Constipation, either acute or chronic, can be described as difficult, infrequent, or incomplete bowel movements. The stool tends to be small and/or hard. Bowel movements should, under normal circumstances, occur at least daily.
Acute constipation generally results from a change in diet and/or lifestyle, significant stress, drug side effects, or some organic cause. Saline oral preparations and enemas, Epsom salts, or magnesium citrate preparations can be safely used if necessary.
Chronic constipation is usually due to diet, colon health problems, insufficient dietary fiber and roughage, a sedentary lifestyle, ignoring defecation urges, or frequent traveling. Chronic constipation is also associated with some disease conditions such as hypothyroidism, dehydration and nerve injury. Psychogenic constipation is described as an obsessive-compulsive fixation on frequency and quality of bowel movements.
Do not ignore the urge to defecate. Doing so can reduce the reflex and cause constipation to worsen. The delayed bowel movement becomes more difficult to pass and the unpleasant experience starts a negative feedback cycle. Chronic constipation is more common in women. The use of laxatives should be avoided unless the problem cannot be dealt with otherwise.
General rules for treating constipation
Before using laxatives, try first to remove any underlying cause. Make sure you are:
- Getting regular aerobic exercise
- Having or trying to have your movement at the same time each day
- Drinking enough water. Increase water consumption to 8 glasses per day
- Avoid refined foods which have had fiber taken out of them (white flour, white rice, peeled vegetables, etc.)
- Increase fiber (both water-soluble and non-water-soluble types) in the diet with more fruits and vegetables. If too difficult for now, try supplementing natural fibers like flax, psyllium, pectin, and guar gum. These possess a mild laxative action due to their ability to attract water and form a gelatinous mass.
- Consider the possibility of food allergies, especially milk, when you see diarrhea, alternating constipation and diarrhea, anal fissures, or other general allergy signs. A recent study found that 10 of the 86 patients allergic to milk showed “very delayed reactions” to a cow’s milk challenge averaging over 13 days (range 4-26 days). These “very delayed” reactions included constipation, wheezing, and dermatitis.
The US FDA has issued a final ruling that aloe and cascara sagrada will not be included in the final monograph for
over-the-counter (OTC) laxative drug products because they have not been shown to be generally safe and effective as stimulant laxatives. According to the ruling, aloe extract, aloe flower extract, cascara fluid extract aromatic, cascara sagrada extract, casanthranol, cascara sagrada bark and cascara sagrada fluid extract will no longer be allowed in OTC laxative drug products and are not GRAS (Generally Recognized As Safe) – February, 2002.
Check your transit time by consuming charcoal or beets. It should take from 18 to 24 hours to see evidence in the toilet (black or red). Longer times may result in bowel toxicity symptoms and increase the burden on your liver. If constipation does not improve using the above methods then professional help may be needed.
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Signs, symptoms & indicators of Constipation
(Very) frequent stools or normal stool frequency
Having very watery/having loose stools or having normal stool texture
Conditions that suggest Constipation
Ulcerative Colitis
Dr. Batmanghelidj, MD in his book Your Body’s Many Cries For Water says that the left lower quadrant pain of colitis is sometimes a signal of localized thirst and associated with constipation.
Enlarged Prostate
Chronic constipation has been implicated as a contributing factor to prostatic discomfort when there is an already enlarged gland. A correction of the constipation will bring some relief of symptoms since the rectum puts pressure on the prostate gland when it is enlarged. In addition, there is a buildup of waste products in the circulation with chronic constipation. This will indirectly have an effect on the function of the prostate.
Adult Acne
Bowel toxins from poor digestion or a prolonged transit time may contribute to acne.
Adolescent Acne
Bowel toxins from poor digestion or a prolonged transit time may contribute to acne.
Risk factors for Constipation
Stress
In a study of 34 women with chronic constipation, investigators led by Dr. Anton Emmanuel and colleagues at St. Mark’s Hospital in Middlesex linked emotional distress with changes in the nerve pathway that helps control gut function. They say the findings suggest a specific path through which psychological factors directly influence the digestive system.
