Constipation in Adults

Constipation at a glance

Constipation causes one or more of the following:

Sometimes, crampy pains occur in the lower part of the tummy (abdomen) One may also feel bloated and feel sick if one has severe constipation.

Stools (faeces or motions) becomes hard, and difficult or painful to pass

The time between toilet trips increases compared with your usual pattern.

Here it is important to note that there is a large range of normal bowel habit. Some people normally go to the toilet to pass stools 2-3 times per day. For others, 2-3 times per week is normal. It is a change from one’s usual pattern that may mean that one is constipated.

Causes of constipation

Known causes include the following:

Not drinking much may make constipation worse. Stools are usually soft and easily passed if you eat enough fibre, and drink enough fluid. However, some people need more fibre and/or fluid than others in order to avoid constipation

Not eating enough fibre (roughage) is a common cause. The average person eats about12 grams of fibre each day. But, 18 grams per day is recommended by doctors. Fibre is the part of plant food that is not digested. It remains in one’s gut. It adds bulk to the stool (faeces or motions), and helps one’s bowels to work well. Foods high in fibre include: fruit, vegetables, cereals and wholemeal bread.

A change of medication may be possible. Various medical conditions can cause constipation. Ex: underachieve thyroid, irritable bowel syndrome, conditions that cause poor mobility particularly in elderly.

Some special slimming diets are low in fibre, and may cause constipation.

Some medicines can cause constipation as a side-effect. Examples are painkillers (particularly those with tramadol, or very strong pain killers such as morphine), some antacids, some antidepressants (including amitriptyline) and Iron tablets, but there are many others. See the list of possible side-effects on the leaflet that comes with any medicine that you may be taking.

Pregnancy. About 1 in 5 pregnant women will become constipated. It is due to the hormonal changes of pregnancy that slow down the gut movements. In later pregnancy, it can simply be due to the baby taking up a lot of room in the tummy and the bowels being pushed to one side.

Unidentified cause (idiopathic)

In spite of having a good diet, drinking a lot of fluid, not having a disease or taking any medication that can cause constipation, some people still become constipated. Their bowels are said to be underactive. This is quite common and is sometimes called functional constipation or primary constipation. Most cases occur in women. This condition tends to start in childhood or in early adulthood, and persists throughout life.

Are investigations required ?

Since symptoms are often typical, tests are not usually needed to diagnose constipation. However, tests may be advised if one has any of the following:

If regular constipation is a new symptom, and there is no apparent cause, such as a change in diet, lifestyle, or medication. This is known as a ‘change in bowel habit’ and should be investigated if it lasts for more than about six weeks.

If symptoms are very severe and not helped with laxative medication.

If other symptoms develop such as weight loss, rectal bleeding, loose motions (Diarrhoea). Or if there is history/family history og colon cancer, Inflammatory bowel disease (crohn’s disease/ulcerlative colitis).

Relief from Constipation and its prevention

These measures are often grouped together and called lifestyle advice.

Include plenty of fibre in your diet

Fibre (roughage) is the part of plant food that is not digested. It stays in your gut and is passed in the poo (faeces, stools or motions). Fibre adds bulk and some softness to the stools. High-fibre foods include the following:

Wholemeal or whole-wheat bread, biscuits and flour.

Fruit and vegetables. One should aim to eat at least five portions of a variety of fruit and vegetables each day. One portion is: one large fruit such as an apple, pear, banana, orange, or a large slice of melon or pineapple; OR two smaller fruits such as plums, satsumas, etc; OR one cup of small fruits such as grapes, strawberries, raspberries, cherries, etc; OR one tablespoon of dried fruit; OR a normal portion of any vegetable (about two tablespoons); OR one dessert bowl of salad.

Wholegrain breakfast are rich in fibre. A simple thing like changing one’s regular breakfast cereal can make a big difference to the amount of fibre one eats each day.

Brown rice, and wholemeal spaghetti and other wholemeal pasta.

It may take as long as four weeks before one sees the effect of a high fibre diet or it may be seen in a few days.. It may be found that if one eats more fibre or takes fibre supplements, one may have some bloating and wind at first. This is often temporary. As one’s gut becomes used to extra fibre, the bloating or wind tends to settle over a few weeks. Therefore, if one is not used to a high-fibre diet, it is best to increase the amount of fibre gradually.

It is important to have lots to drink when one eats a high-fibre diet or fibre supplements. One needs to drink at least two litres (about 8-10cups) per day. This is to prevent a blockage of the gut, which is a rare complication of eating a lot of fibre without adequate fluid.

Consume lots of fluids

One must drink at least two litres (about 8-10 cups) of fluid per day. One will pass much of the fluid as urine, but some is passed out in the gut and softens the stools. Most sorts of drinks will do, but alcoholic drinks can be dehydrating and may not be so good. As a start, one should try just drinking a glass of water 3-4 times a day in addition to what one normally drinks.

