Chronic (long term)

Constipation

Chronic (long term) Constipation

Dr. Prasanth Anton Sagayanathan

Dr. Isuru Almeda

Professor Nandadeva Samarasekera

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Published by: Department of Surgery, Faculty of Medicine, University of Colombo. 0112671846

ISBN-978-955-703-0043

Printed by

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Preface

Constipation is a common condition. Neglecting this condition may lead to complications in the long term of which, physical and mental suffering are the major concerns. However, constipation can be prevented by simple modifications in life style and proper knowledge about the condition. This booklet is made to give a basic knowledge about constipation and hope this will help to reduce the anxiety associated with this condition.

Dr. Prasanth Anton Sagayanathan MBBS (Colombo) Dr. Isuru Almeda MBBS (Colombo) Professor Nandadeva Samarasekera MS MD (East Anglia, UK) FRCS (Eng) FRCS (Edin) PGCertMedEd (Dundee)

Department of Surgery, Faculty of Medicine, University of Colombo.

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Table of Contents

What is normal bowel habit? 5

What is chronic (long term) constipation? 6

Who is at risk of constipation? 7

Risk factors 7

What causes constipation? 8

Tests done to identify causes of constipation 10

How is constipation treated? 11

When do you need to see a doctor? 15

What are the complications of chronic (long term) constipation? 16

How can I prevent constipation? 17

Important points to remember 18

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What is normal bowel habit?

Normal bowel habit for a healthy adult may vary due to many factors (e.g. level of activity, amount of water consumption etc.) and each individual may have different bowel motion pattern. But some people tend to think they are constipated if they don't have bowel motion every day. However, it is acceptable to have a range of bowel motions. For some people motions can be three times per day and for others it can be three motions per week.

Figure 1: Patients with constipation suffer from physical & mental distress

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What is chronic constipation?

Constipation means unable to have regular bowel motions. However, it is generally accepted that, if one is having less than three motions per week for more than three months, it is chronic constipation. The criteria for chronic (long term) constipation are given below

● Fewer than three bowel movements per week ● The need to strain during bowel movements for at least 25

percent of the time ● A feeling of not being able to complete your bowel

movement for at least 25 percent of the time ● Hard or lumpy stools for at least 25 percent of the time

If you have at least two of the symptoms listed above and have experienced these symptoms for at least three months, you may have chronic (long term) constipation.

Figure 2: stomach fullness & hard stools

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Who is at risk of chronic constipation?

Chronic constipation is more commonly seen in women than in men, children than in adults and elderly than in younger adults.

Risk factors

● Not having adequate fibre in your diet ● Dehydration or not drinking enough fluids ● Lack of physical activity ● Certain medication used for controlling pain, nausea, high

blood pressure and psychiatric illnesses ● Life changes such as pregnancy, old age ● Changes in lifestyle such as travelling, being bedridden or

chair bound ● Ignoring the urge to have a bowel movement ● Symptoms of depression

Figure 3: Drink more water Figure 4: Some examples of food that have a high fiber content

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What causes constipation? Causes of constipation are mostly multifactorial, however causes can be divided into three broad categories.

Normal transit [functional] constipation

This is the most common type, patients may pass stools at a normal rate, but still feel like they are constipated, difficulty with evacuation and hard stools are the important features of normal transit constipation.

Features

● Stomach fullness and pain / discomfort in your tummy ● Mental distress ● Mostly patients with normal transit constipation

respond to treatment with dietary fibre supplements alone or with addition of an osmotic laxative

Figure 3: Type of stools changes with the severity of constipation

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Slow transit constipation

This type of constipation is most commonly seen in young women who have infrequent bowel movements [once a week or fewer]. If you are suffering from slow-transit constipation, your stools pass more slowly through your large bowel. In addition to this delay you lose the ability to sense when you need to have a bowel movement.

Clinical features

● you may have irregular urge to pass stools ● Stomach fullness and pain / discomfort in your tummy ● Mild disease – fibre supplements in your diet may

increase stool weight and speed up movement in the large bowel

● More severe disease - the response to dietary fibre and to laxatives will be poor,

Pelvic floor dysfunction

Most commonly due to dysfunction of the pelvic muscles and/or anal sphincter. As a result patient will experience poor emptying of bowel even after straining a lot. Most patients give a history of using their fingers to remove the stools from the rectum or pushing the back wall of the vagina to empty the rectum.

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Tests done to identify the causes for chronic constipation

Physical Examination

A doctor may examine your tummy, and listen to the bowel sounds with a stethoscope, In most cases rectal examination may be done to identify local conditions such as anal fissures, piles, rectal masses, impaction of stools and also to identify pressure/tone of the anal sphincter

Laboratory tests

In some cases, blood investigations may be helpful to identify the causes for the constipation e.g. thyroid function tests, serum calcium level, fasting blood sugar etc.