The researchers compared the patients, who had suffered bouts of constipation for an average of 21 years, with a group of women with no history of gastrointestinal illness. All took standard tests that measure psychological symptoms such as anxiety and depression, self-image, social functioning and ability to form intimate relationships.
Women with chronic constipation were more likely than healthy women to report anxiety, depression and feeling less “feminine”. They also found it harder to form close relationships. [Gut Aug 2001;49: pp.209-213]
Regular/daily/ab use of strong laxatives
Regular/daily/ab use of osmotic laxatives
Using laxatives regularly
Fibroids
Mural fibroids (located in the uterine wall) and subserous fibroids (protrude outside the uterine wall) may reach a large size before causing symptoms. These symptoms may include pressure on the bladder with difficulty voiding or urinary frequency and urgency, pressure on the rectum with constipation, lower back and abdominal pain, as well as heavy bleeding.
Constipation suggests the following may be present
Constipation can lead to
Enlarged Prostate
Chronic constipation has been implicated as a contributing factor to prostatic discomfort when there is an already enlarged gland. A correction of the constipation will bring some relief of symptoms since the rectum puts pressure on the prostate gland when it is enlarged. In addition, there is a buildup of waste products in the circulation with chronic constipation. This will indirectly have an effect on the function of the prostate.
Recommendations for Constipation
Bile Salts
Bile salts are often referred to as the body?s natural laxative. In many cases constipation is a result of insufficient bile production. Bile salts can be obtained as a supplement, often in combination with digestive enzymes, and can be very effective for some people. For others, just taking a regular digestive enzyme without any bile salts in it is all that is needed.
Probiotics / Fermented Foods
In a controlled trial of one month, 56 weaning infants were supplemented with fructo-oligosaccharides in their cereal ( 0.75g FOS per serving of cereal; average FOS consumption 0.74g per day). This resulted in more regular, softer stools and less frequent symptoms of constipation. [Br J Nutr 2003;90(3): pp.581-8]
Picrorhiza (Picrorhiza kurroa)
Picrorhiza is used in India for people with constipation due to insufficient digestive secretions. [Nadkarni KM, Nadkarni AK. Indian Materia Medica. Bombay, Popular Prakashan, 1976, pp.953–5]
Herbal Combinations
Digest RC has been used to treat and prevent digestive disorders including constipation.
Triphala is the most popular Ayurvedic herbal formula of India, since it is an effective laxative which also supports the body’s strength. The constitution of vegetarian Hindus cannot tolerate harsh laxatives anymore than vegetarians in other countries. Because of its high nutritional value, Triphala uniquely cleanses and detoxifies at the deepest organic levels without depleting the body’s reserves.
Triphala will prove useful for all kinds of constipation except that caused by a lack of vital energy or chi. Even for the latter type, it will not further deplete such an individual and can be made to work well if it is combined with other chi, blood or yang-warming tonic herbs such as ginseng for chi tonification, tang kuei for blood tonification and prepared aconite for yang tonification.
Coffee Enema
If you find that an enema is useful for stimulating a needed bowel movement, this may be an opportunity to try the coffee enema. If no added benefit is noticed beyond that of the water enema, the CE (coffee enema) can be discontinued.
Supplemental Fiber
Psyllium is a popular fiber supplement which cleanses the intestines and promotes softer stools. It is a good source of both soluble and insoluble fiber.
Vegetarian/Vegan Diet
A vegetarian diet is generally higher in fiber than non-vegetarian diets. Constipation amongst those on vegan and raw-food diets is extremely rare.
Increased Water Consumption
Drinking water adds fluid to the colon and bulk to stools, making bowel movements softer and easier to pass. People who have problems with constipation should drink enough water every day, at least eight 8-ounce glasses depending on weight. Other liquids such as coffee and soft drinks contain caffeine and seem to have a dehydrating effect.
