Constipation, can't go to the toilet?

According to a National Health Interview Survey, about 30 million people in the United States have frequent constipation. Those reporting constipation most often are women and adults age 65 and over. Pregnant women may have constipation, and it is a common problem following childbirth or surgery.

Constipation is one of the most common gastrointestinal complaints. However, most people treat themselves without seeking medical help, as is evident from the millions of dollars Americans spend on laxatives each year.

To understand constipation, it helps to know how the colon (large intestine) works. As food moves through the colon, it absorbs water while forming waste products, or stool. Muscle contractions in the colon push the stool toward the rectum. By the time stool reaches the rectum, it is solid because most of the water has been absorbed.

The hard and dry stools of constipation occur when the colon absorbs too much water or if the colon's muscle contractions are slow or sluggish, causing the stool to move through the colon too slowly.

Common causes of constipation are:

• Not enough liquids
• Lack of exercise
• Changes in life or routine such as pregnancy, older age, and travel
• Abuse of laxatives
• Ignoring the urge to have a bowel movement
• Not enough fiber in the diet

The most common cause of constipation is a diet low in fiber found in vegetables, fruits, and whole grains and high in fats found in cheese, eggs, and meats. People who eat plenty of high-fiber foods are less likely to become constipated.

Fiber--both soluble and insoluble--is the part of fruits, vegetables, and grains that the body cannot digest. Soluble fiber dissolves easily in water and takes on a soft, gel-like texture in the intestines. Insoluble fiber passes through the intestines almost unchanged. The bulk and soft texture of fiber help prevent hard, dry stools that are difficult to pass.

Some medications can cause constipation. They include:

• Pain medications (especially narcotics)
• Antacids that contain aluminum and calcium
• Blood pressure medications (calcium channel blockers)
• Antiparkinson drugs
• Antispasmodics
• Antidepressants
• Iron supplements
• Diuretics
• Anticonvulsants

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.

Several kinds of diseases can cause constipation:

• Neurological disorders
• Multiple sclerosis
• Parkinson's disease
• Chronic idiopathic intestinal pseudo-obstruction
• Stroke
• Spinal cord injuries
• Metabolic and endocrine conditions
• Diabetes
• Uunderactive or overactive thyroid gland
• Uremia
• Hypercalcemia
• Systemic disorders
• Amyloidosis
• Lupus
• Scleroderma

Intestinal obstruction, scar tissue (adhesions), diverticulosis, tumors, colorectal stricture, Hirschsprung's disease, or cancer can compress, squeeze, or narrow the intestine and rectum and cause constipation.

Some people have chronic constipation that does not respond to standard treatment. This rare condition, known as idiopathic (of unknown origin) chronic constipation may be related to problems with intestinal function such as problems with hormonal control or with nerves and muscles in the colon, rectum, or anus. Functional constipation occurs in both children and adults and is most common in women.

Colonic inertia and delayed transit are two types of functional constipation caused by decreased muscle activity in the colon. These syndromes may affect the entire colon or may be confined to the lower or sigmoid colon.

Functional constipation that stems from abnormalities in the structure of the anus and rectum is known as anorectal dysfunction, or anismus. These abnormalities result in an inability to relax the rectal and anal muscles that allow stool to exit.

Most people with constipation do not need extensive testing and can be treated with changes in diet and exercise. For example, in young people with mild symptoms, a medical history and physical examination may be all the health care practitioner needs to suggest successful treatment. The tests the health care practitioner performs depend on the duration and severity of the constipation, the person's age, and whether blood in stools, recent changes in bowel movements, or weight loss have occurred.

The health care practitioner may ask a patient to describe his or her constipation, including duration of symptoms, frequency of bowel movements, consistency of stools, presence of blood in the stool, and toilet habits (how often and where one has bowel movements). A record of eating habits, medication, and level of physical activity or exercise will also help the doctor determine the cause of constipation.

The clinical definition of constipation is any two of the following symptoms for at least 12 weeks (not necessarily consecutive) in the previous 12 months:

• Straining during bowel movements
• Lumpy or hard stool
• Sensation of incomplete evacuation
• Sensation of anorectal blockage/obstruction
• Fewer than three bowel movements per week

A physical exam may include a rectal exam with a gloved, lubricated finger to evaluate the tone of the muscle that closes off the anus (anal sphincter) and to detect tenderness, obstruction, or blood. In some cases, blood and thyroid tests may be necessary to look for thyroid disease and serum calcium or to rule out inflammatory, neoplastic, metabolic, and other systemic disorders.

