WHAT IS CONSTIPATION?
Chronic constipation is a common, symptom-based disease that has no biological markers; this means that a patient’s perception and report of the problem is the major determinants for diagnosis (1).
Patients usually define their constipation as unsatisfactory defecation that differs from their normal defecation pattern. It is usually based on a reduced frequency or ease of passing stool, a sense of incomplete stool removal, stool that is hard or lumpy, straining or difficulty passing stool, prolonged time to defecate or pass stool, or need for manual maneuvers to pass stool. However, the problem with diagnosing constipation using self-reported symptoms is that reports are often inaccurate unless patients use stool diaries (1,2,3).
A more functional definition for constipation is classified as the Rome criteria which were initially developed by gastroenterologists, psychiatrists, psychologists, physiologists, and health services investigators through international consensus in 1991. Its third iteration is currently used primarily in clinical research and research settings (4,5,6).
- Must include 2 or more of the following:
- Straining during at least 25% of defecations
- Lumpy or hard stools in at least 25% of defecations
- Sensation of incomplete evacuation for at least 25% of defecations
- Sensation of anorectal obstruction/blockage for at least 25% of defecations
- Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor)
- Fewer than 3 defecations per week
- Loose stools are rarely present without the use of laxatives
- Insufficient criteria for irritable bowel syndrome
Note: Criteria fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis.
RISK FACTORS AND SYMPTOMS OF CONSTIPATION
Constipation can be a primary condition that happens on its own or it can be a secondary condition caused by medical problems (3).
Primary constipation can be caused by aging, depression, inactivity, low-calorie intake, low income, and low education level, number of medications being taken, physical and sexual abuse and being female – there has been a higher incidence of self-reported constipation in women (2). Other risk factors of primary constipation include a family history of colon cancer, Hematochezia, Anemia, weight loss ≥5 kg in previous 6 months, positive result of fecal occult blood test and persistent constipation unresponsive to treatment (8). However, exercise and a high-fiber diet may be protective factors against primary constipation (2).
- Drugs like narcotics, anticholinergics (tricyclic antidepressants, antipsychotics, and anti-Parkinson’s medications), calcium channel-blockers, diuretics, and over-the-counter drugs including antacids containing calcium or aluminum, calcium supplements, nonsteroidal anti-inflammatory drugs, oral iron supplements, and antihistamines
- Metabolic conditions like Hypercalcemia, severe hypothyroidism, diabetes mellitus (with autonomic neuropathy) and hypokalemia
- Gastrointestinal conditions like colorectal carcinoma, diverticulosis, stricture, hemorrhoids, and rectal prolapse
- Neurological conditions like Parkinson’s disease, Multiple sclerosis, spinal cord injury, stroke, and autonomic neuropathy
- Cognitive/ psychiatric conditions including depression, anxiety, somatization, and dementia
CONSTIPATION FACTS AND STATISTICS
- The estimated prevalence of chronic constipation is 2% to 27% amongst adults (of all ages) in the Western hemisphere (9,10).
- Annually, constipation accounts for 2.5 million physician visits, 20,000 hospitalizations, and 3 million laxative prescriptions in the United States (11).
- Prevalence of constipation rises dramatically with age. After 65, 30% - 40% of adults living in the community and 50% - 60% of adults living in nursing homes experience chronic constipation. After 80, about 50% of adults experience chronic constipation (8,9).
- Long-term care facilities spend an estimate of US$2253 per year per resident managing their constipation (12).
- Constipation is reportedly the cause for almost 5% of all pediatric outpatient visits and >25% of referrals to gastroenterology specialists in the US (13).
- In 2009, worldwide prevalence functional constipation was between 7 and 30% and up to 10% of children in the US suffered from chronic constipation (13).
MEDICAL TREATMENT OF CONSTIPATION
Common treatments to manage constipation include:
- Bulk laxatives including dietary fiber, psyllium, polycarbophil, methylcellulose, and carboxymethylcellulose
- Osmotic agents like saline laxatives (magnesium, sulfate, potassium and phosphate salts), poorly absorbed sugars (Lactulose, sorbitol, mannitol, lactose, glycerin suppositories) and Polyethylene glycol laxatives
- Stimulant laxatives including surface-active agents (docusate and bile salts) diphenylmethane derivatives: (phenolphthalein, bisacodyl, sodium picosulfate)
- Other pharmacological constipation medicines include: Cisapride, norcisapride, prucalopride, tegaserod, Colchicine, Misoprostol, Bethanechol, neostigmine, Naloxone, and naltrexone (15,17,18,19).
