Thursday, March 7, 2013

Constipation


Introduction 

Constipation is a common condition that affects people of all ages. It can mean that you are not passing stools (poo) regularly, or you are unable to completely empty your bowels.
Constipation can also cause your stools to be hard, lumpy, large or small.
The severity of constipation varies from person to person. Many people only experience constipation for a short time, but for others, constipation can be a chronic (long-term) condition that causes significant pain and discomfort and affects quality of life.
Read more information about the symptoms of constipation.

What causes constipation?

It's often difficult to identify the cause. However, there are a number of things that increase the risk of constipation, including:
  • Not eating enough fibre, such as fruit, vegetables and cereals
  • A change in your routine or lifestyle, such as a change in your eating habits
  • Ignoring the urge to pass stools
  • Side effects of certain medication
  • Not drinking enough fluids
  • Anxiety or Depression
In children, poor diet, fear about using the toilet and poor toilet training can all be responsible.

Should I see Dr. B C Shah?

You may be able to help treat constipation yourself by making simple changes to your diet and lifestyle. If these changes do not help, see Dr. B C Shah.
You should also speak to Dr. B C Shah is you suspect your child might be constipated.

Treating constipation

An oral laxative (medication to help you empty your bowels) is usually prescribed to treat constipation.
Treatment for constipation is effective, although in some cases it can take several months before a regular bowel pattern is re-established.

Preventing constipation

Making diet and lifestyle changes, such as eating high-fibre foods, drinking plenty of fluids and regularly exercising will help to prevent or ease your constipation.
It may also help to give yourself enough time and privacy to pass stools comfortably and never ignore the urge to go to the toilet.

Complications

For most people constipation rarely causes any complications, but people with long-term constipation can develop:
  • Haemorrhoids (piles)
  • Faecal impaction (where dry, hard stools collect in the rectum)
  • Faecal incontinence (the leakage of liquid stools)

Who is affected?

Constipation can occur in babies, children and adults, and affects twice as many women as men.
Older people are five times more likely than younger adults to have constipation, usually because of diet, lack of exercise, use of medication and poor bowel habits.
Approximately 40% of pregnant women experience constipation during their pregnancy.

Symptoms of constipation

When you are constipated, passing stools becomes more difficult than it used to be.
Normal bowel habits vary from person to person. For example, some adults normally go to the toilet more than once a day, whereas it's normal for others to go only every three or four days. Some infants pass stools several times a day, while others pass stools only a few times a week.

Difficulty passing stools

Passing stools may feel more difficult for several reasons. For example, you may be going significantly less frequently or much less effectively (you feel you are unable to completely empty your bowel).
Passing stools may also seem more difficult because your stools are:
  • Dry, hard and lumpy
  • Abnormally large
  • Abnormally small
As well as causing a change in your normal bowel habits, constipation can also cause the following symptoms:
  • Stomach ache and cramps
  • Feeling bloated
  • Feeling nauseous
  • Loss of appetite

Constipation in children

As well as infrequent or irregular bowel movements, a child with constipation may also have the following signs and symptoms:
  • Loss of appetite
  • Lack of energy
  • Being irritable, angry or unhappy
  • Foul-smelling wind and stools
  • Abdominal pain and discomfort
  • Soiling their clothes
  • Generally feeling unwell
If your child has these symptoms or has spoken to you about having difficulty passing stools, speak to Dr. B C Shah.

Causes of constipation 

Most cases of constipation are not caused by a specific condition and it may be difficult to identify the exact cause.
However, several factors can increase your chances of having constipation, including:
  • Not eating enough fibre, such as fruit, vegetables and cereals
  • A change in your routine or lifestyle, such as a change in your eating habits
  • Having limited privacy when using the toilet
  • Ignoring the urge to pass stools
  • Immobility or lack of exercise
  • Not drinking enough fluids
  • Being underweight or overweight
  • Anxiety or depression
  • Psychiatric problems, such as those brought on by sexual abuse, violence or trauma

Medication

Sometimes, constipation may be a side effect of a medicine that you are taking. Common types of medication that can cause constipation include:
  • Aluminium antacids (medicine to treat indigestion)
  • Antidepressants
  • Antiepileptics (medicine to treat epilepsy)
  • Antipsychotics (medicine to treat schizophrenia and other mental health conditions)
  • Calcium supplements
  • Codeine, found in some types of painkiller
  • Diuretics (water tablets)
  • Iron supplements
If your constipation is caused by medication, the condition usually eases once you stop taking the medicine. However, under no circumstances should you stop taking your medication unless Dr. B C Shah advises you to.
Speak to Dr. B C Shah if you experience constipation due to a medicine. He may be able to prescribe an alternative.