Extensive testing usually is reserved for people with severe symptoms, for those with sudden changes in number and consistency of bowel movements or blood in the stool, and for older adults. Additional tests that may be used to evaluate constipation include

• Colorectal transit study
• Anorectal function tests

Because of an increased risk of colorectal cancer in older adults, the doctor may use tests to rule out a diagnosis of cancer, including

• Colorectal transit study. This test, reserved for those with chronic constipation, shows how well food moves through the colon. The patient swallows capsules containing small markers that are visible on an x ray. The movement of the markers through the colon is monitored with abdominal x rays taken several times 3 to 7 days after the capsule is swallowed. The patient follows a high-fiber diet during the course of this test.
• Anorectal function tests. These tests diagnose constipation caused by abnormal functioning of the anus or rectum (anorectal function). Anorectal manometry evaluates anal sphincter muscle function. For this test, a catheter or air-filled balloon inserted into the anus is slowly pulled back through the sphincter muscle to measure muscle tone and contractions.
• Defecography is an x ray of the anorectal area that evaluates completeness of stool elimination, identifies anorectal abnormalities, and evaluates rectal muscle contractions and relaxation. During the exam, the doctor fills the rectum with a soft paste that is the same consistency as stool. The patient sits on a toilet positioned inside an x ray machine and then relaxes and squeezes the anus to expel the paste. The doctor studies the x rays for anorectal problems that occurred as the paste was expelled.
• Barium enema x ray.This exam involves viewing the rectum, colon, and lower part of the small intestine to locate any problems. This part of the digestive tract is known as the bowel. This test may show intestinal obstruction and Hirschsprung's disease, a lack of nerves within the colon.

The night before the test, bowel cleansing, also called bowel prep, is necessary to clear the lower digestive tract. The patient drinks a special liquid to flush out the bowel. A clean bowel is important, because even a small amount of stool in the colon can hide details and result in an incomplete exam.

Because the colon does not show up well on x rays, the doctor fills it with barium, a chalky liquid that makes the area visible. Once the mixture coats the inside of colon and rectum, x rays are taken that reveal their shape and condition. The patient may feel some abdominal cramping when the barium fills the colon, but usually feels little discomfort after the procedure. Stools may be a whitish color for a few days after the exam.

An examination of the rectum and lower (sigmoid) colon is called a sigmoidoscopy. An examination of the rectum and entire colon is called a colonoscopy.

The patient usually has a liquid dinner the night before a sigmoidoscopy and takes an enema early the next morning. A light breakfast and a cleansing enema an hour before the test may also be necessary.

To perform a sigmoidoscopy, the doctor uses a long, flexible tube with a light on the end called a sigmoidoscope to view the rectum and lower colon. First, the doctor examines the rectum with a gloved, lubricated finger. Then, the sigmoidoscope is inserted through the anus into the rectum and lower colon.

The procedure may cause a mild sensation of wanting to move the bowels and abdominal pressure. Sometimes the doctor fills the colon with air to get a better view. The air may cause mild cramping.

To perform a colonoscopy, the doctor uses a flexible tube with a light on the end called a colonoscope to view the entire colon. This tube is longer than a sigmoidoscope. The same bowel cleansing used for the barium x ray is needed to clear the bowel of waste.

The patient is lightly sedated before the exam. During the exam, the patient lies on his or her side and the doctor inserts the tube through the anus and rectum into the colon. If an abnormality is seen, the doctor can use the colonoscope to remove a small piece of tissue for examination (biopsy). The patient may feel gassy and bloated after the procedure.

Although treatment depends on the cause, severity, and duration, in most cases dietary and lifestyle changes will help relieve symptoms of constipation and help prevent it.

Diet

A diet with enough fiber (20 to 35 grams each day) helps form soft, bulky stool. A 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. A high fiber supplement can also be helpful for busy people. 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.

Lifestyle Changes

Other changes that can help treat and prevent constipation include drinking enough water and other liquids such as fruit and vegetable juices and clear soups, 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, health care professionals 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, also helps prevent constipation. A alternative would be oxy-powder as it is gentle and non-habit forming.

People who are dependent on laxatives need to slowly stop using them. A health care practitioner can assist in this process. In most people, this restores the colon's natural ability to contract.

Other Treatments

Treatment may be directed at a specific cause. Colonics can be helpful to re-establish good bowl habits.

A doctor may recommend discontinuing medication or performing surgery to correct an anorectal problem such as rectal prolapse (try to avoid surgery at all cost, only if you have exhausted all other alternatives and you are sure that it is what YOU want)

Sometimes constipation can lead to complications. These complications include hemorrhoids caused by straining to have a bowel movement or anal fissures (tears in the skin around the anus) caused when hard stool stretches the sphincter muscle. As a result, rectal bleeding may occur, appearing as bright red streaks on the surface of the stool.

Sometimes straining causes a small amount of intestinal lining to push out from the anal opening. This condition, known as rectal prolapse, may lead to secretion of mucus from the anus. Usually eliminating the cause of the prolapse, such as straining or coughing, is the only treatment necessary. Severe or chronic prolapse requires surgery to strengthen and tighten the anal sphincter muscle or to repair the prolapsed lining.

Constipation may also cause hard stool to pack the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition, called fecal impaction, occurs most often in children and older adults. An impaction can be softened with mineral oil taken by mouth and by an enema . After softening the impaction, the doctor may break up and remove part of the hardened stool by inserting one or two fingers into the anus.