Definition of Constipation
The definition of constipation includes the following:
- infrequent bowel movements (typically three times or fewer per week)
- difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools), or
- the sensation of incomplete bowel evacuation.
The Rome III criteria are widely used to diagnose chronic constipation, and are helpful in separating cases of chronic functional constipation from less-serious instances.
Constipation in children usually occurs at three distinct points in time: after starting formula or processed foods (while an infant), during toilet training in toddlerhood, and soon after starting school (as in a kindergarten).
After birth, most infants pass 4-5 soft liquid bowel movements (BM) a day. Breast-fed infants usually tend to have more BM compared to formula-fed infants. Some breast-fed infants have a BM after each feed, whereas others have only one BM every 2–3 days. Infants who are breast-fed rarely develop constipation. By the age of two years, a child will usually have 1–2 bowel movements per day and by four years of age, a child will have one bowel movement per day.
Cause of Constipation
The causes of constipation can be divided into congenital, primary, and secondary. The most common cause is primary and not life threatening. In the elderly, causes include: insufficient dietary fiber intake, inadequate fluid intake, decreased physical activity, side effects of medications, hypothyroidism, and obstruction by colorectal cancer.
Constipation with no known organic cause, i.e. no medical explanation, exhibits gender differences in prevalence: females are more often affected than males.
Primary or functional constipation is ongoing symptoms for greater than six months not due to any underlying cause such as medication side effects or an underlying medical condition. It is not associated with abdominal pain thus distinguishing it from irritable bowel syndrome. It is the most common cause of constipation.
Constipation can be caused or exacerbated by a low fiber diet, low liquid intake, or dieting.
Many medications have constipation as a side effect. Some include (but are not limited to); opioids (e.g. common pain killers), diuretics, antidepressants, antihistamines, antispasmodics, anticonvulsants, and aluminum antacids
Metabolic & Muscular
Metabolic and endocrine problems which may lead to constipation include: hypercalcemia, hypothyroidism, diabetes mellitus, cystic fibrosis, and celiac disease. Constipation is also common in individuals with muscular and myotonic dystrophy.
Structural and Functional Abnormalities
Constipation has a number of structural (mechanical, morphological, anatomical) causes, including: spinal cord lesions, Parkinsons, colon cancer, anal fissures, proctitis, and pelvic floor dysfunction.
Constipation also has functional (neurological) causes, including anismus, descending perineum syndrome, and Hirschsprung’s disease. In infants, Hirschsprung’s disease is the most common medical disorder associated with constipation. Anismus occurs in a small minority of persons with chronic constipation or obstructed defecation.
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. When a child holds in the stool a combination of encouragement, fluids, fiber, andlaxatives may be useful to overcome the problem.
Signs and Symptoms of Constipation
The Rome II Criteria for constipation require at least two of the following symptoms for 12 weeks or more over the period of a year:
- Straining with more than one-fourth of defecations
- Hard stool with more than one-fourth of defecations
- Feeling of incomplete evacuation with more than one-fourth of defecations
- Sensation of anorectal obstruction with more than one-fourth of defecations
- Manual maneuvers to facilitate more than one-fourth of defecations
- Fewer than three bowel movements per week
- Insufficient criteria for irritable bowel syndrome
Risk Factors for Constipation
- Being an older adult
- Confined to bed
- Irritable bowel syndrome
- Colon cancer
- Eating a diet that’s low in fiber
- Not getting adequate fluids
- Taking certain medications, including sedatives, narcotics or certain medications to lower blood pressure
- Undergoing chemotherapy
Women are more frequently affected by constipation, and children more than adults.
Prevention from Constipation
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. Children benefit from scheduled toilet breaks, once early in the morning and 30 minutes after meals
Treatment of Constipation
The main treatment of constipation involves the increased intake of water and fiber (either dietary or as supplements). 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. However, enemas are generally useful only for stool in the rectum, not in the intestinal tract.
If laxatives are used, milk of magnesia is recommended as a first-line agent due to its low cost and safety. Stimulants should only be used if this is not effective. In cases of chronic constipation, polyethylene glycol appears superior to lactulose. prokinetics may be used to improve gastrointestinal motility. A number of new agents have shown positive outcomes in chronic constipation; these include prucalopride, and lubiprostone.
Constipation that resists the above measures may require physical intervention such as manual disimpaction (the physical removal of impacted stool using the hands).
Lactulose and milk of magnesia have been compared with polyethylene glycol (PEG) in children. All had similar side effects, but PEG was more effective at treating constipation. Osmotic laxatives are recommended over stimulant laxatives.