Pregnancy

About 40% of women experience some form of constipation during their pregnancy, mostly during the early stages of their pregnancy.
Constipation occurs during pregnancy because your body produces more of the female hormone progesterone which acts as a muscle relaxant.
Your bowel normally moves stools and waste products along to the anus by a process known as peristalsis. This is when the muscles that line the bowel contract and relax in a rippling, wave-like motion. An increase in progesterone makes it more difficult for the bowel muscles to contract, making it harder to move waste products along.
If you are pregnant, there are ways that you can safely treat constipation without harming you or your baby. 

Other conditions

In rare cases, constipation can be a sign of an underlying condition, such as:

Babies and children

Constipation in babies and children is quite common. A Poor diet, fear about using the toilet and poor toilet training can all be responsible.

Poor diet

Children who are over-fed are more likely to have constipation, as are those who do not get enough fluids. Babies who have too much milk are also more likely to get constipation. As with adults, it is very important that your child has enough fibre in their diet.

Toilet training

Make sure that you do not make your child feel stressed or pressured about using the toilet. It is also important to let your children try things by themselves (when appropriate). Constantly intervening when they are using the toilet may make them feel anxious.

Toilet habits

Some children can feel stressed or anxious about using the toilet. They may have a phobia about using the toilet, or feel that they are unable to use the toilets at school.
This fear or phobia may be the result of your child experiencing pain when passing stools. This can lead to poor bowel habits, where children ignore the urge to pass stools and instead withhold them for fear of experiencing pain and discomfort. However, this will mean that their condition only worsens.

Other conditions

In rare cases, constipation in babies and children can be a sign of an underlying condition such as:
  • Hirschsprung's disease, which affects the bowel, making it difficult to pass stools
  • Anorectal malformation, where the baby's anus and rectum do not form properly
  • Spinal cord abnormalities, including rare conditions such as spina bifida and cerebral palsy
  • Cystic fibrosis, a genetic condition that causes the body to produce thick and sticky mucus, which can lead to constipation

Diagnosing constipation 

Constipation is a very common condition. Dr. B C Shah will not usually need to carry out any tests or procedures, but will confirm a diagnosis of constipation based on your medical history and your symptoms.
Dr. B C Shah will ask you some questions about your bowel habits. Do not feel embarrassed about describing your bowel pattern and stools to him. It is important that Dr. B C Shah is aware of all of your symptoms so he can make the correct diagnosis.
Dr. B C Shah may also ask questions about your diet, level of exercise and whether there have been any recent changes in your routines.
Doctors define constipation in a number of ways:
  • Opening the bowels less than three times a week
  • Needing to strain to open your bowels on more than a quarter of occasions
  • Passing a hard or pellet-like stool on more than a quarter of occasions

Physical examination

If Dr. B C Shah suspects that you may have faecal impaction (when dry, hard stools collect in your rectum), he may carry out a physical examination. 
A typical examination will begin with you lying on your back while Dr. B C Shah feels your abdomen. You will then lie on your side while Dr. B C Shah performs a rectal examination using a lubricated, gloved finger. He can feel for any stools that may have collected.
Dr. B C Shah will rarely have to conduct an internal physical examination on a child. Instead, the diagnosis can normally be made by feeling their abdomen (tummy).

Further tests

If you are experiencing severe symptoms, your doctor may request further tests, such as blood tests or thyroid tests, to diagnose or rule out other conditions.
As there is an increased risk of colorectal cancer in older adults, Dr. B C Shah may also request tests to rule out a diagnosis of cancer, including a barium enema or colonoscopy.

Treating constipation 

Treatment for constipation depends on the cause, how long you have had the condition and how severe your symptoms are. In many cases it is possible to relieve symptoms through dietary and lifestyle changes.
This section covers the following:
  • Lifestyle advice
  • Laxatives
  • Treating faecal impaction
  • Pregnancy or breastfeeding
  • Babies who have not yet been weaned
  • Babies who are eating solids
  • Children

Lifestyle advice

Dr. B C Shah will first advise you about how you can change your diet and lifestyle, which may mean that your constipation passes without the use of medication.
Some ways you can help treat your constipation are listed below.
  • Increase your daily intake of fibre. You should eat at least 18-30g of fibre a day. High-fibre foods include fruit, vegetables and cereals.
  • Add some bulking agents, such as wheat bran, to your diet. These will help make your stools softer and easier to pass.
  • Avoid dehydration by drinking plenty of water.
  • Get more exercise by going for a daily walk or run.
  • If your constipation is causing pain or discomfort, you may want to take a painkiller such as paracetamol. Make sure you always follow the dosage instructions carefully. Children under 16 years of age should not take aspirin.
  • Identify a routine of a place and a time of day when you are comfortably able to spend time in the toilet. Respond to your bowel's natural pattern: when you feel the urge, do not delay. 
If these diet and lifestyle changes do not help, Dr. B C Shah may prescribe an oral laxative.

