot), cascara (Peri-Colace), castor oil (Ricinus), or bysacodil (Dulcolax), induce muscle contractions by stimulating nerves in colonic wall. Taken by mouth they work in 6 to 8 hours; suppositories work in 15 to 60 minutes. They are meant for temporary use like emptying bowel before diagnostic procedures or prevent constipating effect of opioids.

Contraindications: third trimester of pregnancy, intestinal obstruction, hemorrhoids, anal fissure, diabetes, heart or renal disease.

Side effects: cramps, vomiting, dehydration. Uterine contractions in third trimester of pregnancy, and intestinal cramps in breast-fed infants (senna enters breast milk). Prolonged use can lead to dehydration, hypokalemia, hyponatremia, lazy colon, colon infection, irritable bowel syndrome, and, rarely, liver damage. Dantron should be restricted to use in terminally ill people, because of possible genotoxicity. Phenolphthalein, frequent ingredient, might be cancerogenic. Senna may cause dark coloration of colon, seen on colonoscopy, but it does not cause any symptoms and there is no evidence of increased cancer risk.

NOTE: Bowel cleansing solutions, like sodium picosulphate, are not appropriate for treating constipation. They are only indicated as treatments to clear the bowel before colonic investigation or surgery.

Laxatives Abuse

People, dependent on laxatives, need to slowly stop using them. For most people, stopping laxatives restores the colon’s natural ability to contract in some weeks. Laxatives should not be stopped at once but gradually and under guidance of a doctor.

Surgery

Surgical removal of the colon may be (rarely) needed in severe constipation with complete colon unresponsiveness.

Prognosis of Constipation

It is impossible to predict the prognosis of constipation. It depends on how a patient sticks with appropriate food and life style or on underlying disease.

Some Facts about Laxatives and Constipation:

1. Laxatives do not help in real weight loss. Their “weight loss” effect is due to less water absorption and hence dehydration. Nutrients are absorbed in small intestine where laxatives have no effect.

2. There is no evidence of developing true physical addiction to laxatives and tolerance to stimulant laxatives is uncommon. On the other hand, it’s the fact that a person who start using laxatives often increases their dose and constipation still doesn’t improve.

3. There is no evidence that poisonous substances would be absorbed from the gut during constipation.

4. There was no different stool transit time found between luteal and follicular phases of the menstrual cycle (1).
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References:

1. http://blackwell-synergy.com/doi/abs/10.1111/j.1572-0241.2005.40885.x MYTHS ABOUT CONSTIPATION

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