Constipation in a young child seen on X-ray. Constipation refers to bowel movements that are infrequent or hard to pass. The stool is often hard and dry. Common causes include slow movement of stool within the colon, irritable bowel syndrome, and pelvic floor disorders. Treatment of constipation depends on the underlying cause and the duration that it has been present. Measures that may help include drinking enough fluids, eating more fiber, and exercise. Constipation is a symptom, not a disease. Most commonly, constipation is thought of as infrequent bowel movements, usually less than 3 stools per week.
The Rome Criteria are a set of symptoms that help standardize the diagnosis of constipation in various age groups. These criteria help physicians to better define constipation in a standardized manner. The causes of constipation can be divided into congenital, primary, and secondary. The most common kind is primary and not life-threatening. It can also be divided by the age group affected such as children and adults. Primary or functional constipation is defined by ongoing symptoms for greater than six months not due to an underlying cause such as medication side effects or an underlying medical condition. Secondary causes include side effects of medications such as opiates, endocrine and metabolic disorders such as hypothyroidism, and obstruction such as from colorectal cancer. Constipation can be caused or exacerbated by a low-fiber diet, low liquid intake, or dieting.
Dietary fiber helps to decrease colonic transport time, increases stool bulk but simultaneously softens stool. Therefore, diets low in fiber can lead to primary constipation. Many medications have constipation as a side effect. Systemic diseases that may present with constipation include celiac disease and systemic sclerosis. Constipation also has neurological causes, including anismus, descending perineum syndrome, and Hirschsprung’s disease. Spinal cord lesions and neurological disorders such as Parkinson’s disease and pelvic floor dysfunction can also lead to constipation. Voluntary withholding of the stool is a common cause of constipation.
The choice to withhold can be due to factors such as fear of pain, fear of public restrooms, or laziness. A number of diseases present at birth can result in constipation in children. The diagnosis is typically made based on a person’s description of the symptoms. Constipation is traditionally defined as three or fewer bowel movements per week. This in the context of accompanied symptoms help physicians discover the cause of constipation. Poor dietary habits, previous abdominal surgeries, and certain medical conditions can contribute to constipation. Diseases associated with constipation include hypothyroidism, certain types of cancer, and irritable bowel syndrome. Separating non-life-threatening from serious causes may be partly based on symptoms. For example, colon cancer may be suspected if a person has a family history of colon cancer, fever, weight loss, and rectal bleeding.
A physical examination should involve at least an abdominal exam and rectal exam. Abdominal exam may reveal an abdominal mass if there is significant stool burden and may reveal abdominal discomfort. Rectal examination gives an impression of the anal sphincter tone and whether the lower rectum contains any feces or not. Functional constipation is common and does not warrant diagnostic testing. Imaging and laboratory tests are typically recommended for those with alarm signs or symptoms. The laboratory tests performed depends on the suspected underlying cause of the constipation. Abdominal X-rays are generally only performed if bowel obstruction is suspected, may reveal extensive impacted fecal matter in the colon, and may confirm or rule out other causes of similar symptoms.
Colonoscopy may be performed if an abnormality in the colon like a tumor is suspected. Other tests rarely ordered include anorectal manometry, anal sphincter electromyography, and defecography. Mechanisms that can normalize these aberrant motor patterns may help rectify the problem. The Rome III Criteria for functional constipation must include two or more of the following and present for the past three months, with symptoms starting for at least 6 months prior to diagnosis. Constipation is usually easier to prevent than to treat. Following the relief of constipation, maintenance with adequate exercise, fluid intake, and high-fiber diet is recommended.
A limited number of causes require urgent medical intervention or will result in severe consequences. The treatment of constipation should focus on the underlying cause if known. The routine use of laxatives is discouraged, as having bowel movements may come to be dependent upon their use. Enemas can be used to provide a form of mechanical stimulation. Soluble fiber supplements such as psyllium are generally considered first-line treatment for chronic constipation, compared to insoluble fibers such as wheat bran. Side effects of fiber supplements include bloating, flatulence, diarrhea, and possible malabsorption of iron, calcium, and some medications. If laxatives are used, milk of magnesia or polyethylene glycol are recommended as first-line agents due to their low cost and safety.
Regular exercise can help improve chronic constipation. In refractory cases, procedures can be performed to help relieve constipation. Sacral nerve stimulation has been demonstrated to be effective in a minority of cases. Complications that can arise from constipation include hemorrhoids, anal fissures, rectal prolapse, and fecal impaction. Constipation is the most common chronic gastrointestinal disorder in adults. It is more common in women, the elderly and children. 9 billion in the US annually. More than four million Americans have frequent constipation, accounting for 2. 5 million physician visits a year.
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