Constipation: Management and Causes in Adults.

This article in the self learn series is for student nurses and members of the public. It is not to be used for medical diagnosis and/or treatment. However, it contains valuable information on how to prevent and manage constipation. The writer is a Lecturer in Health Sciences and a Registered Nurse.

What is constipation? Constipation is defined as having a bowel movement fewer than three times per week. With constipation stools are usually hard, dry, small in size, and difficult to eliminate. Some people who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel.

Some people think they are constipated if they do not have a bowel movement every day. However, normal stool elimination may be three times a day or three times a week, depending on the person.

Constipation is a symptom, not a disease. Almost everyone experiences constipation at some point in their life, and a poor diet typically is the cause. Most constipation is temporary and not serious. Understanding its causes, prevention, and treatment will help most people find relief.

Normal Faecal Matter and Pattern!

Normal faecal pattern and consistency is the end result of a series of healthy behaviours and proper eating habits. Individuals who exercise daily are more likely to have normal stools. The reason for this is that movement of the body also moves the contents of the intestines. Many of you who are nurses will have noticed that patients who are confined to the bed are more likely to be constipated. So, if you want to have a regular bowel habit, start doing a certain amount of age appropriate activity. The intestines are from 30 to 40 feet long from the tip of our mouths to the anus. The fecal matter has to be squeezed through this lengthy tube which also has folds of different shapes and sizes. In addition to this there are small folds and fingerlike projections which effectively increase the distance the food has to travel and the resistance it has to overcome.

The high stress of society is also a cause of constipation. Many of you will wonder what I really mean. It would be most useful to be able to refer to one’s self for this example. The urge to go to the toilet, is greatest after morning breakfast. However, if after breakfast we are in a hurry, we jump into the car and off we go to work. We deliberately suppress our desire to evacuate our bowels. I am sure you can recall the numerous occasions when you have continued to do what you were doing despite the fact that there was an urge to use the toilet. I have done this, on numerous times. Somehow the importance of getting to work earlier is always the driving force to put off going to toilet. At other times, the taught that is going on in my mind is, “I will go to toilet at work” but when I get there the work pressure takes over and I find that I have not gone to the toilet, all day.

Picture 1: Gross Anatomy of Human Intestinal tract.
(Our intestines are 30 to 40 feet long)

In an ideal situation, if habit is formed to go to the toilet each morning, then it will continue until one unlearns it. So, if you have a habit of going to toilet each morning do your best to maintain it.

I have mentioned that our intestines are 30 to 40 feet. If we drink plenty, then the semi digested food can be pushed along quite easily. The intestines have the ability to continuously squeeze food forward. When we drink large amounts of tea, coffee, and alcohol we are removing fluid from our body. All of these liquids are diuretics – i.e. they reduce the total amount of water available for the intestine to push the semi-digested food forward from the stomach into the duodenum, then to the small intestine, and then to the large intestine and finally to be stored in the rectum until expelled. Chronic dehydration can lead to chronic constipation.

Chronic constipation results in the stretching of the large bowel wall permanently. Once this wall becomes stretched, the muscle fibers within it are also stretched out of shape. This means that this muscle will no longer be able to function normally to squeeze and push the faecal mass along. This lack of muscle power results in further stretching as the bowel becomes even more filled with feces. Chronic constipation is very difficult to treat and often require medical intervention.

One other major cause of constipation is the excessive consumption of refined carbohydrates . In other words, we are not eating enough fruit vegetables and fiber. The fibers in fruit and vegetables distend the intestines. Distended intestines contract more vigorously and are able to move the food forward. One point to remember is the intestines will not work if there is no stimulus for them to work. The roughage (fiber) is actually the stimulus for the intestines to push the food forward. If we consume refined foods, drink plenty of coffee and alcohol then we are not giving our intestines either the stimulus or the physical capacity to push the fecal matter forward. A useful reminder, at this point is that the food has to be pushed forward, downward, upward and through all the narrow passages and bends. It is a tall order even in ideal conditions.

Please review the diagram below to understand peristalsis. Note that without the bulk to stimulate peristalsis there will be no peristalsis. If there is no peristalsis, then the food will not move forward. The result will be constipation.

Many modern medications cause constipation. These include ordinary medications like paracetamol, ibuprofen, codeine, many antihistamines and anti-emetics etc. When a client is on one of these medications the importance of fluids cannot be overstated.

As we get older our bodies slow down, this includes the gut. Most of may need help with managing our more healthily from professionals.

Pregnancy is a major cause of constipation. It is due to the pressure of the fetus on all the intestines.

When we are traveling, we tend to become constipated because we tend to ignore the urge to have a bowel movement. This process is exactly as when we are rushing off to work.

