Constipation and Evacuatory Disorders

Constipation is the most common gastrointestinal complaint in the United States, resulting in about 2 million annual visits to the doctor and about $725 million spent on over-the-counter laxatives each year. Those reporting constipation most often are women, children, and adults age 65 and over. Pregnant women also complain of constipation, and it is a common problem following childbirth and surgery.

Constipation means that a person has less than three bowel movements in a week. Other common complaints are stools which are hard and dry and may be difficult and painful to pass. Other symptoms include feeling bloated and uncomfortable.

The “normal” range of bowel movements is quite variable. Some people move their bowels 1-3 times per day and some only once or twice a week. Each person’s body finds its own normal number of bowel movements. It is a change in usual bowel habit that may suggest a problem.

Causes
To understand constipation, it helps to know how the colon (large intestine) works. As food residue moves through the colon, it absorbs water while forming stool. Muscle contractions in the colon push stool toward the rectum. By the time stool reaches the rectum, it is solid because most of the water has been absorbed. The hard and dry stools of constipation occur when the colon absorbs too much water. This happens because the colon’s muscle contractions are slow, causing the stool to move through the colon too slowly. The following lists the most common causes of constipation:

• not enough fiber in the diet
• not enough liquids in the diet
• lack of exercise
• medications such narcotics, antidepressants or iron pills
• irritable bowel syndrome
• changes of life or routine such as pregnancy and travel
• abuse of laxatives
• ignoring the urge to have a bowel movement
• specific diseases such as multiple sclerosis or slow thyroid
• problems with the colon and rectum such as diverticulosis or cancer

Diagnosis
Most people do not need extensive testing and can be treated with changes in diet and exercise. Usually a medical history and physical examination may be all the doctor needs to suggest successful treatment.

Medical History
The doctor may ask the patient to describe his or her constipation, including duration of symptoms, frequency of bowel movements, consistency of stools, presence of blood in the stool and toilet habits (how often and where one has bowel movements). Recording eating habits, medications and level of physical activity or exercise also helps the doctor determine the cause of constipation.

Physical Examination
The examination may include evaluation of the abdomen and a digital rectal examination to detect tenderness, obstruction or blood.

Special Tests
Extensive testing is usually reserved for people with severe symptoms, for those with sudden changes in number and consistency of bowel movements or blood in the stool. The following tests may be used to rule-out colon cancer:

• Barium enema: in this test the patient is given barium by enema and then x-rays are taken to identify any irregularities.
• Sigmoidoscopy: this test examines the inside of the lowest part of the colon using a thin, flexible, lighted tube called an endoscope.
• Colonoscopy: this procedure examines the entire colon using an endoscope.

Steps to Relieving Constipation

• Eat more fiber. A diet with enough fiber (25 – 30 grams each day) helps form soft, bulky stool. High fiber foods include beans, whole grains and bran cereals and fresh fruits and vegetables. Limit foods that have little or no fiber such as ice cream, cheese, snacks like chips and pizza, and processed foods like instant mashed potatoes or already-prepared frozen dinners. Processed fiber can be obtained in the form of powder, pill or wafers.
• Drink plenty of water and other liquids such as fruit and vegetable juices and clear soup. Liquids help to keep the stool soft and easy to pass.
• Get enough exercise. Regular exercise appears to help keep your system active and healthy. You do not have to be a great athlete – a 20 to 30 minute walk every day will do the trick.
• Allow yourself enough time to have a bowel movement. Sometimes we feel so hurried that we do not pay attention to our bodies’ needs. Make sure you do not ignore the urge to have a bowel movement.
• Use laxatives only if a doctor says you should. Laxatives are medicines that will make you pass a stool. Most people who are mildly constipated do not need laxatives. However, if you are doing all the right things and you are still constipated, your doctor may recommend laxatives for a limited time.
• Check with your doctor about medications you may be taking. Some medications may cause constipation. They include calcium pills, pain pills with codeine in them, some antacids, iron pills, diuretics (water pills), and medicines for depression.

When these measures fail to improve constipation, patients can benefit from evaluation at a specialized medical center. Special tests of the motor function of the colon and the ano-rectal (anus and rectum) area are done to identify patients who can benefit from treatment with biofeedback, or in extreme cases, require surgery to remove the colon.