Constipation is defined as having a bowel movement fewer than three times per week. With constipation stools are usually hard, dry, Esophagus small in size, and difficult to eliminate. Some people who are constipated find it painful to Liver Stomach have a bowel movement and often experience straining, bloating, and the sensation of a full Pancreas bowel. Large Some people think they are constipated if they intestine do not have a bowel movement every day. However, normal stool elimination may be Small three times a day or three times a week, intestine depending on the person. Rectum Constipation is a symptom, not a disease. Anus Almost everyone experiences constipation at some point in their life, and a poor diet Appendix typically is the cause. Most constipation is temporary and not serious. Understanding its The digestive tract. causes, prevention, and treatment will help most people find relief. Self-treatment of constipation with overthe- counter (OTC) laxatives is by far the most Who gets constipated? common aid. Around $725 million is spent on Constipation is one of the most common laxative products each year in America. gastrointestinal complaints in the United States. More than 4 million Americans have frequent What causes constipation? constipation, accounting for 2.5 million To understand constipation, it helps to know physician visits a year. Those reporting how the colon, or , works. As food constipation most often are women and adults moves through the colon, the colon absorbs ages 65 and older. Pregnant women may have water from the food while it forms waste constipation, and it is a common problem products, or stool. Muscle contractions in the following childbirth or surgery. colon then push the stool toward the rectum. By the time stool reaches the rectum it is solid, because most of the water has been absorbed.