High/Increased Fiber Diet
A diet with enough fiber (20 to 35gm each day either from food or supplements) helps form a soft, bulky stool. High-fiber foods include beans, whole grains and bran cereals, fresh fruits, and vegetables such as asparagus, Brussels sprouts, cabbage and carrots. For people prone to constipation, limiting foods that have little or no fiber such as ice cream, cheese, meat, and processed foods is also important.
Soy Isoflavones (genistein, daidzein)
Amongst 65 children aged 11 to 72 months with chronic constipation, 68% had a positive response with regard to bowel movements while receiving soy milk.
Therapeutic Fasting
Water or juice fasting is indicated for those with constipation, and many times the fast will produce more regular bowel movements.
Increased Fruit/Vegetable Consumption
Raisins have a mild laxative effect. They soften the stool and speed transit time through the colon. Prunes are even more widely recognized for this effect.
Dairy Products Avoidance
A double-blind trial found that chronic constipation among infants and problems associated with it were triggered by intolerance to cows’ milk in two-thirds of the infants studied. Symptoms disappeared in most infants when cows’ milk was removed from their diet. [N Engl J Med 1998;339: pp,1100-4]
Dairy products are also devoid of fiber which is important in maintaining normal bowel movements.
Chewing Gum
Xylitol is a natural sugar substitute that is very low in calories simply because the human body cannot digest it. A known side effect of xylitol is that it can cause loose stools, so some people find it helpful for constipation.
Conventional Drugs / Information
Research has found that a medication, tegaserod, is effective in treating nearly all symptoms associated with chronic constipation (CC), a common disorder of the gastrointestinal tract that affects approximately 15% of the Western population at any one time. Tegaserod is currently the only drug aside from laxatives found to be effective at treating such a wide variety of symptoms.
“Chronic constipation is a complex medical disorder and several bodily mechanisms are involved in its development,” says Stefan Muller-Lissner, M.D., lead author of the study. “The positive results we have found from tegaserod treatment in relieving this array of symptoms could potentially benefit millions.”
The long-term safety, efficacy and tolerability of tegaserod have been proven. Patients show no serious side-effects from long-term usage and maximal improvements were observed after approximately 6 months of further treatment and were sustained thereafter. [The American Journal of Gastroenterology, 27 Nov 2006]
Well, another drug bites the dust. The Food and Drug Administration (FDA) has requested that Novartis Pharmaceuticals Corporation of East Hanover, New Jersey, voluntarily discontinue marketing of Zelnorm (tegaserod) based on the recently identified finding of an increased risk of serious cardiovascular adverse events (heart problems) associated with use of the drug. Novartis has agreed to voluntarily suspend marketing of the drug in the United States.
Zelnorm is a prescription medicine approved in July 2002 for short-term treatment of women with irritable bowel syndrome whose primary symptom is constipation. It was subsequently approved in August 2004 for treatment of chronic constipation for men and women under age 65. Zelnorm is marketed in 55 countries.
FDA is currently advising patients who are using Zelnorm to contact their health care providers to discuss treatment alternatives. Patients who are taking Zelnorm should seek emergency medical care if they experience severe chest pain, shortness of breath, dizziness, sudden onset of weakness or difficulty walking or talking, or other symptoms of a heart attack or stroke.
“This decision reflects the FDA’s commitment to continuously monitor approved drugs throughout their marketing life, and take action when we believe the risks exceed the benefits,” said Dr. Douglas Throckmorton, Deputy Director for the Center for Drug Evaluation and Research. “Here, a potential risk of very serious harm to patients who have this non-life-threatening condition was recently identified, making this action necessary.”
Throughout February and March 2007, Novartis reported to FDA the results of a new analysis of 29 short-term (1 – 3 months) randomized, controlled clinical trials of Zelnorm. FDA has concluded, based on these data that for most patients the benefits of this drug no longer outweigh the risks.
