Constipation Matters, Cause and Treatment

Common Causes of Constipation and How to Manage it Appropriately Nurses Education Article

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

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Amy White FNP MSN BSN RN

About Amy White FNP MSN BSN RN

Amy White FNP MSN BSN RN has 18 years experience and specializes in Gastroenterology.

2 Articles   7 Posts

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Specializes in retired LTC.

Enjoying this article also, but I think I need to question your diagnostic definition of "stool frequency of less than 3 BMs per week that can involve having to strain and pass hard stools". For some clients, I would counter-claim that the 3 times could be more freq but still with the straining and hard stool. And that's not taking into acct any remedial efforts.

I also proffer that diagnoses can include 'dormant' diverticuli. Also the results of stringent and/or prolonged dieting.

I speak from experience. Like I notice that you omitted the 'gold standard' PRUNES and dried apricots!  I would also like to add that if a client finds some safe regimen that seems to be working, by all means, CONTINUE it without deviation. REGULARITY! CONTINUITY!

Again, an informative article.

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Specializes in ICU, travel.

I appreciate writing decently written health content. Not the great American novel, but if you got paid for writing health content over some snot nosed 23 year old with a BA in English whose Instagram career isn't covering all the bills, I support this. 

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Specializes in retired LTC.

I too appreciate the easiness of reading some articles. Not interested in reading some EB references awaiting doctoral defense and presentation for thesis publication.

Not for this site.

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Specializes in Psych, Addictions, SOL (Student of Life).

A generally good article but I question the following statement; 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.

Low fiber diets are notorious for causing constipation. Natural fiber is the first rung of defense against normal types of constipation. I see no benefit is removing dietary fiber from fruits and whole grains and then adding a laxative. I have had multiple bowel surgeries and foe a time had a lot of issues with constipation and IBS. A naturopath I know suggested adding fresh pineapple to my diet twice week. The fruit is high in natural fiber and the enzymes in the fruit break down compacted stool and act as a mild laxative. Once I started on this regimen I have never had constipation again.

Hppy 

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Specializes in retired LTC.

Hppy - now I have to check out fresh pineapple enzymes with statins! It just kills me that I have to restrict grapefruit. 

Amy - I find it very interesting (and at times confusing) that certain dietary recommendations sooo interfere with recommendations needed for other disease processes. I have GI issues (hence my interest in your articles). I also have gout, anemia & diverticuli, et al. And I take some meds which come with their own restrictions.  It's a rough hoe at times for me to balance dietary avoidances/allowances (on top of the need to lose wt). Is it any wonder that pts struggle?!?

Is Therapeutic Dietary Consult a covered therapy service like PT/OT/RT? It should be! I would just love it someone could just generate a specialized graph that could overlay my dietary DO's and don't'S. (Hint: any entrepreneurs reading?)

Didn't quite mean to hijack your post.

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Specializes in retired LTC.

Looked it up - I'm OK with pineapple & statins.

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Specializes in Gastroenterology.

Thanks for all the comments and feedback. I guess what I was eluding to when I said low fiber with adhesive disease and keeping stools soft and moving is I see lots of folks taking in large amounts of fiber without enough water intake and causing impactions. So, for those people, increasing water intake with fiber may help, but for some, fiber can still constipate given the severity of adhesive disease present. Sorry I wasn't clear. Thanks so much for your feedback though, really appreciate it! And yes, prunes and apricots should've been number 1 and 2 on my list! How did I forget those!? Also, medical conditions, medications, and food choices overlap all the time, and they can be very confusing. Dieticians should be covered and shame on insurance companies if they're not!

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Specializes in Gastroenterology.

amoLucia, can I use your real name for a testimonial from you on my diarrhea article for my website? 

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