Constipation occurs when the colon absorbs too may cause older people to eat soft foods that are much water or if the colon’s muscle contractions processed and low in fiber. are slow or sluggish, causing the stool to move through the colon too slowly. As a result, stools Not Enough Liquids can become hard and dry. Common causes of Research shows that although increased fluid constipation are intake does not necessarily help relieve  not enough fiber in the diet constipation, many people report some relief  lack of physical activity (especially in from their constipation if they drink fluids such the elderly) as water and juice and avoid dehydration.  medications Liquids add fluid to the colon and bulk to stools,  milk making bowel movements softer and easier to  pass. People who have problems with  changes in life or routine such as constipation should try to drink liquids every pregnancy, aging, and travel day. However, liquids that contain caffeine, such  abuse of laxatives as coffee and cola drinks will worsen one’s  ignoring the urge to have a bowel symptoms by causing dehydration. Alcohol is movement another beverage that causes dehydration. It is  dehydration important to drink fluids that hydrate the body,  specific diseases or conditions, such as especially when consuming caffeine containing stroke (most common) drinks or alcoholic beverages.  problems with the colon and rectum  problems with intestinal function Lack of Physical Activity (chronic idiopathic constipation) A lack of physical activity can lead to constipation, although doctors do not know Not Enough Fiber in the Diet precisely why. For example, constipation often People who eat a high-fiber diet are less likely to occurs after an accident or during an illness become constipated. The most common causes when one must stay in bed and cannot exercise. of constipation are a diet low in fiber or a diet Lack of physical activity is thought to be one of high in fats, such as cheese, eggs, and meats. the reasons constipation is common in older Fiber—both soluble and insoluble—is the part people. of fruits, vegetables, and grains that the body cannot digest. Soluble fiber dissolves easily in Medications water and takes on a soft, gel-like texture in the Some medications can cause constipation, intestines. Insoluble fiber passes through the including: intestines almost unchanged. The bulk and soft  pain medications (especially narcotics) texture of fiber help prevent hard, dry stools that  antacids that contain aluminum and are difficult to pass. calcium  blood pressure medications (calcium Americans eat an average of 5 to 14 grams of channel blockers) fiber daily,* which is short of the 20 to 35 grams  antiparkinson drugs recommended by the American Dietetic  antispasmodics Association. Both children and adults often eat  antidepressants too many refined and processed foods from which the natural fiber has been removed.  iron supplements A low-fiber diet also plays a key role in  diuretics constipation among older adults, who may lose  anticonvulsants interest in eating and choose foods that are quick to make or buy, such as fast foods, or prepared foods, both of which are usually low in fiber. Also, difficulties with chewing or swallowing Changes in Life or Routine  stroke During pregnancy, women may be constipated  spinal cord injuries because of hormonal changes or because the  Metabolic and endocrine conditions uterus compresses the intestine. Aging may also  diabetes affect bowel regularity, because a slower  uremia metabolism results in less intestinal activity and  hypercalcemia muscle tone. In addition, people often become  poor glycemic control constipated when traveling, because their normal  hypothyroidism diet and daily routine are disrupted.  Systemic disorders  amyloidosis Abuse of Laxatives  lupus The common belief that people must have a  scleroderma daily bowel movement has led to self- medicating with OTC laxative products. Problems with the Colon Although people may feel relief when they use and Rectum laxatives, typically they must increase the dose Intestinal obstruction, scar tissue—also called over time because the body grows reliant on adhesions—diverticulosis, tumors, colorectal laxatives in order to have a bowel movement. As stricture, Hirschsprung’s disease, or cancer can a result, laxatives may become habit-forming. compress, squeeze, or narrow the intestine and Ignoring the Urge to Have a rectum and cause constipation. Bowel Movement Problems with Intestinal People who ignore the urge to have a bowel movement may eventually stop feeling the need Function to have one, which can lead to constipation. The two types of constipation are idiopathic Some people delay having a bowel movement constipation and functional constipation. because they do not want to use toilets outside Irritable bowel syndrome (IBS) with the home. Others ignore the urge because of predominant symptoms of constipation is emotional stress or because they are too busy. categorized separately. Children may postpone having a bowel Idiopathic—of unknown origin—constipation movement because of stressful toilet training or does not respond to standard treatment. because they do not want to interrupt their play. Functional constipation means that the bowel is Specific Diseases healthy but not working properly. Functional Diseases that cause constipation include constipation is often the result of poor dietary neurological disorders, metabolic and endocrine habits and lifestyle. It occurs in both children disorders, and systemic conditions that affect and adults and is most common in women. organ systems. These disorders can slow the Colonic inertia, delayed transit, and pelvic floor movement of stool through the colon, rectum, or dysfunction are three types of functional anus. constipation. Colonic inertia and delayed transit are caused by a decrease in muscle activity in Conditions that can cause constipation are the colon. These syndromes may affect the found below: entire colon or may be confined to the lower, or sigmoid, colon.  