Chronic Constipation – Symptoms, Causes, Tests, Treatment

Constipation is a common bowel habit problem characterized by not passing stool at least three times in a week. Not every person will have a daily bowel movement but once the stool has not been evacuated after 3 days, it undergoes changes that makes it difficult to pass out. It cannot be simply treated with laxatives. Chronic constipation needs a multipronged approach, including diet, lifestyle and medication.

Symptoms of Chronic Constipation

Constipation is considered chronic, when it lasts for more than 3 months. Symptoms include straining during the bowel movement, hard stool, abdominal pain or bloating and bad breath. If not appropriately treated and managed, it can lead to complications such as fecal impaction and hemorrhoids (piles), which may present with additional symptoms such as fecal incontinence (bowel accidents) with impaction and rectal bleeding with hemorrhoids.

Read more about constipation symptoms.

Causes of Chronic Constipation

Causes of constipation include inappropriate diet, dehydration, inactivity, psychological causes, gastrointestinal and other chronic diseases, and drugs.

How to Get Rid of Constipation?

To get rid of chronic constipation, you might need to:

1. Change your diet. Check list of fiber-rich foods, low-FODMAP diet in IBS
2. Drink enough fluid
3. Become more physically and mentally active
4. Cope with stress, make right life decisions
5. Lose some weight
6. Drop some drugs you do not really need (after discussion with your doctor)

If you think you tried “everything” and “nothing helped” you might ask your gastroenterologist to have some investigations.

Investigations in Chronic Constipation

1. Physical Examination

During physical examination, a gastroenterologist might detect:

• A lump in your lower left abdomen (hard stool in the colon)
• Skin tears (fissures) or abnormal openings (fistula) around your anus
• Hemorrhoids or rectal prolapse
• Increased tonus of the muscle that closes the anus
• Digital rectal examination can reveal hard stool in the rectum, a polyp or, in men, enlarged prostate
• In women, posterior vaginal wall palpation may give evidence of internal rectal prolapse or rectocele.

2. Laboratory Tests

• Blood tests may reveal:
  • Abnormal levels of potassium, calcium, sodium or magnesium
  • Elevated white blood cells (in Crohn’s disease)
  • Elevated blood glucose (in diabetes)
  • Low thyroxine (in hypothyroidism)
• Fecal occult blood test may be done in chronically constipated patients after age of 50; positive test raise suspicion for colonic cancer.
• Stool test for ova and parasites (O&P test) may reveal intestinal parasites

3. X-Ray or CT

• Double contrast X-ray with barium enema or gastrografin enema may reveal intestinal diverticula or tumor.
• Abdominal CT can reveal abdominal tumor.

4. Anal Ultrasound and Colonoscopy

Anal ultrasound may reveal damage of the anal sphincter or changes in the tissues around the anus. Investigation takes 5-10 minutes as an outpatient.

Colonoscopy with biopsy is needed to confirm Crohn’s disease, colorectal cancer, Hirschsprung’s disease or other disorders in the colon.

5. Functional Tests

Functional tests may be done, when constipation does not respond to any treatment.

In defecography, a radiologists fills the last part of your colon with barium paste and ask you to expel it with a bowel movement. Defecation is observed with a fluoroscope (a kind of X-ray video). Obstruction in the anal canal may be detected this way. Dynamic MRI defecography can show eventual disorders in the rectal or pelvic floor muscles.

In balloon expulsion test, a balloon filled with water is inserted in the rectum. Decreased ability to expel the balloon suggests weakness of rectal muscles.

With anorectal manometry, pressure within the anal canal is measured and may reveal increased tension of the anal muscles. Electromyography can reveal disorders in the anal and pelvic floor muscles and related nerves.

Bowel transit time (the time in which foods travel from your mouth to the anus) is evaluated by a pellet test. You swallow a pill, which can be detected by an X-Ray, and then the travel of the pill is checked by an X-ray in the next hours and days. The test can reveal a lazy colon (colon inertia).

Laparoscopy may reveal abdominal adhesions causing partial bowel obstruction.

Treatment of Chronic Constipation

Treatment of chronic constipation depends on the cause. If basic prevention measures (see above) do not help, laxatives, or, rarely operative stool removal or bowel surgery might be needed.

Laxatives

Laxatives are drugs that promote bowel evacuation and they should normally used only by patients who need to avoid straining (because of danger of stroke or heart attack), those with painful anal conditions (like anal fissure), before gut investigation, before or after a surgery, and in bedridden patients.

Constipation may also result from the administration of some diet pill on a regular basis. The phenomenon is more common among individuals who aim to lose weight fast and sustain their bodies on very small amounts of food. Laxatives should not be the first choice of chronic constipation unless otherwise advised by a doctor,

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 doctor guidance.

Surgical Treatment of Constipation

Surgical removal of the (part of the) colon may be (rarely) needed in severe constipation with complete colon unresponsiveness (severe cases of lazy colon, Hirschsprung’s disease).

Prognosis of Constipation

It is impossible to predict the prognosis of constipation; it depends on how you maintain appropriate diet and active life style, and on eventual underlying disease you have.

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 that cause weight gain are absorbed in the 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 is the fact that a person who start using laxatives often increases their dose and constipation still does not 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).

References:

1. Myths about constipation(blackwell-synergy.com)