Sorbitol

Sorbitol is a naturally occurring sugar. It is not digested very well and draws water into the gut, which has an effect of softening the stools. In effect, it acts like a natural osmotic laxative (osmotic laxatives are explained later). So, one may wish to include some foods that contain sorbitol in your diet. Fruits (and their juices) that have a high sorbitol content include apples, apricots, gooseberries, grapes (and raisins), peaches, pears, plums, prunes, raspberries and strawberries. The concentration of sorbitol is about 5-10 times higher in dried fruit. Dried or semi-dried fruits make good snacks and are easily packed for transport – for example, in a packed lunch.

Workout regularly

Keeping one’s body active helps to keep one’s gut moving. It is well known that disabled people, and bed-bound people (even if just temporarily whilst admitted to hospital) are more likely to get constipated.

Toileting routines

One should not ignore the feeling of needing the toilet. Some people suppress this feeling if they are busy. It may result in a backlog of stools which is difficult to pass later. When one goes to the toilet, it should be unhurried, with enough time to ensure that one can empty the bowel.

When mobility is limited – for example, in people who are frail or who have dementia – it is important for carers to see that they have sufficient help to get to the toilet at the time they need to go; also, that they have a regular, unhurried toilet routine, with privacy.

As a rule, it is best to try going to the toilet first thing in the morning or about 30 minutes after a meal. This is because the movement (propulsion) of stools through the lower bowel is greatest in the mornings and after meals (due to the gastrocolic reflex).

Positioning on the toilet is also important, especially for elderly people with constipation. Western-style toilets actually make things more difficult – squatting is probably the best position in which to pass stools. Putting a small footstool under one’s feet is a simple way to change one’s toilet position to aid the passage of stools. Relax, lean forward and rest your elbows on thighs. One should not strain and hold breath to pass stools.

Remedies for constipation

Treatment with a laxative is needed only if the lifestyle measures above do not work well. It is still worth persisting with these methods, even if one ends up needing to use laxatives.

For short-term uncomplicated constipation, one may even choose to treat oneself by buying laxatives in the pharmacy. In short-term constipation, laxatives can be stopped once the stool (faeces or motions) becomes soft and easily passed again. You should probably visit your doctor if you are struggling to manage short-term constipation yourself, or if you have longer-term (chronic, or persistent) constipation. All the different types of laxative are available on prescription.

Chronic (persistent) constipation can be more difficult to treat. Laxatives are usually needed for longer periods (sometimes even indefinitely) and they should not be stopped abruptly. Chronic constipation is sometimes complicated by a backlog of hard faeces building up in the bowel (faecal loading) or even partially blocking it (impaction). If loading and impaction occur they need to be treated first, often with much higher doses of laxatives. Then a normal maintenance dose of laxatives is used to keep the bowels moving.

Four main groups of laxatives that work in different ways:

Stimulant laxatives.

Faecal(stool) softener laxatives.

Bulk-forming laxatives.

Osmotic laxatives.

Bulk-forming laxatives

Sometimes these are known as fibre supplements. These increase the bulk of your stools in a similar way to fibre. They can have some effect within 12-24 hours but their full effect may take several days to develop.

Unprocessed bran is a cheap fibre supplement. If one takes bran, it is best to build up the amount gradually. Start with two teaspoons a day, and double the amount every five days until one reaches about 1-3 tablespoons per day. One can sprinkle bran on breakfast cereals, or mix it with fruit juices, milk, stews, soups, crumbles, pastries, scones, etc.

Other fibre supplements include ispaghula (psyllium), methylcellulose, sterculia, wheat dextrin, inulin fibre, and whole linseeds (soaked in water).

A gentle caution: fibre and bulk-forming laxatives partly work by absorbing water (a bit like blotting paper). The combination of bulk-forming laxatives and fluid usually produces soft, bulky stools which should be easy to pass out.

When one eats a high-fibre diet or takes bulk-forming laxatives:

One should have plenty to drink. At least two litres per day (8-10 cups). The stools may become dry and difficult to pass if one does not have enough to drink. Very rarely, lots of fibre or bulk-forming laxatives and not enough fluid can cause an obstruction in the gut.

One may notice an increase in wind (flatulence) and tummy (abdominal) bloating. This is normal and tends to settle down after a few weeks as the gut becomes used to the increase in fibre (or bulk-forming laxative).

Occasionally, bulk-forming laxatives can make symptoms worse if one has very severe constipation. This is because they may cause abdominal bloating and discomfort without doing much to clear a lot of faeces which are stuck further down the gut.

Stimulant laxatives

These stimulate the nerves in the large bowel (the colon and rectum, sometimes also called the large intestine). This then causes the muscle in the wall of the large bowel to squeeze harder than usual. This pushes the stools along and out. Their effect is usually within 8-12 hours. A bedtime dose is recommended so you are likely to feel the urge to go to the toilet sometime the following morning. Stimulant laxative suppositories act more quickly (within 20-60 minutes). Possible side-effects from stimulant laxatives include abdominal cramps, and long-term use can lead to a bowel that is less active on its own (without laxatives). This can be thought of as a ‘lazy bowel’.

Stimulant laxatives include bisacodyl, dantron, docusate, glycerol, senna and sodium picosulfate.

Osmotic laxatives

These work by retaining fluid in the large bowel by osmosis (so less fluid is absorbed into the bloodstream from the large bowel). There are two types – lactulose and a group called macrogols (also called polyethylene glycols).