Biofeedback
Chronic constipation affects 15 to 20 percent of the U.S. population. Nearly one-third of affected people have dyssynergic defecation, in which muscles used for bowel movements do not work well, but there’s some good news. University of Iowa research shows biofeedback treatment can successfully retrain muscles.
The biofeedback approach was better than standard treatment of laxatives, diet and exercise or another treatment (sham) that included muscle relaxation and coping strategies. The findings appear in the March 2007 issue of the journal Clinical Gastroenterology and Hepatology.
Many people with dyssynergic defecation have life-long constipation and experience significant difficulty with passing stools but are unaware that they have this particular type of chronic constipation, said Satish Rao, M.D., professor of internal medicine at the UI Roy J. and Lucille A. Carver College of Medicine.
“People with dyssynergic defecation cannot sense stool in their bowel or have difficulty using bodily mechanisms to expel the stool. However, they often don’t seek help beyond using over-the-counter laxatives, and some doctors aren’t aware of the condition either,” Rao said.
The biofeedback technique involves making people more aware of unconscious or involuntary bodily functions involved in defecation. The technique includes placing a pencil-thin probe into the rectum to provide feedback information about how the body muscles are performing. This data, as well as visual and verbal feedback techniques, help individuals relearn the normal process of having a bowel movement.
The study included 79 adults, with an average age of 43, who had dyssynergic defecation. The 69 female and eight male participants were randomly assigned to one of three study groups: standard, biofeedback or “sham” biofeedback.
In the biofeedback group, 79 percent of the individuals had corrected bowel function at the end of the study. In contrast, only 4 percent of the sham group and slightly more than 8 percent of the standard group showed corrected muscle function.
Aerobic Exercise
Lack of exercise can lead to constipation, although doctors do not know precisely why.
Test for Food Allergies
Constipation triggered by food allergies might be responsible for chronic constipation in some adults. Individual foods, such as milk and milk-containing products, may be at fault in some individuals.
Magnesium
When given orally in sufficient quantities, magnesium citrate or sulfate (Epsom salts) is not fully absorbed but attracts water into the colon and thus acts as an effective laxative. Most people have heard of milk of magnesia, a form of magnesium sold as a laxative in drugstores. It is completely natural, safe, and it works very well, aside from a slightly unpleasant taste. Other forms of magnesium, including magnesium chloride, have a higher absorption rate. They may not be quite as effective as laxatives but they don’t taste as bad, they are gentler and can help while at the same time also providing magnesium for the body.
MSM (Methyl Sulfonyl Methane)
Some patients with chronic constipation have experienced continuing relief with a daily supplement of 100-500mg of MSM. The effect appears particularly strong in those who are older.
Reading List
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Enema
In general, children under 18 months of age can be given a glycerine suppository. Children between 18 months and 9 years can either be given a Fleets enema or 1/2 of a Dulcolax suppository. Older children can be given a regular Fleets enema or a whole Dulcolax suppository.
Up to five cases of acute hemodynamic deterioration, including one death, have been associated with the use of milk and molasses enemas for constipation in children. The four children who recovered required aggressive resuscitation. [J Pediatr Gastroenterol Nutr 2003;36(1): pp.144-8]
In children, you should avoid the regular use of an enema or suppository and try to solve the problem dietarily. The infrequent use of a water only or saline enema is considered safe.
The occasional use of an enema in an older child or adult should not result in any complications. If a coffee enema is indicated, it will not only help your liver, but produce a healthy evacuation as well.
Key
| Weak or unproven link |
| Strong or generally accepted link |
| Proven definite or direct link |
| Strongly counter-indicative |
| May do some good |
| Likely to help |
| Highly recommended |
Glossary
Constipation
Difficult, incomplete, or infrequent evacuation of dry, hardened feces from the bowels.
Acute
An illness or symptom of sudden onset, which generally has a short duration.
Chronic
Usually Chronic illness: Illness extending over a long period of time.
