• Constipation
• Causes
• Fibre and herbal
• Osmotic / stimulant
• Elderly / travel
• Obstruction

Constipation can be distressing!!

• Normal bowel habit (frequency of bowel motions) varies greatly from person to person.

  • For 9 out of 10 people this is between one bowel motion every 3 days to 3 bowel motions per day.
  • A bowel habit outside of this range is more likely to be abnormal.
    
    

• Constipation can be defined as

  • Having a bowel habit less than once per 3 days and having symptoms of abdominal bloating, lower abdominal discomfort and nausea.
  • AND / OR a sensation of difficulty passing a bowel motion with excess straining and hard bowel motions.
  • It is possible to have significant constipation even with a bowel movement once per day if that movement is small or ineffective.
  •  This is usually, but not always, associated with the symptom of incomplete emptying. That is a feeling that there is "still more to pass".
  • Sometimes there is a sensation of a "blockage" with straining. This problem can be defined as "obstructed defecation"
  • It usually related to problems with co-ordination of pelvic floor muscles and contractions of the rectum. One underlying problems may be a rectocoele.
    
    

• My pick for best three laxatives
  

• Kiwi Crush  - a glass a day of concentrated kiwi fruit juice
• Movicol  -  a sachet of powder that draws in or retains water in the colon
• MgLax  - a capsule containing Mg and aloe vera  -like old-fashioned Epsom salts in a capsule (more details in section on osmotic laxatives)
  
  

• Constipation is more common in the elderly (see section).

• Many people find that they develop constipation with travel (see section).

Causes of constipation.

• Mild and temporary symptoms may result from;
  • Dietary changes.
  • Travel or a period of inactivity or immobility.
  • Inadequate fluid intake.
    
• Life-long constipation is a different issue (see below)
  • This is usually due to slow transit of colon.
  • There is an inherited abnormality of the muscular activity of the colon.
  • There is a generalised problem with the colon.
    • This means it is not just the process of defaecation that is affected.
    • The transit time around the colon is prolonged.
    • The frequency of bowel motions can be relatively normal but with small and ineffective bowel motions.
      
• Constipation can be part of irritable bowel syndrome or diverticular disease.
  • In this situation there is more variability of bowel habit (episodes of diarrhoea as well).
  • Refer directly to these topics.
    
• Constipation is also associated with painful anal conditions, in particular anal fissure.
  • Bowel habit is inhibited because of the "knowledge" that it will be painful to pass the motion.
    
• Some medications are aggravating factors.
  • "Pain-killers" - particularly Codeine, Paradex, Tramol, Morphine elixer or capsules.
  • Calcium channel blockers for hypertension (Verapamil, Diltiazem).
  • Some antidepressants (e.g. Amitriptyline, Nortriptyline).
  • Antispasmodics - given for "colic" e.g Buscupan, Merbentyl, Colofac.
  • Aluminium-containing antacids.
  • Calcium supplements.
  • Iron tablets.
  • Diuretics (fluid tablets usually given for hypertension).
    
• Other causes.
  • Depression can contribute to an existing problem.
  • Low level of thyroid hormone (hypothyroidism).
  • Diseases of the spinal cord disease (particularly in the lower back).

Life-long constipation (usually slow transit constipation).

• The dominant problem is slow movement of faeces around the colon (large bowel) rather than a problem with the process of actually going to the toilet (defaecation)
• This could be termed "lazy bowel" or a "slow" colon.
• Usually the diagnosis is suggested by a history starting in teenage years or early 20’s.
  • The problem is more common in females.
  • Often there is a family history (mother or grandmother has similar problems).
• For most people minimal investigation is required.
  • A blood test for thyroid function and blood test for calcium should be done.
  • An abdominal X-ray is most useful to show "loading/fullness" of all of the colon with faeces.
  • This X-ray can be a baseline examination and follow-up X-rays can show if there has been improvement with treatment.
• If there are relatively recent problems with constipation then the colon should be inspected by colonoscopy.
• A colonic transit study will confirm the diagnosis but is not usually required.
  • This involves swallowing marker beads and then plain X-rays of the abdomen over 5 days.
  • OR involves a nuclear medicine study with scans on a daily basis that follow a radio-labelled meal.

