History: An individual's medical history is very important in determining the diagnosis of constipation. A medical history from a patient with constipation will find out about a patient's dietary habits, physical activity level, medications, and existing diseases that can contribute to constipation. The doctor may ask a patient to describe his or her constipation, including duration of symptoms, frequency of bowel movements, consistency of stools, presence of blood in the stool (which may also indicate colon cancer), and toilet habits (how often and where one has bowel movements).
Physical examination: A physical examination may identify diseases that can cause constipation such as scleroderma (excessive deposits of connective tissue in organs), intestinal pseudo-obstruction (decreased ability of the intestines to move stool), Hirschsprung's disease (enlargement of the colon that stops the flow of stool), irritable bowel syndrome (IBS), diverticulitis (formation of pouches in the colon), and Chagas disease (tropical disease caused by a parasite). A rectal examination with the finger may uncover a tight anal sphincter that may be making defecation difficult. If a stool-filled colon can be felt through the abdominal wall, it suggests that constipation is severe. Stool in the rectum suggests a problem with the anal, rectal, or pelvic floor muscles.
Blood tests: Blood tests may be used to evaluate underlying conditions in constipation. Blood tests include thyroid hormone (to detect hypothyroidism), blood glucose levels (to determine if diabetes is present) and calcium (to uncover excess parathyroid hormone). Other blood tests can include serum cortisol levels (the stress hormone), that may indicate Addison's disease (a disease of the adrenal gland), myeloma (cancer of the bone marrow), and porphyria (blood disorder dealing with iron content).
Abdominal x-ray: Large amounts of stool in the colon usually can be seen on simple x-ray films of the abdomen. The more stool that is found, the more severe the constipation.
Barium enema: A barium enema, also called a lower GI or gastrointestinal series, is an x-ray study in which liquid barium is inserted into the rectum and colon through the anus. The barium outlines the colon on the x-rays and defines the normal or abnormal anatomy of the colon and rectum. Barium enema can detect tumors and narrowings (strictures) in the colon.
Sigmoidoscopy or colonoscopy: An examination of the rectum and lower (sigmoid) colon is called a sigmoidoscopy. An examination of the rectum and entire colon is called a colonoscopy. The individual will have a liquid dinner the night before a colonoscopy or sigmoidoscopy. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soft drinks. Whole bowel irrigation with large quantities of fluid (usually 1 gallon) is performed using a solution of polyethylene glycol and electrolytes (GoLYTELY®). Then an enema (Fleet's Enema®) is used early the next morning to ensure all contents are out of the colon. An enema an hour before the test may also be necessary. During a sigmoidoscopy, a long, flexible tube with a light on the end (called a sigmoidoscope) is used to view the rectum and lower colon. The patient may be lightly sedated before the exam (usually Versed® or midazolam) and can even watch the procedure on a screen. The procedure may cause abdominal pressure and a mild sensation of wanting to have a bowel movement. Air injected into the colon can cause cramping and gas.
During a colonoscopy, a flexible tube with a light on the end (called a colonoscope) is used to view the entire colon. This tube is longer than a sigmoidoscope. The patient lies on his or her side sedated, and a tube is inserted through the anus and rectum into the colon. If an abnormality is seen, the doctor can use the colonoscope to remove a small piece of tissue for examination (biopsy). Gas and bloating are common side effects with a colonoscopy.
Colorectal transit study: This test shows how well food moves through the colon. The patient swallows capsules containing small plastic markers that are visible on an x-ray. The movement of the markers through the colon is monitored by abdominal x-rays taken several times 3 to 7 days after the capsule is swallowed. The patient eats a high-fiber diet during the course of this test.
Defecography: Defecography is a modification of the barium enema examination. A thick, pasty preparation of barium is inserted into the rectum of the patient through the anus. X-rays then are taken while the patient expels the barium. The barium clearly outlines the rectum and anus, demonstrating the changes taking place in the muscles of the pelvic floor (connective tissue directly under the pelvis) during defecation.
Anorectal manometry: In this procedure, a narrow, flexible tube is inserted into the anus and rectum. A small balloon is then inflated at the tip of the tube, allowing a measure of the coordination of the muscles in the bowel.
Colonic motility studies: Colonic motility studies are similar to anorectal motility studies in many aspects. A very long, narrow, flexible tube is inserted through the anus and passed through part or the entire colon during a procedure called colonoscopy. Sensors within the tube measure the pressures that are generated by the contractions of the colonic muscles. These contractions are the result of coordinated activity of the colonic nerves and muscles. If the activity of the nerves or muscles is abnormal, the pattern of colonic pressures will be abnormal.
signs and symptoms
Signs and symptoms of constipation include difficult bowel movement, dry bowel movement, painful bowel movement, dry feces, small feces, hard feces, absent bowel movement, infrequent bowel movements, fecal straining, abdominal pain and bloating, nausea, vomiting, weight loss, uncomfortable feeling, fatigue, and diarrhea.
risk factors and causes
Medications: Many medications commonly cause constipation. Some of the most common ones include anticonvulsants such as and carbamazepine (Tegretol®), phenytoin (Dilantin®), and valproic acid (Depakote®), aluminum-containing antacids such as Alternagel®, Amphojel®, Basaljel®, Gaviscon®, Maalox®, and Mylanta®, Riopan®, and Tums®, certain antidepressants (called TCA or tricyclics) such as amitriptyline (Elavil®), doxepin (Sinequan®), and imipramine (Tofranil®), antihistamines such as diphenhydramine (Benadryl® and cetirizine, Zyrtec®), calcium channel blocking drugs such as amlodipine (Norvasc®) and diltiazem (Cardizem®), diuretics such as hydrochlorothiazide and furosemide (Lasix®), iron supplements, and narcotic pain medications such as hydrocodone (Vicodin®, Lortab®), hydromorphone (Dilaudid®), meperidine (Demerol®), morphine (MS Contin®), and oxycodone (Percocet®, Oxycontin®).