Magnesium
An essential mineral. The chief function of magnesium is to activate certain enzymes, especially those related to carbohydrate metabolism. Another role is to maintain the electrical potential across nerve and muscle membranes. It is essential for proper heartbeat and nerve transmission. Magnesium controls many cellular functions. It is involved in protein formation, DNA production and function and in the storage and release of energy in ATP. Magnesium is closely related to calcium and phosphorus in body function. The average adult body contains approximately one ounce of magnesium. It is the fifth mineral in abundance within the body--behind calcium, phosphorus, potassium and sodium. Although about 70 percent of the body's magnesium is contained in the teeth and bones, its most important functions are carried out by the remainder which is present in the cells of the soft tissues and in the fluid surrounding those cells.
Colon
The part of the large intestine that extends to the rectum. The colon takes the contents of the small intestine, moving them to the rectum by contracting.
Hypothyroidism
Diminished production of thyroid hormone, leading to low metabolic rate, tendency to gain weight, and sleepiness.
Psychogenic
Of a psychological origin.
Obsessive-Compulsive
People with Obsessive-Compulsive Disorder (OCD) have obsessions and/or compulsions. Obsessions refer to recurrent and persistent thoughts, impulses, or images that are intrusive and cause severe anxiety or distress. Compulsions refer to repetitive behaviors and rituals (such as hand washing, hoarding, ordering, checking) or mental acts (like counting, repeating words silently, avoiding). These obsessions and compulsions significantly interfere with normal routine, functioning, social activities and relationships.
Laxative
A substance (food, herb, chemical) that stimulates evacuation of the bowels. Examples include cascara sagrada, senna, castor oil, aloe vera, bisacodyl, phenolphthalein and many others.
Aerobic
Using oxygen. For example, aerobic exercises such as running, swimming, bicycling or playing tennis use up lots of oxygen and burn up lots of calories and fat.
Flax
Flax Seed or Flax Oil. Flax oil is nutty-flavored oil that is pressed out of flax seeds and is one of the richest sources of Essential Fatty Acids (especially Omega-3 oil), a vital element for good health. The oil making process removes many of the seed's phytoestrogens which offer several health-related benefits including reducing the risk of cancer and alleviating menopausal symptoms. Many choose to use the whole seed because of its fiber and lignan content. Flaxseed oil is light- and temperature-sensitive and must be stored in the refrigerator.
Allergy
Hypersensitivity caused by exposure to a particular antigen (allergen), resulting in an increased reactivity to that antigen on subsequent exposure, sometimes with harmful immunologic consequences.
Diarrhea
Excessive discharge of contents of bowel.
Dermatitis
A general term used to refer to eruptions or rashes on the skin.
Stimulant Laxative
Stimulant laxatives are believed to stimulate nerve endings in the nerve plexuses of the bowel wall, increasing the movement of its content via several mechanisms. The most common active ingredients include the Anthraquinones (Senna, Aloin, Frangula, Cascara and Powdered rhubarb) and the Diphenylmethane derivatives (Bisacodyl, Sodium picosulfate, Phenolphthalein). Traditionally-used castor oil has fallen into disuse because of its 'drastic' action and unpleasant taste.
Peristalsis
Movement characterized by alternate circular contraction and relaxation of the intestine or other tubular structure which propels the contents onward.
FDA
The (American) Food and Drug Administration. It is the official government agency that is responsible for ensuring that what we put into our bodies - particularly food and drugs - is safe and effective.
Over-The-Counter
A drug or medication that can legally be bought without a doctor's prescription being required.
Colitis
Inflammation of the colon.
Prostate
The prostate gland in men that surrounds the neck of the bladder and the urethra and produces a secretion that liquefies coagulated semen.
Acne
A chronic skin disorder due to inflammation of hair follicles and sebaceous glands (secretion glands in the skin).
Gastrointestinal
Pertaining to the stomach, small and large intestines, colon, rectum, liver, pancreas, and gallbladder.
Anxiety
Apprehension of danger, or dread, accompanied by nervous restlessness, tension, increased heart rate, and shortness of breath unrelated to a clearly identifiable stimulus.