Diagram 2. Showing the Ascending colon, the transverse colon, the descending colon and the sigmoid colon .

Abuse of laxatives

Some patients abuse laxatives in order to loose weight. This abuse builds up a tolerance to laxatives. The end result is almost like addiction. Such patients need to take very large doses of laxatives for them to be effective. When Below is list of medications/conditions which cause constipation.

•  pain medications (especially narcotics)

•  antacids that contain aluminum and calcium

•  blood pressure medications (calcium channel blockers)

•  antiparkinson drugs

•  antispasmodics

•  antidepressants

•  iron supplements

•  diuretics

•  anticonvulsants

•  Surgery / paralytic ileus

Diseases that cause constipation include neurological disorders, metabolic and endocrine disorders, and systemic conditions that affect organ systems. These disorders can slow the movement of stool through the colon, rectum, or anus.

Other conditions that can cause constipation are found below.

Neurological disorders

•  multiple sclerosis

•  Parkinson’s disease

•  chronic idiopathic intestinal pseudo-obstruction

•  stroke

•  spinal cord injuries

Metabolic and endocrine conditions

•  diabetes

•  uremia

•  hypercalcemia

•  poor glycemic control

•  hypothyroidism

Systemic disorders

•  amyloidosis

•  lupus

•  scleroderma

For some citizens of this earth milk is very constipating and should be avoided or additional fibres be consumed to increase gut motility. If the patient is passing flatus, it can be reasonable to assume that the patient has fair gut motility.

Some clients have irritable bowel syndrome. This is characterized by periods of constipation followed by bouts of diarrhea. Such individuals should seek medical help and stay these patients stop taking laxatives they become constipated. In other words they have become dependent upon laxatives.

In the hospital setting many patients become constipated post operatively because they have been starved, dehydrated and fluids have been removed from their bodies. To make matters worse they are often given many medications which are often constipating. Abdominal surgery temporarily slows gut motility. This is constipating too. It is for this reason patients are encouraged to start eating drinking as soon as gut motility returns.

Some problems of the gut with reference to distribution of nerve endings in the rectum and colon can be constipating. Please see self learning series number 8 (diagram is given there).

Finally, problems with intestinal function (chronic idiopathic constipation) cause constipation. These are a group of factors which are not clearly understood.

In conclusion I must state that the most common causes of constipation are chronic dehydration, lack of fiber, lack or exercise and high stress. Each and all remedies must aim to address all of these issues. Further, they must address underlying behavioral issues and life choices. An effective, sustainable bowel routine is necessary to prevent chronic constipation. This can only happen if the natural process of peristalsis is allowed to do the work it is designed to do. At this moment it is appropriate to look at the peristaltic process.

Diagram 1: The Physiology of Peristalsis

(from http://www.vivo.colostate.edu/hbooks/pathphys/digestion/basics/peristalsis.html)

Peristalsis is a unique activity of smooth muscle contraction and relaxation. This activity pushes the food / waste forward from the oesophagus, into the stomach, into the duodenum, the small intestine, large intestines and finally into the rectum. It is stored in the rectum until it is filled and then expelled as faecal matter. Many anatomy and physiology books describe this process in a lot of detail but for he purposes of this article it is sufficient to say that the intestines cannot function properly if there is insufficient fibre, fluid and activity. Peristalsis is not affected by vagotomy or sympathectomy. This clearly indicates that the stimulus is strictly intrinsic, meaning that the stimulus to contract arises from within the intestine. Mechanical distension and mucosal irritation stimulate afferent enteric neurons. We will discuss this when we are discuss treatment and management. One last point, the intestines can be cut and sutured without anaesthesia because there is no nerve supply to them.

Good Bowel Habit = Good Nurition + Fluids + Exercise

.

This is the second part of this article I look at the possible interventions with a view the managing constipation, I prefer to call it, “good bowel habit”.

Management of Constipation

Treatment and management depends on the cause, severity, and duration of the constipation, in most cases dietary and lifestyle changes will help relieve symptoms and help prevent them from recurring.

Diet

A diet with enough fiber (20 to 35 grams each day) helps the body form soft, bulky stool. A well informed nurse, doctor or dietitian can help plan an appropriate diet. High-fiber foods include beans, whole grains and bran cereals, fresh fruits, and vegetables such as asparagus, Brussels sprouts, cabbage, and carrots. For people prone to constipation, limiting foods that have little or no fiber, such as ice cream, cheese, meat, and processed foods, is also important.

Change of lifestyle and / or job.

Other changes that may help treat and prevent constipation include drinking enough water and other liquids, such as fruit and vegetable juices and clear soups, so as not to become dehydrated, engaging in daily exercise, and reserving enough time to have a bowel movement. In addition, the urge to have a bowel movement should not be ignored.

