It is important to distinguish acute (recent onset) constipation from chronic (long duration) constipation. Acute constipation requires urgent assessment because a serious medical illness may be the underlying cause (for example, tumors of the colon).

Clinical criteria

• Straining during the bowel movement (passing stools) more than 25% of time
• Hard (pellet like) stools more than 25% of time

• Incomplete evacuation more than 25% of time

• Bowel movements fewer than three per week

Common causes

• Inadequate fluid intake
• Inadequate fiber in diet
• Inadequate activity or mobility
• Frequent use and abuse of laxatives
• Irritable bowel syndrome
• Inattention to bowel habits or ignoring the urge to have a bowel movement
• Hemorrhoids and anal fissure
• Hypothyroidism

• Depression

• Neurological conditions like Parkinson’s, multiple sclerosis, and injury to spinal cord

Drugs causing constipation

• Strong pain medicines (narcotics) – morphine, codeine
• Iron and calcium supplements
• Antacids containing calcium or aluminum
• Antidepressants

• Anticonvulsants

• Anti Parkinson medications

Clinical features

• Less than 3 stools per week
• Hard stools
• Excessive straining during bowel movements
• Feeling of incomplete evacuation after having a bowel movement
• Finger evacuation or manipulation of your lower abdomen

• The discomforts of chronic constipation can go way beyond having infrequent bowel movements.

• This motility problem can also lead to bloating, abdominal pain and an increased sensation of intestinal gas.

Risk factor

• Older adults
• Sedentary life styles or confined to bed
• Inadequate fluids and fiber rich foods

• Undergoing chemotherapy

• Women and pregnancy

Complications

Hemorrhoids – due to spasm of the anal sphincter muscle and engorgement of blood vessels

Anal fissure- as a result of hard stool stretches the sphincter muscle

Fecal impaction

Rectal prolapsed

Lazy bowel syndrome- due to abuse and over abuse of laxatives

Warning about constipation

• Constipation lasted for more than 2 weeks
• Blood in the stools

• Unexplained weight loss

• Severe abdominal pain with bowel movements

Tests and diagnosis

• Barium enema X-ray
• Flexible sigmoidoscopy

• Colonoscopy

• Thyroid profile

Preventive measures

• Need to consume 8- 10 glasses of water every day
• Choose fiber rich foods- green leafy veg, carrot, beans, sprouts, and lady’s finger. Whole grain cereals and pulses. Fruits like banana, watermelon, papaya, guava, and others
• Reduce low fiber foods- fatty foods, refined foods, junk foods, carbonated beverages, and others
• Regular exercises like brisk walking, leg raising exercises, biking or swimming
• Don't ignore the urge to have a bowel movement. The longer you delay, the more water is absorbed from your stool and the harder it becomes.

• Avoid overuse of laxatives/ stool softener like dulcolax or docusates.

• For occasional relief try a saline laxative such as milk of magnesia, this draws water into the colon to lubricate the stool.

Treatment

Laxatives

These over-the-counter medications should be considered as a last resort because they can become habit-forming.

There are several different types of laxatives:

• Stimulant laxatives – castor oil, bisacodyl, sennakot
• Stool softeners- docusates. It’s also used in hemorrhoids and anal fissure
• Saline laxatives- magnesium citrate (milk of magnesia), magnesium hydroxide, and sodium phosphate

• Hyperosmolar laxatives-  lactulose, sorbitol and polyethylene glycol

• Lubricant laxatives- mineral oil and fleet

Fiber supplements

• Also called bulk laxatives, generally considered the safest laxative.
• Ex- Psyllium husk, ispaghula husk.
• These agents must be taken with plenty of water.

• This medication is generally well tolerated. Bloating, gas, and a feeling of fullness may occur.

• They are also used in IBS, spastic colon, hemorrhoids and to reduce the cholesterol levels

5 –HT- 4 agonists

Ex- Tegaserod

Used in chronic idiopathic constipation and irritable bowel syndrome

Chloride channel activators

The agent lubiprostone (Amitiza) is available by prescription and increases fluid content of stool.