Constipation

What is Constipation ?

Constipation refers to having difficulty and irregular bowel movements, usually less than three times a week. It’s a very common issue in the U.S., often leading people to seek medical help from colorectal surgeons and gastroenterologists. People may not realize they have constipation until they start experiencing related problems like anorectal disorders.

There are several specific kinds of constipation, each with unique aspects and causes. One common type is functional constipation, which is seen in both adults and children. This type is characterized by infrequent and difficult bowel movements without any obvious physical or organic reason. Around 29.6% of children worldwide endure this type, and it accounts for 3% to 5% of children’s doctor visits in the U.S. There’s a significant healthcare cost associated with this condition. For most patients, no single cause is identified, and a third of these children continue having this issue into adulthood. Other problems that spiral from this condition may include fecal incontinence and behavioral issues related to difficulty in bathroom habits. The causes behind functional constipation are not fully understood, but several factors are observed to contribute, including pain, fever, dehydration, dietary and fluid intake, psychological problems, toilet training, effects of certain medicines, and a family history of constipation.

Chronic idiopathic constipation is another common type, marked by irregular and difficult bowel movements without a clear physical or anatomical reason. Though it affects less than 5% of patients, this form is chronic, generally lasting for a long time. The symptoms are usually infrequent hard or difficult bowel movements. Treatment usually involves changes in lifestyle, diet, and in some cases, medication. These measures aim to relieve symptoms and enhance the person’s quality of life.

A third type of constipation, secondary constipation, has definite causes like certain medications, medical conditions, dietary factors, or physical issues in the digestive system. Treating this type often involves tackling the underlying cause, such as changing medications, dealing with related health conditions, or changing dietary habits. Properly identifying and treating these causes is crucial in effectively relieving symptoms of constipation.

Understanding these different types of constipation is vital for healthcare professionals, as it helps them tailor precise diagnosis and treatment plans, optimising patient care and results.

What Causes Constipation ?

Constipation can be caused by a variety of things, separated into certain groups:

One category is called Primary or Idiopathic, where organic causes have been ruled out. This typically includes constipation due to unwilling behavior of passing stools. This category can be broken down into:

1. Normal-transit constipation: Here, the stool moves at a normal speed through the colon, but individuals find it hard to pass their stools.
2. Slow-transit constipation: This includes infrequent bowel movements, or difficulty and straining when trying to defecate. They also experience reduced activity in the colon muscle.
3. Pelvic floor dysfunction: This is distinct by weaknesses in the pelvic floor muscles. Often resulting in a feeling of incomplete bowel movements, prolonged or intense straining, and using physical pressure to aid in defecation.

Dietary issues can include things like not enough fiber or water in your diet, or too much coffee, tea, or alcohol. Not getting enough exercise can also be a factor.

Physical causes could be things like narrowing or blockage of the anus, ruptured hemorrhoids, narrowing of the intestines, tumors that block the flow, and tightening of the anus.

Abnormalities in muscles causing constipation could include conditions like prune belly syndrome, gastroschisis, Down syndrome, and muscular dystrophy.

Nerve-related causes can lead to issues in the intestine’s structure. These can include conditions like Hirschsprung disease, pseudo-obstruction, intestinal neuronal dysplasia, spinal cord defects, tethered cord, and spina bifida. Additionally, other nerve disorders like stroke, Parkinson’s disease, multiple sclerosis, Chagas disease, and familial dysautonomia can lead to constipation.

Drugs including anticholinergics, narcotics, antidepressants, and many more can contribute to constipation.

Metabolic and hormonal disorders also lead to constipation. This includes conditions like low potassium levels, high calcium levels, underactive thyroid, diabetes, and diabetes insipidus.

Other causes include a range of conditions such as celiac disease, cow milk protein allergy, cystic fibrosis, inflammatory bowel disease, and scleroderma.

