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Constipation

National Digestive Diseases Information Clearinghouse

What is ? The absorbs water and any remaining nutrients from partially digested Constipation is a condition in which a person food passed from the . The has fewer than three bowel movements a large intestine then changes waste from week or has bowel movements with stools liquid to a solid matter called stool. Stool that are hard, dry, and small, making them passes from the colon to the . The painful or difficult to pass. People may feel rectum is located between the last part of bloated or have pain in their —the the colon—called the —and area between the chest and hips. Some the anus. The rectum stores stool prior people think they are constipated if they do to a bowel movement. During a bowel not have a bowel movement every day. Bowel movement, stool moves from the rectum to movements may occur three times a day or the anus, the opening through which stool three times a week, depending on the person. leaves the body. Most people get constipated at some point in their lives. Constipation can be acute, which means sudden and lasting a short time, or chronic, which means lasting a long time, even years. Most constipation is acute and not dangerous. Understanding the causes, prevention, and treatment of constipation can help many people take steps to find relief.

What is the gastrointestinal (GI) tract? Colon The GI tract is a series of hollow organs joined in a long, twisting tube from the mouth to the anus. The body digests food using the movement of muscles in the GI tract, along with the release of hormones Rectum and enzymes. Organs that make up the Anus GI tract are the mouth, , , small intestine, large intestine—which includes the , cecum, colon, and The lower GI tract rectum—and anus. The intestines are sometimes called the bowel. The last part of the GI tract—called the lower GI tract— consists of the large intestine and anus. www.myGANV.com | (703) 698-8960 How common is constipation • neurological and metabolic disorders and who is affected? • GI tract problems Constipation is one of the most common GI • functional GI disorders problems in the United States, affecting an estimated 42 million people, or 15 percent of Diets Low in Fiber the population. People of any age, race, or The most common cause of constipation is a gender can get constipated. Those reporting diet with too little fiber. Fiber is a substance constipation most often are women, adults in foods that comes from plants. Fiber helps ages 65 and older, non-Caucasians, and stool stay soft so it moves smoothly through people in lower socioeconomic classes.1 the colon. Liquids such as water and juice Constipation is also a common problem help fiber to be more effective. during pregnancy, following childbirth or surgery, or after taking medications to Older adults commonly do not get enough relieve pain from things such as a broken fiber in their diets. They may lose interest in bone, tooth extraction, or back pain. In eating because food does not taste the same 2004, 6.3 million outpatient visits were due to as it once did, they do not feel hungry as constipation and 5.3 million prescriptions for often, they do not want to cook, or they have constipation medications were written.2 problems with chewing or swallowing. These factors may lead an older adult to choose foods that are quick to make or buy, such as What causes constipation? fast foods or prepared foods, which are often Constipation is caused by stool spending too low in fiber. much time in the colon. The colon absorbs too much water from the stool, making Lack of Physical Activity it hard and dry. Hard, dry stool is more A lack of physical activity can lead to difficult for the muscles of the rectum to constipation, although scientists do not know push out of the body. why. For example, constipation often occurs after an accident or during an illness when a Common factors or disorders that lead to person must stay in bed and cannot exercise. constipation are Lack of physical activity is thought to be one • diets low in fiber of the reasons constipation is common in older adults. • lack of physical activity • medications Medications • life changes or daily routine changes Medications that can cause constipation include • ignoring the urge to have a bowel movement • pain medications, especially narcotics • antacids that contain aluminum and calcium 1Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. • calcium channel blockers, which are American Journal of . 2004;99:750–759. used to treat high blood pressure and 2Everhart JE, ed. The Burden of Digestive Diseases in heart disease the United States. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Dept. of Health and Human Services; 2008. NIH Publication 09–6433. 2 Constipation • medications that treat Parkinson’s Ignoring the Urge to Have a disease—a disorder that affects nerve Bowel Movement cells in a part of the brain that controls muscle movement—because these People who ignore the urge to have a bowel medications also affect the nerves in the movement may eventually stop feeling colon wall the need to have one, which can lead to constipation. Some people delay having a • antispasmodics—medications that bowel movement because they do not want prevent sudden muscle contractions to use toilets outside their home, particularly • some antidepressants public restrooms, or they feel they are too busy. • iron supplements • diuretics—medications that help the Neurological and Metabolic kidneys remove fluid from the blood Disorders • anticonvulsants—medications that Certain neurological and metabolic disorders decrease abnormal electrical activity in can cause food to pass through the digestive the brain to prevent seizures system too slowly, leading to constipation. Neurological disorders, such as spinal cord Constipation can also be caused by overuse injury and parkinsonism, affect the brain and of over-the-counter . A is spine. Parkinsonism is any condition that medication that loosens stool and increases leads to the types of movement changes seen bowel movements. Although people may in Parkinson’s disease. Metabolic disorders, feel relief when they use laxatives, they such as diabetes and hypothyroidism, disrupt usually must increase the dose over time the process the body uses to get energy from because the body grows reliant on laxatives food. Hypothyroidism is a disorder that to have a bowel movement. Overuse of causes the body to produce too little thyroid laxatives can decrease the colon’s natural hormone, which can cause many of the ability to contract and make constipation body’s functions to slow down. worse. Continued overuse of laxatives can damage nerves, muscles, and tissues in the GI Tract Problems large intestine. Some problems in the GI tract can compress or narrow the colon and rectum, causing Life Changes or Daily Routine constipation. These problems include Changes • adhesions—bands of tissue that can During pregnancy, women may be connect the loops of the intestines to constipated because of hormonal changes or each other, which may block food or because the uterus compresses the intestine. stool from moving through the GI tract Aging can affect bowel regularity, because of a gradual loss of nerves stimulating the • —a condition that occurs muscles in the colon, which results in less when small pouches, or sacs, form and intestinal activity. People can also become push outward through weak spots in constipated while traveling, because their the colon wall; the pouches are called normal diet and daily routine are disrupted. diverticula

