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Constipation

Constipation

Also known as Costiveness, Dyschezia

Overview

Constipation is a common health problem that causes difficulty in passing stools and emptying the bowels. Almost everyone goes through constipation at some point in their lives. While constipation is uncomfortable, it is usually considered a symptom rather than a disease in itself. The various causes of constipation include diet that is not sufficient in fiber content, inadequate fluid intake, sedentary lifestyle, stress or sometimes an effect of some underlying medical condition of intake of specific medicines.


Prevention of constipation is centred around change in dietary and lifestyle habits. One should eat a high fiber diet comprising fruits, vegetables, legumes and whole grains. Restrict foods such as processed and packaged foods, milk and meat products.

Maintaining optimal fluid intake along with restricting intake of alcohol and caffeine in the form of coffee and soft drinks can also help in preventing constipation. Exercise regularly, do not delay the urge to pass stools and try to manage your stress levels.

 

Along with these changes, treatment of constipation involves many home remedies and use of over the counter laxatives. If relief from constipation is still not achieved, or in case of problems like pain while passing stools or rectal bleeding, it is always better to consult a doctor as long term use of laxatives or chronic constipation can lead to several other complications.

Key Facts

Usually seen in
  • Adults above 60 years of age
Gender affected
  • Both men and women but more common in women
Body part(s) involved
  • Intestine
  • Anus
  • Rectum
Prevalence
Mimicking Conditions
  • Ulcerative Colitis
  • Microscopic Colitis
  • Crohn's Disease
  • Lactose Intolerance
  • Celiac Disease
  • Gallstones
  • Pancreatitis
  • Endometriosis
  • Cow’s milk protein allergy
Necessary health tests/imaging
Treatment
Specialists to consult
  • General Physician
  • Gastroenterologist
  • Pediatrician (in case of children)

Symptoms Of Constipation

The symptoms of constipation include:

  • Reduced bowel movement of less than three times a week

  • Passing hard and lumpy stools

  • Straining while passing stools

  • Feeling of fullness, even after passing stools

  • Feeling of not able to completely evacuate the stools from the rectum

  • Feeling of a blockage in the rectum that prevents passing of stools

  • Some people may even need digital evacuation of stools

  • Bloating 

  • Feeling sluggish

  • Abdominal pain

Causes Of Constipation

Some of the common cases of constipation include:

1. Poor dietary habits

One of the common causes of constipation is poor dietary habits that can affect bowel movements. If your diet fails to include foods rich in fibre such as fruits and vegetables in the right quantity, it can affect digestion and passing of stools. This is because fibre acts as a natural laxative, which holds water in the stool, increases its bulk and makes it easy to pass. 


2. Insufficient fluid intake

Lack of sufficient water in the body can lead to dehydration is another factor that can cause constipation. When you suffer from dehydration, the body tries to conserve water by removing water from the stools. As a result, the stools contain less amount of water, which makes it harder to pass them from rectum.


3. Use of certain medicines

Constipation can be caused as a side-effect of certain medicines such as iron salts, opioids, sedatives, over the counter antacids and some of the drugs used to lower blood pressure. So if you are taking any of these medicines, then do consult your doctor. He may either change the dosage of the medicines or help you treat constipation with medicines or laxatives.

The list of certain medicines that can cause constipation include:

  • Paracetamol - if more than seven tablets are taken in a week

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) like  ibuprofen

  • Iron and calcium supplements

  • Aluminum-containing antacids

  • Anticholinergic agents or medicines that oppose the actions of the neurotransmitter acetylcholine. These include drugs for Parkinson’s disease, depression, delusions, hallucinations, and muscular spasms.

  • Anticonvulsants (drugs used to treat seizures) such as carbamazepine, phenobarbital, and phenytoin.

