Constipation is one of the most common gastrointestinal problems experienced by the general population; a study was undertaken to identify laxative usage within the Indian population in patients diagnosed by their General Practitioner (GP) as having constipation, estimated an Indian prevalence of up to 52 percent. Despite the high prevalence, constipation is often both misdiagnosed and under-treated. Particular groups of the population appear to be particularly vulnerable, such as children, women, older person and those undergoing palliative care.
Definition of constipation
The individual needs to have had 2 or more of the following symptoms present for at least 3 months:
- Lumpy or hard stools
- The sensation of incomplete evacuation
- The sensation of anorectal obstruction manual maneuvers to facilitate evacuation
- Less than 3 bowel movements per week
Constipation is considered to be the result of slow gut transit or dysfunctional evacuation. In slow gut transit, the stool moves very slowly through the colon which results in large, hard stools that are difficult to pass. As one of the functions of the colon is to reabsorb water from the stools, the longer the stools stay in the colon, the more water is drawn out. In a dysfunctional evacuation, although there may be a normal stool transit time, it is unable to be expelled from the rectum.
Acute constipation is more often associated with organic disease. It is important to determine whether the patient has a history or signs and symptoms of a neurological, endocrine, or metabolic disorder. These include abdominal pain, nausea, cramping, vomiting, weight loss, any blood in the stool, rectal bleeding, rectal pain, and fever.
Assessment of constipation:
Clarification of what the patient means by ‘constipation’ is important, as many individuals feel constipated because they are not opening their bowels on a daily basis, even if they are passing stools regularly with no apparent problem. The Bristol Stool Chart (Figure 1) should be used to determine the nature of the bowel movements (size, consistency, frequency), and the duration of constipation noted. Assessment of dietary fiber intake, level of physical activity, and use of medications, including over-the-counter (for example, laxatives) is also required. The patient’s perspective and concerns should be elicited, and a careful psychosocial history should be obtained; signs of depression or anxiety should be noted as these are known contributory factors. In adults, a rectal examination and palpation should be undertaken to detect the presence of masses, anal and perianal fissures, inflammation, or the presence of hard stool. In children, digital rectal examination (DRE) purely to establish if constipation is present is not recommended. As constipation is known to also affect the activity of the bladder it is important that any assessment also includes a review of the lower urinary tract.
Figure 2 gives an overview of suggested generic treatment and laxative options for adults presenting with constipation. Diet and lifestyle advice is the first-line option. Patients should be provided with advice and information which includes an explanation and etiology of constipation and an overview of treatment options. Patients should be advised not to ignore any spontaneous urge to defecate and to adopt the correct toilet position with the knees slightly higher than the hips, with feet supported on a step if necessary (Figure 3). Utilizing the gastro-colic reflex, particularly in the morning or after meals, should be encouraged.
For those with a very sedentary lifestyle, particularly the elderly, increasing physical activity may be helpful in stimulating bowel movements. Increased fluid intake may be of benefit for those individuals, particularly the elderly, whose daily intake of fluid is less than recommended volumes (approximately 2 liters per day). It is generally accepted that fiber is known to increase stool weight and shorten gut transit time with a recommended dose of 20-30g per day. It is important that any increase in fiber intake is done slowly. For individuals whose constipation remains unresolved despite these measures, consideration should be given to the use of laxatives or referral to a specialist service.
Constipation in childhood
Laxatives should be instigated as first-line treatment, with Polyethylene Glycol being the laxative of choice. Diet and lifestyle changes should also be addressed, but should not be seen as a standalone first-line treatment in any but mild-acute cases. The key issue with infants and children is to commence laxatives early, at a dose that produces regular soft formed stools and to continue with laxative treatment for at least 6 months if necessary to reduce the risk of relapse.
Constipation in women
Constipation appears to be more common in women for a number of reasons, including pregnancy and childbirth. Prucalopride as an option for women with unresolved chronic constipation in whom standard treatment (the use of two laxatives from different classes at the highest tolerated recommended dose, for at least 6 months) has failed to provide adequate relief. Prucalopride is not a laxative; it belongs to a group of medicines that enhance gut motility (prokinetics) and is a selective 5-HT4 receptor agonist. However, prucalopride should only be prescribed by a clinician with experience of treating constipation and who has carefully reviewed the woman’s treatment history
Constipation in pregnancy
Constipation is reported to be second only to nausea as the most common gastrointestinal complaint in pregnancy, resulting from physiological and anatomical changes in the gastrointestinal tract. It is estimated that between 11 and 38 percent of women who are pregnant experience problems with constipation. It is suggested that dietary and lifestyle changes should always be tried first and if these fail to resolve constipation, then the use of bulk-forming laxatives such as Isabgol, or osmotic laxatives such as PEG, should be tried.
Constipation in the older person
Constipation is said to affect up to 50 percent of older adults in the community and 74 percent of those living in nursing homes. Within the elderly population, constipation is more likely to have a multifactorial etiology including lifestyle and dietary issues; disease comorbidities, and side effects of poly-pharmacy. As a result, there often needs to be a multi-factorial treatment approach to take into account all the contributory factors.
Constipation is one of the most common gastrointestinal conditions found in the community. The delivery of patient-centered care which aims to individualize the treatment of constipation to the individual will help not only improve treatment outcomes but potentially shorten treatment time and reduce the risk of complications developing. For those individuals whose constipation fails to respond to community intervention then referral on for further investigation and treatment should be instigated.
Dr. Shrish Bhatnagar,
Consultant Pediatric Gastroenterologist, Hepatologist and Therapeutic Endoscopist
MD(Ped), SR(Ped Gastro, SGPGIMS), MIAP, MISG
Sparsh Child Care and Gastro Center, C Block, Near Post Office, Rajaji Puram, Lucknow.
Associate Prof. Pediatrics (Sub Specialty Pediatric Gastroenterology), ELMCH & VPIMS.
Lucknow. UP. 226017