3 Constipation • colon polyps—growths on the surface of – feeling as though something is the colon that can be raised or flat blocking stool from passing at least 25 percent of the time • tumors—abnormal masses of tissue that result when cells divide more than they – using their fingers to help with stool should or do not die when they should passage at least 25 percent of the time • celiac disease—an immune reaction – having fewer than three bowel to gluten, a protein found in wheat, movements per week rye, and barley, that causes damage to the lining of the small intestine and • Rarely passing loose stools without the prevents absorption of nutrients use of laxatives Read more about the Celiac Disease • Not having Awareness Campaign at www.celiac.nih.gov. (IBS) Functional GI Disorders IBS is a functional GI disorder with symptoms that include abdominal pain or Functional GI disorders are problems discomfort, often reported as cramping, caused by changes in how the GI tract works. along with , constipation, or both. People with a functional GI disorder have Read more in Irritable Bowel Syndrome at frequent symptoms; however, the GI tract www.digestive.niddk.nih.gov. does not become damaged. Functional constipation often results from problems with muscle activity in the colon or anus that How is the cause of delay stool movement. constipation diagnosed? Functional constipation is diagnosed in To diagnose the cause of constipation, the people who have had symptoms for at least health care provider will take a medical 6 months and meet the following criteria for history, perform a physical exam, and order the last 3 months before diagnosis:3 specific tests. The tests ordered depend on how long the person has been constipated; • Two or more of the following symptoms: how severe the constipation is; the person’s – straining to have a bowel movement age; and whether the person has had blood at least 25 percent of the time in stools, recent changes in bowel habits, or weight loss. Most people with constipation – having lumpy or hard stools at least do not need extensive testing and can be 25 percent of the time treated with changes in diet and exercise. – feeling as though stool is still in the rectum after a bowel movement at least 25 percent of the time

3Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. In: Drossman DA, ed. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. Lawrence, KS: Allen Press, Inc.; 2006: 515–523. 4 Constipation Medical History Blood test. A blood test involves drawing The health care provider may ask questions blood at a health care provider’s office or about the person’s constipation, including a commercial facility and sending it to a how long symptoms have been present, lab for analysis. The blood test can show frequency of bowel movements, consistency if there may be an underlying disease or of stools, and presence of blood in the stool. condition causing constipation. For example, The health care provider may ask questions low levels of thyroid hormone may indicate about the person’s eating habits, medication, hypothyroidism. and level of physical activity. A record of Lower GI series. A lower GI series is an this information can be prepared before the x-ray exam that is used to look at the large visit to help the health care provider make a intestine. The test is performed at a hospital diagnosis. or an outpatient center by a radiologist—a doctor who specializes in . Physical Exam The health care provider may give the person A physical exam should include a rectal exam written bowel prep instructions to follow at with a gloved, lubricated finger to evaluate home. The person may be asked to follow the tone of the muscle that closes off the a clear liquid diet for 1 to 3 days before the anus—called the anal sphincter—and to procedure. A laxative or an may be detect tenderness, obstruction, or blood. used before the test. An enema involves The health care provider may perform a flushing water or laxative into the anus using test for blood in the stool by placing a small a special squirt bottle. The medications sample of the person’s stool on a paper card cause diarrhea, so the person should stay and adding a drop or two of testing solution. close to a bathroom during the bowel prep. A color change is a sign of blood in the stool. For the test, the person will lie on a table Diagnostic Tests while the radiologist inserts a flexible tube Additional testing is usually reserved into the person’s anus. The large intestine for older adults and people with severe is filled with barium, a chalky liquid, making symptoms, sudden changes in the number signs of problems that may be causing and consistency of bowel movements, or constipation show up more clearly on x rays. blood in the stool. Additional tests that may For several days, traces of barium in the be used to evaluate constipation include large intestine cause stools to be white or • blood test light colored. and repeated bowel movements may cause anal soreness. A • lower GI series health care provider will provide specific • flexible or instructions about eating and drinking after the test. • colorectal transit studies • anorectal function tests •

5 Constipation Flexible sigmoidoscopy or colonoscopy. The Colorectal transit studies. These tests show tests are similar, but a colonoscopy is used how well food moves through the colon. to view the rectum and entire colon, while • Radiopaque markers. With this a flexible sigmoidoscopy is used to view just technique, the person swallows capsules the rectum and lower colon. These tests containing small markers that are are performed at a hospital or an outpatient visible on an x ray. The markers move center by a gastroenterologist—a doctor who through the GI tract just as food and specializes in digestive diseases. For both waste do and are passed naturally with tests, a health care provider will give written stool. During the course of this test, bowel prep instructions to follow at home. the person eats a high-fiber diet to help The person may be asked to follow a clear stool move through the GI tract. Three liquid diet for 1 to 3 days before either test. to 7 days after the person swallows The night before both tests, the person may the capsules, abdominal x rays, taken need to take a laxative. One or more enemas several times, monitor the movement may also be required the night before and of the markers through the colon. An about 2 hours before both tests. x-ray technician takes the x rays in a In most cases, light anesthesia, and possibly hospital department or health pain medication, is used during a flexible care provider’s office, and a radiologist sigmoidoscopy or colonoscopy. For either interprets the x rays. test, the person will lie on a table while the • Scintigraphy. This type of nuclear gastroenterologist inserts a flexible tube into medicine study relies on the detection the anus. A small camera on the tube sends of small amounts of radiation after a video image of the intestinal lining to a a person eats a meal containing computer screen. The test can show signs of radioactive chemicals. The dose of the problems in the lower GI tract. radioactive chemicals is small; therefore, The gastroenterologist may also perform scintigraphy is not likely to cause damage a , a procedure that involves taking to cells. Special external cameras and a small piece of intestinal lining tissue for computers are used to create images of examination with a microscope. The person the radioactive chemicals as they move will not feel the biopsy. A pathologist—a through the intestine. To prepare for doctor who specializes in diagnosing the test, the person may need to stop diseases—examines the tissue in a lab. taking some medications and should not eat any food after midnight the night Cramping or bloating may occur during before the test. Scintigraphy is done as the first hour after the test. Driving is an outpatient procedure by a specially not permitted for 24 hours after a flexible trained technician, and a radiologist sigmoidoscopy or colonoscopy to allow interprets the results. the sedative time to wear off. Before the appointment, a person should make plans for Anorectal function tests. These tests a ride home. Full recovery is expected by the diagnose constipation caused by anorectal next day. dysfunction, which refers to problems with the anus and rectum. To prepare for these

