http://www.medicine-on-line.

com Constipation: 1/7

Case 034: Constipation

Author: David C Chung MD, FRCPC

Affiliation: The Chinese University of Hong Kong

Mr. Lin Sen, a 56 year old accountant, presented to the Outpatient Clinic
complaining of “constipation”. He described his complaint as a gradual decrease in
frequency of defecation over the years to once or twice per week from his usual 4 – 5
times a week in his younger years. The consistency and shape of the stool have also
changed to firm and pellet-like. The color of the stool has remained brown to dark
brown and was never black, tarry, or streaked with blood. Most of the time he had to
strain while defecating but there was no bowel cramps or pain at the anal region. He
denied any change in his diet. He has experimented with herbal cures and laxatives
recommended by friends and relatives but the result was far from satisfactory.

1. What is “constipation”?

There is no uniform definition of “constipation”. A patient may complain of

“constipation” because of one or more of the following:
o Bowel movements that is too infrequent, usually less than 3 times/week.
o Bowel movements that produces too small an amount of stool.
o Having to wait with anticipation when going to the toilet but producing no stool.
o Having to strain during defecation.
o Sensation of obstruction at the anal outlet.
o Sensation of incomplete emptying.
o Hard or lumpy stool.
Criteria have been proposed to define chronic functional constipation in adults,
children, and infants (e.g. the Roman II Criteria). While these criteria establish a
standard definition suitable for epidemiological investigations, they are not
suitable for clinical application. In clinical practice, “constipation” remains a
complaint perceived by the patient.
http://www.medicine-on-line.com Constipation: 2/7

2. How should “constipation” be evaluated in the clinic?

“Constipation” is not a disease entity but a symptom associated with a large

number of local and systemic disorders. Common conditions include:
ƒ Obstructive Neoplasm, diverticular disease, volvulus, external
compression by pelvic masses.
ƒ Painful anal lesions Perianal abscess, anal fissure or fistula,
thrombosed hemorrhoid.
ƒ Endocrine/metabolic Hypothyroidism, diabetes mellitus, hypokalemia,
hypercalcemia.
ƒ Neurogenic Spinal cord injury, autonomic peripheral
neuropathy, Parkinson’s disease, senility.
ƒ Drugs related Opioids, antacids (containing aluminum and
calcium salts), anticholinergic drugs, tricyclic
antidepressants, clonidine, cholestyramine,
calcium channel blockers, laxative abuse.
ƒ Psychiatric Depression.
ƒ Idiopathic Irritable bowel syndrome, low dietary fiber content,
sedentary lifestyle, poor hydration, advancing age.

History

When obtaining a history from the patient, he should be asked to describe clearly
what he means by “constipation” and if it causes him discomfort. The time of
onset and duration of the complaint are equally important. These general
questions should be followed by others that are relevant and targeted to
differentiate the disorders mentioned above. In addition, special attention should
be paid to the following alarm features:
ƒ Age over 50 years.
ƒ First degree relative with history of colon cancer.
ƒ Constipation of recent onset rather than chronic.
ƒ Weight loss.
ƒ Diarrhea as well as constipation.
http://www.medicine-on-line.com Constipation: 3/7

ƒ Frank blood in the stool or melena.

ƒ Iron deficiency anemia from chronic blood loss.
Presence of these alarm features should raise the possibility of colorectal
malignancy.

Physical Examination

The physical examination should be guided by findings in the history and should
include a digital rectal examination, during which the tone and control of the anal
sphincter should be assessed, the rectal contents carefully palpated, and stool
screened for occult blood. Presence of occult blood in the stool is another alarm
feature that should raise the possibility of colon cancer.

Diagnostic Investigations

Diagnostic investigation should be tailored according to the findings in the history

and physical examination. If alarm features are present, the patient should be
regarded as having colorectal cancer until proven otherwise and he should have
a full work-up, including colonoscopy or combined barium enema and flexible
sigmoidoscopy. In the absence of alarm features, laboratory tests can be limited
to complete blood count; plasma potassium, calcium, creatinine, and thyroid
stimulating hormone levels; fasting plasma glucose level; and plain supine and
upright films of the abdomen.

There are other investigative procedures: including colonic transit time,

defecography (views of contrast medium being expelled from the rectum),
anorectal manometry and colonic motility studies. Decision to use these tools
should rest with the specialist gastroenterologist.

3. What is the treatment for “constipation”?

Treatment of “constipation” should be directed towards correction of the

underlying cause. When no organic cause can be found, “constipation” is said to
be idiopathic. Idiopathic “constipation” is a diagnosis by exclusion. Effective
http://www.medicine-on-line.com Constipation: 4/7