Risk Factors and Frequency for Constipation

Chronic constipation is a widespread problem, affecting about 15% of people in the United States. It led to as many as 5.7 million doctor visits in 2006, with 2.7 million of those visits listing constipation as the main concern. Around the world, about 12% of people report suffering from constipation, with those living in the Asian Pacific and the Americas experiencing it twice as often as people in Europe.

Though constipation can affect people of any age, from babies to the elderly, it’s more common in women. The number of people suffering from constipation tends to increase with age; up to 40% of adults over the age of 65 say they’re affected by it. In addition, nonwhite populations have a 30% higher prevalence of constipation than white populations.

• Babies and young infants typically have more than 4 bowel movements a day.
• By toddlerhood, the frequency of bowel movements tends to decrease to 1 to 2 a day.
• At this stage, toddlers usually gain voluntary control over their bowel movements.

Signs and Symptoms of Constipation

Diagnosing constipation shouldn’t be based solely on asking patients if they’re feeling constipated, as some might underreport their condition. It’s crucial to gather comprehensive information about the patient’s health history, including their medications, previous colonoscopies, surgeries, and any relevant medical issues. As part of the process, the patient’s usual bowel habits, changes in their bowel routine such as ‘missing a day’, the hardness of the stools, any accompanying symptoms, and straining during bowel movements should be evaluated.

Signs that are particular causes for concern include:

• Rectal bleeding
• Abdominal pain
• Vomiting
• Loss of appetite
• Unexplained weight loss
• Family history of gastrointestinal cancer
• Inability to pass gas
• Abdominal mass
• A feeling of incomplete evacuation
• Manual stool extraction
• Straining
• Urgency for bowel movement
• Inability to retain enema

The physical examination starts with checking the patient’s weight and overall nutrition. The abdomen is checked for distension, unusual or absent bowel sounds, tenderness, or masses. The rectal examination includes checking for masses, hemorrhoids, anal and perianal fissures, inflammation, rectal prolapse, and hard stool. The color and consistency of the stool are observed and a detailed neurologic exam is done. The patient is also evaluated for signs of depression, anxiety, and physical symptom disorder.

For children with constipation, a detailed history is particularly significant. This includes details about the time of their first bowel movement after birth, the duration of the condition, the frequency of bowel movements, stool consistency and size, whether defecation is painful, whether there’s blood in the stool or toilet paper, and if defecation is associated with abdominal pain. It’s also important to ask about accidental bowel leakage, which can sometimes be mistaken for diarrhea. The impact of medications and the family’s social environment should be taken into consideration too.

The physical assessment of an infant or child should watch out for ‘alarm’ signs, for example, bloody diarrhea in a constipated infant may indicate Hirschsprung disease. An abdominal examination may reveal distention or a palpable “mass” in the lower abdomen. A rectal exam would be conducted to check for hard stool or a rectal mass. The size and position of the anal opening are visually and physically checked to detect any rectal prolapse.

The Rome IV criteria for adults and children can help in determining a diagnosis of functional constipation (details of the Rome IV criteria to be provided).

Testing for Constipation

For patients suffering from chronic constipation, extensive evaluation should usually start after a few months (around 3 to 6) of unsuccessful standard treatments. At this point, it’s important to repeat rectal and perineal exams. Conducting tests on the anus and rectum can be useful if over-the-counter solutions have not provided any relief. Blood tests and other laboratory investigations usually don’t form a key part of the early stages of checking for constipation.

For children experiencing ongoing constipation, routine use of specific imaging tests or laboratory tests isn’t typically recommended. But if standard medical treatments aren’t working, further diagnostic checks can help identify the cause and guide future treatment. These further checks might include anorectal manometry, colonic manometry, colonic transit studies, and imaging techniques like x-ray and ultrasound.

Now, while dealing with rectal bleeding, the patient might develop anemia, which would show on a complete blood cell count. Doctors may conduct fecal occult blood testing in patients with constipation to rule out the presence of any obstructive cancer in the colon. If a patient has a fever or abdominal pain, checking their white blood cell count may be helpful because it could hint at an underlying blockage in the intestines, leading to more intensive investigations. Other potentially useful tests can include thyroid function checks, because underactive thyroid can cause constipation. For patients who’s constipation doesn’t respond to dietary changes, it might be necessary to check thyroid-stimulating hormone (TSH) levels.

