CONSTIPATION

DR. AHMED AL-

BUHAIRI
 Constipation

 Very common symptom

 Affects more than1 in 5 of the population

 More common in women and the elderly (due to comorbid medical conditions,

medications, poor eating habits, decreased mobility, and in some cases, inability to sit
on a toilet (bed- bound patients)).
 Constipation

Definition
 Infrequent passage of stools (<3/week)
 Passage of hard stools
 Difficult passage of stool (straining or sensation of anorectal blockage)
 A sensation of incomplete evacuation
 Constipation
Stool consistency can be determined based on the Bristol Stool Form Scale ( BSFS)
 Constipation

Bowel habits vary from person to person and are affected by age,
physiology, diet, and social and cultural influences.

In Western society, normal stool frequency ranges from 2 to 3/day to 2 to

3/week.
 Constipation

Constipation can be classified into:

 Primary

 Secondary

Or
 Acute

 Chronic
 Constipation

 Primary Constipation
o No structural abnormalities or systemic disease
o The most common

 Can be classified into three broad categories:

 Normal transit (59%)
 Slow transit (13%)
 Defecatory disorders (25%)
May overlap: Defecatory disorders with slow transit (3%)
 Constipation

Normal-transit constipation
 Stool traverses with
o Normal rate
o Normal frequency

 Likely due to passage of hard stools or difficulties of evacuation.

 Constipation

Slow-transit constipation
 Stool traverses with
o Slow rate
o Infrequent bowel movements (usually less than once a week).

 Predominantly in young women, often starts at puberty.

 Constipation

Normal defecation requires coordination between

 Relaxation of the anal sphincter

 Relaxation of the pelvic floor musculature

 Increased abdominal pressure Impaired relaxation or paradoxical contraction

during straining prevent evacuation and results in defecatory disorder.

 Constipation
Patients with defecatory disorders do not generate adequate rectal propulsive forces, do not relax
the puborectalis and the external anal sphincter during defecation, or both
 Constipation
Defecatory disorders
Also may be referred to as dyssynergia, anismus, dyschezia, disordered evacuation, dysfunction of pelvic
floor or anal sphincters, or functional defecatory disorders.
 Women more often than men

 Patients may complain of

o Sense the presence of stool and the need to defecate but are unable.
o Excessive straining
o Sense of incomplete evacuation, or
o Need for digital manipulation
 Constipation

Secondary Constipation
 Systemic disorders (neurologic dysfunction, myopathies, endocrine
disorders, electrolyte abnormalities (eg, hypercalcemia or hypokalemia).
 Medication side effects (common cause).
 Colonic lesions and anorectal problems that obstruct fecal passage:
o Neoplasms and strictures.
o Anorectal problems (anterior rectocele, rectal prolapse, higher
mucosal intussusception).
 Constipation

In many patients, constipation is associated with sluggish movement of stool

through the colon. This delay may be due to drugs, organic conditions, or a
disorder of defecatory function (ie, pelvic floor dysfunction), or a disorder that
results from diet.
Excessive straining, perhaps secondary to pelvic floor dysfunction, may
contribute to anorectal pathology (eg, hemorrhoids, anal fissures, and rectal
prolapse) and possibly even to syncope.
 Constipation

Foods likely to cause constipation or help control loose bowel

movements
White rice, white bread, potatoes, pasta

Meat, veal, poultry, fish

Cooked vegetables

Bananas
 Constipation

Acute vs. chronic constipation

cute constipation suggests an organic cause, whereas chronic constipation
may be organic or functional.
There is some overlap between acute and chronic causes of constipation. In
particular, drugs are common causes of chronic constipation.
 Causes of Acute Constipation

