Constipation and catharsis W. Grant Thompson,* md Constipation is endemic in the Western Of the beliefs handed down to us by In the spastic type of irritable colon world. Stool consistence and associated our forefathers, the concept of regu- syndrome the stool is hard, scybalous symptoms are more important than larity is among the most enduring. and often associated with lower abdom¬ stool frequency. The patient's attitude Since antiquity an empty colon has inal pain.4 These symptoms relate to towards his bowel habit is also been equated with purity; and what excessive segmental contraction of the important. Exclusion of "organic" generations of mothers have cherished, lower colon and rectum, and the in¬ disease, reassurance and discussion let no man put asunder. Nevertheless, dividual subsequently has a feeling of of normal variations of bowel habit are there is a logical approach to "con- incomplete evacuation. Constipation necessary first steps in treatment. stipated" patients, and physicians may alternate with periods of diarrhea. Adequate bulk in the stool must be should be firm in their convictions, Hemorrhoids and fissures may com- ensured, either through diet or which, in turn, should be based on plicate the passage of stony stools. Less bulking agents, and bowel retraining science, not fantasy. commonly, obstipation may result from attempted. Laxatives should be The definition of constipation is elu- an atonic, lax colon, in which pro¬ reserved for episodes of constipation sive. The world's record for rectal con¬ gressive peristaltic activity is decreased, following enforced bedrest, or as a tinence is held by a man who resisted a condition characterized by Sir Arthur preparation for diagnostic procedures. the temptations of the toilet for 368 Hurst as dyschezia.5 This may occur Long-term use should be avoided. days.1 He is said to have become weak spontaneously but is also seen follow¬ after delivering 36 / of feces on June ing chronic abuse of laxatives. La constipation est endemique dans le 21, 1901, but "there was much rejoic- Constipation may result from a wide monde occidental. La consistance des ing in the family". Statistically the variety of local and systemic condi¬ selles et les symptdmes associes "normal population" has from three tions. Perianal disorders such as fis¬ sont plus importants que la frequence bowel movements per week to three a sures or localized proctitis may lead to de la defecation. L'attitude du day.2 The 1% of individuals who fail conscious or subconscious defence of patient a I'egard de ses habitudes outside that range are unusual but not the area by the withholding of stool. de defecation est aussi importante. necessarily abnormal. It is probable that Cancer of the colon, diverticular dis¬ Apres avoir elimine la possibilite the actual frequency of motions is not ease and volvulus are causes of a re¬ d'une cause organique, les relevant, although it may be of great cent change in bowel habit and must premieres etapes necessaires au concern to the patient. More important be rigorously excluded. In hypothyroid- traitement consistent a rassurer le are the consistence of the stool and ism or dehydration, appropriate re¬ patient et a discuter avec lui des associated symptoms. placement therapy may be curative. variations normales des habitudes de Many drugs, including codeine, some defecation. On doit assurer un volume Pathophysiologic considerations antihypertensive agents, iron, aluminum de selles adequat, par le regime and calcium compounds, are constipat- alimentaire ou a I'aide d'agents There are two modes of colonic ing. Inactivity, such as that following mucilagineux, et une reeducation des motor activity.3 The first is propulsive surgery, or travel, especially with habitudes de defecation doit etre contractions or mass movements, long change in time zones, may induce this tentee. Les laxatifs doivent etre recognized by radiologists. These peri¬ distressing nuisance, and it is a frequent reserves aux episodes de constipation staltic rushes are more frequent in diar¬ consequence of pregnancy and of old tels ceux qui suivent les periodes rhea than in constipation. The other age. Endogenous depression often pro¬ d'alitement forcees, ou a la preparation mode is segmental or nonpropulsive ac¬ duces constipation, which may im¬ pour les tests de diagnostic. Leur tivity, which appears to have a mixing prove with antidepressant therapy. utilisation en traitement prolonge and braking function. Such activity Parents reward their children for a doit etre evitee. tends to be decreased in diarrhea and successful bowel action and imbue in increased in some patients with con¬ many the idea that daily movements that succeeds in are essential for cleanliness or ?Associate professor of medicine, University stipation. Segmentation purity. of Ottawa; gastroenterologist, Ottawa Civic isolating part of the colon from the Psychoanalysts have attributed repres- Hospital remainder may generate very high pres¬ sion of defecation to anal eroticism. If Reprint requests to: Dr. W.G. Thompson, sures and result in dilatation the patient is an unmarried it is lst link, Ottawa Civic Hospital, Ottawa, ON proximal girl KIY 4E9 or diverticula formation. said that marriage may effect a cure.