Bowel Habits: Bowel movements are under voluntary control, meaning that the normal urge people feel when they need to have a bowel movement can be suppressed. Although occasionally it is appropriate to suppress an urge to defecate, such as during a meeting or in a car, doing this too frequently can lead to a disappearance of urges and result in constipation.
Diet: Lack of fiber in the diet may cause constipation. Fiber is important in maintaining a soft, bulky stool. Americans eat an average of 5 to 14 grams of fiber daily, which is short of the 20 to 35 grams recommended by the American Dietetic Association. Both children and adults often eat too many refined and processed foods from which the natural fiber has been removed. The best natural sources of fiber are fruits (apples, plums), vegetables such as green leafy vegetables and cruciferous vegetables (broccoli, cabbage), and whole grains. A diet high in fat including foods such as cheese, eggs, and meats may contribute to constipation, due to the difficulty in digesting these foods.
Dehydration: Dehydration (or lack of water) can also cause constipation. Liquids add fluid to the colon and bulk to stools, making bowel movements softer and easier to pass. However, liquids that contain caffeine, such as coffee and cola drinks, may worsen symptoms (caffeine tends to dehydrate the body). Alcohol is another beverage that causes dehydration. It is important to drink fluids that hydrate the body, the main one being water.
Lack of exercise: A lack of physical activity can lead to constipation. Exercise may increase the muscular contractions of the intestine, thus helping bowel movements. Exercise is also important for relieving stress, which contributes to constipation. Lack of physical activity is thought to be one of the reasons constipation is common in older people.
Laxatives: One suspected cause of severe constipation is the over-use of stimulant laxatives such as aloe, castor oil, rhubarb, and senna. An association has been reported between the chronic use of stimulant laxatives and damage to the nerves and muscles of the colon, resulting in constipation. The body may actually become physically dependent upon the laxative in order to have a bowel movement. Potassium (a mineral that is crucial for heart and muscle function) imbalances, from long-term use of laxatives (especially at high dosages) has been blamed for deaths of apparently otherwise healthy women. Stimulant laxatives are the most likely laxative to cause side effects. These can include abdominal discomfort, stomach cramps, diarrhea, upset stomach, vomiting, and yellow-brown urine.
Hormonal disorders: Hormonal changes can affect bowel movements. For example, menopause causes estrogen levels to decline, resulting in constipation in many individuals. High levels of female hormones during a woman's menstrual periods and pregnancy may also cause constipation. Thyroid hormone imbalances such as hypothyroidism (too little thyroid hormone) and hyperparathyroidism (too much parathyroid hormone, which raises calcium levels) can cause constipation.
Diseases of the colon: There are many diseases that can affect the function of the muscles and/or nerves of the colon. These include diabetes, scleroderma (excessive deposits of connective tissue in organs), intestinal pseudo-obstruction (decreased ability of the intestines to move stool), Hirschsprung's disease (enlargement of the colon that stops the flow of stool), irritable bowel syndrome (IBS), diverticulitis (formation of pouches in the colon), and Chagas disease (tropical disease caused by a parasite). Cancer with tumors that block the colon can also cause constipation.
Central nervous system diseases: A few diseases of the brain and spinal cord may cause constipation, including Parkinson's disease, multiple sclerosis (loss of muscle control and coordination), and spinal cord injuries.
Colonic inertia: Colonic inertia is a condition in which the nerves and/or muscles of the colon do not work normally resulting in a decrease in the evacuation of stool from the body. The cause of colonic inertia is unclear. Colonic inertia can be the result of the chronic use of stimulant laxatives, or diseased muscles and nerves in the colon.
Pelvic floor dysfunction: Pelvic floor dysfunction (also known as outlet obstruction or outlet delay) refers to a condition in which the muscles of the lower pelvis that surround the rectum (the pelvic floor muscles) do not work normally. These muscles are critical for normal bowel movements. The causes of why these muscles fail to work properly in some people are not known.
Psychosomatic: Psychosomatic problems, such as anxiety and stress, may cause constipation.
Others: Some individuals will experience constipation during colds and the flu, possibly due to dehydration and lack of proper diet. Lead poisoning may also cause constipation.
Constipation is not usually serious and will self-resolve, although it can be very uncomfortable. Constipation can lead to abdominal pain, rectal discomfort, abdominal fullness and bloating, nausea, fatigue (tiredness), and loss of appetite. Persistent straining can cause hemorrhoids or fissures (tears in the anus). As a result, rectal bleeding may occur, appearing as bright red streaks on the surface of the stool.
Severe constipation (chronic) can cause fecal impaction, or a mass of hard stool unable to be eliminated by normal bowel movement. An impaction can cause serious consequences if left untreated, such as ulceration and death of anal tissue.
The over use of laxatives use can cause the bowels to become dependent upon the laxatives (lazy bowel syndrome). Poor absorption of vitamins and minerals may also occur with laxative use.
Constipation has been linked with colon cancer, stroke, headaches, heart attacks, and varicose veins.