Causes Examples

Bowel obstruction Volvulus, hernia, adhesions, fecal impaction

Peritonitis, major acute illness (eg, sepsis), head or spinal

Adynamic ileus
trauma, bed rest

Anticholinergics (eg, antihistamines, antipsychotics,

antiparkinsonian drugs, antispasmodics), cations (iron,
Drugs aluminum, calcium, barium, bismuth), opioids, calcium channel
blockers, general anesthetics
Constipation shortly after start of therapy with the drug
 Causes of Chronic Constipation
Causes Examples
Colonic tumor Adenocarcinoma of sigmoid colon
Diabetes mellitus, hypothyroidism, hypocalcemia or hypercalcemia,
Metabolic disorders
pregnancy, uremia, porphyria
Central nervous system
Parkinson disease, multiple sclerosis, stroke, spinal cord lesions
disorders
Peripheral nervous system
Hirschsprung disease, neurofibromatosis, autonomic neuropathy
disorders
Systemic sclerosis, amyloidosis, autoimmune myositis, myotonic
Systemic disorders
dystrophy
Slow-transit constipation, irritable bowel syndrome, pelvic floor
Functional disorders
dysfunction ( functional defecatory disorders)
Dietary factors Low-fiber diet, sugar-restricted diet, chronic laxative abuse
Asynchrony of anorectal muscles leading to difficult evacuation and
Dyssynergic defecation constipation; typically, sensation of incomplete evacuation plus
excessive straining and, particularly, digital disimpaction
 Evaluation of Constipation
History
What is meant by “constipation”
Distinguish primary from secondary causes of constipation .
History of present illness should ascertain a lifetime history of the patient’s stool
frequency, consistency, need to strain or use perineal maneuvers (eg, pushing on the
perineum, gluteal region, or recto-vaginal wall) during defecation, and satisfaction after
defecation should be obtained, including frequency and duration of laxative or enema use.
Some patients deny previous constipation but, when questioned specifically, admit to
spending 15 to 20 minutes per bowel movement.
The presence, amount, and duration of blood in the stool should also be elicited.
Change in caliber of the stool or blood in the stool (suggesting cancer).
 Evaluation of Constipation
History
Review of systems should seek symptoms of causative disorders and systemic symptoms
suggesting chronic diseases should also be sought.
Past medical history should ask about known causes, including previous abdominal
surgery and symptoms of metabolic (eg, hypothyroidism, diabetes mellitus) and
neurologic (eg, Parkinson disease, multiple sclerosis, spinal cord injury) disorders.
Prescription and nonprescription drug use should be carefully assessed, with specific
questioning about anticholinergic and opioid drugs.
 Evaluation of Constipation
Physical examination
A general examination is done to look for signs of systemic disease.
Abdominal masses should be sought by palpation.
Digital rectal examination:
 Should be done for fissures or presence of blood.
 Assessment for anatomic abnormalities, such as anal stricture, masses, rectocele, rectal
prolapse, or perineal descent during straining.
 Assessment of pelvic floor motion during simulated defecation (ie, the patient’s ability
to “expel the examiner’s finger”).
 Patients with defecatory disorders may have increased anal resting tone (or anismus),
reduced (ie, < 2 cm) or increased (ie, > 4 cm) perineal descent, and/or paradoxical
contraction of the puborectalis during simulated evacuation.
 Evaluation of Constipation
Red flags
Certain findings raise suspicion of a more serious etiology of chronic constipation:
o Age 50 years or more
o Hematochezia or positive fecal occult blood tests [FOBT] or fecal immunochemical
tests [FIT]),
o Weight loss
o Severe constipation of recent onset/worsening in older patients
o Family history of colon cancer or IBD
 Evaluation of Constipation
Interpretation of findings
A tense, distended, tympanitic abdomen, particularly when there is nausea and vomiting,
suggests mechanical obstruction.
New-onset constipation that persists for weeks or occurs intermittently with increasing
frequency or severity, in the absence of a known cause, suggests colonic tumor or other
causes of partial obstruction.
Acute constipation coincident with the start of a constipating drug in patients without red
flag findings suggests the drug is the cause.
 Evaluation of Constipation
Interpretation of findings
Certain symptoms (eg, a excessive straining, sense of anorectal blockage, prolonged or difficult defecation,
need for digital disimpaction), particularly when associated with abnormal (ie, increased or reduced)
perineal motion during simulated evacuation, suggest a defecatory disorder.
Patients with irritable bowel syndrome (IBS) typically have abdominal pain with disordered bowel habits.
Patients with chronic constipation who do not meet the criteria for IBS may have functional constipation.
 Evaluation of Constipation
Testing
Testing is guided by clinical presentation.
 Patients with a clear etiology (drugs, trauma, bed rest) may be treated symptomatically
(trial of dietary fibre and/or laxatives) without further study.
 Patients with symptoms of bowel obstruction require flat and upright abdominal x-rays,
and possibly a CT scan.
 Patients with red flags or without a clear etiology should have colonoscopy and a
laboratory evaluation (complete blood count, thyroid-stimulating hormone, fasting
glucose, electrolytes, and calcium). If normal, may be treated symptomatically.
 Further tests are usually reserved for patients with abnormal findings on the previously
mentioned tests or who do not respond to symptomatic treatment.
 Evaluation of Constipation
Non-responder to symptomatic treatment:
Anorectal manometry with balloon expulsion (to identify pelvic floor disorders and
dyssynergic defecation).
Defecography to further assess pelvic floor function.
Colon transit studies: If manometry is negative and the primary complaint is infrequent
defecation, colonic transit times should be measured with radiopaque markers (Sitz
markers), scintigraphy, or a wireless motility capsule. In patients with chronic
constipation, it is important to distinguish between slow-transit constipation (abnormal
Sitz marker radiopaque study) and pelvic floor muscle dysfunction (markers retained only
in distal colon).
 Management of Constipation