Imaging tests become particularly crucial if the patient’s symptoms suggest problems either within the abdomen or through the entire body. For instance, an upright chest x-ray and standing and lying abdominal x-rays might be needed. An abdominal x-ray can show whether there is compacted feces in the colon and can distinguish between fecal impaction, obstruction of the bowel, and fecalith (hardened stool).

If needed, a patient might undergo abdominal computed tomography (CT scan) to check for an abdominal abscess. If patient experiences acute constipation with an empty rectal vault and a dilated colon filled with air or stool, it could indicate a large bowel obstruction, which would require further checks through a Gastrografin enema or a lower gastrointestinal endoscopy, whichever is more suited.

Anorectal manometry, a test to evaluate the function of the anus and rectum, can help identify possible causes of constipation or loss of bowel control. This test can aid in diagnosing Hirschsprung disease, however, a rectal suction biopsy is the main test of choice for this disease.

Colonoscopy and insertion of a catheter, also known as, colonic manometry, can help determine reasons for constipation. Similarly, conducting colonic transit studies using radiopaque markers to check the speed of stool passing through intestines is useful, too.

Finally, if an obstruction is suspected in the anal canal, defecography may be conducted. This involves filling the rectosigmoid junction of colon with barium and then studying the defecation process under fluoroscopy (kind of an x-ray movie).

Treatment Options for Constipation

Managing constipation in adults involves an all-round approach, targeting the root causes and focusing on regular bowel movements and easing symptoms. Initially, changing diet and lifestyle habits is vital – increasing consumption of fiber-rich foods like fruits, vegetables, and whole grain, drinking plenty of fluids to soften stools, scheduling bathroom time and staying active can help improve bowel regularity.

Physical therapy focused on the pelvic floor can be beneficial for patients with pelvic floor dysfunction. In cases where stress or anxiety worsens symptoms, therapies like biofeedback and cognitive-behavioral therapy can prove useful. Over-the-counter medications such as bulk-forming agents, stool softeners or osmotic agents may provide temporary relief – these should be used sparingly and their long-term use should be closely monitored.

If these methods prove ineffective, prescription medications might be necessary. These include a wide range of options, such as lubiprostone, which increases intestinal fluid and speeds up gut transit, and linaclotide, which accelerates bowel movements. Both are approved by the FDA for treating chronic idiopathic constipation and should be taken with certain precautions. Other prescription alternatives for chronic constipation include plecanatide, which promotes intestinal fluid, and prucalopride, which increases bowel movement frequency. However, all these drugs should be taken under medical supervision and can lead to side effects like nausea or diarrhea.

If constipation is caused by disorders like colonic inertia, surgical intervention like total abdominal colectomy with ileorectal anastomosis may be required. When constipation results from other underlying conditions like thyroid or neurological disorders, it’s important to address these root causes. Medication adjustment can also be part of the treatment plan, as many drugs can affect normal bowel behavior.

Treating constipation in children also involves a combination of medical supervision, dietary changes, behavioral modifications, and toilet training guidance. Good fiber and fluid intake along with regular physical activity are advised. Routine use of prebiotics or probiotics, however, isn’t usually recommended for treating childhood constipation. Laxatives are typically the first-line treatment, often proving beneficial if used correctly. The use of other medications, again, must be closely monitored, especially in the long term.

In resistant cases of constipation, advanced therapies or surgical interventions may be needed. Biofeedback therapy, although beneficial for defecation dynamics, hasn’t shown significant effects on constipation itself. Sacral nerve stimulation has also been used, showing short-term benefits. About 10% of children with functional constipation who get referred to a pediatric surgeon may need surgical treatment, the goal of which is to relieve symptoms. Various surgical techniques may be employed depending on the condition.

What else can Constipation be?

