Constipation

Signs and Symptoms

• Fewer than 3 bowel movements a week
• Sudden decrease in the number of bowel movements
• Stools harder than usual
• Bowel still feels full after bowel movement
• Feeling bloated
• Straining during bowel movements

Many times constipation can be treated with over-the-counter remedies.

Causes

Constipation is most often caused by a low-fiber diet, lack of exercise, dehydration, or delay in going to the bathroom when you have the urge to defecate. Stress and travel can also contribute to constipation or other changes in bowel habits.

Other times, diseases of the bowel (such as irritable bowel syndrome), pregnancy, certain medical conditions (like an underactive thyroid or cystic fibrosis), mental health problems (such as depression), neurological diseases, metabolic disorders, or medications may cause constipation. More serious causes, like colon cancer, are not common.

More women than men seek help for constipation, suggesting that a hormonal imbalance may play a role.

Among the medications that can cause constipation are:

Some pain medications:

• Hydrocodone (Vicodin, Lortab)
• Hydromorphone (Dilaudid)
• Meperidine (Demerol)
• Oxycodone (Percocet, Oxycontin)

Anticonvulsants:

• Phenytoin (Dilantin)
• Valproic acid (Depakote)

Antacids:

• Gaviscon
• Maalox
• Mylanta
• Tums

Tricyclic antidepressants:

• Amitriptyline (Elavil)
• Doxepin (Sinequan)
• Imipramine (Tofranil)

Antihistamines:

• Diphenhydramine (Benadryl)
• Cetirizine (Zyrtec)

Analgesics:

• Acetaminophen
• Aspirin
• Non-steroidal anti-inflammatory drugs

Dopaminergic medications

Constipation in children often occurs if they hold back bowel movements when they are not ready for toilet training, or are afraid of it.

Diagnosis

Your doctor will perform a physical examination, which may include a rectal exam, and a pelvic exam if you are a woman. The doctor will check your medications to make sure they are not causing constipation and may run several tests to diagnose underlying illness. The following tests may help diagnose the cause of constipation:

• Blood tests
• Stool studies
• X-rays of the abdomen
• Upper GI series (to look at the esophagus, stomach, and upper part of the small intestines)
• Barium enema (to look at the colon)
• Proctosigmoidoscopy (an examination of the lower bowel) or, depending on the symptoms, a colonoscopy (an examination of the entire colon from the inside)

Preventive Care

Avoiding constipation is easier than treating it but involves the same lifestyle measures.

• Eat lots of fiber.
• Drink plenty of fluids each day (at least 8 glasses of water per day).
• Exercise regularly.
• Go to the bathroom when you have the urge. DO NOT wait.

Your doctor may suggest other alternatives.

Treatment Approach

Most mild cases of acute constipation can be treated with over-the-counter laxatives. However, these medications are only designed for short-term use. You can often prevent or treat chronic constipation with a combination of changes in your diet (like eating more fiber), drinking more water, and getting enough exercise. Your health care provider may talk with you about your bowel habits. For example, if you consistently delay going to the bathroom when you feel the urge, you could make constipation worse. Your doctor may ask you to use a laxative or stool softener or suggest a bulk-forming agent, such as psyllium, bran, or methylcellulose. In addition, certain herbs may help promote bowel activity. Use laxative herbs with caution because, like medications, they may become less effective if you use them constantly.

Studies support the use of biofeedback for obstructive constipation. One study found that obstructive constipation was corrected in 79% of people who received biofeedback compared to only 4% of those who received placebo treatment.

Lifestyle

Getting enough fiber in your diet (20 to 35g per day) helps prevent constipation. Vegetables, fresh fruits (especially dried fruits) and whole grains, including wheat and bran, or oatmeal cereals, are excellent sources of fiber. To reap the benefits of fiber, you must drink plenty of fluids (especially water) to help pass the stool. If adding more fiber to your diet causes gas or bloating, try adding fiber gradually.

Regular exercise also helps maintain good bowel movements. Even if you are in a wheelchair or bed, you can change position frequently and perform abdominal contraction exercises and leg raises. A physical therapist can recommend a program of exercises that's right for you.

Additional tips include:

• Take time to eat, breathe slowly and deeply, and chew food thoroughly.
• Cut back on high-sugar, high-fat foods.
• Drink plenty of liquids.
• Try a fiber supplement, such as Metamucil or Citrucel. Be sure to drink plenty of water, or these supplements could make constipation worse.

Medications

Your doctor may recommend a laxative to relieve temporary constipation. However, you should not use laxatives to treat chronic constipation. Many laxatives are available, both over the counter and by prescription. Laxatives can interact with a number of medications, so talk to your doctor before taking one if you also take other medications.

Bulk-forming laxatives. Often prescribed first for constipation, they can work as quickly as 12 hours after use. They swell in the intestines, softening the stool and making it easier to pass. Bulk-forming laxatives are made of indigestible fiber and are safe for long-term use, but you must take them with enough water or they can cause obstructions in the intestines. In some people they may cause bloating and abdominal pain. Bulk-forming laxatives include those made from psyllium (Metamucil, Fiberall), methylcellulose (Citrucel), and polycarbophil (FiberCon).

Stimulant laxatives. Work by causing the muscles in the intestines to contract, moving the stool along. They are designed for short-term use and can cause dehydration and problems with the body's electrolyte balance. Stimulant laxatives include Dulcolax, Correctol, Ex-Lax, castor oil, Senna, and Senokot.

Osmotic laxatives. Increase the amount of water in your intestines, making stool softer. They can be quick acting, but they can cause loss of fluids and electrolytes. Osmotic laxatives include lactulose (Cephulac), available by prescription, and polyethelyne glycol (MiraLAX); and saline laxatives, such as magnesium citrate and milk of magnesia.