 Treatment of underlying cause

 Any identified conditions should be treated.
 Possibly discontinuation of causative drugs.
 Dietary and lifestyle measures
 Laxatives
 Specialist center for defecatory disorders
 Management of Constipation

Lifestyle measures:
Optimal toileting habits (regular timing, proper positioning,
and abdominal pressure).
Regular exercise.
 Management of Constipation
Diet measures:
 Adequate fluid and dietary fiber intake.
 The diet should contain enough fiber (typically 15 to 20 g/day) to ensure adequate
stool bulk. Certain components of fiber also absorb fluid, making stools softer and
facilitating their passage.
 Vegetable fiber, which is largely indigestible and unabsorbable, increases stool bulk.
Fruits and vegetables are recommended sources, as are cereals containing bran.
Trial of fiber supplements:
 Most likely to benefit patients with normal colonic transit.
 No benefit or exacerbate symptoms in colonic inertia, defecatory disorders, opioid-
induced or IBS.
 Management of Constipation

Laxatives
On an intermittent or chronic basis for constipation that does not respond to dietary and
lifestyle changes.
 Initially trial with a brief course of osmotic laxatives.
 Laxatives should be used judiciously.
 Some (eg, phosphate, bran, cellulose) bind drugs and interfere with absorption.
 Rapid fecal transit may rush some drugs and nutrients beyond their optimal absorptive locus.
 Contraindications to laxative use include acute abdominal pain of unknown origin, inflammatory
bowel disorders, intestinal obstruction, gastrointestinal bleeding, and fecal impaction.
 Management of Constipation
Type of laxatives Mechanisms
BULK-FORMING Retaining water in stool, increasing stool bulk, and
improving consistency
STOOL SOFTENER Promoting luminal water binding by detergent-like
action, increasing stool bulk
OSMOTIC Nonabsorbable osmotic agents increasing the
colonic inflow of fluid and electrolytes.
Soften the stool and stimulate colonic contractility.
The onset of action is generally within 24 hours.
For more rapid treatment of acute constipation,
purgative laxatives may be used.
STIMULANT Stimulating colonic contractility and increasing
intestinal secretion. For patients with incomplete
response to osmotic agents, may be prescribed as
needed as a “rescue” agent or on a regular basis
three or four times a week. The onset of action is
generally within 6–12 hours after oral ingestion or
15–60 minutes after rectal administration.
Examples
Dietary fibre, wheat bran, methylcellulose, mucilaginous gums (e.g. sterculia), mucilaginous
seeds and seed coats (e.g. ispaghula husk)
May cause distention or flatulence (diminishes over several days).
Response is not immediate, increases in dosage should be made gradually over 7–10 days.
Docusate sodium, docusate calcium
Magnesium-containing saline laxatives (sulphate/hydroxide/citrate), Nondigestible
carbohydrates (lactulose, polyethylene glycols (PEGs)). They are preferred to the stimulant
laxatives.
Nondigestible carbohydrates may induce bloating, cramps, and flatulence. PEGs are not
