Constipation in Adults Overview

Constipation in Adults Overview

Constipation refers to a decrease in the frequency of bowel movements or difficulty in passing stools. The stool of a constipated person is typically hard because it contains less water than normal. Constipation is a symptom, not a disease.

Generally, constipation is difficult to define clearly because as a symptom it varies from person to person. In addition, because we generally don't discuss the frequency of our bowel movements or observe each other having them, it is often difficult for people to know whether they are having less frequent stools, or experiencing increased difficulty in moving their bowels than others.

• The "normal" frequency of bowel movements varies greatly, ranging from 3 movements per day to 3 per week. Such variation may occur among cultures and groups of people, among individuals, or even for an individual person without necessarily being a sign of disease. However, if a person has had a generally even frequency of bowel function that changes acutely and persists in its new form for longer periods of time, this may be a reason to consult a physician. Generally, if a person has not moved the bowels for 3 successive days, the intestinal contents harden, and the person experiences difficulty or even pain during defecation, medical care should be sought.
• A common misconception about constipation is that wastes stored in your body are absorbed, are dangerous to your health, and may shorten your life-span. Some people have an underlying fear that they will be "poisoned" by their own intestinal wastes (feces) if they retain the waste in their bodies for more than a certain length of time. None of this is true. There is little evidence that "colonic cleansing" improves health in individuals with normal bowel function.
• Older people are five times more likely than younger people to complain about the onset of new constipation.

Constipation in Adults Causes

Constipation may result from a poor diet, poor bowel habits, or problems in elimination of stool, whether physical, functional, or voluntary.

These are the most common causes of constipation:

Poor diet: Eating foods rich in animal fats (dairy products, meats, and eggs) or refined sugar but low in fiber (whole grains, fruits, and vegetables) .

Inadequate fluid intake: Not drinking enough water can lead to hard dry stools. Fluid is absorbed in the intestine, and people who don't drink enough water may not pass enough water into the colon to keep their stools soft.

Caffeine and alcohol: These induce increased urination of water. This leads to (relative) dehydration that increases water absorption from the intestine. This can in turn lead to constipation when not enough fluid is retained in the stool.

Poor bowel habits: Ignoring the desire to have bowel movements may initiate a cycle of constipation.

• After a period of time, the person may stop feeling the desire to move the bowels.
• This leads to progressive constipation. For example, some people may avoid using public toilets or ignore going to the toilet because they are busy.

Medications: Many medications can cause constipation.

• Antacids that contain aluminum hydroxide (Alternagel, Alu-Cap, Alu-Tab, Amphojel, Dialume) and calcium carbonate (Rolaids, Mylanta, Maalox, Tums, etc.)
• Antispasmodic drugs
• Antidepressants
• Iron tablets
• Anticonvulsant drugs
• Diuretics (because they can work like caffeine and alcohol as mentioned previously)

• Painkillers, narcotic-containing drugs, for example, may suppress bowel function.

Travel: Changes in lifestyle, low fluid intake, and eating fast food may cause constipation.

Irritable bowel syndrome (IBS, spastic colon):  Because of changes in bowel function, if a person has this disorder, he or she may have crampy abdominal pain, excessive gas, bloating, and constipation, sometimes alternating with diarrhea.

Laxative abuse: Habitually using laxatives will gradually produce dependency on them.

• The person may eventually require increasing amounts of laxatives to move the bowels.
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• In some instances, the bowel will become insensitive to laxatives and the person will not be able to move the bowels even with laxatives.

Pregnancy: Constipation during pregnancy may be due to several factors. Each of the following conditions produces severe pain on defecation, which may trigger a reflex spasm of the anal sphincter muscle. The spasm may delay bowel movement and decrease the desire for bowel opening as a means to avoid the anal pain.