NATURAL WAYS TO SUPPORT A HEALTHY DIGESTIVE TRACT
Practices to Support a Healthy Digestive Tract:
Natural treatment for chronic functional constipation primarily involves lifestyle modification on exercise and diet (increasing fiber and water intake), behavior modifications, education on toilet habits and patient support and reassurance (8,9,10).
Natural Supplements That Support a Healthy Digestive Tract:
- Daikenchuto (21,22,23)
- Glucomannan (24,25,26,27,28)
- Inulin (29,30)
- Probiotics (31)
- Rhamnus nakaharai (32,33,34)
- Aloe vera (35,36)
- Blonde psyllium (37,38,39)
- Senna (40,41,42)
- Elderberry (43)
- Guar gum (44,45,46)
- Lactobacillus (47,48,49)
- Wheat bran (50,51,52)
- Gray JR. What is chronic constipation? Definition and diagnosis. Can J Gastroenterol. 2011;25 Suppl B(Suppl B):7B-10B.
- Locke GR, Pemberton JH, Phillips SF. AGA technical review on constipation. American Gastroenterological Association. Gastroenterology. 2000;119(6):1766-1778.
- Paré P, Bridges R, Champion MC, et al. Recommendations on chronic constipation (including constipation associated with irritable bowel syndrome) treatment. Can J Gastroenterol. 2007;21 Suppl B(Suppl B):3B-22B.
- Banerjee R, Choung OW, Gupta R, et al. Rome I criteria are more sensitive than Rome II for diagnosis of irritable bowel syndrome in Indian patients. Asian Institute of Gastroenterology, 6-3-661.
- Drossman DA, Creed FH, Olden KW, Svedlund J, Toner BB, Whitehead WE. Psychosocial aspects of the functional gastrointestinal disorders. Gut. 1999;45 Suppl 2:II25-30.
- Rome Foundation. Guidelines--Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders. J Gastrointestin Liver Dis. 2006;15(3):307-312.
- Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional Bowel Disorders. Gastroenterology. 2006;130(5):1480-1491. doi:10.1053/j.gastro.2005.11.061
- Gandell D, Straus SE, Bundookwala M, Tsui V, Alibhai SMH. Treatment of constipation in older people. CMAJ. 2013;185(8):663-670. doi:10.1503/cmaj.120819
- Gallagher P, O’Mahony D. Constipation in old age. Best Pract Res Clin Gastroenterol. 2009;23(6):875-887. doi:10.1016/j.bpg.2009.09.001
- Pohl D, Tutuian R, Fried M. Pharmacologic treatment of constipation: what is new? Curr Opin Pharmacol. 2008;8(6):724-728. doi:10.1016/J.COPH.2008.07.008
- Beck DE. Evaluation and management of constipation. Ochsner J. 2008;8(1):25-31.
- Frank L, Schmier J, Kleinman L, et al. Time and economic cost of constipation care in nursing homes. J Am Med Dir Assoc. 3(4):215-223. doi:10.1097/01.JAM.0000019536.75245.86
- Kranz S, Brauchla M, Slavin JL, Miller KB. What do we know about dietary fiber intake in children and health? The effects of fiber intake on constipation, obesity, and diabetes in children. Adv Nutr. 2012;3(1):47-53. doi:10.3945/an.111.001362
- Ilan J.N. Koppen, Sophie Kuizenga-Wessel, Peter L. Lu, Marc A. Benninga, Carlo Di Lorenzo, Victoria A. Lane, Marc A. Levitt RJW and DY. Surgical decision-making in the management of children with intractable functional constipation: What are we doing and are we doing it right?- ClinicalKey. J Pediatr Surgery,. 2016;51(10):1607-1612.
- Portalatin M, Winstead N. Medical management of constipation. Clin Colon Rectal Surg. 2012;25(1):12-19. doi:10.1055/s-0032-1301754
- Jordan S. The Prescription Drug Guide for Nurses: 9780335225477: Medicine & Health Science Books @ Amazon.Com. McGraw-Hill Education(UK); 2008. https://www.amazon.com/Prescription-Drug-Guide-Nurses/dp/0335225470. Accessed July 19, 2018.
- Gandell D, Straus SE, Bundookwala M, Tsui V, Alibhai SMH. Treatment of constipation in older people. CMAJ. 2013;185(8):663-670. doi:10.1503/cmaj.120819
- Siegel JD, Di Palma JA. Medical treatment of constipation. Clin Colon Rectal Surg. 2005;18(2):76-80. doi:10.1055/s-2005-870887
- Liu LWC. Chronic constipation: current treatment options. Can J Gastroenterol. 2011;25 Suppl B(Suppl B):22B-28B.