Neurological disorders  multiple sclerosis Pelvic floor dysfunction is caused by a weakness  Parkinson’s disease of the muscles in the pelvis surrounding the anus  chronic idiopathic intestinal pseudo- and rectum. However, because this group of obstruction muscles is voluntarily controlled to some extent, biofeedback training is somewhat successful in  fewer than three bowel movements per retraining the muscles to function normally and week improving the ability to have a bowel movement. Physical Examination Functional constipation that stems from A physical exam may include a rectal exam with problems in the structure of the anus and rectum a gloved, lubricated finger to evaluate the tone is known as anorectal dysfunction, or . of the muscle that closes off the anus—also These abnormalities result in an inability to relax called anal sphincter—and to detect tenderness, the rectal and anal muscles that allow stool to obstruction, or blood. In some cases, blood and exit. thyroid tests may be necessary to look for thyroid disease and serum calcium or to rule out People with IBS having predominantly inflammatory, metabolic, and other disorders. constipation also have pain and bloating as part of their symptoms. Extensive testing usually is reserved for people with severe symptoms, for those with sudden How is the cause of changes in the number and consistency of bowel movements or blood in the stool, and older constipation identified? adults. Additional tests that may be used to The tests the doctor performs depend on the evaluate constipation include duration and severity of the constipation, the  a colorectal transit study person’s age, and whether blood in stools,  anorectal function tests recent changes in bowel habits, or weight loss have occurred. Most people with constipation  a defecography do not need extensive testing and can be treated with changes in diet and exercise. For Because of an increased risk of colorectal example, in young people with mild cancer in older adults, the doctor may use symptoms, a medical history and physical tests to rule out a diagnosis of cancer, exam may be all that is needed for diagnosis including a and treatment.  barium enema x ray  sigmoidoscopy or colonoscopy Medical History The doctor may ask a patient to describe his or Colorectal transit study. This test shows how her constipation, including duration of well food moves through the colon. The patient symptoms, frequency of bowel movements, swallows capsules containing small markers that consistency of stools, presence of blood in the are visible on an x ray. The movement of the stool, and toilet habits—how often and where markers through the colon is monitored by one has bowel movements. A record of eating abdominal x rays taken several times 3 to 7 days habits, medication, and level of physical activity after the capsule is swallowed. The patient eats a will also help the doctor determine the cause of high-fiber diet during the course of this test. constipation. Anorectal function tests. These tests diagnose The clinical definition of constipation is constipation caused by abnormal functioning of having any two of the following symptoms for the anus or rectum—also called anorectal at least 12 weeks—not always consecutive— function. in the previous 12 months:  Anorectal manometry evaluates anal  straining during bowel movements sphincter muscle function. For this test,  lumpy or hard stool a catheter or air-filled balloon is inserted  sensation of incomplete evacuation into the anus and slowly pulled back  sensation of anorectal blockage/obstruction through the sphincter muscle to measure sigmoid, colon is called a sigmoidoscopy. An muscle tone and contractions. examination of the rectum and entire colon is  Balloon expulsion tests consist of called a colonoscopy. filling a balloon with varying amounts The person usually has a liquid dinner the of water after it has been rectally night before a colonoscopy or sigmoidoscopy inserted. Then the patient is asked to expel the balloon. The inability to expel and takes an enema early the next morning. a balloon filled with less than 150 mL of An enema an hour before the test may also be water may indicate a decrease in bowel necessary. function. To perform a sigmoidoscopy, the doctor uses a long, flexible tube with a light on the end, called Defecography is an x ray of the anorectal area a sigmoidoscope, to view the rectum and lower that evaluates completeness of stool elimination, colon. The patient is lightly sedated before the identifies anorectal abnormalities, and evaluates exam. First, the doctor examines the rectum with rectal muscle contractions and relaxation. a gloved, lubricated finger. Then, the During the exam, the doctor fills the rectum with sigmoidoscope is inserted through the anus into a soft paste that is the same consistency as stool. the rectum and lower colon. The procedure may The patient sits on a toilet positioned inside an cause abdominal pressure and a mild sensation x-ray machine, then relaxes and squeezes the of wanting to move the bowels. The doctor may anus to expel the paste. The doctor studies the x fill the colon with air to get a better view. The rays for anorectal problems that occurred as the air can cause mild cramping. paste was expelled. Barium enema x ray. This exam involves To perform a colonoscopy, the doctor uses a viewing the rectum, colon, and lower part of flexible tube with a light on the end, called a the to locate problems. This colonoscope, to view the entire colon. This tube part of the digestive tract is known as the is longer than a sigmoidoscope. During the bowel. This test may show intestinal exam, the patient lies on his or her side, and the obstruction and Hirschsprung’s disease, doctor inserts the tube through the anus and which is a lack of nerves within the colon. rectum into the colon. If an abnormality is seen, the doctor can use the colonoscope to remove a The night before the test, bowel cleansing, small piece of tissue for examination (biopsy). also called bowel prep, is necessary to clear The patient may feel gassy and bloated after the the lower digestive tract. The patient drinks procedure. a special liquid to flush out the bowel. A clean bowel is important, because even a small How is constipation treated? amount of stool in the colon can hide details and Although treatment depends on the cause, result in an incomplete exam. severity, and duration of the constipation, in Because the colon does not show up well on x most cases dietary and lifestyle changes will rays, the doctor fills it with barium, a chalky help relieve symptoms and help prevent them liquid that makes the area visible. Once the from recurring. mixture coats the inside of the colon and rectum, x rays are taken that show their shape and Diet condition. The patient may feel some abdominal A diet with enough fiber (20 to 35 grams each cramping when the barium fills the colon but day) helps the body form soft, bulky stool. A usually feels little discomfort after the doctor or dietitian can help plan an appropriate