• Mechanical pressure on the bowel by the heavy womb
• Hormonal changes during pregnancy
• Changes in food and fluid intake
• Anal fissure (cracks in the anus)
• Painful hemorrhoids (piles)
• Anal stenosis (narrow anus)

Intestinal obstruction: Mechanical compression and interference with the normal functions of the bowel may occur in the following ways:

• Scarring of the intestine from inflammation due to diseases such as diverticulitis or Crohn's disease (an inflammatory bowel disease)
• Inflammatory adhesions and joining of tissues
• Intestinal cancers
• Abdominal hernia, loops of the intestine become obstructed
• Gallstones that have become immovably wedged in the intestine
• Twisting of the intestine upon itself (volvulus)
• Foreign bodies (swallowed or introduced into the intestine from the anus)
• Intussusception refers to "telescoping of the intestine" in which one part of the intestine is drawn into another part (This occurs mainly in children.)
• Postoperative adhesions (internal scarring after previous abdominal surgery) can block the small intestine and cause the inability to pass gas or move the bowels, but relatively rarely blocks the large intestine (colon).

Mechanical problems of the anus and rectum (the bottom part of the colon) that includes the rectum pushing out the anus (rectal prolapse) or into the vagina.

Damage to nerves within the intestine: (Spinal cord tumors, multiple sclerosis, or spinal cord injuries may produce constipation by interfering with the function of the nerves supplying the intestine.)

Connective tissue diseases: Conditions such as scleroderma and lupus

Poor-functioning thyroid gland: A low production of thyroxin, a hormone produced by the thyroid gland, hypothyroidism, causing constipation

Lead poisoning and other metabolic disorders

Age: Older adults are more likely to have constipation for the following reasons:

• Poor diet and insufficient intake of fluids
• Lack of exercise
• Side effects of prescription drugs used to treat other conditions
• Poor bowel habits
• Prolonged bed rest, for example after an accident or during an illness
• Habitual use of enemas and laxatives

It should be noted that although that this is a long list of possibly scary causes of constipation, most chronic constipation is simply from inadequate intake of dietary fiber and water, and can be managed by substantially increasing the intake of both.

Constipation in Adults Symptoms

An individual may exhibit a broad range of symptoms of constipation depending on his or her normal bowel habits, diet, and age. These are common problems a person may have if he or she is constipated:

• Difficulty in starting or completing a bowel movement
• Infrequent and difficult passage of stool
• Passing hard stool after prolonged straining
• If the person has irritable bowel syndrome (IBS), crampy abdominal pain, excessive gas, a sense of bloating, and a change in bowel habits
• If the person has an intestinal obstruction, nausea, vomiting, no defecation, and inability to pass gas
• Distended abdomen, headaches, and loss of appetite
• Coated (furred) tongue, bad breath (halitosis), and bad taste in the mouth

When to Seek Medical Care for Constipation

Call your health care practitioner if you have these concerns:

• Symptoms are severe and last longer than 3 weeks
• Recent and significant change in bowel habits, for instance, constipation alternates with diarrhea
• Severe pain in the anus during a bowel movement
• Symptoms of other diseases in addition to constipation (for example, tiredness, fatigue, poor tolerance to cold weather may suggest the need to assess thyroid function for hypothyroidism, an underactive gland.)
• Constipation for 2 weeks or longer with returning abdominal pain, which might be a sign of lead poisoning

When to seek emergency medical care

Although constipation may be extremely uncomfortable, it is usually not serious. It may signal a serious underlying disorder, however, such as cancer of the bowel. Because constipation may lead to complications, go to a hospital's emergency department for any of the following reasons:

• Rectal bleeding
• Anal pain and hemorrhoids
• Anal fissures or cracks in the mucous lining (severe pain during defecation in the anal area)
• Fecal impaction (immovable intestinal contents) in very young children and in older adults
• Rectal prolapse or sagging (Occasionally, straining causes a small amount of the intestinal lining to push out from the rectal opening. This may lead to secretion of mucus that may stain the undergarments.)
• Recurrent vomiting with constipation and abdominal pain (This may suggest intestinal obstruction and needs urgent hospital treatment.)
• Severe abdominal pain with the constipation that is constant and worsening, especially if it is accompanied by a fever.

Constipation in Adults Diagnosis

Your health care practitioner may ask the affected individual several questions, conduct a physical exam, and perform certain lab tests to find out the possible causes of his or her constipation.

