Constipation

What is constipation?
Constipation is the term generally used to describe either an infrequent bowel pattern or difficulty in passing hard, dry stools. Your doctor may define constipation as:

• Opening your bowels less than 3 times per week.
• Needing to strain to open your bowels on more than a quarter of occasions.
• Passing a hard or pellet-like stool on more than a quarter of occasions.

Most people will experience symptoms of constipation for a short period at some point however for others constipation is a long-term, chronic problem that can have a negative impact on their quality of life. A sudden change in bowel habit towards constipation may be a sign of other problems within the bowel and should be discussed with your G.P

What causes constipation?
There may be one or a combination of various reasons that contribute to the cause of constipation. These include:

• Diet – not eating enough foods that contain fibre such as fresh fruit and vegetables, wholegrain breads and cereals. A daily intake of approximately 6-8 glasses of fluid, 2 litres, is required alongside a high fibre diet to add bulk to the stool, making it easier for the bowel to move it through.
• Toilet habits – ignoring the urge to have your bowels open will keep stool in the bowel for longer than is ideal. This causes the stool to dry out and as a result it becomes hard and more difficult to pass. A change to your daily routine or eating habits may also have an effect on your bowel health.
• Medication – certain medications including some pain-killers, anti-depressants, iron supplements, water tablets can have side effects which can cause constipation.
• Co-existing health problems – An underactive thyroid gland (a small gland in your neck), Parkinson’s disease, Multiple Sclerosis and spinal cord injury may all contribute to the cause of constipation.
• Bowel transit or evacuation problems – a physical reason within the bowel or back passage that slows the passage of stool or causes difficulty when passing a motion.

Complications of constipation
If not treated, constipation may lead to other bowel complications. Prolonged straining to pass hard stool can cause an increase in pressure within the bowel and rectum. This may cause:

• Haemorrhoids (piles/swollen blood vessels).
• Diverticulum (hollow pouches in the lining of the bowel wall i.e. diverticular disease). Diverticulae may become inflamed and or infected causing abdominal discomfort.
• Rectal prolapse. Similarly stool that is not moving through the bowel can collect and become hard.
  Eventually if not passed, the stool will impact and block the bowel. This can cause abdominal discomfort, bleeding and overflow incontinence of liquid stool. If you have faecal impaction it is unlikely that you will able to naturally pass the stool and will need assistance.

What tests might I have?
In order to help understand the cause of your constipation and treat you correctly, your specialist may advise that you have certain tests. These may include any or all of the following:

• Blood tests – to check your thyroid gland is working correctly and check your calcium levels.
• Slow transit studies – you will be given a course of radio opaque tablets to swallow. These tablets show up on x-rays. Over the next couple of days you will be asked to return to the hospital to have several x-rays at different time intervals. The x-rays will show how long it takes the capsules to pass through the digestive system and bowel.
• Ano-rectal physiology (manometry) – a catheter probe with a small balloon is inserted into the anal canal (back passage). The other end is attached to a machine which measures the pressure in the balloon as you are asked to squeeze and relax the muscles in your rectum. This gives information as to how toned the muscles in your rectum and anal canal are and how well the muscles and nerves are working together to co-ordinate a bowel motion.
• Defaecating Proctogram – a special barium paste enema, which shows up on x-rays is inserted into the anal canal. A series of x-rays are then taken as the enema is passed naturally into a specially designed toilet. Although the test can cause embarrassment it may be necessary to provide information to help to understand your constipation symptoms and every effort will be taken to maintain your dignity and privacy.
• Flexible sigmoidoscopy/Colonoscopy – a fine endoscopic tube is passed into the anal canal and examines the inner lining of the bowel. Either the full length of the bowel is viewed (colonoscopy) or the examination is limited to the rectum and last section of the large bowel (flexible sigmoidoscopy). This test is used to eliminate any other problems within the bowel.

What is the treatment for constipation?
For many people it is possible to relieve constipation through dietary and lifestyle changes such as:

• Increase your daily fibre intake. High fibre foods include fruit, vegetables and high fibre cereals. Gradually increase the fibre in your diet so as to avoid bloating and abdominal discomfort.
• Increase your fluid intake to avoid dehydration, aim to drink at least 6-8 glasses of fluid a day. Carbonated drinks and caffeine can stimulate the bowel to work.
• Do not ignore the urge to have a bowel motion. Try to work with your bowel’s own pattern and establish a regular routine for opening the bowel. For many people the urge to pass stool will occur after the first meal of the day when eating stimulates the muscles in the bowel, this is known as the gastro-colic reflex.
• Abdominal massage – massaging the abdomen (tummy) in a clockwise motion can stimulate transit of stool through the bowel.
• Positioning on the toilet – using a foot stool when sitting on the toilet will lift the height of your knees above your hips. This helps to naturally open up the ano-rectal angle and relax the puborectalis muscle to assist a natural bowel motion with less need for straining.

Laxatives
Your G.P or specialist may prescribe you laxatives. These work to either soften your motion so that it is easier to pass or stimulate the bowel wall to move the stool through. There are various types of laxatives and you may use one or a combination dependent upon your symptoms.

• Bulk-forming laxatives. These work by helping your stool to retain fluid, making it softer and easier to pass. Common types include fybogel, ispaghula husk and methylcellulose. You need to drink plenty of fluid with them for them to work well.
• Osmotic laxatives. If a bulk forming laxative has not been sufficient in alleviating constipation you may also try an osmotic one which works to keep more fluid in the bowel. This prevents the stool from drying out and being difficult to pass. Examples include, Movicol, Laxido and lactulose.
• Stimulant laxatives – If the stool is soft but difficult to pass, a stimulant may be required to assist the bowel muscles in moving the stool through to the rectum and back passage. Examples include Bisocodyl, Senna, Docusate (which softens stool as well as stimulates) and sodium picosulphate. Stimulant laxatives are generally only used for short periods as long term use can affect the muscles in the bowel wall and rectum making them work less effectively.

In a small number of cases constipation is not relieved by dietary adaptations and laxative use alone. For these individuals alternative management options will be discussed with the specialist healthcare professional.

Online resources/links
For further information please visit:
https://www.nhs.uk/conditions/constipation/
https://gutscharity.org.uk/advice-and-information/symptoms/constipation/