- Zhang T, Chon TY, Liu B, et al. Efficacy of Acupuncture for Chronic Constipation: A Systematic Review. Am J Chin Med. 2013;41(04):717-742. doi:10.1142/S0192415X13500493
- Hirose T, Shinoda Y, Kuroda A, et al. Efficacy and Safety of Daikenchuto for Constipation and Dose-Dependent Differences in Clinical Effects. Int J Chronic Dis. 2018;2018:1-7. doi:10.1155/2018/1296717
- Yuki M, Komazawa Y, Kobayashi Y, et al. Effects of Daikenchuto on Abdominal Bloating Accompanied by Chronic Constipation: A Prospective, Single-Center Randomized Open Trial. Curr Ther Res Clin Exp. 2015;77:58-62. doi:10.1016/j.curtheres.2015.04.002
- Hirose T, Shinoda Y, Kuroda A, et al. Efficacy and Safety of Daikenchuto for Constipation and Dose-Dependent Differences in Clinical Effects. Int J Chronic Dis. 2018;2018:1296717. doi:10.1155/2018/1296717
- Loening-Baucke V, Miele E, Staiano A. Fiber (glucomannan) is beneficial in the treatment of childhood constipation. Pediatrics. 2004;113(3 Pt 1):e259-64.
- Staiano A, Simeone D, Del Giudice E, Miele E, Tozzi A, Toraldo C. Effect of the dietary fiber glucomannan on chronic constipation in neurologically impaired children. J Pediatr. 2000;136(1):41-45.
- Han Y, Zhang L, Liu X-Q, Zhao Z-J, Lv L-X. Effect of glucomannan on functional constipation in children: a systematic review and meta-analysis of randomised controlled trials. Asia Pac J Clin Nutr. 2017;26(3):471-477.
- Chen H-L, Cheng H-C, Wu W-T, Liu Y-J, Liu S-Y. Supplementation of konjac glucomannan into a low-fiber Chinese diet promoted bowel movement and improved colonic ecology in constipated adults: a placebo-controlled, diet-controlled trial. J Am Coll Nutr. 2008;27(1):102-108.
- Chen H-L, Cheng H-C, Liu Y-J, Liu S-Y, Wu W-T. Konjac acts as a natural laxative by increasing stool bulk and improving colonic ecology in healthy adults. Nutrition. 2006;22(11-12):1112-1119. doi:10.1016/j.nut.2006.08.009
- Micka A, Siepelmeyer A, Holz A, Theis S, Schön C. Effect of consumption of chicory inulin on bowel function in healthy subjects with constipation: a randomized, double-blind, placebo-controlled trial. Int J Food Sci Nutr. 2017;68(1):82-89. doi:10.1080/09637486.2016.1212819
- Den Hond E, Geypens B, Ghoos Y. Effect of high performance chicory inulin on constipation. Nutr Res. 2000;20(5):731-736. doi:10.1016/S0271-5317(00)00162-7
- Huang R, Hu J. Positive Effect of Probiotics on Constipation in Children: A Systematic Review and Meta-Analysis of Six Randomized Controlled Trials. Front Cell Infect Microbiol. 2017;7:153. doi:10.3389/fcimb.2017.00153
- Ko W-C, Chen M-C, Wang S-H, Lai Y-H, Chen J-H, Lin C-N. 3- O -Methylquercetin More Selectively Inhibits Phosphodiesterase Subtype 3. Planta Med. 2003;69(4):310-315. doi:10.1055/s-2003-38874
- Jiang J-S, Shih C-M, Wang S-H, Chen T-T, Lin C-N, Ko W-C. Mechanisms of suppression of nitric oxide production by 3-O-methylquercetin in RAW 264.7 cells. J Ethnopharmacol. 2006;103(2):281-287. doi:10.1016/j.jep.2005.08.005
- Lin CN, Lu CM, Lin HC, Ko FN, Teng CM. Novel antiplatelet naphthalene from Rhamnus nakaharai. J Nat Prod. 1995;58(12):1934-1940.
