Constipation ConstipationCausesFibre and herbalOsmotic / stimulantElderly / travelObstruction 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 less than one bowel motion 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". This symptom usually relates to problems with co-ordination of pelvic floor muscles or to underlying problems such as prolapse of the rectal mucosa or a rectocoele (section on "obstruction" for further details). Management is discussed in detail in the next sectionsThere are a wide variety of treatment optionsThe simple advice to have a high fibre diet, take plenty of water and have regular excercise can be helpful for many but if this doesn't work then you need to read on...!!My pick for best three laxatives suitable for long-term use Kiwi Crush - a glass a day of concentrated kiwi fruit juice Movicol (now called Lax-sachets) - a sachet of powder that draws in or retains water in the colon MgLax - a capsule containing Mg - 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) and lower abdominal cramping pain. Refer directly to these topics. Constipation may 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 can cause constipation. "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. Sometimes the diagnosis is clear from abdominal examination that shows loading or distension of the colon on both sides of the abdomenA 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.The diagnosis can also be suggested if usual bowel preparation for colonoscopy does not work and extra bowel cleansing fluid is required 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 constipationFibre 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. The benefits of increased fluid intake are modest - perhaps no help for many people. 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 Psyillium seed (Metamucil) or Isphagula (Normacol, Isogel).Metamucil is easy to take because it can be dissolved easily into a flavoured drink but may be more likely to increase bloating and windMy 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.Another fibre option is resistant starch. A popular product is wheat dextran (marketed as Benefibre). This is easy to take but will often cause increased abdominal bloating. There is some theoretical evidence of benefit (as a prebiotic) but no clinical studies support this concept Fibre is actually only a modest laxative and sometimes the side-effects outweigh the benefits. The health advantages of fibre have been over-emphasized. The evidence for prevention of bowel cancer and diverticular disease is modest and no other health benefits have been proven Dietary changes(other than fibre) Kiwifruit. This is best natural laxative. Take as fresh fruit in season. 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 Nekta - 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. Natural and Herbal products. Some reasonable options Aloe Vera juice has a mild laxative effect as well as some anti-spasmodic effect. This may be useful if cramping pain is prominentSlippery Elm has a modest laxative effect. Flaxseed oil (see www.theshop.co.nz (choose health post) or www.goodhealth.co.nz). Modest laxative effect Phloe is a product derived from kiwifruit. This has no advantages over taking kiwifruit concentrates (Kiwi Crush, Nekta juice). My impression is that it has less activity than these other kiwifruit options. It is marketed as having combined effect - fibre and prebiotic effect - there is nothing special about these claims Another product is Bio Biotics (made by 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. The effect on constipation will be minimal 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 detailsSenna is a herb that has been used as a laxative for centuries. It is a stimulant laxative with all the disadvantages discussed in the sectionMovicol is a very effective and safe long term treatment for constipationDifferent types of "laxatives"The term "laxative" means any agent that helps constipation. The negative view of laxatives comes from the possible long-term risks of stimulant laxatives (see below) 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 at higher doses 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 cause 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 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 soughtOsmotic laxativesThey work by drawing in water into the colon. This is achieved by taking an inert compound that is not absorbedThey are very useful treatments for long-standing constipationMagnesium(e.g MgLax)Magnesium salts are an old-fashioned treatment (Epsom salts) but are 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.Maintenance dose is 1-3 capsules per day.Magnesium is safe for long term use - except if there is renal diseaseThe effect can take to several days to start and the best maintenance dose may take some weeks to work out (through trial and error - "titration"). If this leads to diarrhoea then this is good news - it means the magnesium is effective and a lower maintenance dose may prove effective without causing unacceptable diarrhoeaKlean-Prep (colonoscopy washout solutions)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.One simple approach for maintenance treatment is to take one glass per dayOne 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.Some people before to use this approach as "rescue" treatment. i.e taking 1-2 litres as a partial clearout perhaps every 4 weeks. There is no risk with this approachMore recently Moviprep has become a popular solution for colonoscopy preparation. This could also be used in the same way. Two litres gives a complete "washout for most people - therefore 0.5 to 1.0 litres will give a good relief of constipation if used on an intermittent basis. Movicol or Lax-sachetsMovicol is very similar to Klean Prep. Lax sachets have recently replaced Movicol in NZ as a cheaper but equivalent treatmentOne 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 1-2 days may be enough. Maintenance does above 2 sachets daily are rarely required. Specialist review is required if higher doses are not working.These sachets are very convenient to take on holidays if travel is the initiating event for constipation. The sachets are relatively expensive (up to 80 cents per sachet) - the cheapest prices are online (e.g www.pharmacydirect.co.nz).Lax-sachets are now funded with a Special Authority application by a specialist (90 sachets per month are funded on prescription)For difficult constipation combinations of treatment may be required. The combination of Movicol (2 sachets per day) and MgLax (3-4 caps per day) is often effective for very resistant constipation. Thgis may be required if there has been long term dependence on stimulant laxativesConstipation in the elderly Constipation is more common in the elderly. There are age-related changes such as decreased sensation of need to defaecate and 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)and 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 This means that there is a "functional blockage" when attempting to pass a bowel motion. It is important that there is investigation by colonoscopy to exclude any actual obstruction."obstructed defecation" may be because the pushing forces are misdirected - perhaps due to a rectocoele (see below) or because there is prolapse of some rectal mucosa which forms a blockage in front of the bowel motions.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.Other tests may be required. Anorectal manometry or pressure studies helps determine if there is inco-ordination of the pelvic floor and rectal muscles. This may be able to be retrained using biofeedback techniques and pelvic floor excercisesWhat treatments are available? A trial of high fibre supplements should be considered. 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.