Constipation
W. Ali H. MD Medicine (I), Tanmeet Sethi, MD
Overview: Constipation
Constipation is estimated to affect up to 28% of the population, most commonly older adults, women, and children, and results in more than $6.9 billion in medical costs.
The symptom is usually intermittent and self-limiting, although some patients require intervention to achieve resolution. Table 45-1 demonstrates defining criteria for constipation, but in prac-tical clinical terms, the complaint of constipation and even the diagnosis are often made more subjectively.
Asking what patients mean by the statement "I am constipated" may be the most important first step to management. Most patients complaining of constipation describe a perception of difficulty with bowel movements or a discomfort related to bowel movements.
The most common terms used by young healthy adults to define constipation are straining (52%), hard stools (44%), and the inability to have a bowel movement (34%).
Important points to consider
Routine diagnostic testing is not recommended for patients with no alarm symptoms and no signs of organic disorder.
Increasing fiber intake too quickly can cause abdominal bloating or flatulence. To optimize compliance, increase fiber gradually over at least 2 to 3 weeks to 20 to 25 g/day and ensure increased fluid intake to avoid these symptoms.
An example of a 20-g fiber breakfast: ½ cup bran (10g), three dried figs (10g). Make palatable with 1 cup soy or almond milk (1g fiber), 1 tablespoon brown sugar for taste, and 1 tablespoon of cinnamon (slows absorption of sugar).
Other high-fiber foods: 1 large apple or pear (5g), 5 cup raspberries (9g), 1 cup Raisin Bran (5g), 2 Brazil nuts (2.5g), 23 almonds (3.5g), 1 cup peas (16g), 1 cup black beans (15g), 1 artichoke (10g), 1 cup cooked broccoli (5g).
In pregnant women, fiber supplements in the form of
bran and wheat fiber were found to increase bowel frequency, soften stool, and be better tolerated than were stimulant laxatives.
Evidence supports a 4- to 6-week trial of elimination of dairy products as a component of the integrative treatment of childhood constipation.
One double-blind multi-center study showed psyllium (5.1g twice daily) to be superior to docusate sodium (100mg twice daily) for softening stools by increasing stool water content and to have greater overall laxative efficacy in subjects with chronic idiopathic constipation.
In childhood constipation, explain the physiologic changes that occur as a consequence of chronic constipation, including a diminished ability to recognize the need to stool or that soiling has occurred." Explain that this condition is common and is multifactorial in origin for most children and stress the need to avoid demeaning or embarrassing the child.
Using magnesium citrate, 150-mg capsules, to help with constipation: Start with two capsules at bedtime and two in the morning. If no stool occurs the next morning after 4 days, add one capsule (three) at bedtime. Add one capsule to the evening dose every 4 days until a soft stool is produced each morning. One of the first side effects of magnesium is diarrhea.
This helps prevent toxicity from taking too much magnesium. Stop at eight capsules (total: six at bedtime and two in the morning). Use magnesium-containing laxatives cautiously in patients with congestive heart failure and chronic renal insufficiency because of the potential for electrolyte imbalances.
Prevention Prescription
Eat high amounts of fiber-rich foods, including beans.
vegetables, fruits, whole grain cereals, and bran.
Minimize high-fat, low-fiber foods such as processed foods, dairy products, and meat products. Drink an adequate amount of fluid each day to stay hydrated, and increase the amount of water if using higher doses of fiber.
Engage in regular physical activity to avoid constipation.
Adopt a good self-care and stress management program to avoid the impact of stress on gut function.
Stay tuned to the body's natural signals to pass stool. advantage of the gastrocolic reflex and allow Take elimination to occur after meals. In young children, ensure adequate fiber as they transition to solid foods.
Integrative Therapeutics Review
In this summary of therapeutic options for the treatment of constipation, the interventions are presented in a ladder approach from the least to the most invasive options. Although patients with more moderate to severe constipation may travel up the ladder more quickly, the initial approaches are critical for all patients.
Adults
Removal of exacerbating factors
Review the patient's medication list, and eliminate any medications that may be causing or exacerbating the condition.
Behavioral training
If patients experience difficulty in expulsion of stool, they should be advised to place a support approximately 6 inches in height under their feet when they are sitting on a toilet seat, to flex the hips toward a squatting posture.
Nutrition
Include a gradually increasing amount of fiber in the diet up to 20 to 25 g a day through fruits, vegetables, whole grain breads and unrefined cereals, flax, or bran.
Encourage increased fluid intake, especially with the introduction of increased fiber in the diet.
Movement
Encourage regular physical activity.
Supplements
Consider adding a commercially packaged fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel). Be sure to take it with at least 8 to 12 oz of liquid. Using less fluid can worsen constipation (see Table 45-3).
Consider a probiotic strain of Bifidobacterium or Lactobacillus of at least 10 colony-forming units.
Mind-body therapy
Address stress management skills.
Biofeedback
In cases of pelvic floor dysfunction, this is a critical component of therapy.
Pharmaceuticals
If the foregoing interventions do not resolve symptoms, consider osmotic laxatives with polyethylene glycol (17 to 34g once or twice daily) as first-line therapy.
For severe cases, a prescription chloride channel activator (lubiprostone, 8 to 24 mcg twice daily for adults) may be necessary.
Children
Behavioral training
Encourage daily sitting on the toilet, preferably after meals, and avoid embarrassing or punishing the child. Using a stool under the feet can also be used for children during toilet training.
Removal of exacerbating factors
Consider a 4-to 6-week trial of elimination of dairy products.
Nutrition
Ensure an adequate amount of fiber in the diet. Use the age +5 daily grams of fiber rule as a general guideline for dosing.
Increase fluid intake and, in particular, the amount of sorbitol-containing fruit juices (e.g., apple, pear) for osmotic effect.
Movement
Encourage regular physical activity.
Supplements
Consider adding a commercially packaged fiber supplement if necessary.
Consider a probiotic strain of Bifidobacterium or Lactobacillus of at least 10 colony-forming units.
Pharmaceuticals
If these interventions do not resolve symptoms, consider osmotic laxatives with polyethylene glycol (0.5 to 4 teaspoons a day, depending on age)as first-line medical treatment.
Key Web Sources
http://www.acg.gi.org/Patient
http://www.acg.gi.org/patients/pdfs/CommonGIProblems2.pdf
http://www.mayoclinic.com/health/constipation-in-children/D501138
http://nutritioncaremanual.org/vault/editor/Docs/Constipation Nutrition Therapy FINAL.pdf
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