Answers to these questions will help the doctor assess the affected person's condition and plan treatment options.

• What are your normal bowel habits?
• How long have you had difficulty in passing stool?
• When was the last time you passed stool?
• Are you able to pass gas?
• Do you experience any abdominal or anal pain?
• Could you indicate with your finger the site of your pain?
• How would you describe your abdominal pain?
• Have you noticed any changes in your body temperature?
• Have you tried any medication? Did it help?
• Do you usually take laxatives or an enema? If yes, what type of laxatives and how many tablets per day do you usually take?
• Do you feel that you always need laxatives to pass stool?
• Do you have any other symptoms?
• Any changes in your appetite?
• Any changes in your body weight?
• Do you feel better after passing stools?
• Do you feel sick? Have you thrown up?
• Any hospital admission or investigations for similar illness?
• Are you pregnant?
• Do you smoke cigarettes? When did you start smoking? How many cigarettes do you smoke per day?
• Do you drink alcohol? Coffee? Tea?
How much?
• Do you use drugs? Any medications?
• Have you ever had surgery? What surgery? When?
• Any joint pain, eye problems, back or neck pain, or skin changes?
• Do you usually prefer the warm weather?
• Do you usually feel tired?
• Do you have a family history of constipation or bowel cancer?
• Have you ever been screened for colon cancer?

The health care practitioner will examine the patient's abdomen, anus, and other body systems including the nervous system, the thyroid gland (for any goiter), and the musculoskeletal system. What the health care practitioner examines will depend on the patient's answers to the questions and any history that may suggest certain disorders.

The health care practitioner will decide which tests the patient needs based on his or her symptoms, history, and exam. These tests will help assess the actual cause of the problem. The most commonly used tests may include the following:

Lab Tests

• Examining a stool sample under a microscope
• Complete blood count (CBC) and blood film
• Thyroid function tests if hypothyroidism is suspected

Imaging

• Upright plain X-ray of the chest and abdomen may show free air from intestinal perforation or signs of intestinal obstruction
• Barium enema may reveal a disease of the colon
• Assessment of food movement may demonstrate a prolonged and delayed transit time

Procedures

• Sigmoidoscopy may help to detect problems in the rectum and lower colon. The doctor will insert a flexible lighted instrument through the anus to visualize the rectum and the lower intestine.
• Colonoscopy uses an internal examination, your doctor can suspect the diagnosis of irritable bowel syndrome by ruling out more serious disorders. The doctor also may take tissue biopsies for further studies to assess the cause underlying your symptoms.

Constipation in Adults Treatment

If the patient's bowel is not blocked, realistic goals of medical treatment must be established between the patient and health care practitioner.

• All cases will require dietary advice. Treatment may be difficult, particularly in those with chronic constipation.
The doctor may prescribe bulk-forming agents in addition to dietary changes.
• Increased activity in the elderly and regular exercise in younger people will help.

Constipation in Adults Self-Care at Home

• Fiber: Get more fiber or bulk in the diet. If this cannot be done adequately by diet changes, consider adding a fiber supplement to the diet. There are many of these available, including psyllium (Metamucil) and methylcellulose (Citrucel). In general, these fiber supplements are not drugs and are safe and effective if taken together with sufficient water. They are not laxatives and must be taken regularly (whether you are constipated or not) in order for them to help you avoid future constipation. They are generally taken suspended in a glass of water one to three times daily. Start with once daily, and increase to twice daily after a week, and then to three times daily after another week if necessary.
• Exercise: Regular physical activity is an important component in bowel health. Try a daily exercise such as the knee-to-chest position. Such positions may activate bowel movements. Spend about 10-15 minutes in this position. Breathe in and out deeply.
• Hydration: Drink plenty of fluids, especially water and fruit juices. Drink 6-8 glasses of water daily in addition to beverages with meals.
• Alcohol and Caffeine: Decrease alcohol intake and caffeinated beverages, including coffee, tea, or cola drinks. In general, it is a good idea to have an extra glass of water (over and above the 6 to 8 daily mentioned previously) for every cup of coffee, tea, or alcoholic drink.
• Bowel Hygiene: Go to the toilet at the same time every day, preferably after meals, and allow enough time as not to strain.
• Laxatives: Avoid using over-the-counter laxatives. Try to avoid laxatives containing senna (Senokot) or buckthorn (Rhamnus purshiana) because long-term intake may damage the lining of the bowel and injure nerve endings to the colon.