Stool softeners. Often recommended after surgery, these laxatives make the stool softer. They are generally used in combination with stimulant laxatives, and can take 3 days to work.

Lubricant laxatives. Coat the stool and help it move through the intestine. The most common lubricant laxative is mineral oil. Mineral oil can have side effects; if it is accidentally aspirated (breathed in), it can cause pneumonia.

Suppositories. Suppositories, which are inserted into the rectum, may make it easier to pass hard stools (glycerin suppositories) or they can be a stimulant laxative that is absorbed into the body (Dulcolax suppositories).

Enemas. Saline enemas work like osmotic laxatives, while mineral oil enemas work like lubricant laxatives. You should not use enemas on a regular basis; they can cause electrolyte imbalances.

Tegaserod (Zelnorm). A prescription drug used to treat constipation in people with IBS. Because of an increased risk of cardiac problems (including heart attack and stroke), the Food and Drug Administration (FDA) restricts the use of Zelnorm to people who have found other treatments unsafe or ineffective.

Never give laxatives or enemas to children unless instructed by your doctor. People with any kind of bowel obstruction, abdominal inflammation, or kidney or heart failure should never take over-the-counter laxatives without talking to their physician.

Nutrition and Dietary Supplements

Adding more fiber to your diet and drinking adequate water usually helps relieve constipation. It is important to take any fiber supplement with plenty of water to avoid intestinal obstruction.

• Psyllium is a kind of soluble fiber used as a bulk-forming laxative in products such as Metamucil. It comes from a shrub-like herb called Plantago ovata that grows worldwide. Each plant can produce up to 15,000 tiny, gel-coated seeds, from which psyllium husk is derived. Psyllium can help relieve both constipation and diarrhea. It is used to treat irritable bowel syndrome, hemorrhoids, and other intestinal problems. When psyllium husk comes in contact with water, it swells and forms a gelatin-like mass that helps transport stool through the intestinal tract.
• Glucomannan is another type of soluble fiber, that comes from the root of the konjac plant (Amorphophallus konjac). Several studies have indicated it may be helpful for constipation.
• Probiotics, or "good" bacteria, keep the intestines healthy, however, studies using them to treat constipation have shown mixed results. Common types of probiotics include Lactobacillus, Bifidobacteria, and Sacchromyces boulardi. In one study, daily intake of yogurt-containing galacto-oligosaccharides, prunes, and linseed reduced the severity of constipation in elderly subjects with mild constipation. Another study found that constipation symptoms improved after subjects ate probiotic enriched artichokes compared to subjects who ate "normal" artichokes. People who are severely immunocompromised should use caution when taking probiotics. Speak with your physician.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, can trigger side effects and can interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care provider.

Herbs used for constipation fall into two categories: bulk-forming laxatives and stimulant laxatives.

Bulk-forming laxatives

Flaxseed (Linum usitatissimum) contains soluble fiber and is available as a powder or as whole or crushed seeds, which can be mixed with water or juice. Flaxseed is different from flaxseed oil, which is not used for constipation.

Other bulk-forming laxatives include:

• Fenugreek (Trigonella foenum-graecum)
• Barley (Hordeum vulgare)

Stimulant laxatives

Stimulant laxatives can cause pain, dehydration, and electrolyte imbalances, as well as interfere with other medications. Speak with a knowledgable practitioner.

• Senna (Cassia acutifolia, Cassia angustifolia, Cassia senna) and Cascara segrada (300 mg daily) are used in over-the-counter laxatives. Both work by irritating the colon wall, causing muscles to contract, and are only for short-term use.
• Aloe (Aloe vera, Aloe barbadensis, Aloe ferox) juice or aloe latex, a yellow, bitter liquid derived from the skin of the aloe leaf, is a powerful laxative. However, it can cause painful cramping and is not recommended. Other gentler, herbal laxatives from the same plant family as aloe, such as cascara and senna, are generally recommended first.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of constipation based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type. A constitutional type is defined as a person's physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

• Calcarea carbonica. For constipation without the urge to have a bowel movement; for children who often feel better when constipated rather than when bowel habits are normal; this remedy is most appropriate for individuals who tend to be overweight, lack stamina, experience heartburn, and produce sour-smelling belches; the individual may also suffer from pica (a craving for something not normally considered nutritional, such as dirt, clay, or chalk) and milk sensitivity.
• Nux vomica. For constipation accompanied by a constant urge to move the bowels, but with little success; or for constipation associated with overeating, alcohol, or drug use; this remedy is most appropriate for individuals who tend to be sensitive to noise, odors, and light.
• Silica. For constipation with the sensation that stool remains in the rectum after bowel movements; children for whom this remedy is appropriate may be wary of going to the bathroom; this remedy is most appropriate for individuals who tend to dislike cold temperatures, but prefer cold foods and drinks.
• Bryonia. For constipation with large, hard, dry stools; food feels like a lump in the individual's stomach and he or she may suffer from headaches with pain in both temples that may worsen with motion; this remedy is most appropriate for individuals who tend to be disagreeable, prefer cool rooms with open air, and whose thirst is quenched with cold drinks.
• Lycopodium. For small, hard stools with flatulence and bloating following a meal; this remedy is appropriate for individuals, particularly children, who fear being alone and have worsened symptoms in the late afternoon and early evening.

Other Considerations

Pregnancy

Constipation is common in pregnancy and is usually relieved by making dietary changes and drinking more water. If you are pregnant, do not take any herbs or over-the-counter laxatives that are stimulant laxatives because they might cause contractions. In fact, you should talk to your doctor before using any laxative if you are pregnant.

Prognosis and Complications

Passing large, wide stools may tear the mucosal membrane of the anus, especially in children. This can cause bleeding and the possibility of an anal fissure.

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