Constipation is defined medically as fewer than three stools per week and severe constipation as less than per
week. Constipation arises when the patient experiences a reduction in their normal bowel habit accompanied with
more difficult defecation and /or hard stools. It occurs in all age groups, but is especially common in the elderly.
This may be a result of sedentary lifestyle, a decreased fluid intake, poor nutrition, avoidance of fibrous foods
and chronic illness. Women are two to three times more likely to suffer from constipation than men and 40% of
women in late pregnancy experience constipation. The normal length of time between bowel movements varies
widely from person to person. Some people have them three times a day. Others have them only once or twice a
week. Constipation lasting 6 weeks or more is said to be chronic. Changes in job or marital status can precipitate
depressive illness that can manifest with physiological symptoms such as constipation.
Etiology
The normal function of the large intestine is to remove water and various salts from the colon, drying and
expulsion of the feces. Any process that facilitates water resorption will generally lead to constipation. The
commonest cause of constipation is an increase in intestinal tract transit time of food, which allows greater water
resorption from the large bowel leading to harder stools that are more difficult to pass. This is most frequently
caused by a deficiency in dietary fiber, a change in lifestyle and/or environment and medication.
Symptoms
o Lower abdominal discomfort and bloating
o Fewer bowel movements
o A sense of incomplete evacuation
o Specks of blood in the toilet pan might be present
o The child is more irritable and have a decreased appetite
Causes
o Antacid medicines containing calcium or aluminum
o Medicines, e.g. phenothiazines, beta blocker, diltiazem, verapamil and ferrous sulphate
o Eating a lot of dairy products
o Eating disorders
o Irritable bowel syndrome
o Bowel obstruction
o Anal fissure
o Spinal cord injury
o Stroke
o Colon cancer/ Rectal cancer
o Resisting the urge to have a bowel movement, which some people do because of hemorrhoids
o Hypothyroidism
Diagnosis
o Blood tests (hypothyroidism)
o Sigmoidoscopy (to examine the rectum and the lower portion of the colon)
o Colonoscopy
o Anorectal manometry (to measure the coordination of the muscles the patient uses to move the bowels)
o Defecography (may reveal a prolapse or problems with muscle function and muscle coordination)
o MRI Defecography (The MRI scanner can visualize and assess the function of the defecation muscles.
This test also can diagnose problems that can cause constipation, such as rectocele or rectal prolapse)
Treatment
Diet and lifestyle changes
o Increase fiber intake (14 grams of fiber for every 1,000 calories in the daily diet)
o Exercise most days of the week. Physical activity increases muscle activity in the intestines.
o Don't ignore the urge to have a bowel movement
Laxatives
o Fiber supplements, e.g., psyllium, calcium polycarbophil and methylcellulose fiber
o Bulk-forming laxatives, Ispaghula husk
o Stimulants, e.g., bisacodyl, Dulcolax and senna-sennosides
o Osmotics, e.g., magnesium hydroxide, magnesium citrate, lactulose, polyethylene glycol,
polyethylene glycol
o Lubricants (Lubricants such as mineral oil enable stool to move through your colon more easily)
o Stool softeners, e.g., docusate sodium and docusate calcium moisten the stool by drawing water
from the intestines.
o Enemas and suppositories, e.g., Sodium phosphate, soapsuds or tap water enemas can be useful to
soften stool and produce a bowel movement. Glycerin or bisacodyl suppositories also can soften
stool.
o Lubiprostone and linaclotide (work by drawing water into your intestines and speeding up the
movement of stool)
o Misoprostol, colchicine/probenecid and onabotulinumtoxin-A (also called botulinum toxin type A
or Botox) all work in different ways and may be used to treat chronic constipation.
Alternative medicine
o Using a probiotic such as bifidobacterium or lactobacillus may be helpful
o Fructooligosaccharide, a sugar that occurs naturally in many fruits and vegetables, may be helpful
Complications
o Hemorrhoids
o Anal fissure
o Fecal impaction (Chronic constipation may cause an accumulation of hardened stool that gets stuck in the
intestines)
o Rectal prolapse (Straining to have a bowel movement can cause a small amount of the rectum to stretch
and protrude from the anus)
Patients presenting with acute constipation with no other symptoms apart from very small amounts of
bright red blood can be managed in the pharmacy. If blood loss is substantial (stools appear tarry, red or
black) or the patient has other associated symptoms such as malaise and abdominal distension and is over
40 years old then referral is needed.