Kiwi fruit combined with aloe vera juice is great natural treatment for constipation

Fibre and fibre supplements

• A high-fibre diet, regular exercise and increased fluid intake may help simple diet-related transient constipation but often has no effect for more long-standing symptoms.
  • Note: the benefits of increased fluid intake are modest - perhaps no help for many.
  • It is common for a high fibre diet to aggravate symptoms of bloating and abdominal discomfort.
• Fibre supplements (available from the chemist).
  • May be derived from Physillium seed (Metamucil) or Isphagula (Normacol, Isogel).
  • My preferred option is Normacol. This is the most insoluble fibre (inert) and less likely to aggravate abdominal bloating i.e less fermentable by colonic bacteria.
• Fibre is actually only a modest laxative and sometimes the side-effects outweigh the benefits.
• The health advantages of fibre have been over-emphasized

Dietary changes(other than fibre)

• Kiwifruit.
  • This is best natural laxative.
  • Take as fresh fruit in season.
  • Now available as Kiwi Crush – a freeze-dried or frozen concentrate - made by Nature's Spark.
  • Other brands of kiwifruit drinks are also available in the supermarket. A good product is produced by Neckta - there is a combination of Kiwifruit juice with aloe vera
    
• Prunes or prune juice.
  • This has some activity for some people.
  • Other food items with some effect are figs, dried fruits.
  • These options tend to aggravate bloating and wind.

Herbal products.

• Some reasonable options;
  • Aloe Vera juice has a mild laxative effect as well as some anti-spasmodic effect.
  • Slippery Elm has a more effective laxative effect.
  • Flaxseed oil (see www.theshop.co.nz (choose health post) or www.goodhealth.co.nz).
  • Some combination treatments are currently promoted.  Phloe is a product with an extract (enzyme) from kiwifruit combined with a fibre supplement and a probiotic.  This is perhaps trying to cover too many options and not achieving any!
  • Another product is Bio Biotics (Life Stream) - this has a prebiotic and a probiotic.  Prebiotics increase the supply of butyrate to the colon  -  the result of bacterial breakdown of a larger molecule  - this is of theoretical advantage only and has problems with excess wind formation
    
  • Herbal combinations that contain bowel stimulants (see next section on "stimulants") should be avoided e.g containing senna, cascara unless discussed with your doctor
    

Pigmented appearance of colon that results from long term use of stimulant laxatives like Senna. See text for more details


Senna is a herb that has been used as a laxative for centuries. It is a stimulant laxative with all the disadvantages discussed in the section


Movicol is a very effective and safe long term treatment for constipation

Prescribed medication (laxatives).

• Lactulose
  • This is sweet tasting syrup that is available on prescription.
  • It is a non-absorbed large sugar molecule.
  • This is an effective option and suitable for long-term treatment.
  • There are often problems with aggravation of bloating and leakage of faeces if “overdone”.
  • It is safe for long-term use and is suitable for diabetics as there is no absorption of sugar.
    
• Stool softeners.
  • Stool softeners (e.g. Coloxyl) are not much help.
  • They are used mainly for treatment of painful anal conditions.
    
    

• Stimulant laxatives.

  • This group includes;
    • Senna (Coloxy with Senna, Sennapod, Senakot, Laxsol - all tablets).
    • Bisacodyl (Dulcolax tablets and Microlax enemas).
  • They are present in various herbal combinations (e.g Alpine Tea).
  • They are effective laxatives but can aggravate cramping abdominal pain.
  • There is a possible risk of long-term damage to myenteric plexus – the nerves that stimulate the muscles of the colon.
    • The degree of risk may have been over-emphasized in the past.
    • The advice for many years has been to reserve these drugs for short-term use only.
  • However for many people with slow-transit constipation these stimulant laxatives are sometimes the most effective treatment.
    • If used for long-term treatment the dose should be limited.
    • I suggest an acceptable maximum dose of 2 tablets of Coloxyl with Senna 3x weekly.
    • It is important that the dose remains low - this may be achieved by using combinations of treatments rather than relying solely on stimulant laxatives.
  • There is no advantage in using these drugs by the rectal route(e.g Microlax enemas)– there is still the risk of long-term damage.
  • There is a change in the lining of the bowel called melanosis coli.
    • This is usually seen at colonoscopy (see picture)
    • This is due to long-term use of stimulant laxatives.
    • This change in itself is not hazardous but I generally take this to be a warning that an acceptable dose has been exceeded and that other ways of managing constipation need to be sought.
  