  • Cancer drugs such as vinblastine, vincristine, vindesine, and vinorelbine

  • Calcium-channel blockers such as verapamil

  • Water pills (diuretics) such as furosemide


4. Underlying medical conditions

Constipation can be caused by various health conditions like the following:

  • Irritable bowel syndrome 

  • Endocrine disorders like Diabetes, Hypothyroidism, Hyperparathyroidism,  Hypercalcemia, Hypokalemia, insufficient production of pituitary hormones

  • Tumor of the adrenal gland

  • Delayed emptying of the colon caused by pelvic floor disorders and colon surgery

  • Diverticular disease

  • Bowel obstruction

  • Narrowing of colon or bowel stricture

  • Colorectal cancer

  • Other abdominal cancer that presses on the colon

  • Rectal cancer

  • Lazy bowel syndrome in which there is slow movement of waste through the digestive tract

  • Neurogenic disorders like spinal cord injury, stroke, multiple sclerosis, Parkinson’s disease, brain injury etc.

  • Structural defects in the digestive tract like fistula, imperforate anus, malrotation etc.

  • Diseases like amyloidosis, lupus erythematosus, and scleroderma


5. Overuse of laxatives

Laxatives are common medicines used to treat constipation. In most cases, people with this condition do not consult a doctor but use laxatives to get rid of constipation. However, it is reported that overuse of laxatives is not good for your health. People who use laxatives frequently tend to lose the ability to pass stools without such aids. Hence, in the long run, it can lead to more use of laxatives and an increased risk of constipation.

The use of conventional laxatives, as a first step for the treatment of constipation, are not effective in many cases. Moreover, laxatives can cause drug interactions with other medications.

Risk Factors For Constipation

The risk factors for constipation include:

  • Age - constipation is more common in older adults

  • Gender - constipation occurs more frequently in women

  • Resisting or delaying the urge to pass stools

  • Travel or other changes in daily routine

  • Less physical activity - people with more sedentary lifestyle are more likely to have constipation

  • Stress

  • Depression or any eating disorder

  • Pregnancy especially during the last months

  • During menopause


Constipation is a common symptom during pregnancy, but this doesn’t mean that every pregnant woman will suffer from constipation. So, if you are pregnant and suffering from constipation, here’s a quick guide with tips to help control the condition.

Diagnosis Of Constipation

The diagnosis of constipation depends largely on the patient’s history. The doctor will take:

  • Medical history (other health problems and medications taken)

  • Dietary history (intake of fiber and water)

  • Symptoms history (duration and severity)

Physical examination

This may include 

1. Abdominal examination in which the abdomen may be examined for distension. The enlarged or swollen bowel may point towards constipation.

2. Rectal examination may be done to look for scars, hemorrhoids, fistulas or fissures around the perineum, the area between anus and scrotum (in males) or vulva (in females).


Laboratory test

These tests may be done to look for underlying conditions that cause constipation. These may include:

1. Blood tests to check for hemoglobin, thyroid stimulating hormone (TSH), calcium, and glucose levels to reveal signs of risk factors like anemia, hypothyroidism, hyperparathyroidism, diabetes etc.


2. Stool Examination
to check for any signs of infection, inflammation, and cancer.


3. Radiology tests
such as Abdominal X-ray, CT scan or MRI of the colon to assess the length and width of the colon or any lesion that may cause obstruction.


4. Barium enema
study is an imaging study that uses x-rays along with an enema (containing barium) to detect abnormalities inside the colon. The contrast solution containing barium is injected into the rectum. Barium enema produces better images as compared to other imaging studies.


5. Defecography
is a modification of the barium enema examination. A thick paste of barium is inserted into the rectum of a patient through the anus. This procedure then examines the process of defecation and gives information about anatomical abnormalities of the rectum and pelvic floor muscles during defecation.


6. Magnetic resonance imaging defecography
is one of the latest tests for evaluating defecation. It is similar to barium defecography, however, MRI is used instead of X-rays to provide images of the rectum during defecation.


7. Colonic transit
(marker) studies involve consuming a small amount of a radioactive substance usually in the form of a pill, and then tracking the amount of time and how the substance moves through the colon.