Endoscopy assessment

This test is not done routinely, but in selected patients based on the indication, clinical decision will be taken by the doctor. In this test your doctor inserts a flexible lighted tube with a camera into the anus to visualize your large bowel.

Figure 4: Patient undergoing colonoscopy Figure 5: Endoscopic view of large bowel

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How is constipation treated? Lifestyle changes

Increase your fibre intake:

An average adult person needs 20-30 grams of fibre per day. Therefore eat food which are rich in fibre (e.g. fruit and vegetables). Aim to eat at least five portions of different fruits and vegetables each day. Whole grain foods and cereals, legumes, oats, nuts and seeds are the best sources of fibre.

Increase your physical activity:

Physical activity increases the muscle activity in intestine which keeps your gut moving. In addition, thirty minutes daily exercise at least three times per week protects you from cardiovascular diseases as well.

Increase your fluid intake:

It is recommended that adults consume at least 2 litres of water per day.

Don’t ignore the urge to use the toilet:

Some people suppress the feeling of bowel emptying if they are busy. It may result in hardening of stools which is difficult to pass later. Have a regular time to pass stools, preferably in the morning or 30 minutes after a meal because movements of the stools through the lower bowel is greatest at this time

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Medication

Bulking Agents:

These substances absorb liquids in the intestines and swell to form a soft, bulky stool. Also known as fibre supplements, these agents must be taken with water.

Osmotic Laxatives:

Draw water into the bowel from surrounding body tissues, providing a soft stool mass.

Stimulant Laxatives:

Encourage bowel movements by acting on the intestinal wall, causing rhythmic muscle contractions.

Stool Softners:

Help liquids mix into the stool and prevent dry, hard stool masses. Stool softeners are not laxatives, but can be used to help relieve excess straining or painful passage of stool due to a tear in the lining of the anus.

Emollients: Coat the bowel and the stool mass with a waterproof film so stool remains soft.

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Pelvic muscle training

As we already mentioned before, physical activity increases the muscle activity in the intestine which keep your gut moving. A well-coordinated muscle activity in the pelvis is needed to pass stools without difficulty. Some patients with constipation suffer from poor coordination of this muscle activity. A method called biofeedback training can actually help the patients to learn how to relax and tighten the muscles in the pelvis. Relaxing the pelvic floor muscles at the right time during bowel evacuation can help you pass stool more easily.

Figure 6: Picture showing pelvic muscle changes during passage of stool

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Surgery

Surgery is a treatment option especially when all other treatment modalities have failed and if the cause for the constipation is due to structural abnormalities such as rectocele, fissure and narrowing which can be corrected by surgery. When a patient has tried all other modalities without success especially when they have the slow transit constipation, surgical removal of part of the colon is an option but this type of operations are very rarely done.

Figure 7: Picture of a diverticula [an out pouch in your colon]

Figure 8: picture showing haemorrhoid

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When do you need to see a doctor?

Constipation can be more troublesome and it can badly affect your day to day activity as well as your quality of life. There are few symptoms along with your constipation considered as warning/ alarming symptoms. These symptoms may indicate a more serious underlying problem. These symptoms include,

● Recent onset or worsening constipation ● Fever higher than 100° F or 38° C ● Blood in the stools ● Nausea (feeling vomitish) and/or vomiting (throwing up)

with your constipation ● Stomach looks swollen and/or feels hard when you touch it. ● Pain in your stomach and you are unable to pass gas ● Loss of weight and/or loss of appetite

Figure 9: Consult your doctor if you have these symptoms

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What are the complications of long term constipation? Anal fissure

Frequent bouts of constipation may cause a split (tear) in the anal skin with the passage of particularly big or hard stools (faeces). This is a very painful condition and you may even see a small amount of fresh red blood. Treatment of an anal fissure involves lifestyle modifications (mentioned earlier) to keep the stools soft and sometimes the doctor may prescribe laxatives too (to make the stools soft and easy to pass). Local anaesthetic ointments or glyceryl trinitrate (GTN) ointment may be prescribed by your doctor to ease the pain and help to relax the muscles which will help the fissure to heal.

Inactive/ sluggish bowel Constipation in the long term along with the frequent use of a laxative will make the bowel become inactive. It means bowel will not work on its own without medication.

Stool impaction When you have severe constipation, large mass of hard stools can block the rectum. This condition needs more medical attention with higher doses of laxatives. Sometimes enemas and suppositories are also used.

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How can I prevent constipation? Drink more water

Have a regular toilet routine Increase your fibre intake

Increase your physical activity

Figure 10: Have regular toilet routine

Figure 11: Increase your physical activity

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Important points to remember

Figure 12: Summary of the treatment given in a stepwise approach

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Notes

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