6 Constipation tests, the person should use an enema and toilet inside an x-ray machine. The person not eat anything 2 hours prior to the test. is first asked to pull in and squeeze the Anesthesia is not needed for these tests. sphincter muscles to prevent leakage. Then the person is asked to strain to have a bowel • Anal manometry uses pressure sensors movement. The radiologist studies the x rays and a balloon that can be inflated in for anorectal problems that occurred as the the rectum to check the sensitivity paste was expelled. and function of the rectum. Anal manometry also checks the tightness of the anal sphincter muscles around How is constipation treated? the anus. For this test, a thin tube Treatment for constipation depends on with a balloon on its tip and pressure the cause, severity, and duration of the sensors below the balloon is inserted constipation and may include one or more of into the anus until the balloon is in the the following: rectum and pressure sensors are inside the anus. The tube is slowly pulled • changes in eating, diet, and nutrition back through the sphincter muscle to • exercise and lifestyle changes measure muscle tone and contractions. • medication The test takes about 30 minutes. • surgery • Balloon expulsion tests consist of filling a balloon with varying amounts • of water after it has been inserted into First-line treatments for constipation include the rectum. The person is given a changes in eating, diet, and nutrition; stopwatch and instructed to go to the exercise and lifestyle changes; and laxatives. restroom and measure the amount of People who do not respond to these first-line time it takes to expel the balloon. If the treatments should talk with their health care person cannot expel a balloon filled with provider about other treatments. less than 150 milliliters of water or it takes longer than 1 minute to expel the Eating, Diet, and Nutrition balloon, the person may have a decrease The Academy of Nutrition and Dietetics in function for evacuation of stool. recommends consuming 20 to 35 grams of Defecography. This x ray of the anorectal fiber a day for adults. Americans consume area shows how well the person can hold only 15 grams a day on average.4 People and evacuate stool. The test also identifies often eat too many refined and processed structural changes in the rectum and anus, foods from which the natural fiber has been such as and rectal . removed. A health care provider can help Rectocele is a condition in which the rectum plan a diet with the appropriate amount of protrudes through the vagina, and rectal fiber. A list of high-fiber foods is shown on prolapse is a condition in which the rectum page 8. People prone to constipation should drops down through the anus. To prepare limit foods that have little or no fiber, such as for the test, the person uses two enemas ice cream, cheese, meat, and processed foods. and does not eat anything 2 hours prior to the test. During the test, the health care provider fills the rectum with a soft paste 4Slavin JL. Position of the American Dietetic that shows up on x rays and is the same Association: health implications of . consistency as stool. The person sits on a Journal of the American Dietetic Association. 2008;108:1716–1731. 7 Constipation Examples of Foods That Have Fiber Beans, cereals, and breads Fiber 1/2 cup of beans (navy, pinto, 6.2–9.6 grams kidney, etc.), cooked 1/2 cup of shredded wheat, 2.7–3.8 grams ready-to-eat cereal 1/3 cup of 100% bran, 9.1 grams ready-to-eat cereal 1 small oat bran muffin 3.0 grams 1 whole-wheat English muffin 4.4 grams

Fruits 1 small apple, with skin 3.6 grams 1 medium pear, with skin 5.5 grams 1/2 cup of raspberries 4.0 grams 1/2 cup of stewed prunes 3.8 grams

Vegetables 1/2 cup of winter squash, cooked 2.9 grams 1 medium sweet potato, baked in skin 3.8 grams 1/2 cup of green peas, cooked 3.5–4.4 grams 1 small potato, baked, with skin 3.0 grams 1/2 cup of mixed vegetables, cooked 4.0 grams 1/2 cup of broccoli, cooked 2.6–2.8 grams 1/2 cup of greens (spinach, collards, 2.5–3.5 grams turnip greens), cooked

Source: U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines for Americans, 2010.

Drinking water and other liquids, such as Exercise and Lifestyle Changes fruit and vegetable juices and clear soups, Engaging in daily exercise can help people may make fiber in the diet more effective in with constipation. Another strategy is normalizing bowel function and maintaining to try to have a bowel movement at the regularity. A health care provider can give same time each day. The best time is 15 to advice about how much a person should 45 minutes after breakfast because eating drink each day based on the person’s health helps stimulate the colon. People with and activity level and where the person lives. constipation should reserve enough time to have a bowel movement and be sure not to ignore the urge to have a bowel movement.

