CONSTIPATION

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).

Chronic constipation according to the Rome III diagnostic criteria (1,6,7):

1. Must include 2 or more of the following:
2. Straining during at least 25% of defecations
3. Lumpy or hard stools in at least 25% of defecations
4. Sensation of incomplete evacuation for at least 25% of defecations
5. Sensation of anorectal obstruction/blockage for at least 25% of defecations
6. Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor)
7. Fewer than 3 defecations per week
8. Loose stools are rarely present without the use of laxatives
9. 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).

Secondary constipation is constipation that is experienced as an addition to medical factors including (1,2,8,9)

• 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).

Biofeedback, defecation training, acupuncture, massages, and surgery are some less common alternatives (8,9,15,20).

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)

REFERENCES

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