  

• Osmotic laxatives

  • These are a group of compounds that work by drawing in water into the colon.
    • They are very useful treatments for long-standing constipation.
    • These are compounds that are inert – not absorbed.
    • They are safe for long-term use and gentle in action.
  • Magnesium salts are an old-fashioned treatment (Epsom salts).
    • This is relatively unpalatable and there has not been a commercially acceptable product until recently.
    • MgLax (Good Health) is a capsule that contains magnesium and aloe vera.
    • Three to five capsules daily may be required for initial relief of constipation.
    • 1-3 capsules daily may be enough to maintain a good bowel habit.
    • They are available through health food outlets or online (try www.theshop.co.nz - choose health post - or directly to www.goodhealth.co.nz).
  • Colonoscopy lavage solutions are very effective.
    • This product can be bought from the chemist as Klean-Prep(or Glycoprep).
    • Four sachets make up four litres – enough fluid to completely clear the colon.
    • A simple approach for maintenance treatment is to take one glass per day.
    • One litre can be made up at a time and stored in the fridge in a sealed container.
    • Some chemists may not be familiar with this approach but it is safe and well-tested.
  • This type of treatment is now available in a more convenient form as Movicol sachets.
    • Movicol is very similar to Klean Prep.
    • One sachet is dissolved in water and taken once per day. Two sachets daily may be required to relieve severe constipation.
    • Once the “blockage” has been cleared then a maintenance dose of 1 sachet every 2 days may be enough.
    • These sachets are very convenient to take on holidays if travel is the initiating event for constipation.
    • The sachets are relatively expensive (up to $1.40 per sachet) - the cheapest prices are online (e.g www.pharmacydirect.co.nz).
    • Movicol is now funded with a Special Authority application by a specialist

Constipation in the elderly

• Constipation is more common in the elderly.
  • There are age-related changes.
    • Secreasing sensation.
    • Weakness of the muscles involves in defaecation
  • Other factors may be;
    • Reduced mobility.
    • Impaired intellectual function.
    • Poor access to toilets.
    • Drugs (as per list above).
    • Parkinson’s disease.
      
• In the elderly faecal retention can lead to impaction of faeces in the rectum.
  • This gives the impression of diarrhoea (sometimes called overflow diarrhoea).
    • There is the leakage of loose faeces around an obstruction caused by impacted faeces.
    • This can lead to faecal incontinence.
    • There may be a mistaken diagnosis of diarrhoea and treatment with anti-diarrhoeal medication is given which further aggravates the problem.
  • The diagnosis is obvious with a rectal examination.
  • The treatment is disimpaction with enemas and also lavage solution “from the top”.
    
• Severe constipation in the elderly may be missed.
  • Abdominal pain and distension may give the impression of a bowel obstruction.
  • Pressure on the bladder may cause urinary retention.
  • Restlessness or confusion may be the most obvious issues and the constipation missed.
    
• The most useful diagnostic test is a plain abdominal X-ray.

Travel constipation

• Many people find that they develop constipation with travel.
  • Usually there is a background of tendency to constipation at other times but this is manageable within the context of usual lifestyle.
  • Contributing factors are different toilet facilities, change in diet, stress and hectic schedules, dehydration with long haul flights.
  • A useful medication to take is Movicol - convenient once daily sachets.
    • If the problem is predictable it is better to start early to prevent later problems during the trip.

Obstructed defaecation

1. This means that there is a "functional blockage" when attempting to pass a bowel motion.
2. It is important that there is investigation by colonoscopy to exclude any actual obstruction.
3. This symptom called "obstructed defecation" can be because the pushing forces are misdirected - perhaps due to a rectocoele (bulging of the rectum- usually forwards into the vagina) or because there is prolapse of some rectal mucosa which forms a blockage in front of the bowel motions.

What is a rectocoele?

• A rectocoele is a bulge from the rectum into the vagina.
  • This is often part of a generalised weakness of the pelvic support.
  • It may be associated with a cystocoele - bulging of the bladder into the vagina.
    
• Risk factors are
  • Multiple or difficult deliveries; forceps or perineal tears.
  • A long history of constipation and straining.
  • A hysterectomy.
  • Mostly occurs post-menopausal.
    
• Symptoms include
  • A "bulging sensation".
  • Difficult evacuation with straining.
  • Sensation of incomplete emptying.
  • Improvement by pressing against the back wall of the vagina.
    
• Diagnosis is by a special X-ray called a defecating proctogram.
  • Barium paste is inserted into rectum.
  • X-ray pictures taken during defaecation.
    
• What treatments are available?
  • A trial of high fibre supplements should be considered. Best option is Normacol.This may not work and may aggravate bloating.
  • Gentle laxatives other than fibre are worth a trial.
    • i.e osmotic laxatives such as MgLax, Movicol
  • Surgical treatment should only be considered if there are troublesome symptoms and careful evaluation suggests that the rectocoele is the problem is the main option.
    • This is a repair called a rectoplexy.
    • Surgical access to the rectum is usually through the anus.