procedure. Stools may be white in color for a diet. High-fiber foods include beans, whole few days after the exam. grains and bran cereals, fresh fruits, and vegetables such as asparagus, brussels sprouts, Sigmoidoscopy or colonoscopy. An cabbage, and carrots. For people prone to examination of the rectum and lower, or constipation, limiting foods that have little or no stimulant laxatives, might increase a fiber, such as ice cream, cheese, meat, and person’s risk for cancer. The Food and processed foods, is also important. Drug Administration has proposed a ban on all over-the-counter products Lifestyle Changes containing phenolphthalein. Most Other changes that may help treat and prevent laxative makers have replaced, or plan constipation include drinking enough water and to replace, phenolphthalein with a safer other liquids, such as fruit and vegetable juices ingredient. and clear soups, so as not to become dehydrated, engaging in daily exercise, and reserving enough  Osmotics cause fluids to flow in a time to have a bowel movement. In addition, the special way through the colon, resulting urge to have a bowel movement should not be in bowel distention. This class of drugs ignored. is useful for people with idiopathic constipation. Brand names include Laxatives Cephulac, Sorbitol, and Miralax. People with diabetes should be monitored for Most people who are mildly constipated do not electrolyte imbalances. need laxatives. However, for those who have made diet and lifestyle changes and are still constipated, a doctor may recommend laxatives  Stool softeners moisten the stool and or enemas for a limited time. These treatments prevent dehydration. These laxatives are often recommended after childbirth or can help retrain a chronically sluggish bowel. surgery. Brand names include Colace For children, short-term treatment with and Surfak. These products are laxatives, along with retraining to establish suggested for people who should avoid regular bowel habits, helps prevent constipation. straining in order to pass a bowel A doctor should determine when a patient movement. The prolonged use of this needs a laxative and which form is best. class of drugs may result in an Laxatives taken by mouth are available in electrolyte imbalance. liquid, tablet, gum powder, and granule forms. They work in various ways:  Lubricants grease the stool, enabling it to move through the intestine more  Bulk-forming laxatives generally are easily. Mineral oil is the most common considered the safest, but they can interfere with absorption of some example. Brand names include Fleet and medicines. These laxatives, also known Zymenol. Lubricants typically stimulate as fiber supplements, are taken with a bowel movement within 8 hours. water. They absorb water in the intestine and make the stool softer. Brand names  Saline laxatives act like a sponge to include Metamucil, Fiberall, Citrucel, draw water into the colon for easier Konsyl, and Serutan. These agents must passage of stool. Brand names include be taken with water or they can cause Milk of Magnesia and Haley’s M-O. obstruction. Many people also report no Saline laxatives are used to treat acute relief after taking bulking agents and constipation if there is no indication of suffer from a worsening in bloating and bowel obstruction. Electrolyte abdominal pain. imbalances have been reported with extended use, especially in small  Stimulants cause rhythmic muscle children and people with renal contractions in the intestines. Brand deficiency. names include Correctol, Dulcolax, Purge, and Senokot. Studies suggest that phenolphthalein, an ingredient in some  Chloride channel activators increase tub baths, ice packs, and application of a intestinal fluid and motility to help stool special cream to the affected area. Treatment pass, thereby reducing the symptoms of for anal fissures may include stretching the constipation. One such agent is Amitiza, sphincter muscle or surgically removing the which has been shown to be safely used tissue or skin in the affected area. for up to 6 to 12 months. Thereafter a doctor should assess the need for Sometimes straining causes a small amount of continued use. intestinal lining to push out from the anal opening. This condition, known as rectal People who are dependent on laxatives need to prolapse, may lead to secretion of mucus from slowly stop using them. A doctor can assist in the anus. Usually eliminating the cause of the this process. For most people, stopping laxatives prolapse, such as straining or coughing, is the restores the colon’s natural ability to contract. only treatment necessary. Severe or chronic prolapse requires surgery to strengthen and tighten the anal sphincter muscle or to repair the Other Treatments prolapsed lining. Treatment for constipation may be directed at a specific cause. For example, the doctor may Constipation may also cause hard stool to pack recommend discontinuing medication or the intestine and rectum so tightly that the performing surgery to correct an anorectal normal pushing action of the colon is not enough problem such as rectal prolapse, a condition in to expel the stool. This condition, called fecal which the lower portion of the colon turns inside impaction, occurs most often in children and out. older adults. An impaction can be softened with mineral oil taken by mouth and by an enema. People with chronic constipation caused by After softening the impaction, the doctor may anorectal dysfunction can use biofeedback to break up and remove part of the hardened stool retrain the muscles that control bowel by inserting one or two fingers into the anus. movements. Biofeedback involves using a sensor to monitor muscle activity, which is Hope Through Research displayed on a computer screen, allowing for an accurate assessment of body functions. A health The Division of Digestive Diseases and care professional uses this information to help Nutrition at the National Institute of Diabetes the patient learn how to retrain these muscles. and Digestive and Kidney Diseases supports basic and clinical research into gastrointestinal Surgical removal of the colon may be an option conditions, including constipation. Researchers for people with severe symptoms caused by are studying the anatomical and physiological colonic inertia. However, the benefits of this characteristics of rectoanal motility and the use surgery must be weighed against possible of new medications and behavioral techniques, complications, which include abdominal pain such as biofeedback, to treat constipation. and diarrhea.