Constipation in Adults Medications

If these initial measures fail, the health care practitioner may try a number of laxatives on a short-term basis. The patient must consult with his or her doctor before using any of these agents, particularly on long-term basis.

• Mineral oils can be very helpful in the short-term, but are associated with health risks for long-term use. They also can cause substantial diarrhea if too much is taken.
• Sodium docusate or calcium docusate may be useful when the patient must avoid straining for a short period of time, such as after a heart attack, during pregnancy, or after gastrointestinal surgery. They often will lose their effectiveness after several days.
• Fiber supplements as mentioned previously.

A doctor will treat any underlying diseases (intestinal obstruction, anal fissure, hemorrhoids, and bowel cancer).

• If the patient has irritable bowel syndrome (IBS), he or she should stop smoking and avoid coffee and milk-containing foods. A food diary may help to identify foods that seem to worsen the symptoms.
• Thyroxin will be prescribed if the doctor determines through clinical and laboratory tests that the patient has an underactive thyroid gland (hypothyroidism).

Constipation in Adults Home Remedies

Aloe juice and aloe latex have been used as laxatives, but should not be confused with aloe vera gel used for wound healing or sunburn. The FDA rules that aloe is not safe as a stimulant laxative. Rhubarb or any tonics containing it are also not proven safe as a laxative.

NOTE: If you choose to use remedies involving homeopathy, herbs, dietary and nutritional supplements, acupressure, aromatherapy, and other alternative or complementary healing methods, be advised that these products and techniques have usually not been scientifically proven to treat, prevent, or cure any disease. Serious interactions with prescription and nonprescription medications are always a possibility. Keep your doctor informed about every medication or medicine-like substance you use and seek medical advice before taking any medication or remedy.

Constipation in Adults Follow-up

• If the person has specific disorders such as hypothyroidism, scleroderma, and lupus, he or she may require regular follow-ups with a health care practitioner.
• Elderly people with a history of fecal impaction and fecal incontinence should be followed regularly to ensure that they do not develop further attacks.
• Young people with anorexia nervosa need a team of specialists to assess and follow the underlying illness, as well as to provide support and education.

Constipation in Adults Prevention

• Develop regular bowel habits. Set aside time before or after breakfast to use the toilet.
• Do not ignore the desire to defecate. Answer nature's call to empty your bowel as soon as possible.
• Eat a well-balanced diet that includes wheat grains, fresh fruits, and vegetables. Recent evidence suggests that increasing dietary fiber intake may help some people with hard stools, but is not necessarily of benefit in every person with constipation.
• Drink plenty of water and fruit juice.
• Exercise regularly. Walking is especially important.
• Avoid intake of medications that may cause constipation. Your doctor or pharmacist can help you in this regard.
• The use of laxatives can make a constipation problem worse in the long-term and should be avoided.

Constipation in Adults Prognosis

Most people with constipation have no physical disease of the digestive system nor any widespread disease associated with constipation. Most of the time, constipation is related to poor dietary habits, low fluid intake, and lack of exercise.

• For people with constipation caused by illness, recovery will be determined by how sick the affected individual is.
• The person will usually recover well if his or her constipation is caused by hemorrhoids or anal fissures.

Irritable Bowel Syndrome

Irritable Bowel Syndrome Overview

Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder of unknown cause. Common symptoms include abdominal cramping or pain, bloating and gassiness, and altered bowel habits.

Irritable bowel syndrome has also been called spastic colon, functional bowel disease, and mucous colitis. However, IBS is not a true "colitis." The term colitis refers to a separate group of conditions known as inflammatory bowel disease (IBD).