When trying to figure out the cause of constipation, doctors have a long list of potential conditions to consider. This includes, but isn’t limited to:

• Belly hernias
• Tears in the skin of the anus (anal fissures)
• Birth defects in the anus and rectum (anorectal malformations)
• Anxiety disorders
• Appendicitis (inflammation of the appendix)
• Chagas disease
• Colon or rectal cancer
• Blockage of the colon
• Crohn’s disease (inflammatory bowel disease)
• Depression
• Diverticulitis (inflammation of pouches that form in the walls of the colon)
• Hirschsprung’s disease (a birth defect in which some nerve cells are missing in the colon)
• Conditions affecting the pituitary gland
• Hypothyroidism (low thyroid hormone levels)
• Ileus (loss of normal muscular function in the gut, causing blockage)
• Extra high pressure or achalasia in the internal anal sphincter
• Disorders that affect intestinal movement
• Blockage of the intestine
• Irritable bowel syndrome
• Blockage of the large bowel
• Multiple endocrine neoplasia type 2 (a genetic condition that impacts the endocrine glands)
• Ogilvie syndrome (a disorder of the colon)
• Pelvic floor muscle dysfunction
• Pelvic or rectal tumors or masses
• Infections in the belly and blood
• Rectal prolapse (the rectum protrudes from the anus)

In addition, doctors would also consider:

• Problems related to social and mental health
• Side effects from certain medications
• Abnormalities of the spinal cord
• Cystic fibrosis (a lung disorder that can affect other organs)
• Disorders that affect the body’s connective tissues
• Celiac disease (gluten intolerance)
• Problems digesting cow’s milk protein
• Parkinson’s disease (a progressive nervous system disorder)

What to expect with Constipation

Most people with constipation experience improvement with comprehensive treatments. However, a small number of adults become seriously impacted by constipation, and around 30% of children with constipation will continue to have symptoms into adulthood.

Certain factors may lead to a worse outcome, including being female, experiencing the onset of constipation at an older age, having a longer time period before treatment begins after symptoms appear, and having a longer time for food to move through the large intestine.

It’s important to note that treatments don’t always work or may only work for a short time. Furthermore, constipation often returns in many patients, mainly because they don’t stick to their recommended diets. Chronic constipation can also significantly decrease the quality of life for those who experience it.

In severe cases, a surgical procedure called a total abdominal colectomy may be needed, but choosing the right patient for this process is crucial for achieving a good result. The most challenging cases involve patients who are dependent on laxatives, resist changing their lifestyle, and continue to use various laxatives.

Possible Complications When Diagnosed with Constipation

Constipation can affect a patient’s life in various ways depending on how severe it is and what exactly is causing it. There are several complications that can occur:

• Abdominal discomfort or cramps
• Decreased quality of life
• Hemorrhoids
• Anal fissures (tiny tears in the tissue lining the anus)
• Damage to the pelvic floor (the muscles, ligaments, and tissues that support the organs in your pelvis)
• Fecal incontinence (inability to control bowel movements)
• Urinary retention (difficulty or inability to pee)
• Stercoral perforation (when hardened feces tear the walls of the bowel)
• Rectal prolapse (the part of your intestine that connects to the anus slips outside the body)
• Volvulus (twisting of the intestines)
• Fistula-in-ano (an infected tunnel that forms between the skin and the anus)

Preventing Constipation

In managing constipation, it’s very important that people understand what’s happening in their body. Knowing about their condition helps them take an active role in improving their health. It’s critical for people to know about typical reasons they might be constipated – like not eating enough fiber, not drinking enough water, or not getting enough exercise. For anyone dealing with constipation, understanding the need for a balanced diet full of fiber, regular exercise, and plenty of water is key to promoting healthy bowel movements.

Sometimes, people who don’t get enough fiber or fluids in their diet may need to supplement these for life. It’s also important to stick with any treatment plans, be able to recognize the symptoms of constipation, and know when it’s time to get help from a doctor. Educating people about this common stomach issue can help prevent constipation, improve their quality of life, and reduce the chance of any related complications.