Can constipation be serious?

Sometimes constipation can lead to complications. These complications include hemorrhoids, caused by straining to have a bowel movement, or anal fissures—tears in the skin around the anus—caused when hard stool stretches the sphincter muscle. As a result, rectal bleeding may occur, appearing as bright red streaks on the surface of the stool.

Treatment for hemorrhoids may include warm

Points to Remember For More Information  Constipation affects almost International Foundation for Functional everyone at one time or another. Gastrointestinal Disorders  Many people think they are P.O. Box 170864 Milwaukee, WI 53217 Phone: constipated when, in fact, their 1–888–964–2001 or 414–964–1799 Fax: 414– bowel movements are regular. 964–7176 Email: [email protected] Internet:  The most common causes of www.iffgd.org constipation are poor diet and lack of exercise. American Gastroenterological Association

 Other causes of constipation National Office 4930 Del Ray Avenue Bethesda,

include medications, irritable MD 20814 Phone: 301–654–2055 Fax: 301–

bowel syndrome, abuse of 654–5920 Email: [email protected] Internet:

laxatives, and specific diseases. www.gastro.org

 A medical history and physical

exam may be the only diagnostic

tests needed before the doctor

suggests treatment. Publication courtesy of the National Institute of Diabetes and Digestive and Kidney Diseases  In most cases, following these simple tips will help relieve symptoms and prevent recurrence This publication is not copyrighted. The Clearinghouse encourages users of this of constipation: o Eat a well-balanced, high- publication to duplicate and distribute as many copies as desired. fiber diet that includes beans, bran, whole grains, fresh This publication is available at fruits, and vegetables. www.digestive.niddk.nih.gov. o Drink plenty of liquids. o Exercise regularly. o Set aside time after breakfast or dinner for undisturbed visits to the toilet. o Do not ignore the urge to have a bowel movement. o Understand that normal bowel habits vary. o Whenever a significant or prolonged change in bowel habits occurs, check with a doctor.  Most people with mild constipation do not need laxatives. However, a doctor may recommend laxatives for a limited time for people with chronic constipation.