Lactulose can take up to two days to have any effect so it is not suitable for the rapid relief of constipation. Possible side-effects of lactulose include abdominal pain and bloating. Some people find the taste of lactulose unpleasant. Macrogols act much faster, and can also be used in high doses to clear faecal loading or impaction. Stronger osmotic laxatives (such as magnesium salts and phosphate enemas) can be used to clear the bowel quickly and in situations such as before bowel surgery.

Faecal softeners

These work by wetting and softening the faeces. The most commonly used is docusate sodium (which also has a weak stimulant action too). Bulk-forming laxatives also have some faecal-softening properties. Arachis (peanut) oil enemas are occasionally used to soften impacted faeces in the rectum (the lowest part of the colon, just before the back passage (anus)).

Liquid paraffin used to be commonly used as a faecal softener. However, it is now not recommended, as it may cause side-effects such as seeping from the anus and irritation of the skin, and it can interfere with the absorption of some vitamins from the gut.

Suggested laxative and the span of usage

The one recommended by your doctor will depend on factors such as your own preference, the symptoms of constipation that you have, possible unwanted effects, your other medical conditions, and cost. However, as a general rule:

Treatment with a bulk-forming laxative is usually tried first.

If stool (faeces or motions) remains hard despite using a bulk-forming laxative, then an osmotic laxative tends to be tried, or used in addition to a bulk-forming laxative.

If stools are soft but you still find them difficult to pass then a stimulant laxative may be added in.

High doses of the macrogol osmotic laxatives are used to treat faecal loading and impaction – this should be under the supervision and advice of a doctor.

One should use a laxative only for a short time, when necessary, to get over a bout of constipation. Once the constipation eases, one should normally stop the laxative. Some people get into the habit of taking a laxative each day ‘to keep the bowels regular’ or to prevent constipation. This is not advised, especially for laxatives which are not bulk-forming.

More Remedies

Constipation is usually helped by the above treatments. Mostly, laxatives are taken by mouth (orally). In some cases, it is preferable also to treat constipation by giving medication via the back passage (anus).

Suppositories are pellet-shaped laxatives that are inserted into the lowest part of the colon (the rectum), via the anus. Glycerol suppositories act as a stimulant within the rectum, encouraging the passing of stool (faeces or motions). Sometimes, an enema is needed in severe constipation.

An enema is a liquid that is inserted into the rectum and lower colon, via the anus. Enemas can be used to clear out the rectum in severe constipation.

Other treatments may be advised by a specialist for people with severe constipation who have not been helped by the treatments listed above.

Complications of long-term (chronic) constipation

Short-term constipation or intermittent bouts of constipation are unlikely to cause any long-term problems. Sometimes a split or tear in the anal skin (an anal fissure) can occur with the passage of particularly big or hard poo (faeces, stools or motions). This is very painful, and there may be a small amount of fresh red blood on the toilet paper. Treatment of an anal fissure involves lifestyle measures (mentioned earlier) to keep the stools soft, and perhaps laxatives too, to keep the stools really easy to pass. Local anaesthetic ointment or glyceryl trinitrate (GTN) ointment can be prescribed to ease the pain and help relax the muscles around the back passage (anus), to help the fissure to heal.

Chronic constipation and long-term use of laxatives can mean that your bowel becomes sluggish and ‘lazy’. This means that the bowel doesn’t work very well on its own, without medication. Constipation then becomes a vicious cycle and even more chronic. One should try to avoid getting into this situation. Some people with persistent and severe constipation do require regular laxatives.

Severe chronic constipation can result in faecal impaction. This is something that is more likely in the elderly and infirm. Basically, a large mass of hard faeces blocks the rectum. The mass is too big to pass and the rectum is stretched and enlarged, so the muscles within it don’t work so well to push faeces out. Sometimes people with this problem think that they have diarrhoea. This is because liquid faeces, from above the blockage, leak round the big lump of faeces, and out of the anus. This is known as overflow diarrhoea. In this situation, one may also have faecal incontinence – that is, have no control over this liquid faeces leaking out. Faecal impaction with overflow diarrhoea is likely if one has been getting progressively more constipated, and then get liquid faeces, possibly explosive, and without much control. If a doctor or nurse examines the anus, the hard faeces can often be felt, confirming the diagnosis.

In order to treat impaction, higher doses of laxatives need to be used. Movicol is often used, and sometimes enemas or suppositories. Temporarily, symptoms of diarrhoea may worsen, but it is important to keep up with treatment, to clear the blockage. After the large mass of faeces is cleared, laxatives are often needed for a while (or perhaps even long-term or intermittently), to prevent the problem recurring.

CONCLUSION

One of the most common problems is constipation. It means either going to the toilet less often than usual to empty the bowels, or passing hard or painful stools (also called faeces or motions). The causes of constipation may be not eating enough fibre, or not consuming enough fluids. Constipation can also be a side-effect of certain medicines, or related to an underlying medical condition. However, in many cases, the cause is not clear.

Laxatives are a group of medicines that can treat constipation. Ideally, laxatives should only be used for short periods of time until symptoms ease