8. Colonoscopy or endoscopy
of the colon is a diagnostic method in which a long, flexible, lighted tube is inserted through the rectum to get an internal view of the colon. During this procedure, biopsy may also be taken to test for cancer or any other problem. 

Prevention Of Constipation

1. Eat a high fiber diet comprising fruits, vegetables, legumes and whole grains. Restrict foods with low amounts of fiber such as processed and packaged foods, milk and meat products.

2. Drink a minimum of 8 glasses of water during a day. Restrict intake of alcohol and caffeine in the form of coffee and soft drinks as they tend to dehydrate the body.

4. Stay active and exercise regularly

5. Do not delay the urge to pass stools

6. Try to manage stress

Specialist To Visit

In most cases, constipation improves on its own with simple changes in diet. However,  consult a doctor if you have 

1. Had less than three bowel movements in a week

2. Pain while passing stools

3. Rectal bleeding


Doctors/specialists who can help in the diagnosis and treatment of constipation are:

  • General Physician

  • Gastroenterologist

  • Pediatrician(in case of children)

Is Constipation Not A Serious Condition?
Though, many times it is taken lightly, it should not be ignored. It may not lead to life-threatening complications, however, untreated constipation can cause painful hemorrhoids and anal fissures. Constipation should never be avoided as its persistence can severely impact a person’s day-to-day chores. Consult the right expert.
Is Constipation Not A Serious Condition?

Treatment Of Constipation

Treatment for constipation mainly includes lifestyle changes and medications to soften the stools or stimulate its movement through the colon. Mild constipation gets better with lifestyle modifications. However, severe constipation may require medications.


1. Lifestyle modifications

Constipation can be easily avoided by making a few changes to our daily habits including diet and lifestyle. These include:

Dietary Changes

  • First and foremost, drinking at least 3 litres of water is a must for adults. Water hydrates the body and softens stool and aids its movement from the colon.

  • Include fibre-rich vegetables like carrots, cabbage, cauliflower, broccoli, spinach, varieties of gourd etc. in your diet. Blanch the veggies and sprinkle on some seasoning and spices. Have portions equivalent to 250-300 grams daily.

  • A fruit a day will keep constipation blues away. Besides containing dietary fibre, fruits like orange, apple, papaya, dates, figs etc. are packed with nutrients.

  • Substitute white rice and polished wheat with whole grain products like brown rice and unpolished wheat. Oats also have similar qualities. Eat a cup full of these healthy grains daily to fight constipation.

Here is a list of food to avoid during constipation.

Lifestyle Changes

  • Using the toilet at a fixed time every day will trick the body’s biological clock into creating a routine to defecate effectively. The morning is the best time to get started in this regard.

  • Avoid alcoholic drinks as much as possible. Alcohol dehydrates the body and causes stool to harden.

  • Start exercises like jogging, cycling, running and swimming to boost your metabolic rate and fight constipation.

  • Lessen or eliminate the consumption of oil and sugar-rich food from your diet as these upset digestion, cause constipation and lead to obesity.

2. Medicines

Laxatives are compounds which promote bowel movements and are used to relieve and prevent constipation. Some of these medicines are available over the counter (OTC) and come in the form of capsules, suppositories, enemas, pills, gums, and liquids. Most laxatives are advised to be used only for a short period of time. Use medicines only if recommended by your doctor.

  • Bulking agents such as bran and psyllium are fiber supplements, which are usually recommended for normal constipation.They contain fiber which add bulk to the stools and helps the stools to quickly move through the colon. People on bulking agents should drink ample amounts of water to maintain hydration. 

  • Lubricants help in smooth movement of stools through the colon.eg. mineral oil.

  • Stool softeners work by moistening the stools eg. docusate sodium

  • Osmotic laxatives stimulate the absorption of water from the body to make stools softer. These include lactulose, lactitol or polyethylene glycol.

  • Stimulant laxatives help in contracting the muscles in the intestines rhythmically. Examples include castor oil, sodium picosulfate, and bisacodyl.