treatment involves counseling, lifestyle and dietary modification, stopping or

changing constipating medications, and correct choice and use of laxatives.
o The following points are important in counseling:
ƒ Reassure patient the underlying cause is not cancer, a common concern
of all patients with perceived changes in bowel habit.
ƒ Find out the patient’s expectation. Explain that frequency of bowel
movement can range from 3/day to 3/week in normal subjects and daily
movement is not essential to good health.
ƒ Explain that any treatment plan can take 2 months or longer to take effect;
that quick-fix with laxative may seem attractive but can be deleterious to
bowel function.
ƒ Enlist support from family members.
o In lifestyle and dietary modification, the patient should be advised that regular
patterns of bowel movements depend on good living and eating habits:
ƒ A major contributing factor to constipation among city dwellers is
sedentary lifestyle. Physically active individuals are much less prone to
“constipation”. Increasing the amount of exercise should be part of the
management plan to treat “constipation”. The intensity of exercise need
not be vigorous. Thirty minutes of exercise that increases the breathing
rate of the subject without causing breathlessness 5 days a week is ample.
Exercise has other benefits. Readers can visit this Medicine-On-Line
article http://www.medicine-on-line.com/en/detail_revisited.php?id=2 for more
information.
ƒ Regular bowel habits can be re-trained by encouraging the patient to set
aside a fixed time of the day for excretory function. First thing in the
morning is convenient but any other time is equally acceptable, so long the
time is protected from other activities. Colonic peristalsis increases after
food enters an empty stomach (the gastrocolic reflex), making the time
soon after a meal most appropriate for bowel training. The bowel may not
move initially but the patient can develop a regular habit with training and
persistence.
ƒ Increasing the amount of dietary fibers to 20 – 30 G daily has been shown
to improve the regularity of bowel movements. Food high in dietary fibers
http://www.medicine-on-line.com Constipation: 5/7

includes fruits, green leafy vegetables, brown rice or red rice in Asian diet,
and bran or whole-grain bread and cereal in Western diet. Dietary fiber
acts through its ability to provide bulk, its binding with fecal bile salts to
produce a cathartic effect, and its metabolism by colonic bacteria to
products that act as an osmotic cathartic.
ƒ Dietary fiber attracts water and increases stool bulk. In the absence of
adequate fluid intake, dietary fiber remains dry and can cause constipation.
This is especially a problem in patient on diuretic therapy. It is
recommended that patients without cardiac or renal diseases should
consume eight 250 ml (8 oz) glasses of non-caffeinated and non-alcoholic
drinks per day.
o Stop all unnecessary medications that can cause “constipation” and change
those that are necessary to ones with less constipating effect. In this respect,
be aware that the patient may be self-medicating himself with non-prescription
drugs and health food supplements that contain constipating compounds (e.g.
anticholinergic drugs).
o Although regarded by some physicians and patients as the mainstay of
“constipation” treatment, laxatives can have harmful side effects and should
be prescribed intelligently. Chronic abuse of even safe laxatives has the
potential to cause harm, not least fluid and electrolyte imbalance.
ƒ Commercial fiber supplements like psyllium (Metamucil) and
methylcellulose (Citrucel) are generally safe and are often prescribed in
place of or to complement a high fiber diet. However they can cause gas
formation and bloating, a problem that can be avoided by starting at a low
dose and gradually increasing the dose over time to the recommended.
Like high-fiber diet, fiber supplement should be taken with an adequate
amount of oral fluid.
ƒ By increasing the water content of feces, stool softeners like docusate
(Colace) soften and lubricate the fecal mass. They are particularly suitable
for “constipation” caused by hard dry stools. They are relatively harmless
in short-term use.
ƒ Enemas and suppositories invoke the evacuation reflex by distending the
rectal ampulla and can be helpful in bowel training. Among enema
http://www.medicine-on-line.com Constipation: 6/7

solutions, lukewarm tap-water enema is the agent of choice because it

does not irritate the colonic mucosa. Care should be exercised in repeated
use, however, because it can cause hyponatremia. Glycerin suppository
contains a hygroscopic agent and a lubricant and is relatively begnin. It
promotes colonic peristalsis by water retention.
ƒ Osmotically active agents act by retaining water within the gut lumen, thus
soften stool and stimulate peristalsis. They include the magnesium and
phosphate salts and non-digestible sugars, and polyethylene glycol.
Magesium salt laxatives (e.g. milk of magnesia) are mild in effect and safe
in action but can cause magnesium and sodium overload in patients with
renal dysfunction. Phosphate salt solutions (e.g. Fleet Phospo-Soda) are
more suitable for colonic preparation before surgery or x-ray and
endoscopic procedures and not for treatment of chronic constipation.
Lactulose (a synthetic disaccharide of galactose and fructose) is effective
and safe for long term use but expensive. The cheaper sorbitol is equally
efficacious. Polyethylene glycol in powder form (e.g. Movicol, Miralax) is
also used in short term (2 weeks or less) treatment of “constipation”. This
preparation should not be confused with polyethylene glycol-electrolyte
solutions (Colyte or Golytely), which are used in colonic preparation before
procedures.
o The diphenylmethane derivative bisacodyl, anthraquinone preparations
(senna and cascara) and castor oil are stimulant / irritant laxatives. They act
by inducing a low grade inflammatory reaction in the bowel wall to stimulate
intestinal motility. Long term use can damage intestinal epithelium and enteric
neurons, resulting in bowel refractoriness and worsening “constipation”.

Further readings

Richter JM. Chapter 65: Approach to the patient with constipation. In Goroll AH et al
(editors): Primary Care Medicine, 5th edition. Lippincott Williams & Wilkins; 2006.

Pasricha PJ. Chapter 37: Treatment of disorders of bowel motility and water flux;
antiemetics; agents used in biliary and pancreatic disease. In Brunton LL et (editors):
http://www.medicine-on-line.com Constipation: 7/7

Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 11th edition.

McGraw-Hill; 2006.

Arce DA et al. Evaluation of constipation. American Family Physician 2002;65:2283.