Introduction
The feature picture shows a meal. [1] The intended message of this picture is to remind ourselves of the relationship between food choices and constipation. Most of us would have experienced an occasional episode of constipation. In some individuals constipation occurs frequently. Also in some individuals it seems more frequent with increasing age.
Definitions of normal and abnormal bowel habits
Constipation means different things to different individuals (Singhealth.com).[2] “Most commonly, it refers to infrequent bowel movements, but some interpret it as a decrease in the amount of stool. Others describe constipation as difficulty in passing motion, a sense of incomplete evacuation, or the need for medication to help pass motion.”. This is a nice quotation on constipation.
1-Constipation is generally defined as having a bowel movement less that 3 times a week (Mayo Clinic, 2022).[3]. Note that it can be normal not to have a bowel movement every day, provided this is habitual for you. On the other hand, if you are the kind of person with regular daily bowel movements, a change of frequency can be abnormal, even if it is still more than three times a week.
2-Red flags. The following are red flags- meaning you need to attend to it by seeing a doctor: (1) Change of bowel movement frequency or change of stool size, lasting three weeks or longer, and (2) Unexplained loss of weight. See your doctor without delay if any of these is the case. [2]
Symptoms & signs, and causes
Symptoms & signs
Symptoms of constipation can be varied. What is important is to spot the red flags described above.
Causes
1-Physiological causes [3]
- Inadequate fibre in the diet — We need to eat more vegetables, whole grain cereals, beans if this is the problem
- Inadequate exercise — We need to stay as active as possible and try to exercise regularly
- Ignoring the urge to pass motion — We need to obey the urge. Good also to create a regular schedule for bowel movements especially after a meal
2-Part of a chronic disease. [3]
- Type 2 diabetes mellitus (T2DM) — this is very common
- Underactive thyroid (Hypothyroidism)
- Overactive parathyroid gland (hyperparathyroidism) – this is not so common compared to hypothyroidism
3-Blockages in colon or rectum [3]
- Blockage in the large intestine (bowel obstruction) – could be due to a colon cancer, or rectal cancer. May present with swelling of abdomen.
- Narrowing of the colon (bowel stricture) — if blockage is complete may also cause swelling of abdomen
- Adhesions (gumming of intestines together from previous surgery) — can cause complete obstruction of the intestines and result in swelling of abdomen.
- Compression from a mass outside the colon e.g. a large tumor in the pelvis, rectocele, cystocele.
4-Problems with nerves around the colon and rectum [3]
- Parkinson’s disease
- Spinal cord injury
- Stroke.
Investigations & Diagnosis, and Treatment Pointers
Investigations & Diagnosis
- Blood tests. Test for low thyroid function (hypothyroidism) or high calcium levels (for hyperparathyroidism) — if the the history and examination have suggestive clinical features.
- Abdominal X-ray. This can show intestinal obstruction if this is present.
- Sigmoidoscopy to see the lower colon (also called sigmoid colon), and rectum.
- Colonoscopy to see the rectum and entire colon using a flexible, camera-equipped tube called the colonoscope.
Treatment pointers [4]
1-Diet and lifestyle changes
- Increase fibre intake if this is low. Begin slowly to increase vegetables in your diet.
- Exercise most days of the week. If you are not already exercising, talk to your doctor whether you are fit enough to start on an exercise programme.
- Do not ignore the urge to have a bowel movement.
2-Laxatives
The following laxatives are useful and are available over the counter:
- Gut stimulants: Sennosides (Senokot); Bisacodyl (Dulcolax).
- Osmotics: Lactulose, polyethylene glycol (Miralax), Milk of Magnesia
- Fibre supplements: Psyllium (Metamucil) is a commonly used example.
- Suppositories: Glycerin suppositories, Bisacodyl suppositories — this is for effective evacuation within 30 minutes of application.
3-Surgery
- If the cause is a blockage, rectocele, or stricture, surgery will be required.
Take home messages
- Constipation is a common problem and is defined as having fewer than three bowel movements a week.
- There are 4 groups of causes.
- Investigations consist of blood tests, abdominal X-ray, sigmoidoscopy, and colonoscopy.
- Treatment pointers consist of diet and lifestyle changes, laxatives, and surgery where indicated.
Acknowledgments: Thanks are due to Orijit Chatterjee for the Unsplash picture
References
- Orijit Chatterjee. Unsplash
- Anon. Chronic Constipation. Department of Family Medicine, Sengkang General Hospital. https://www.singhealth.com.sg/patient-care/conditions-treatments/chronic-constipation URL: Accessed 27 Sep 22.
- Mayo Clinic Staff Writers. Constipation — Symptoms & causes. Mayo Clinic, 2022. https://www.mayoclinic.org/diseases-conditions/constipation/symptoms-causes/syc-20354253
- Mayo Clinic Staff Writers. Constipation — Diagnosis & Treatment. Mayo Clinic, 2022. https://www.mayoclinic.org/diseases-conditions/constipation/diagnosis-treatment/drc-20354259