Constipation Matters, Cause and Treatment

Constipation can slow you down and at times can make you feel bloated, gassy, and irritable. Constipation is defined as a stool frequency of less than three bowel movements per week that can involve having to strain and pass hard stools.

Let’s look at some causes of this common condition and ways to manage it better.

Medical conditions that can be associated with constipation include:

• Diabetes Mellitus
• Hypothyroidism
• Autonomic neuropathy
• Hypokalemia
• Hirschsprung disease
• Anorexia nervosa
• Intestinal pseudo-obstruction
• Pregnancy
• Multiple sclerosis
• Dysmotility
• Spinal cord injury
• Dyssynergic defecation
• Parkinson's disease
• Irritable bowel syndrome

Drugs associated with constipation include:

• Opiates
• Antihistamines
• Calcium channel blockers
• Antispasmodics
• Antihypertensives
• Antidepressants
• Antacids / Carafate
• Antipsychotics
• Iron supplements
• Barium (for studies)

Medical and surgical history, as well as medications, can play a huge role in managing this condition.  

Another thing to consider is how many abdominal surgeries have been performed. Adhesive disease (scar tissue) builds up with each abdominal surgery and can entrap bowel loops and cause partial or even complete bowel blockages. The goal here is to keep bowels soft and moving, often adhering to a low fiber diet (to avoid bulky stools) in combo with a stool softener and mild laxative, such as Miralax.

Avoiding stimulant laxatives (Senna, Senekot, Dulcolax, Milk of Magnesia, etc) long-term is a good idea because they can make the colon lazy and dependent on them. If these drugs are utilized, using them sporadically every other day or even every third day is best in combo with a stool softener and Miralax as needed. Utilizing fiber in dietary and supplement form is good to try first.

There are two different kinds of fiber: Soluble and Insoluble. Soluble fiber dissolves in water and is made of carbohydrates. Examples include fruits, oats, barley, and legumes (beans and peas), while insoluble fiber is derived from plant cell walls and does not dissolve in water. Examples of insoluble fiber include wheat, rye, and other grains. Dietary fiber is the sum of soluble and insoluble fiber.

Fibrous foods include:

• Raspberries
• Pears
• Apples with skin
• Oranges
• Strawberries
• Green peas
• Turnip greens
• Brussel sprouts
• Baked potato with skin
• Sweet corn
• Cauliflower
• Carrots
• Barley, cooked
• Bran flakes
• Quinoa, cooked
• Oatmeal
• Whole wheat bread
• Chia seeds
• Almonds  Pistachios
• Black or baked beans
• Bananas
• Broccoli

Fiber supplements include Citrucel, Benefiber, and Metamucil. There are other brands available but these have worked well for many patients in my practice. Adding fiber may cause some abdominal bloating or gas initially, but this can be minimized by starting with the lowest dose and slowly increasing as tolerated. The recommended dose of fiber is 20-35 grams per day. When discussing dietary fiber, it is good to consider dietary habits in general as this could easily be a factor in bowel habit changes.

Biofeedback is a behavioral approach that can be used to improve the contraction of pelvic floor muscles. A pelvic floor specialist is often utilized to help with this type of therapy for patients who may have anal sphincter dysfunction that may be the primary concern disguised as constipation.

Some patients come in saying they’ve had constipation their entire lives and now they have diarrhea. While a change in bowel habits does warrant further investigation (infectious, inflammatory, pancreatic insufficiency, etc), one must consider overflow diarrhea. This happens when a person becomes impacted and the colon is trying to push stool out and water ends up going around the impacted stool.

This typically requires an abdominal x-ray to assure this is what’s going on before ordering a bowel-prep-equivalent purge. If this is confirmed on x-ray, a Miralax or Golytely bowel purge is in order, but only if vomiting isn't a factor. If it is, proceed with a Gastrograffin enema in the x-ray department to help evacuate stool.

Once the stool is evacuated, a discussion about a daily bowel regimen is in order. It may be a combo of fiber, stool softener (docusate sodium), and Miralax. If this regimen doesn’t work for them, it may be time to look at more potent laxatives such as Linzess, Amitiza, Trulance, or Motegrity. These are prescription laxatives and will need to be managed by a primary care physician or gastroenterologist.

Constipation has many factors to consider such as medical and surgical history, medications, dietary and supplemental fiber as well as dietary indiscretion, pelvic floor dysfunction, and potential impaction. Discussion with a primary care physician or gastroenterologist is key in managing this common condition. It often takes several visits to pinpoint the specific cause and best treatment options.

References

www.mayoclinic.org
UpToDate: Evidence-based Clinical Decision Support