fermented anaerobically in the colon to gas (an advantage over lactulose).
Magnesium-containing saline laxatives should not be given to patients with chronic renal
insufficiency.
Purgative laxatives (PEGs and magnesium citrate).
Bisacodyl,
Anthraquinones e.g. senna and dantron (for the terminally ill),
Sodium picosulfate.
Oral agents are usually administered once daily at bedtime.
 Management of Constipation
Type of laxatives Mechanisms Examples
CHLORIDE Stimulate intestinal chloride secretion resulting in Activation of chloride channels (lubiprostone), guanylcyclase C (linaclotide and plecanatide).
SECRETORY AGENTS increased intestinal fluid and accelerated colonic Expensive (reserved for patients who have suboptimal response or side effects with less
transit. expensive agents).
SEROTONERGIC Selective 5-HT4 receptor activation with Prucalopride,
AGONISTS enhancement of gut motility by contraction of Tegaserod
proximal smooth muscles and relaxation of distal
smooth muscles; cAMP mediated colonic chloride
secretion
OPIOID-RECEPTOR Long-term use of opioids can cause constipation Methylnaltrexone, naloxegol, and naldemedine.
ANTAGONISTS by inhibiting peristalsis and increasing intestinal
fluid absorption. Mu-opioid receptor antagonists
that block peripheral opioid
receptors (including in the gastrointestinal tract)
without affecting central analgesia.
 Management of Constipation

Referred to a specialist center

 Defecatory disorders
 Biofeedback therapy
Pelvic floor dyssynergia (anismus).
 Surgery
Anterior rectocele or internal anal mucosal intussusception.
Rarely (subtotal colectomy) for severe slow-transit constipation.
 Injection
Anterior mucosal prolapse
 Fecal Impaction

 May cause or develop from constipation, common among older patients, particularly with
prolonged bed rest or decreased physical activity. It is also common after barium has been
given by mouth or enema. Leads to obstruction to fecal flow and partial or complete large
bowel obstruction.
Predisposing factors
o Medications (eg, opioids)
o Severe psychiatric disease
o Prolonged bed rest
o Neurogenic disorders of the colon, and spinal cord disorders
 Fecal Impaction

Fecal Impaction
 Clinical presentation
o Decreased appetite
o Nausea and vomiting
o Abdominal pain and distention
o Paradoxical “diarrhea” as watery mucus or fecal material leaks around the impacted
feces, mimicking diarrhea (overflow diarrhea).
 Firm feces are palpable on digital examination.
 Fecal Impaction

 Initial treatment
 Relieving the impaction by
Enemas of tap water followed by small enemas (100 mL) of commercially prepared hypertonic solutions.
If these do not work, manual fragmentation and disimpaction of the mass may be necessary. This
procedure is painful, so perirectal and intrarectal application of local anesthetics (eg, lidocaine 5%
ointment or dibucaine 1% ointment) is recommended. Some patients require sedation.
 Long-term care
 Maintaining soft stools and regular bowel movements.
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