Constipation - home health advice

Overview
Definition

Constipation, a condition in which a person has difficult or infrequent passage of feces, can be a symptom of an underlying pathology or an acute or chronic condition in itself, lasting days, months, or years. Normal bowel movements occur from two or three times a week to two or three a day. Constipation usually results from a delay in transit within the colon from a wide variety of causes. Constipation can occur at any age, and most people have constipation sometime in life, but it is more frequent in infancy and old age.
Etiology

Most cases of constipation result from changes in diet or physical activity, including inadequate fluid intake. Psychological factors, particularly depression, may cause acute or chronic constipation. Chronic abuse of laxatives or cathartics can also lead to chronic constipation. Psychogenic constipation may be the patient's misunderstanding of what constitutes abnormal bowel movements and an overreaction to less frequent bowel movements or changes in feces. The following may cause constipation.

Drugs:

* Aluminum and calcium antacids
* Anticholinergics
* Antidepressants
* Calcium supplements
* Calcium-channel blockers
* Cholestyramine
* Narcotics
* Sympathomimetics, including pseudoephedrine
* Tranquilizers and sedatives

Structural abnormalities:

* Anorectal fissures or thrombosed hemorrhoids
* Strictures
* Tumors

Endocrine or metabolic disorders or changes:

* Hypothyroidism
* Hypercalcemia
* Hypokalemia
* Pregnancy

Neurological disorders:

* Parkinson's disease
* Cerebrovascular events
* Spinal cord tumors
* Trauma

Smooth muscle or connective tissue disorders:

* Amyloidosis
* Scleroderma

Congenital impairments:

* Aganglionic megacolon (Hirschsprung's disease)
* Neuromuscular bowel impairment
* Irritable bowel syndrome

Risk Factors

* Decrease in exercise or activity, often occurring with illness and travel
* Dietary changes
* Use of many medications
* Low fiber diet
* Caffeine use
* Diuretic use

Signs and Symptoms

* Infrequent, difficult passage of stools (less than three times a week)
* Sudden and significant decrease in frequency of bowel movements
* Stools harder than normal, possibly impacted
* Sensation of incomplete bowel emptying
* Bloated sensation

Differential Diagnosis

Before the constipation is treated as a primary condition, underlying medical or psychogenic causes should be ruled out.
Diagnosis

The history of bowel-elimination frequency and consistency is important, along with any changes in activity or diet. The medical history may reveal a patient with a misconception about normal elimination habits or neurotically preoccupied with bowel movements. Most systemic diseases that produce constipation as a symptom also result in other signs and symptoms. Intestinal problems such as strictures or tumors often present with other gastrointestinal symptoms, such as abdominal pain or bleeding. Idiopathic diet-induced or drug-induced constipation is not usually associated with such other signs and symptoms.
Physical Examination

Inspect and palpate for abdominal masses. Inspect the anorectal area for fissures, hemorrhoids, and stenosis or stricture secondary to surgery or inflammation. Rectal exam for possible masses or impacted stool.
Laboratory Tests

Lab tests are generally necessary only if a medical disorder is suspected or if patient is over 50 years of age:

* Test stool for occult blood
* CBC for anemia if colorectal neoplasm suspected
* Thyroid function tests
* Electrolytes and calcium levels
* Blood sugar

Pathology/Pathophysiology

Constipation not related to a medical condition produces no pathological findings.

On physical examination:

* Gaping or asymmetrical anal opening may indicate a neurologic disorder.
* Masses may be found in abdomen or rectum, indicating further studies.
* Laboratory testing may detect occult blood in stool. If positive, follow with colonoscopy to rule out malignancy.

On endoscopy:

* Carcinoma or polyp
* Inflamed hemorrhoids or fissures, resulting from or promoting constipation
* Melanosis coli (brown pigmentation of the mucosa), indicating chronic laxative abuse

On rectal biopsy:

* Amyloidosis
* Ulcerative colitis
* Crohn's disease
* Hirschsprung's disease (The barium enema may reveal an obstructing tumor, stricture, or narrowed rectal segment characteristic of Hirschsprung's disease.)

Imaging

Barium enema may be performed if an obstructing lesion is suspected.
Other Diagnostic Procedures

* Anoscopy and proctosigmoidoscopy or colonoscopy are performed in acute cases with unknown cause.
* Rectal biopsy may be performed if indicated for a suspected lesion.
* Colonic motility tests or transit studies are reserved for more severe cases in which conventional treatments fail.

Treatment Options
Treatment Strategy

Treatment focuses on the underlying disease or removing factors causing the constipation. Chronic constipation can usually be prevented with a combination of diet, fluid intake, exercise, and, when necessary, short-term use of a laxative. Educate the patient about normal variations in bowel movements and bowel retraining (consistent, unhurried elimination practices). Discourage chronic use of laxatives.

In the absence of underlying pathology:

* Eliminate medications that may be causing the constipation.
* Increase fluid intake.
* Encourage a diet rich in fiber (whole-grain bread or cereal, bran, green vegetables, fruits).
* Check for food allergies.

Bowel retraining should emphasize a regular daily routine with sufficient time for a bowel movement shortly after mealtime. Lukewarm tap water enemas or bisocodyl suppositories (Dulcolax) may assist in starting the retraining program.
Drug Therapies

Laxatives: Few comparative data are available for the different classes of laxatives, and with more than 700 commercial products available, the choice is often individual preference. Laxatives are contraindicated with any bowel obstruction, acute intra-abdominal inflammation, or renal or heart failure.