Laxatives

Most people who are mildly constipated do not need laxatives. However, for those who have made diet and lifestyle changes and are still constipated, a doctor may recommend laxatives or enemas for a limited time. These treatments can help retrain a chronically sluggish bowel. For children, short-term treatment with laxatives, along with retraining to establish regular bowel habits, helps prevent constipation.

A doctor should determine when a patient needs a laxative and which form is best. Laxatives taken by mouth are available in liquid, tablet, gum powder, and granule forms. They work in various ways:

• Bulk-forming laxatives generally are considered the safest, but they can interfere with absorption of some medicines. These laxatives, also known as fiber supplements, are taken with water. They absorb water in the intestine and make the stool softer. Brand names include Metamucil, Fiberall, Citrucel, Konsyl, and Serutan. These agents must be taken with water or they can cause obstruction. Many people also report no relief after taking bulking agents and suffer from a worsening in bloating and abdominal pain.

• Stimulants cause rhythmic muscle contractions in the intestines. Brand names include Correctol, Dulcolax, Purge, and Senokot. Studies suggest that phenolphthalein, an ingredient in some stimulant laxatives, might increase a person’s risk for cancer. The Food and Drug Administration has proposed a ban on all over-the-counter products containing phenolphthalein. Most laxative makers have replaced, or plan to replace, phenolphthalein with a safer ingredient.

• Osmotics cause fluids to flow in a special way through the colon, resulting in bowel distention. This class of drugs is useful for people with idiopathic constipation. Brand names include Cephulac, Sorbitol, and Miralax. People with diabetes should be monitored for electrolyte imbalances.

• Stool softeners moisten the stool and prevent dehydration. These laxatives are often recommended after childbirth or surgery. Brand names include Colace and Surfak. These products are suggested for people who should avoid straining in order to pass a bowel movement. The prolonged use of this class of drugs may result in an electrolyte imbalance.

• Lubricants grease the stool, enabling it to move through the intestine more easily. Mineral oil is the most common example. Brand names include Fleet and Zymenol. Lubricants typically stimulate a bowel movement within 8 hours.

• Saline laxatives act like a sponge to draw water into the colon for easier passage of stool. Brand names include Milk of Magnesia and Haley’s M-O. Saline laxatives are used to treat acute constipation if there is no indication of bowel obstruction. Electrolyte imbalances have been reported with extended use, especially in small children and people with renal deficiency.

• Chloride channel activators increase intestinal fluid and motility to help stool pass, thereby reducing the symptoms of constipation. One such agent is Amitiza, which has been shown to be safely used for up to 6 to 12 months. Thereafter a doctor should assess the need for continued use.

• Serotonin agonists help the muscles in your intestines work correctly when a slow-moving digestive system is caused by low levels of serotonin. Serotonin is a neurotransmitter found mostly in the digestive tract. One brand-name agent is Zelnorm, which is prescribed for the short-term treatment of chronic constipation in people less than 65 years of age.

People who are dependent on laxatives need to slowly stop using them. A doctor can assist in this process. For most people, stopping laxatives restores the colon’s natural ability to contract.

Other Treatments

Treatment for constipation may be directed at a specific cause. For example, the doctor may recommend discontinuing medication or performing surgery to correct an anorectal problem such as rectal prolapse, a condition in which the lower portion of the colon turns inside out.

People with chronic constipation caused by anorectal dysfunction can use biofeedback to retrain the muscles that control bowel movements. Biofeedback involves using a sensor to monitor muscle activity, which is displayed on a computer screen, allowing for an accurate assessment of body functions. A health care professional uses this information to help the patient learn how to retrain these muscles.

Surgical removal of the colon may be an option for people with severe symptoms caused by colonic inertia. However, the benefits of this surgery must be weighed against possible complications, which include abdominal pain and diarrhea.

Complications of constipation

In children, this stretched bowel also loses feeling, and this results in the leakage of the fluid portion of the faeces. Children are unable to feel this leaking into their underpants, and are thus frequently accused of being lazy and are rejected by their peers for being smelly. This can lead to significant social and self esteem problems. Children who have suffered with constipation for some time may develop small splits in their anal skin. These are painful and often result in the child being unwilling to pass any further motions, this actually aggravates the constipation. Parachoc will ensure that these children cannot hold on. They simply have to go, and when they do, since the faecal mass is softened, there is minimal pain. This in turn builds up their confidence and reduces the fear of evacuating their bowels.

In adults haemorrhoids may develop as a result of constant straining at the toilet.

This article is not a substitute for medical opinion.