Constipation

It is worth remembering that almost every patient with a rectal prolapse has some abnormality of bowel function. Whether the abnormality of bowel function is the cause of the prolapse or whether the functional bowel abnormality is a consequence of the prolapse is difficult to say.

Constipation can be defined as the passage of hard stools less frequently than the patient’s own normal pattern. Patients should be aware that a daily bowel movement is not always necessary or ‘normal’.

Groups II and III younger than Group IV (p < 0.04). Fewer patients in Groups I and III stooled spontaneously than patients in Group IV (p < 0.02).

Over-the-counter (OTC) sales of laxatives generate $400 million annually in the United States. Because approximately 30% of healthy elderly people use laxatives regularly, the elderly contribute substantially to this $400 million market.

It is well known that constipation is a common problem among the elderly and that serious mechanical problems, such as bowel perforation or bowel obstruction, can result from constipation. Also well known is the association of fecal impaction with diarrhea and even incontinence.

Stimulant laxatives are thought to act on the intramural nervous plexus or intestinal smooth muscle. There is some reason to be concerned that prolonged use of any of the stimulant laxatives may damage the myenteric plexus, thereby impairing bowel function.

Constipation is among the most common gastrointestinal disorders. It is so prevalent, in fact, that it has been considered endemic in the elderly population.

Acute constipation usually responds well to dietary measures. Constipation induced by whole cow’s milk will improve if formula is reintroduced for a few months.

Constipation is commonly defined as the paucity of bowel movements. However, patients may have constipation regardless of the number of bowel movements in a unit of time.

A change in lifestyle may have a positive impact. Here, patients should start by trying to reduce daily stress.

Hirschsprung’s disease is the result of congenital absence of the parasympathetic ganglion cells of the intramural plexus of the distal colon and rectum. This defect leads to persistent contraction of the affected bowel segment.

A detailed history is important, and certain topics should be covered in particular (Table 2). A complete physical examination should be done, including assessment of growth and development. Most children with idiopathic constipation and encopresis arc normally grown.

The word encopresis was coined by Weissenberg in 1926, who considered this the equivalent of enuresis. Now encopresis is defined as the repetitive passage of formed, semi-formed or liquid stool into the clothing, with no demonstrable organic cause, in a child who should be toilet-trained. Constipation can cause encopresis.

The chief, and perhaps the sole, reason for contemplating invasive investigation of constipated elderly patients is the detection of treatable carcinoma of the colon or rectum. Colorectal carcinoma has a reasonably good prognosis with early treatment. Even when spread has occurred, subsequent quality of life may be substantially enhanced by treatment.

Constipation is a common and subjective symptom that can be related to a multitude of factors, including, dietary, psychological, cultural, anatomic, and functional aspects. In addition, constipation is still surrounded by misconceptions and taboos that hamper an objective evaluation and encourage self-medication that is not always innocuous to the patient.

Many old people seem to regard bowel function as a kind of health barometer and the maintenance of regular bowel action as a form of insurance against ill health. Bertrand Russell, for example, is reported to have believed that his longevity was largely due to efficient bowel function.

Extensive investigations are rarely indicated. All investigations should be guided by the history and clinical findings.

What is constipation? Obviously it concerns frequency and consistency of bowel movements and degree of difficulty in passing stools. Consistency is more important than frequency. Based on British studies the normal range is usually taken to be from three bowel movements per day to three per week.

Age-related problems with bowel function can be classified as those affecting new-borns and infants, those affecting toddlers and preschoolers, and those affecting school-aged children. Fortunately, some of these problems can be prevented. Infrequent stools during the first few weeks of life in a breast-fed baby who is not gaining weight suggest inadequate milk intake.

In clinical practice, it is commonly accepted that fiber therapy and stool-bulking agents are the main therapeutic agents of choice in the initial management of primary constipation. Several clinical trials have been performed on the effects of fiber therapy and constipation.

Irritable bowel syndrome (IBS) is a common chronic intestinal disorder characterized by abdominal discomfort and altered bowel habits. It is estimated that up to 20% of the population of the United States has symptoms suggestive of IBS.

Chronic constipation is important to treat in childhood because obstructive constipation in the young child will interfere with the child’s physical development and overflow faecal soiling in the older child will have a destructive effect on self esteem and confidence. Constipation may also complicate other childhood illness especially urological and neurodevelopmental problems. Evolution and interaction of factors in chronic constipation in childhood.

Table 4 outlines a systematic approach to the treatment of chronic constipation. This scheme assumes that any specific etiologic factors have been identified and dealt with appropriately. The apparently simple issue of ensuring adequate fluid intake can be difficult in patients who are occasionally or regularly incontinent of urine.

Four days after discharge from the hospital, a patient with a recent diagnosis of advanced lung cancer arrived in the emergency department of a Montreal hospital with abdominal pain, nausea and vomiting, and urinary retention. His large bowel was grossly distended with stool, and he required numerous enemas and manual disimpactions to dislodge the large quantities of hard feces. The patient presented a classic example of constipation resulting from narcotic analgesic administration, without any concomitant laxative program.

Functional constipation is defined by the Rome II Coordinated Committees as a group of functional disorders that present with resistant, difficult, infrequent, or seemingly incomplete defecation. Previous definitions have included a regular occurrence (in more than 25% of defecations) of excessive straining, lumpy or hard stools, a sense of incomplete evacuation, a sensation of anorectal obstruction or blockage, or less than three bowel movements per week over at least 12 consecutive weeks in the preceding 2 years. Such disorders may be congenital, as in Hirschsprung’s disease, or acquired later in life as a result of lifestyle or behavior, infection, or because of anatomic or physiologic abnormalities (Figure: Algorithm describing etiologies of various acquired constipation).