8 Constipation Medication to soften them. Stool softeners may When a medication is causing constipation, be suggested for people who should the health care provider may suggest the avoid straining in order to pass a person stop taking the medication or switch bowel movement; they are often to a different medication. recommended after childbirth or surgery. Laxative medications and enemas may be • Lubricants. Brand names include recommended for people who have made Fleet and Zymenol. Lubricants work diet and lifestyle changes and are still by coating the surface of stool, which constipated. Laxatives taken by mouth helps the stool hold in fluid and pass are available in liquid, tablet, powder, and more easily. Lubricants are simple, granule forms. inexpensive laxatives that may be • Bulk-forming agents. Brand names recommended for people with anorectal include Metamucil, FiberCon, Citrucel, blockage. Konsyl, and Serutan. Bulk-forming Other types of laxatives include agents absorb fluid in the intestines, making stools bulkier, which helps • Stimulants. Brand names include trigger the bowel to contract and push Correctol, Dulcolax, Purge, and stool out. These supplements should Senokot. Stimulant laxatives cause be taken with water or they can cause the intestines to contract, which moves obstruction. Bulk-forming agents stool. Stimulants should be reserved are generally considered the safest for constipation that is severe or has laxative, but they can interfere with the not responded to other treatments. absorption of some medications. Many People should not use stimulant people also report no relief after taking laxatives containing phenolphthalein, bulk-forming agents and suffer from as phenolphthalein may increase the bloating and abdominal pain. likelihood of cancer. Most laxatives sold in the United States do not contain • Osmotic agents. Brand names include phenolphthalein. Milk of Magnesia, Fleet Phospho- Soda, Cephulac, Sorbitol, and Miralax. • Chloride channel activators. Osmotic agents help stool retain Lubiprostone (Amitiza) is a chloride fluid, increasing the number of bowel channel activator available with a movements and softening the stool. prescription. This type of laxative These laxatives are usually used by increases fluid in the GI tract. people who are bedridden or cannot Lubiprostone has been shown to be safe take bulk-forming agents. Older when used for 6 to 12 months. adults and people with heart or kidney People who depend on laxatives to have failure should be careful when taking a bowel movement need to talk with their osmotic agents because they can cause health care provider about how to slowly dehydration or a mineral imbalance. stop using them. For most people, stopping • Stool softeners. Brand names include laxatives restores the colon’s natural ability Colace, Docusate, and Surfak. Stool to contract. softeners help mix fluid into stools

9 Constipation Surgery movement. Treatment for may Surgery may be needed to correct an include making dietary changes to prevent anorectal blockage caused by . constipation, taking warm tub baths, and Surgical removal of the colon may be an applying special cream to the affected area option for people whose colon muscles do or using suppositories before bedtime. not work properly, causing severe symptoms Hemorrhoids that do not respond to at-home that do not respond to treatment. However, treatments can be treated by a health care the benefits of this surgery should be provider. Read more in Hemorrhoids at weighed against possible complications, www.digestive.niddk.nih.gov. which include abdominal pain and diarrhea. Anal fissures are small tears in the anus that may cause itching, pain, or bleeding. Biofeedback Treatment for anal fissures may include People with chronic constipation caused making dietary changes to prevent by problems with the anorectal muscles constipation, applying cream to numb can use biofeedback to retrain the muscles. the area or relax the muscles, using stool Biofeedback uses special sensors to measure softeners, or taking warm tub baths. Anal bodily functions. The measurements are fissures that do not respond to at-home displayed on a video screen as line graphs treatment can be treated with minor surgery. and sounds indicate when the person is using the correct muscles. The health care Rectal prolapse can be caused by straining provider uses the information to help the during bowel movements. The condition person modify or change abnormal function. may lead to mucus leaking from the anus. The person practices at home. The person Eliminating the cause of the prolapse, may need to continue practicing for 3 months such as straining or coughing, is usually the to get the most benefit from the training. only treatment needed. Severe or chronic prolapse requires surgery to strengthen and tighten the anal sphincter muscle or to repair What are the complications the prolapsed lining. of constipation? occurs when hard stool Sometimes constipation can lead to packs the intestine and rectum so tightly complications, such as hemorrhoids, anal that the normal pushing action of the colon fissures, rectal prolapse, and fecal impaction. is not enough to expel the stool. This Hemorrhoids are swollen and inflamed condition occurs most often in children and veins around the anus or in the lower older adults. An impaction can be softened rectum that can be caused by straining with mineral oil taken by mouth or through to have a bowel movement. People with an enema. After softening the impaction, hemorrhoids may have that the health care provider may break up appears bright red on the surface of stool, and remove part of the hardened stool by on toilet paper, or in the toilet after a bowel inserting one or two fingers into the anus.

10 Constipation