Constipation

Definition
Constipation refers to the retention or delay of fecal material in the intestinal tract such that fewer
than three bowel movements occur per week.

Constipation is often a symptom of another disease state, such as inflammation of the bowel
(irritable bowel syndrome, or IBS), enlarged toxic colon (Hirschsprung's disease), low thyroid
function (hypothyroidism), diminished inhalation/exhalation capacity of the lungs (chronic obstructive
pulmonary disease, or COPD), stroke, paralysis from spinal cord injury or cauda equina syndrome,
Parkinson's disease, colon cancer, tuberculosis, infection of the colon (diverticulitis), or loss of neural
innervation to the colon (neurogenic disease).

Risk: Constipation occurs most often in women and adults over the age of 65. It is also common in pregnancy and
following childbirth or surgery and individuals who have taken narcotic drugs. Constipation may be complicated by high
consumption of coffee or tea as well as low fiber diets and low caloric intake.

Incidence and Prevalence: Constipation is the most common digestive complaint in the US, with about 3 million
people reporting frequent constipation ("Constipation").

Diagnosis

History: Individuals will report problems having bowel movements or complain of hard, dry stools. Sensations of
fullness or pressure in the rectum and a frequent urge to defecate are also common. After prolonged constipation,
there may be a sense of stomach (epigastric) fullness along with nausea, belching, stomach distention, return of
stomach contents into the mouth (regurgitation), or abdominal discomfort. Long-term, untreated constipation may
produce headache, dizziness (vertigo), general weakness and discomfort (malaise), loss of appetite (anorexia), or a bad
taste in the mouth.

Physical exam: The exam may reveal increased anal canal muscle tone and crack-like lesions on the anus
(anal fissures). The individual may also have a distended abdomen and there could be an accumulation (impaction) of
hardened, dry (inspissated) feces that can be felt in the area of the lower bowel (rectum, or sigmoid/transverse
colon).

Tests: Tests are not ordinarily needed to ascertain that an individual has constipation because the history and
physical exam will provide adequate information. However, in some cases, tests may be performed to identify the
cause of constipation. Thyroid and parathyroid function tests may be performed along with a test for urinary tract
infection. The interior of the colon can be inspected by inserting a flexible optic instrument (endoscope) through the
rectal opening and up into the colon (colonoscopy). The colon can also be visualized on x-ray following a barium
enema. Functional tests may include measurement of transit time through the colon (colorectal transit time) using
radiopaque markers (colonic scintigraphy) or recording abnormal electrical activity of the colon (electromyography).
Anorectal morphology and dynamics can be studied during defecation using a barium paste that reproduces stool
consistency (defecography).

Treatment

Constipation is one of the most common gastrointestinal complaints in the US and most
individuals treat themselves without seeking medical help. Those that do see a doctor are
advised to increase intake of fluids and dietary fiber, and to increase physical activity as much
as possible. Consuming more raw fruits and vegetables, whole grain cereals and breads, or
use of supplements will increase dietary fiber intake. In some cases, individuals may be given
laxatives or gastrointestinal motility drugs. However, dependence on laxatives is a possibility
 and their use should be monitored closely. If there is an underlying cause for the constipation,
such as low thyroid levels or colon cancer, the primary disease is treated appropriately with
medication or surgery (colectomy).
Prognosis

Most individuals can expect a full recovery and a return to normal bowel function. However,
more severe gastrointestinal symptoms may appear if problems with constipation continue. If
surgery is required to remove a cancerous portion of bowel, the individual may require an
artificial opening (stoma) of the colon through the abdominal wall for the purpose of fecal
elimination (colostomy). A colostomy may be temporary or permanent depending upon the
portion of bowel that was surgically removed.
Differential Diagnoses

Colon cancer
Irritable bowel syndrome (IBS)
Low thyroid function (hypothyroidism)
Multiple sclerosis
Progressive systemic sclerosis
Toxic inflamed colon (Hirschsprung's disease)

Rehabilitation

Physical activity should be increased and may involve a supervised ambulatory program, 2 to 3
times per week, 30 to 90 minutes per session (average 45 minutes). Individuals with poor muscle
tone may benefit from exercising the abdominal muscles.

Complications

Complications resulting from constipation include hemorrhoids, anal fissures and anal sphincter
spasm. Very often, chronic constipation is a symptom of an underlying disease state or condition,
and complications may be associated with that condition
Factors Influencing Duration

Length of disability depends on the underlying condition.

Return to Work (Restrictions / Accommodations)

Most individuals will have no work restrictions or accommodations while being treated for
constipation. However, restriction to light or sedentary work for 4 to 6 weeks may be required
when an individual returns to the job after recovery from surgery.
Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may
wish to consider the following questions to better understand the specifics of an individual's
medical case.

Regarding diagnosis:

 Does individual fit the criteria for constipation?

 What is the underlying cause of constipation?
  Does individual have an underlying medical condition that may complicate treatment or impact recovery?

Regarding treatment:

 If there is an underlying cause for the constipation, such as low thyroid levels or colon cancer, was the
primary disease treated appropriately? Is treatment for the underlying disorder effective? Will the individual
require surgery to correct the underlying disorder?
 Is the individual compliant with modification of dietary fiber and fluid intake?
 Does individual exercise routinely?
 If individual is taking laxatives, stool softeners, or medication to improve gastrointestinal muscle function, has
he or she become dependent on these drugs to have a bowel movement? How can individual be effectively
weaned off medication?

Regarding prognosis:

 Has constipation resolved or become less frequent?

 Has individual been compliant with treatment regimen? If not, what can be done to enhance compliance?
 Has underlying condition responded to treatment?
 If constipation was due to bowel cancer, was a colostomy required? Will it be temporary or permanent?
 Have complications occurred as a result of the underlying disease or condition that caused the constipation?
Are complications responding to treatment?