- Surjushe A, Vasani R, Saple DG. Aloe vera: a short review. Indian J Dermatol. 2008;53(4):163-166. doi:10.4103/0019-5154.44785
- Odes HS, Madar Z. A double-blind trial of a celandin, aloevera and psyllium laxative preparation in adult patients with constipation. Digestion. 1991;49(2):65-71. doi:10.1159/000200705
- Attaluri A, Donahoe R, Valestin J, Brown K, Rao SSC. Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther. 2011;33(7):822-828. doi:10.1111/j.1365-2036.2011.04594.x
- Dettmar PW, Sykes J. A Multi-centre, General Practice Comparison of Ispaghula Husk with Lactulose and Other Laxatives in the Treatment of Simple Constipation. Curr Med Res Opin. 1998;14(4):227-233. doi:10.1185/03007999809113363
- Ashraf W, Pfeiffer RF, Park F, Lof J, Quigley EMM. Constipation in Parkinson's disease: Objective assessment and response to psyllium. Mov Disord. 1997;12(6):946-951. doi:10.1002/mds.870120617
- Feudtner C, Freedman J, Kang T, Womer JW, Dai D, Faerber J. Comparative Effectiveness of Senna to Prevent Problematic Constipation in Pediatric Oncology Patients Receiving Opioids: A Multicenter Study of Clinically Detailed Administrative Data. J Pain Symptom Manage. 2014;48(2):272-280. doi:10.1016/j.jpainsymman.2013.09.009
- Agra Y, Sacristán A, González M, Ferrari M, Portugués A, Calvo MJ. Efficacy of senna versus lactulose in terminal cancer patients treated with opioids. J Pain Symptom Manage. 1998;15(1):1-7. doi:10.1016/S0885-3924(97)00276-5
- Ramesh PR, Kumar KS, Rajagopal MR, Balachandran P, Warrier PK. Managing morphine-induced constipation: a controlled comparison of an Ayurvedic formulation and senna. J Pain Symptom Manage. 1998;16(4):240-244.
- Picon PD, Picon R V, Costa AF, et al. Randomized clinical trial of a phytotherapeutic compound containing Pimpinella anisum, Foeniculum vulgare, Sambucus nigra, and Cassia augustifolia for chronic constipation. BMC Complement Altern Med. 2010;10(1):17. doi:10.1186/1472-6882-10-17
- Üstündağ G, Kuloğlu Z, Kirbaş N, Kansu A. Can partially hydrolyzed guar gum be an alternative to lactulose in treatment of childhood constipation? Turk J Gastroenterol. 2010;21(4):360-364.
- Polymeros D, Beintaris I, Gaglia A, et al. Partially Hydrolyzed Guar Gum Accelerates Colonic Transit Time and Improves Symptoms in Adults with Chronic Constipation. Dig Dis Sci. 2014;59(9):2207-2214. doi:10.1007/s10620-014-3135-1
- Patrick PG, Gohman SM, Marx SC, DeLegge MH, Greenberg NA. Effect of Supplements of Partially Hydrolyzed Guar Gum on the Occurrence of Constipation and Use of Laxative Agents. J Am Diet Assoc. 1998;98(8):912-914. doi:10.1016/S0002-8223(98)00210-7
- Coccorullo P, Strisciuglio C, Martinelli M, Miele E, Greco L, Staiano A. Lactobacillus reuteri (DSM 17938) in Infants with Functional Chronic Constipation: A Double-Blind, Randomized, Placebo-Controlled Study. J Pediatr. 2010;157(4):598-602. doi:10.1016/j.jpeds.2010.04.066
- Ojetti V, Ianiro G, Tortora A, et al. The effect of Lactobacillus reuteri supplementation in adults with chronic functional constipation: a randomized, double-blind, placebo-controlled trial. J Gastrointestin Liver Dis. 2014;23(4):387-391.
- Riezzo G, Orlando A, D’Attoma B, Linsalata M, Martulli M, Russo F. Randomised double blind placebo controlled trial on Lactobacillus reuteri DSM 17938: improvement in symptoms and bowel habit in functional constipation. Benef Microbes. 2018;9(1):51-60. doi:10.3920/BM2017.0049
- Maffei HVL, Vicentini AP. Prospective Evaluation of Dietary Treatment in Childhood Constipation: High Dietary Fiber and Wheat Bran Intake Are Associated With Constipation Amelioration. J Pediatr Gastroenterol Nutr. 2011;52(1):55-59. doi:10.1097/MPG.0b013e3181e2c6e2
- McRorie J, Kesler J, Bishop L, et al. Effects of wheat bran and olestra on objective measures of stool and subjective reports of GI symptoms. Am J Gastroenterol. 2000;95(5):1244-1252. doi:10.1111/j.1572-0241.2000.02017.x
- Anti M, Pignataro G, Armuzzi A, et al. Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology. 45(21):727-732.