What Is Constipation
When bowel movements are infrequent and difficult or when there is incomplete emptying of the rectum, it is referred to as constipation. It is not a disease but an underlying symptom of some other disorder.
Constipation is classified as acute and chronic depending on the nature and duration of the condition. When there is a sudden development of severe constipation, it is termed acute constipation. A gradually developed constipation, which continues over a period of time ranging from months to years, is called chronic constipation.
Some people have the misconception that at least one bowel movement a day is necessary and if they fail to have it, they consider it as constipation. The frequency of bowel movements varies from person to person and normally it may range from three movements a day to three a week. More than the frequency, it is the regularity of bowel movements that is important, and what should be considered abnormal is a sudden change in the usual pattern. The consistency, color and quantity of stool also may vary between individuals depending on the quantity and type of foods they consume and also on their body nature. Usually, many abdominal symptoms such as nausea, gas and lack of appetite are blamed on constipation. But, constipation is not the disease which causes those symptoms but it is just another symptom caused by an underlying disease. Overusing laxatives, suppositories and enemas, to ensure daily bowel movements, is an extremely unhealthy practice. The aim should not be daily motions but regularity and ease of bowel movements. Including plenty of fruits and vegetables and unpolished cereals in the diet is a healthier option to avoid constipation.
Complications: Even though constipation is not a disease, it gives rise to many complications which may eventually become disorders of the digestive system.
The following are some of the complications precipitated by frequent constipation:
- Fecal impaction due to hard stools
- hemorrhoids
- Anal fissure
- Diverticular disease
- Rectal prolapse
People who have constipation may develop a complete blockage in the movement of stool due to hard stools in the rectum or in the lower part of the large intestine. This condition is called fecal impaction. It is very common in older people and in those who have been bed ridden for a long time and also in pregnant women. Lack of physical activity and barium based imaging tests are also known to cause this condition. It may result in pain and cramping of the rectum. When mucus and stool in liquid form leak from around the blockage, it would seem as the person is having diarrhea instead of constipation. Such a condition is called paradoxic diarrhea. The person still feels as if the rectum is full, in spite of the diarrhea and the repeated efforts at complete voiding.
When stools are hard and difficult to pass, people tend to strain excessively to bring about a bowel movement. This forceful straining raises the pressure in the veins lining the anus, leading to their enlargement and development of hemorrhoids.
The passage of very hard or very large stool may injure the walls of the anus and may result in cuts called annual fissure.
Sometimes, due to repeated straining, the rectum may get dislocated from its normal position and it may prolapse in to the anus; this condition is called rectal prolapse.
The large intestine may have to use additional force to push hardened stool, especially when it is small too. This weakens the intestinal wall, particularly of the colon, and causes it to bulge outwards and form balloon-like projections called diverticula which can get filled with fecal matter and may start bleeding. If diverticula rupture, a serious condition called peritonitis results.
Complications of constipation being painful, it may induce people to delay or postpone the emptying of bowels, worsening the condition. Laxatives or stool softeners may be required to break this vicious cycle. However, such measures should be resorted to with caution and moderation. Overuse of these substances may interfere with the normal movements of the digestive tract, resulting in chronic constipation.
Several misconceptions about bowel movements often result in the abuse of laxatives. Some cultural and social conditioning dictates these false theories:
- It is necessary to have daily bowel movements
- Stool is an unclean material which should not remain in the body
- All ills of the body stem from accumulation of stool
- Daily habit of emptying the bowels is a cure for all ailments
People with these beliefs spend large amounts of time in the toilet, overstrain themselves and misuse laxatives and enema.
Causes Of Constipation
Constipation can be precipitated by the following:
- Alterations in food habits
- Medications which have the side effect of slowing down bowel movements
- Irregularity in bowel movements
- Overuse or abuse of laxatives
Most of the reasons for constipation can be found in the dietary habits of people. Dehydration due to insufficient intake of water and other liquids is a major cause of constipation. To preserve sufficient volume of water in the body, the water content in the digested food may be reabsorbed into the body while the waste products are passing through the large intestine, making the stool very hard. The fiber contained in fruits, vegetables and unpolished cereals, absorbs and retains large amounts of water. They act as bulking agents, which gives stool a light texture making it easy to move down the intestines with the natural peristaltic movements. If sufficient quantity of fiber is not present in the diet, the stools become compacted and small, making it hard for the intestinal walls to push them forward. Thus, people who eat less vegetables and fruits and more of processed foods tend to have constipation.