Laxatives

Laxatives are a type of medicine that help you pass stools. There are several different types and each one has a different effect on your digestive system.

Bulk-forming laxatives

Dr. B C Shah will normally start you on a bulk-forming laxative. These laxatives work by helping your stools to retain fluid. This means they are less likely to dry out, which can lead to faecal impaction. Bulk-forming laxatives also make your stools denser and softer, which means they should be easier to pass.
Commonly prescribed bulk-forming laxatives include ispaghula husk, methylcellulose and sterculia. When taking this type of laxative, you must drink plenty of fluids. Also, do not take them before going to bed. It will usually be two to three days before you feel the effects of a bulk-forming laxative.

Osmotic laxatives

If your stools remain hard after you have taken a bulk-forming laxative, Dr. B C Shah may prescribe an osmotic laxative instead. Osmotic laxatives increase the amount of fluid in your bowels. This helps to stimulate your body to pass stools and also softens stools.
Commonly prescribed osmotic laxatives include lactulose and macrogols. As with bulk-forming laxatives, make sure you drink enough fluids. It will usually be two to three days before you feel the effect of the laxative.

Stimulant laxatives

If your stools are soft but you still have difficulty passing them,Dr. B C Shah may prescribe a stimulant laxative. This laxative stimulates the muscles that line your digestive tract, helping them to move stools and waste products along your large intestine to your anus.
The most commonly prescribed stimulant laxatives are senna, bisacodyl and sodium picosulphate. These laxatives are usually only used on a short-term basis, and they will usually start to work within 6 to 12 hours.
According to your individual preference and the speed with which you require relief, Dr. B C Shah may decide to combine different laxatives.

How long will I take laxatives for?

If you have only experienced constipation for a short time, Dr. B C Shah will normally advise you to stop taking the laxative once your stools are soft and easily passed.
However, if you have constipation due to a medicine or an underlying medical condition, you may have to take laxatives for much longer, possibly many months or even years.
If you have been taking laxatives for some time, you may have to gradually reduce your dose rather than coming off them straight away. If you have been prescribed a combination of laxatives, you will normally have to reduce the dosage of each laxative, one at a time, before you can stop taking them. This can take several months.
Dr. B C Shah will advise you when it is best to stop taking them. 

Treating faecal impaction

Faecal impaction occurs when stools become hard and dry and collect in your rectum. This obstructs the rectum, making it more difficult for stools to pass along.
If you have faecal impaction, you will initially be treated with a high dose of the osmotic laxative macrogol. After a few days of using this laxative, you may also have to start taking a stimulant laxative.
If you do not respond to these laxatives, you may need one of the medications described below.
  • Suppository: this type of medicine is inserted into your anus. The suppository gradually dissolves at body temperature and is then absorbed into your bloodstream. Bisacodyl and glycerol are two medicines that can be given in suppository form.
  • Mini enema: this is when a medicine in fluid form is injected through your anus and into your large bowel. Docusate and sodium citrate can be given in this way.

Pregnancy or breastfeeding

If you are pregnant, there are ways for you to safely treat constipation without harming you or your baby. Dr. B C Shah will first advise you to change your diet by increasing fibre and fluid intake. You will also be advised to do gentle exercise.
If dietary and lifestyle changes do not work, you may be prescribed a laxative to help you pass stools more regularly.
Lots of laxatives are safe for pregnant women to use because most are not absorbed by the digestive system. This means that your baby will not feel the effects of the laxative.
Laxatives that are safe to use during pregnancy include the osmotic laxatives lactulose and macrogols. If these do not work, Dr. B C Shah may advise a small dose of bisacodyl or senna (stimulant laxatives).
However, senna may not be suitable if you are in your third trimester of pregnancy (27 weeks to birth) because this medicine is partially absorbed by your digestive system.

Babies who have not yet been weaned

If your baby is constipated but has not yet started to eat solid foods, the first way to treat them is to give them extra water between their normal feeds. If you are using formula milk, make the formula as directed by the manufacturer and do not dilute the mixture.
You may want to try gently moving your baby's legs in a bicycling motion or carefully massaging their abdomen (tummy) to help stimulate their bowels.