® CMA JOURNAL/MAY 22, 1976/VOL. 114 927 I know of no controlled trials to sub- can now be taken between the Weser lulose, hemicellulose and lignin.16 In stantiate this. and the Garonne; that the bustling pestle addition to its hydrophilic bulking prop¬ is still, the canorous mortar mute, and erties fibre may have a cathartic effect Constipation, like the irritable colon, the bowels of men locked for fourteen diverticular disease and is up due to the volatile fatty acids released appendicitis, .... degrees of latitude Without castor oil bacterial metabolism. Since there a disease of Western civilization, ap¬ for some to be by is they might months, sure, much evidence that parently attributable to our low-fibre, have carried on a lingering war; but what deficiency of fibre or bulk an refined diet.7 It has been demonstrated can they do without bark [cascara]?14 is important factor in con¬ that the daily stool weight in English stipation, it seems reasonable to in¬ crease the intake of subjects is one third that of Africans Investigation fibre by constipated living under native conditions on an patients.17 As Cleave7 forcefully states, unrefined diet.8 The transit time of the Organic disease must be excluded. this means less refined sugar and flour, bulky African stool is less than half This demands careful history-taking and more natural fruits and whole- that of the British. It would appear that and physical examination and, at least, wheat products. Bran has long been our colons have not had time to adapt sigmoidoscopy.15 Most patients should recognized as an effective laxative to the low-bulk stool that has have a barium enema examination and and this has had scientific confirma- fibre-free, 9,10,18,19 resulted from the refined diet adopted an estimation of hemoglobin concen¬ tjon MiUer's bran> 6 tQ 1Q tea. over the past century. Thus, partially tration. Recent onset of constipation spoonfuls (12 to 20 g) per day, is a filled colons can generate very high seg¬ demands rigorous exclusion of local cheap and effective laxative.9'10'16,18 mental pressures, accounting for the and systemic disease, particularly car¬ Coarse bran has been shown to have pain and constipation of the spastic cinoma of the colon, hypothyroidism a greater water-holding capacity than colon. Peristaltic activity is disordered and depression. The patient's drug his¬ bran made finer by milling;11 this ac¬ and the patient may have an increased tory should be carefully reviewed to counts for the greater effectiveness of transit time. In individuals who are ensure that there is not a pharmaco¬ the former in improving transit time. given 20 g of unprocessed bran daily, logic cause for his symptoms. The resourceful patient may improve the stool bulk is significantly increased palatability of this material by adding by water entrapped in the interstices of Treatment it to cereals, sauces, meat loaves and the dietary residue.9 Such treatment other foods. Liberal use of whole-wheat speeds up transit in those in whom it General measures bread, breakfast cereals and fresh fruits was slow slows tran¬ and vegetables may assist in and, paradoxically, It is believed that exercise providing sit in those in whom it was rapid. In by many extra bulk. other increased bulk promotes a normal bowel habit. Con- Since bran in words, dietary enforced confinement to therapeutic quantities normalizes colon Coarse versely, bed, is inconvenient, many now motility.9,10 such as after a occlusion or a physicians bran is more effective than fine because coronary prescribe bulking agents. The most sa¬ of the former's greater water-holding fractured hip, is frequently associated tisfactory of these is psyllium hydro¬ capacity.11 with constipation, especially if the pa¬ philic mucilloid (Metamucil, tient must grapple with pulleys and Hydrocil). The individual with constipation may This is useful for preventing constipa¬ bedpans. Adequate fluid must also be tion and other manifestations of the complain of foul breath, furred tongue, ensured. The anorexia, flatulence, headache, irritabil- chronically constipated irritable colon syndrome, as an adjunct colon may be retrained. This is best to the of ity, insomnia, and so on. These were therapy perianal disease, and achieved by using natural reflexes to in the prevention, not the of once considered manifestations of auto- advantage. It is recognized that the treatment, intoxication.12 of this con¬ acute diverticulitis. It is superior to Proponents resting colon may be spurred into ac¬ cept held that poisons were elaborated methylcellulose for this purpose.20 The tion by a meal, particularly breakfast. of use in the gut as a result of constipation.