Irritable bowel syndrome is not contagious, inherited, or cancerous. It is estimated that 20% of adults in the U.S. have symptoms of IBS. It occurs more often in women than in men, and the onset occurs before the age of 35 in about half of the cases.

Irritable Bowel Syndrome Causes

The cause of irritable bowel syndrome is currently unknown. IBS is thought to result from an interplay of abnormal gastrointestinal (GI) tract movements, increased awareness of normal bodily functions, and a change in the nervous system communication between the brain and the GI tract. Abnormal movements of the colon, whether too fast or too slow, are seen in some, but not all, people who have IBS.

Irritable bowel syndrome has also developed after episodes of gastroenteritis.

It has been suggested that IBS is caused by dietary allergies or food sensitivities, but this has never been proven.

Symptoms of irritable bowel syndrome may worsen during periods of stress or menses, but these factors are unlikely to be the cause that leads to the development of IBS.

Irritable Bowel Syndrome Symptoms

Irritable bowel syndrome affects each person differently. The hallmark of IBS is abdominal discomfort or pain. The following symptoms are also common:

• Abdominal cramping and pain that are relieved with bowel movements
• Alternating periods of diarrhea and constipation
• Change in the stool frequency or consistency
• Gassiness (flatulence)
• Passing mucus from the rectum
• Bloating
• Abdominal distension

The following are NOT symptoms or characteristics of IBS (but should still be brought to the attention of a physician since they may be signs and symptoms of other conditions):

• Blood in stools or urine
• Black or tarry stools
• Vomiting (rare, though may occasionally accompany nausea)
• Pain or diarrhea that interrupts sleep
• Fever
• Weight loss

When to Seek Medical Care

If a person has any of the symptoms of IBS as discussed previously, or if a person with known IBS has unusual symptoms, a health care practitioner should be consulted. Go to a hospital emergency department if problems are severe and/or come on suddenly.

Irritable Bowel Syndrome Diagnosis

Irritable bowel syndrome can be a very difficult diagnosis to make. IBS is called a diagnosis of exclusion, which means a doctor considers many other alternatives first, performing tests to rule out other medical problems. Some of these tests may include laboratory studies, imaging studies (such as a CT scan or small intestinal X-rays), or a lower GI endoscopy (colonoscopy). An endoscopy is a procedure in which a flexible tube with a tiny camera on one end is passed into the GI tract while the patient is under conscious sedation.

• A combination of history, physical examination, and selected tests are used to help diagnose irritable bowel syndrome.
• No single blood test or x-ray study confirms a diagnosis of IBS.

Irritable Bowel Syndrome Treatment

Irritable Bowel Syndrome Self-Care at Home

Many people may have already modified their diets before seeing a doctor. Temporarily avoiding dairy products may help assess whether symptoms of lactose intolerance are mimicking those of irritable bowel syndrome. Persons who avoid dairy products should exercise and consider taking calcium supplements.

• Certain foods, such as cruciferous vegetables (cauliflower, broccoli, cabbage, brussels sprouts) and legumes (beans) may worsen bloating and gassiness.
• Dietary fiber may lessen symptoms.
• Individuals with IBS should drink plenty of water, and avoid soda, which may cause gas and abdominal discomfort.
• Eating smaller meals may lessen the incidence of cramping and diarrhea.
• Low fat and high carbohydrate meals such as pasta, rice, and whole grain breads may help IBS symptoms (unless the affected individual has celiac disease).

Medical Treatment

Most people with irritable bowel syndrome have problems only occasionally. A few may experience long-lasting problems and require prescription medications.