  • Enemas use a thin tube to inject a liquid or a gas into the rectum to expel its contents. Examples: Phosphate enema, mineral oil retention enema, and soapsuds enema.

  • Suppositories such as those containing glycerin or bisacodyl are placed into the rectum.

  • Chloride channel activators such as Lubiprostone are used to treat chronic constipation.

Here’s more information about different types of laxatives and how they work.

Myths About Constipation!
Constipation is one of the most common health problems. Unhealthy eating practices, inadequate sleep, sedentary lifestyle and stressful life are some of the common triggers for constipation. Common across the population, there are certain myths surrounding constipation.

Complications Of Constipation

Constipation if left untreated or if suffering from a long time may cause:

1. Hemorrhoids, a condition that leads to swollen veins in the rectum and anus. 

2. Rectal prolapse in which a part or the entire wall of rectum stretches and protrudes out from the anus

3. Anal fissures which are small tears in the anus that cause pain and bleeding.

4. Fecal impaction is a condition in which hardened stools get stuck in the intestines due to long term constipation.

Alternative Therapies Of Constipation

Biofeedback

It is used to treat chronic constipation. It involves training of pelvic floor muscles for passing stools by electronic monitoring.


Natural products

Many natural products that may help in constipation are:


Foods To Relieve Constipation

Fruits, cereals, leafy vegetables, curd, and seeds can help you to deal with constipation. These foods are known to add bulk to stools, increase bowel frequency, soften the stools and decrease the gut transit time (which is the time taken by food to move through the digestive tract). However, keep a check on your fiber intake as excess fiber can also worsen constipation. 

Here are some of the common foods to relieve constipation at home.

1. Kiwi

Green kiwi fruit increases the frequency of stools, softens the stools and eases defecation. This could be attributed to the presence of fiber (2-3 gm of dietary fiber per 120 gm of the fruit), which plays a key role in bulking of the stools and relieving constipation. It also contains an enzyme which stimulates the motility of the upper gastrointestinal tract. 

Tip: You can peel the fruit, cut it into thin slices and either eat it raw or add to salads or smoothies to fight constipation.


2. Banana (Kela)

A medium-size banana (which weighs around 100 g) contains about 3 g of fiber. It not only absorbs water to soften the stools but also improves the movement of stool through the intestinal tract.

Tip: Eat a banana every day for regular bowel movements and prevent chronic constipation. Bananas are best eaten as a whole and not in smoothies or milkshakes.


3. Prunes

Dried plums, also known as prunes, contain around 6.1 g of fiber per 100 g of fruit, which is very high as compared to other commonly available fruits. Moreover, it is rich in fructose and contains a high amount of sorbitol (14.7 g per 100 g), a sugar compound that has laxative properties. 

Tip: Eat prunes as a whole. Avoid drinking prune juice to deal with constipation because it has less sorbitol and fiber content.


4. Apple (Seb)

A medium sized apple contains around 4.4 gm of fiber, most of which is pectin. This fibre is broken down into short-chain fatty acids by the intestinal bacteria. These fatty acids absorb water, soften the stool and decrease the intestinal transit time, relieving constipation.

Tip: Eat the apple with its peel to increase your fiber intake. You can add apples to a fruit salad.


5. Pear (Naspati)

You can get around 22% of your daily recommended allowance of dietary fiber if you eat a medium-sized pear. In addition to fiber, pears are also rich in fructose and sorbitol. 

Tip: Pears work best when eaten as a whole. However, drinking pear juice is usually recommended in kids whose intestinal function is not fully matured.


6. Figs (Anjeer)

Raw, as well as dried figs, are a great source of fiber, which not only relieves constipation but also promotes a healthy bowel. Around 75 g of dried figs and raw figs contain 7.3 g and 2 g of fiber respectively.

Tip: You can snack on figs by including them in your fruit salads, juices or smoothies. However, eating it in its whole form is regarded as the best way to up the intake of fiber.


