I have constipation! What can I do about it?
Constipation is a common complaint. Technically it is defined by the presence of either straining with hard stools, or fewer than 3 bowel movements per week for at least 25% of the time. Patients usually complain of constipation when it is a relatively recent phenomenon which is a noticeable change from easier motions in the past. Or else they have symptoms of discomfort from constipation such abdominal bloatedness or pain. Such discomfort can even impair appetite.
Is constipation serious?
That depends on the cause. If you are young (less than say 45 years) then the likelihood of something serious like colon cancer is much less. If you are completely stopped up, passing nothing, not even gas for days and you have abdominal distention and pain, this may be due to intestinal obstruction (usually due to cancer but also post-surgical scarring of the tissues around your intestines – called “adhesions”) which is a medical emergency and you need to be quickly seen in a hospital and by a specialist.
What are the most common causes?
Most patients have “functional constipation” or “constipation predominant irritable bowel syndrome” which means that there is no specific disease causing it. The most consistent problem here is that material takes longer time to transit the small and large intestine. There is a mental overlay in that depression or anxiety are frequently associated with chronic constipation. Lack of fibre in the diet is seldom the cause.
If you have had diabetes mellitus for many years, then the effect of diabetes on the nerves controlling defaecation may be affected (autonomic neuropathy). Other possibilities include hormone imbalance, such as hypo-thyroidism. You should also tell your doctor all the medicines you take as some of them may cause constipation, such as anti-diarrhoea medicines like Imodium or Lomotil, some cough mixtures and aluminium based antacids.
Are there hints of more serious disease?
But if there are “alarm features”, and especially if the patient is more than 45 years old, then it is important to look harder for a serious disease such as cancer. Alarm features include change of stool calibre, severe pain, blood in the stool, loss of appetite and weight, abdominal mass, family history of colon cancer or low haemoglobin (anaemia).
Do I need to be evaluated by a Gastroenterologist?
If you are young and otherwise well and have occasional constipation, you could try to relieve it by taking laxative teas (that often contain the laxative Senna) or over the counter laxatives such as Bisacodyl or Lactulose, over a short period of time. If that relieves you and you are then well afterwards, perhaps there is no need to be checked up. But if you are older, have other illnesses, feel unwell in yourself, have a lot of pain and your constipation is getting worse, then you ought to be evaluated.
General Practitioners are well placed to evaluate your constipation and exclude serious illness. If they are still worried, they may refer you to a Gastroenterologist. The possible tests that may be helpful include blood tests, abdominal x-ray and Colonoscopy (examination of your large intestine by a flexible endoscope).
What can constipation be treated?
If there is a disease such as cancer or hypo-thyroidism, then the disease has to be managed on its own merits.
If no specific cause if found, then we could start with lifestyle and diet modification. You should eat regularly and drink enough water. Bowel movements must be unhurried and you need to set time aside for this, usually after breakfast and/or after dinner. If you don’t take a lot of fibre, you could add more fibre rich food, or eat bran cereal, which sometimes works. Increasing fibre could sometimes add to bloating and cramp however.
Stimulant laxatives can be used if simple measures don’t help. Over the counter medicines like Bisocodyl or Lactulose are safe to take, even over extended periods of time. There are other laxatives such as formulations containing polyethylene glycol (PEG). Other drugs such as Prucalopride, must be prescribed by doctors.
Other treatments include biofeedback (a way of helping the body to respond normally to defaecation stimuli) which is totally harmless and non-invasive. If there is a clear element of anxiety or depression, these must be managed as well. If a couch –potato, increased exercise is sometimes helpful.
Do I need surgery to correct constipation?
If there is colon cancer, surgery might well be appropriate. However, only a tiny fraction of patients with chronic functional constipation are candidates for surgery, which usually means removal of the entire colon. This is obviously drastic and a last resort. Constipation should be evaluated and managed through medical means by Gastroenterologists who will make the decision for surgery if it comes to that.