• A common treatment for IBS is the addition of fiber to the diet. This theoretically expands the inside of the digestive tract, reducing the chance it will spasm as it transmits and digests food. Fiber also promotes regular bowel movements, which helps reduce constipation. Fiber should be added gradually, because it may initially worsen bloating and gassiness.
• Stress may cause IBS "flares." Doctors may offer specific advice on reducing stress. Regularly eating balanced meals and exercising may help reduce stress and problems associated with irritable bowel syndrome.
• Smoking may worsen symptoms of IBS, which gives smokers another good reason to quit.
• Since many patients with irritable bowel syndrome report food intolerances, a food diary may help identify foods that seem to make IBS worse.
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Medications

• Antispasmodic medicines, such as dicycomine (Bemote, Bentyl, Di-Spaz) and hyoscyamine (Levsin, Levbid, NuLev), are sometimes used to treat symptoms of irritable bowel syndrome. Antispasmodic medicines help slow the action of the digestive tract and reduce the chance of spasms. They may have side effects and are not for everyone. Other treatment plans are available, depending on symptoms and condition.
• Antidiarrheal medicines, such as loperamide (Imodium), a kaolin/pectin preparation (Kaopectate), and diphenoxylate/atropine (Lomotil), are sometimes used when diarrhea is a major feature of IBS. Do not take these on a long-term basis without first consulting a doctor.
• Antidepressants may be very effective in smaller doses than those typically used to treat depression. Imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), and desipramine (Norpramin) are some commonly used medicines that may alleviate irritable bowel syndrome symptoms. Some other antidepressants are more commonly prescribed when depression and IBS coexist.
• The following medications are typically reserved for patients with symptoms that do not improve with the above treatments:
• Lubiprostone (Amitiza) is a type of laxative used to treat irritable bowel syndrome with constipation in women who are at least 18 years of age. It is a capsule taken orally, twice a day with food. It is used to relieve stomach pain, bloating, and straining; and produce softer and more frequent bowel movements in people who have chronic idiopathic constipation.
• Alosetron (Lotronex) is a restricted drug approved only for short-term treatment of women with severe, chronic, diarrhea-predominant IBS who have failed to respond to conventional IBS therapy. Fewer than 5% of people with irritable bowel syndrome have the severe form, and only a fraction of people with severe IBS have the diarrhea-predominant type. Alosetron was removed from the United States market but was reintroduced with new restrictions approved by the FDA in 2002. Physicians must be registered with the pharmaceutical manufacturer in order to prescribe the medication. Serious and unpredictable gastrointestinal side effects (including some that resulted in death) were reported in association with its use following its original approval. The safety and efficacy of alosetron has not been sufficiently studied in men; therefore, the FDA has not approved the drug for treatment of IBS in men.
• Tegaserod (Zelnorm) was a medication used to treat IBS but was removed from the market in 2008 due to increased risk of heart attack, stroke, and ischemic colitis.

Irritable Bowel Syndrome Diet and Lifestyle Changes

Diet and lifestyle changes are important in decreasing the frequency and severity of IBS symptoms.

The first thing your doctor may suggest is to keep a food diary. This will help you figure out foods that trigger your symptoms.

• Limit foods that contain ingredients that can stimulate the intestines and cause diarrhea, such as:
  • Caffeine
  • Alcohol
  • Dairy products
  • Fatty foods
  • Foods high in sugar
  • Artificial sweeteners (sorbitol and xylitol)
• Some vegetables (cauliflower, broccoli, cabbage, brussels sprouts) and legumes (beans) may worsen bloating and gassiness and should be avoided.
• Dietary fiber may lessen symptoms of constipation.
• Drink plenty of water, and avoid carbonated drinks such as soda, which may cause gas and discomfort.
• Eat smaller meals and eat slowly to help reduce cramping and diarrhea.
• Low fat, high carbohydrate meals such as pasta, rice, and whole-grain breads may help (unless you have celiac disease).

In addition to dietary changes, there are some healthy habits that may also help reduce IBS symptoms.

• Maintain good physical fitness to improve bowel function and help reduce stress.
• Stop smoking for overall good health.
• Avoid coffee and chewing gum.
• Reducing or eliminating alcohol consumption may help.
• Stress management can help prevent or ease IBS symptoms.
  • Use relaxation techniques: deep breathing, visualization, yoga
  • Do things you find enjoyable: talk to friends, read, listen to music

Irritable Bowel Syndrome Prevention

Follow the diet and lifestyle recommendations as outlined above, and as discussed with your physician. Avoiding triggers is the best way to prevent symptoms of IBS.