Babies who are eating solids

If your baby is eating solid foods, give them plenty of water or diluted fruit juice. Try to encourage them to eat fruit, which can be pureed or chopped, depending on their ability to chew. The best fruits for babies to eat to treat constipation are:
  • Apples
  • Apricots
  • Grapes
  • Peaches
  • Pears
  • Plums
  • Prunes
  • Raspberries
  • Strawberries
Never force your baby to eat food if they do not want to. If you do, it can turn mealtimes into a battle and your child may start to think of eating as a negative and stressful experience.
If your baby is still constipated after a change in diet, they may have to be prescribed a laxative. Bulk-forming laxatives are not suitable for babies, so they will usually be given an osmotic laxative. However, if this does not work, they can be prescribed a stimulant laxative.

Children

As with babies and adults, children with constipation will first be advised to change their diet. If this does not work, laxatives can be prescribed, usually an osmotic laxative followed, if necessary, by a stimulant laxative.
As well as eating fruit, older children should have a well-balanced diet, which also contains vegetables and wholegrain foods such as wholemeal bread and pasta.
Try to minimise stress or conflict associated with using the toilet or meal times. It is important to be positive and encouraging when it comes to establishing a toilet routine. Your child should be allowed at least 10 minutes on the toilet to make sure they have passed as many stools as possible.
To encourage a positive toilet routine, try making a diary of your child's bowel movements linked to a reward system. This can help them focus on using the toilet successfully.
Top tips for parents
  • A diet rich in fibre and with plenty of fluids will help, even if your child is being treated with laxatives.
  • Children with chronic (long-term) constipation do not normally have anything physically wrong with them. However, it can take time to correct the problem, so be patient.
  • Encourage your child to have a regular toilet habit and allow them plenty of time.
  • A reward chart for passing a stool can be useful if your child tends to ‘hold on’.

Complications with constipation 

Constipation rarely causes any complications or long-term health problems. Treatment is usually effective, particularly if it is started promptly.
However, if you have chronic (long-term) constipation, you may be more at risk of experiencing complications.

Haemorrhoids

If you continually strain to pass stools, it can cause pain, discomfort and bleeding. Excessive straining can also lead to haemorrhoids (piles). Haemorrhoids are swollen blood vessels that form in the lower rectum and anus.
Haemorrhoids can cause:
  • itching around the anus
  • swelling of the anus
  • pain
  • bleeding from the anus

Faecal impaction

Chronic constipation can increase the risk of faecal impaction (where dried, hard stools collect in your rectum and anus). Once you have faecal impaction, it is very unlikely that you will be able to get rid of the stools naturally.
Faecal impaction worsens constipation because it makes it harder for stools and waste products to pass out of your anus as the path is obstructed.
If you experience faecal impaction, it can lead to a number of other complications. These include:
  • Swelling of the rectum
  • Losing sensation in and around your anus
  • Faecal incontinence, when you uncontrollably leak soft or liquid stools
  • Bleeding from your anus
  • Rectal prolapse, when part of your lower intestine falls out of place and protrudes from your anus

Psychological effects

If your child experiences faecal incontinence, it may affect them psychologically.
Faecal incontinence can be very upsetting and embarrassing for children. If they are at school, they may find themselves teased or socially excluded. This can make a child feel withdrawn, alone and unable to talk about what they are experiencing.
If you notice a change in your child's behaviour, talk openly and honestly with them and encourage them to tell you how they are feeling.
Also try to speak to your child's teacher to make sure they understand the situation. The teacher can help ensure your child is not upset or left feeling excluded by other children.

Preventing constipation 

Although constipation is common, you can take several steps to prevent it, including making diet and lifestyle changes.

Fibre

Make sure you have enough fibre in your diet. Most adults do not eat enough fibre. You should have approximately 18g of fibre a day. You can increase your fibre intake by eating more:
  • Fruit
  • Vegetables
  • Wholegrain rice
  • Wholewheat pasta
  • Wholemeal bread
  • Seeds
  • Nuts 
  • Oats
Eating more fibre will keep your bowel movements regular because it helps food pass through your digestive system more easily. Foods high in fibre also make you feel fuller for longer.
If you are increasing your fibre intake, it is important to increase it gradually. A sudden increase may make you feel bloated. You may also produce more flatulence (wind) and have stomach cramps.

Fluids

Make sure that you drink plenty of fluids to avoid dehydration and steadily increase your intake when you are exercising or when it is hot. Try to cut back on the amount of caffeine, alcohol and fizzy drinks that you consume.

Toilet habits

Never ignore the urge to go to the toilet. Ignoring the urge can significantly increase your chances of having constipation. The best time for you to pass stools is first thing in the morning, or about 30 minutes after a meal.
When you use the toilet, make sure you have enough time and privacy to pass stools comfortably.

Exercise

Keeping mobile and active will greatly reduce your risk of getting constipation. Ideally, do at least 150 minutes of physical activity every week.
Not only will regular exercise reduce your risk of becoming constipated, but it will also leave you feeling healthier and improve your mood, energy levels and general fitness.

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