Chronic constipation

What is Constipation

Constipation is the passing of hard, dry bowel motions (stools) that may be infrequent or difficult to pass. The most common causes of constipation include a change in routine, not enough fiber in the daily diet, not enough fluids and lack of exercise.

Symptoms of Constipation

• Decreased frequency of defecation
• Hard, dry stools that may be painful to pass
• Straining to pass the motion
• Having to sit on the toilet for much longer than usual
• Sense of incomplete evacuation of bowels
• Bloating

In some cases, constipation is caused by more serious illnesses and events, including tumors and systemic diseases.

Lifestyle-related causes

Constipation can be caused by many different lifestyle factors that often work in combination, including:

• Low-fiber diet – As fiber is indigestible, it adds bulk to the feces, making it more easily pushed along the digestive tract. There are two broad types of fiber; soluble and insoluble. Soluble fiber helps to soften the feces. Good sources of soluble fiber include legumes, fruits, and vegetables. Insoluble fiber adds bulk to the feces, helping it to move more quickly through the bowel. Good sources of insoluble fiber are in wheat bran, whole grain bread, and cereals.
• Insufficient water intake – The fiber in feces will only plump up with water. Chronic Constipation can occur from a high-fiber diet if insufficient water is consumed.
• Lack of regular exercise – Living a sedentary lifestyle or being restricted in movement due to a disability are common causes of  chronic constipation.
• Ignoring the urge to go means that more water will be extracted from the stools, making them difficult to pass. Regularly ignoring this urge may make the body less sensitive to normal signals to go to the toilet.
• Medications – Such as narcotics (particularly codeine), antidepressants, iron supplements, calcium-channel blockers (antihypertensives, particularly verapamil) and non-magnesium antacids are known to slow bowel movements.
• Advancing age – Constipation is more common in the elderly. This is due to a number of factors, including reduced intestinal muscle contractions and reliance on regular medications.
• Diseases – A period of illness, particularly an illness resulting in hospitalization and bed-rest, typically results in constipation. Factors include a change in routine, shyness, reduced food intake, pain (especially after abdominal surgery), and pain-relief medication such as morphine. Short-term treatment with laxatives is often required but may be overlooked.

Medical Causes

Chronic constipation is sometimes symptomatic of underlying medical problems, such as:

• Slow transit – Some people naturally pass motions less often than most people. It seems their bowel ‘pacemaker’ may be less active. These individuals are more likely to become constipated with minor changes in their routine.
• Anal fissure – A tear in the lining of the anus (anal mucosa). The person may resist going to the toilet for fear of pain.
• Obstruction – The rectum or anus may be partially obstructed by, for example, hemorrhoids (piles) or rectal prolapse.
• Rectocoele – The rectum pushes through the weakened rear wall of the vagina when the woman bears down or strains.
• Hernia – An abdominal hernia can reduce intra-abdominal pressure, which makes it more difficult to pass a motion.
• Abdominal or gynecological surgery – A combination of the change in routine, strange surroundings, post-operative pain, and codeine-containing analgesics is a potent cause of constipation and often needs preventive care.
• Irritable bowel syndrome – IBS is Characterized by abdominal pain, bloating, and either constipation or diarrhea or alternating constipation and diarrhea.
• Problems of the endocrine system – Such as hypothyroidism, diabetes or hypopituitarism.
• Tumour – Pain while trying to pass a stool could be a symptom of rectal cancer.
• Diseases of the central nervous system – Such as multiple sclerosis, Parkinson’s disease or stroke are associated with increased susceptibility to constipation

Complications of chronic constipation

Some of the complications of chronic constipation include:

• Fecal impaction – The lower bowel and rectum become so packed with feces that the muscles of the bowels can’t push any of it out.
• Fecal incontinence – An overfull bowel can result in involuntary ‘dribbling’ of diarrhea.
• Hemorrhoids – Constant straining to open the bowel can damage the blood vessels of the rectum.
• Rectal prolapse – The constant straining pushes a section of rectal lining out of the anus.
• Urinary incontinence – The constant straining weakens pelvic floor muscles. This makes the involuntary passing of urine more likely, especially when coughing, laughing or sneezing

Diagnosis of constipation

The underlying reason for constipation must be found. Diagnosis of chronic constipation in India may include:

• medical history
• physical examination
• detailed questioning about medications, diet, exercise, and lifestyle habits

Chronic constipation treatment in India

Treatment of constipation in India depends on the cause, but could include:

• Removal of the impacted feces – Which may involve enemas, stool softeners and a short-term course of laxatives.
• Dietary changes – Such as increasing the amount of fiber in the daily diet. Dietitians generally recommend about 30g of fiber every day. Good sources of fiber include wholegrain cereals, fruits, vegetables, and legumes. The intake of foods such as milk, cheese, white rice, white flour, and red meat should be restricted because they tend to contribute to constipation.
• More fluids – Liquids help to plump out feces. However, it is important to restrict the intake of diuretic drinks such as tea, coffee, and alcohol.
• Fiber supplements – These may be helpful if the person is reluctant or unable to include more wholegrain foods, fresh fruits or vegetables in their daily diet. As fiber supplements can aggravate or cause constipation, always check with your doctor or dietitian when using them.
• Exercise – One of the many benefits of regular exercise is improved bowel motility. Ideally, exercise should be taken every day for about 30 minutes. People with a condition that affects mobility need to be as active as possible each day, as every little bit of regular exercise helps.
• Treatment for the underlying disorder – Such as surgery to repair an abdominal hernia, hormone replacement therapy for hypothyroidism, or anesthetic cream and sitz (salt water) baths for an anal fissure.
• Laxatives – There are two main types: bowel stimulants and agents that increase the water content of the stool. Bowel stimulants increase bowel contractions but may cause cramps. Agents that increase the water content may interfere with the absorption of water from the bowel, or swell or bulk up the stool with fluid. When used appropriately, laxatives can greatly relieve acute and chronic constipation. There is little evidence that chronic use of laxatives at appropriate doses will lead to a ‘lazy’ or ‘twisted’ bowel