Constipation may be caused by certain drugs such as iron supplements, anticholinergic drugs such as certain antidepressants and antihistamines. Opioids, sedatives, antihypertensive drugs, antacids containing aluminum hydroxide and bismuth subsalicylate often cause constipation.
Some people may find it difficult to make a bowel movement, in spite of having the urge to do so. Their stools may not be hard but still it is difficult to pass, probably because the muscles in the rectum or the anus that help in moving the stools do not contract or relax properly. This condition is called dyschezia or disordered defecation. Those who have the abnormal condition called IBS or irritable bowel syndrome often have dyschezia.
Frequent use of laxatives or enemas become addictive and people may find that they are constipated and unable to have a bowel movement without the aid of those substances, which leads to increased use of laxatives, creating a vicious cycle.
There are several other reasons for constipation which may have neurological or metabolic origin. Physical obstructions in the intestines also may result in constipation. When people are recuperating from serious illnesses, prolonged inactivity and decrease in the quantity of food taken may cause constipation. It may be due to the sluggish movement of the intestines resulting from the lessened physical activity or from the lack of bulk in the intestines which makes it harder to push the stool forward.
Obstructions in the intestines may lead to constipation. People who have had surgery of the small intestines are prone to develop scar tissue and adhesions in those areas which can obstruct the smooth passage of stool down the intestines. Large tumors, either cancerous or benign, may block the large intestines, especially in the lower portion called colon, impeding the movement of the stool, resulting in constipation.
Hypothyroidism caused by the decreased production of hormones by the thyroid glands may result in constipation. High levels of calcium in the blood called hypercalcemia also may cause constipation. Certain neurological problems like diabetic neuropathy, Parkinson’s disease and spinal cord injury may affect the nerves of the intestines, causing them to slow down their normal movements, resulting in constipation.
Evaluation
Since constipation is the most common complaint associated with the digestive system and not all kinds of constipation may have serious causes or complications, people should evaluate their condition and look for other symptoms which may necessitate a visit to the doctor
Warning signs: When certain other symptoms are present along with constipation, it may be necessary to consult a doctor as soon as possible. Some of the warning signs given below, when accompanied by constipation, calls for a visit to the doctor right away.
- Swelling up of the abdomen
- Traces of blood in the stool
- Vomiting without any other reason
- Sudden or steadily worsening constipation, especially in older people
- Recent noticeable weight loss without any apparent cause
When to see a doctor: If vomiting, blood in the stool or distention of abdomen are not present, the patient may call the doctor first, before making a visit to the clinic. Taking into account the symptoms present, and the medical history of the patient, doctor may decide whether a visit is necessary. General measures to improve bowel movements, including laxatives, may be prescribed for a trial period which may be enough to clear out the bowels.
When the patient visits the doctor with the complaint of constipation, a physical examination is conducted. Previous medical history, drugs taken, food habits and activities of the patient are all noted. Based on these factors and the physical examination, doctor may decide on further tests and treatment.
Physical examination includes checking the abdomen for signs of distention and the presence of masses in the intestines. Rectum may be manually or visually checked for bleeding, fissures, hemorrhoids and other growths. Body is generally checked for evidence of other diseases and the signs of cachexia, which is muscle and fat tissue atrophy due to severe weight loss.
Doctors frequently ask these questions to ascertain the cause and severity of constipation.
- The usual frequency of bowel movements and the consistency of stool.
- The need or habit of straining to pass stools and whether there is practice of pressing the perineal area to aid defecation.
- Level of satisfaction after a bowel movement, whether there is a feeling of fullness even after defecation.
- The use of laxatives, suppositories and enema.
- Usual diet and the level of physical activity and any recent change in them.
- The drugs which are currently in use and any recent change in the medication.
- neurologic and metabolic disorders such as Parkinson’s disease, diabetes and injury to spinal cord
Testing: When the reason for the constipation is straight forward and clear, further testing may be unnecessary, and measures to relieve the constipation are initiated immediately. But in the absence of any such obvious causes like drug use, physical inactivity or injury, doctors may advice certain tests. If warning signs which often indicate an underlying disorder are present, tests are necessary to identify the exact cause. When constipation is not resolved in a day or two with general measures and the use of laxatives, tests have to be conducted to detect fecal impaction or obstructions in the intestines.
X-rays of the abdomen and ultrasound or CT scans are tests used to detect obstructions in the intestines. Colonoscopy and sigmoidoscopy are done to detect the presence of cancers, diverticula and hemorrhoids. Blood tests to check thyroid function, and the presence of excess calcium levels in the blood, are also conducted.
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Yasser Elnahas
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