7. Spinach (Palak)

Spinach is one of the common leafy vegetables that is loaded with fiber. Moreover, it is also rich in various minerals and vitamins that improve digestion. A cup of spinach contains around 4 g of fiber, which is known to add bulk to stools and makes it easier to move through the gut.

Tip: You can make palak parathas and palak paneer or add palak to smoothies or salads.


8. Oats

Oats are good for people suffering from constipation as it is rich in fiber. Oat bran is the outer covering of the grain, which is loaded with fiber. Moreover, adding around 8 g of oat bran to your diet every day reduces the use of laxatives.

Tip: Oat bran can be added to wheat flour, granola mixes or bakery items. But use oat bran and not ready-to-eat oats, as the latter contains less fiber as compared to oat bran.


9. Flaxseeds (Alsi)

One of the commonly used traditional remedies to deal with constipation, flaxseeds act as a natural laxative. This is due to the presence of soluble as well as insoluble fiber. A tablespoon of roasted flax seeds contains around 3 g of fiber.

Tip: You can add flaxseeds to cereals or use it in salads. Flaxseed powder can be added to wheat flour or milk.


10. Sweet potato (Sakargandi)

Unlike potatoes, sweet potatoes are rich in fiber. A medium-sized sweet potato contains around 3.8 g of both insoluble fibers such as cellulose and lignin and soluble fiber such as pectin. Both types of fiber play a key role in easing constipation by improving the bowel movement and adding weight to stools.

Tip: You can eat sweet potatoes in the boiled or roasted form to increase your intake of fiber. Alternatively, you can steam it, mash it and add it to curries or salads.


11. Probiotics

Probiotics contain bacteria such as bifidobacteria and lactobacilli which help maintain the level of good bacteria in the digestive tract which aids proper digestion.

Tip: Curd and buttermilk are the best natural forms of probiotics that are easily available. You can add curd to your diet.


A few examples of natural drinks that help in relieving constipation instantly.

Yoga for Constipation

Yoga offers several poses that stimulate peristaltic action and increase blood flow to the gut. When done on a regular basis, yoga can help in regular bowel movements.

  • Matsyasana (fish pose)

  • Anjaneyasana (crescent pose)

  • Pavanamuktasana (wind-relieving pose)

  • Balasana (child’s pose)

Frequently Asked Questions

References

  1. Ray G. Evaluation of the Symptom of Constipation in Indian Patients. J Clin Diagn Res. 2016;10(4):OC01-OC3. External Link
  2. Forootan M, Bagheri N, Darvishi M. Chronic constipation: A review of literature. Medicine (Baltimore). 2018;97(20):e10631. External Link
  3. Jani B, Marsicano E. Constipation: Evaluation and Management. Mo Med. 2018;115(3):236-240. External Link
  4. Diaz S, Bittar K, Mendez MD. Constipation. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. External Link
  5. Andrews CN, Storr M. The pathophysiology of chronic constipation. Can J Gastroenterol. 2011;25 Suppl B(Suppl B):16B-21B. External Link
  6. Portalatin M, Winstead N. Medical management of constipation. Clin Colon Rectal Surg. 2012;25(1):12-19.External Link
  7. Krogh K, Chiarioni G, Whitehead W. Management of chronic constipation in adults. United European Gastroenterol J. 2017;5(4):465-472. External Link
  8. Sparberg M. Constipation. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 89. External Link
  9. Bae SH. Diets for constipation. Pediatr Gastroenterol Hepatol Nutr. 2014;17(4):203-208. External Link
  10. Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology. 2020;158(5):1232-1249.e3. External Link
  11. Müller-Lissner S. The pathophysiology, diagnosis, and treatment of constipation. Dtsch Arztebl Int. 2009;106(25):424-432. External Link
  12. Schuster BG, Kosar L, Kamrul R. Constipation in older adults: stepwise approach to keep things moving. Can Fam Physician. 2015;61(2):152-158. External Link
  13. AJ Lembo. Constipation. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap19. External Link
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