Bulk-forming agents are generally effective and work by stimulating contractions of the large intestine, with low risk of adverse effects:

* Psyllium (Konsyl, Metamucil, Perdiem)
* Bran
* Calcium polycarbophil
* Methylcellulose (Citrucel)

Stool softeners increase the amount of water in the stool, increasing bulk and stimulating natural contractions of the large intestine:

* Docusate sodium (Colace)

Saline laxatives, or osmotic laxatives, stimulate the release of cholecystokinin, which stimulates colonic motility; may result in hypermagnesemia in cases of renal failure or hypocalcemia; magnesium compounds prevent absorption of tetracyclines and reduce the effectiveness of digitalis and phenothiazines.

* Milk of magnesia
* Magnesium citrate
* Sodium phosphate
* Lactulose (Chronulac)
* Sorbitol
* Alumina-magnesia (Maalox, Mylanta)

Stimulant laxatives, or irritant laxatives, alter electrolyte transport by intestinal mucosa and increase intestinal activity; adverse effects include impaired bowel motility or dependence with chronic use, hypokalemia, protein-losing enteropathy, and salt overload:

* Anthraquinone derivatives (senna, aloe, cascara)
* Diphenylmethane compounds (phenolphthalein, bisacodyl)

Castor oil increases intraluminal fluid levels and thereby increases motility; not recommended because of fluid and electrolyte alterations.
Complementary and Alternative Therapies

Lifestyle and dietary changes along with nutritional support can contribute to the long-term resolution of constipation. Herbs can be used to help tone and strengthen bowel function. Laxative herbs should be used with caution, as they may become less effective with habitual use. Mind-body techniques, such as meditation and yoga, may help reduce nervous tension that may contribute to constipation.
Nutrition

* Take time to eat in a relaxed atmosphere, breathing slowly and chewing food thoroughly.
* Eat smaller, more frequent meals and avoid overeating at one sitting.
* Eliminate refined foods, sugars, caffeine, alcohol, and dairy products.
* Decrease saturated fats (animal products) and increase essential fatty acids (cold-water fish, nuts, and seeds).
* Increase intake of fresh vegetables, whole grains, and water.
* Stewed or soaked prunes, 1 to 3 a day, have a slightly laxative effect.
* Flax meal, 1 heaping tsp. in 8 oz. of apple juice, provides fiber and essential fatty acids to help relieve constipation and promote normal motility within the digestive tract. Follow with an additional 8 oz. of water.
* Warm lemon water taken before meals stimulates digestion.
* Consider digestive enzymes for chronic constipation.
* Vitamin C 1,000 mg bid to tid.
* Magnesium 250 mg bid to tid.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, or 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

A combination of herbs to help digestion and relieve constipation includes the following in equal parts as a tea or tincture: licorice root (Glycyrrhiza glabra), cascara sagrada (Rhamnus purshiana), dandelion root (Taraxacum officinale), yellowdock (Rumex crispus), fennel seed (Foeniculum vulgare), and ginger (Zingiber officinale). A tea should be steeped for 20 minutes. Drink 1 cup tid before meals. A tincture may be taken tid, 15 to 20 drops before meals. For long-term use (more than two weeks), eliminate cascara and substitute burdock (Arctium lappa). Licorice root is contraindicated in hypertension.
Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing, use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

* Calcarea carbonica for constipation without urge for stool
* Nux vomica for constipation with constant, ineffectual urging for stool
* Silica for constipation with the sensation that stool remains in the rectum after bowel movements

Physical Medicine

Castor oil packs to the abdomen may be useful in resolving constipation. Used externally, castor oil is a powerful anti-inflammatory. Apply oil directly to skin, and cover with a clean, soft cloth (e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or heating pad) over the pack and let sit for 30 to 60 minutes. For best results, use three consecutive days in one week.

Contrast hydrotherapy may help to tone and strengthen bowel function. Alternating hot and cold applications brings nutrients to the site and diffuses metabolic waste from inflammation. The overall effect may be decreased inflammation, pain relief, and enhanced function. Apply hot and cold towels to the abdomen. Alternate 3 minutes hot with 1 minute cold. Repeat three times to complete one set. Do two to three sets/day.
Acupuncture

Constipation may be effectively treated with acupuncture, which can stimulate and tone digestive function.
Massage

Therapeutic massage can induce stress release and relieve constipation that is due to spasm and nervous tension. Massage of abdomen can also stimulate some increase in peristalsis.
Patient Monitoring

If constipation persists despite changes in diet, activity, and fluid intake, investigate further for underlying cause.
Other Considerations
Prevention

For patients with chronic tendencies toward constipation, emphasize the importance of including fiber in the daily diet, adequate fluid intake, exercise, and bowel retraining.
Complications/Sequelae

Megacolon may be acquired in severe cases that have either persisted a long time or have subsequently perforated. Chronic laxative abuse may lead to cathartic colon and fluid and electrolyte abnormalities. Frequent fecal impaction can lead to rectal ulceration. Fluid and electrolyte depletion may result.
Prognosis

In the absence of an underlying condition, constipation should resolve soon with medications if needed and not recur frequently with adequate diet, fluids, and exercise. Occasional constipation is generally harmless.
Pregnancy

Constipation is a common ailment in pregnancy and is usually relieved with dietary changes and increased water intake. Digestive enzymes may be safely taken to support digestion. Herbs that are stimulating to the digestive tract may have a reflexive reaction in uterine muscle and induce contractions. Laxative herbs should not be used in pregnancy without the supervision of a physician.
References

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Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md: Lippincott Williams & Wilkins; 1999.

Hobbs C. Foundations of Health: The Liver and Digestive Herbal. Capitola, Calif: Botanica Press; 1992:129-135.

McRorie JW, Daggy BP, Morel JG, Diersing PS, Miner PB, Robinson M. Psyllium is superior to docusate sodium for treatment of chronic constipation. Aliment Pharmacol Ther. 1998;12:491-497.

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