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Constipation

10-Sep-2014

FACTS:

  • One of the most common digestive disturbances of the digestive tract which can affect people of all ages.
  • Constipation is the decreased frequency, or slowing, of natural peristalsis (intestinal contractions), resulting in harder stools, bowels that do not move regularly, or are not completely emptied when they move. Accumulated feces in the colon can cause attending pain and toxic reactions.
  • The colon is the main reservoir for feces (mainly in the rectum) before defecation. It is where the liquid stool becomes solid, by losing its water, and electrolytes (sodium, etc.). The colon actively secretes bicarbonate and potassium, which explains why severe diarrhea can cause metabolic acidosis as well as hypokalemia (low potassium levels).
  • Chronic constipation leads to a release of backed-up toxins into the bloodstream which then travels to all parts of the body. Unwanted toxins lead to many diseases including appendicitis, rheumatism, arthritis, cataracts, cancer and high blood pressure.
  • Normal bowel movements vary by individual (daily, twice daily, every other day, every third day etc.) Disruptions (change in job or job hours, traveling, moving, etc.) from ones normal routine that cause discomfort is a cause for attention. Medically, constipation is defined as fewer than 3 stools per week. Chronic constipation is less than 1 stool weekly.
  • Constipation could involve straining to empty the bowels, causing discomfort and possibly pain (bigger problem as we age). Straining and chronic constipation can lead to secondary problems like piles or hemorrhoids, fecal impaction (could require hospitalization), anal fissures and fecal incontinence.
  • Over 150 prescription drugs (especially iron-based products, opioids for pain and cancer drugs) can cause or exacerbate constipation.
  • Most cases of constipation is temporary and resolved naturally or with modest intervention (change in diet; increase in daily water consumption; adjustment to break in normal routine; lifestyle changes (stress); natural remedies; home treatments like specific foods; increased fiber or OTC medications).
  • Symptoms, causes, and treatment for chronic constipation in babies & children are different from the treatment given to an adult (why medical consultation is always encouraged especially for infants). In general, treatment best with a change in diet (high- fiber foods), suppositories, natural remedies (4oz.'s/day of prune or apple juice) or home treatments (1 tsp. of dark corn or Karo syrup per 4 oz.'s of formula).
  • Similar to babies & children, pregnant women with constipation should consult their OBGYN for advice & should look to a change in diet, natural remedies, home treatments & suppositories first for relief.

SYMPTOMS:

The most common symptoms are infrequently, irregularity or difficulty in elimination of the hard fecal matter. Other symptoms include a coated tongue, foul breath, loss of appetite, headache, dizziness, dark circles under the eyes, depression, nausea, pimples on the face, ulcer in the mouth, constant fullness in the abdomen (bloated feeling), diarrhea alternating with constipation, varicose veins, pain in the lumbar area, acidity/heartburn and insomnia.

Smaller children are very likely to display a loss of appetite, fatigue, irritability, discontentment, severe abdominal pain & a foul odor from stools or the passing of gas.


NATURAL AND HOME REMEDIES:

  • Increase daily water intake to at least eight (8) glasses of water (8 oz. glasses) & increase physical activity to strengthen the muscles; especially the abdominal muscles (helps prevent constipation).
  • A simple diet consisting of unrefined and high-fiber foods (such as wholegrain cereals, bran, honey, lentils, green & leafy vegetables, fresh & dry fruits, & milk products in the form of butter, clarified butter & cream). Restrict intake of low fiber & high fat foods like red meats, cheese, & other processed or refined foods. Sugar & sugary foods should be strictly avoided. Foods which constipate are all products made of white flour, rice, bread, cakes, pastries, biscuits, cheese, fleshy foods, preserves, white sugar & hard-boiled eggs.
  • Increase daily consumption of fresh fruit juices. Avoid or limit unhealthy artificial drinks & juices or alcoholic & caffeinated beverages, especially sodas high in sugar. In general, all fruits (except banana & jack fruit) are beneficial in the treatment of constipation. Bael fruit (native to India) is regarded as the best of all natural laxatives. Its regular use for two or three months tones up muscle and cleans the colon of old & new accumulated fecal matter. Prunes (plums) have long been an excellent home remedy for constipation (mix with apple or another juice to improve taste). Pears taken exclusively for a few days (a pear diet) helps treat chronic constipation. Guana (when eaten with seeds; one or two a day) provides natural roughage to the diet and helps in the normal evacuation of the bowels. Fresh Grapes (350 gm daily) & Raisins (soak in water for 24-48 hours to increase size; take in morning along with soaked water) help to tone up the stomach & relieve chronic constipation due to their cellulose, sugar & organic acid properties. Oranges (one or two at bedtime & in the morning) stimulates the bowels naturally. Apple pectin (especially for infants) and Apple juice (full glass) helps with constipation and brings fiber to the body. Papaya (large size eaten in morning), Figs (4-5 figs soaked overnight in water and eaten in morning), Dates (not for diabetics) have also shown promise.
  • Chew food properly, avoid hurried meals & irregular meals.
  • Raw spinach juice (100 ml. mixed with equal water taken twice daily) contains the finest organic material for the cleansing, reconstruction and regeneration of the intestinal tract.
  • Half a lime (squeezed in a glass of hot water with 1/2 tsp. of salt) is effective for moderate constipation.
  • Linseed (alse) is extremely useful for difficult cases of constipation (tsp. swallowed with water before each meal) provides both roughage and lubrication.
  • Hot cup of water early in the morning. Add lemon or lime to water and one or more tsp.'s of honey. Sit in a squat position with good posture or sit down and elevate your feet (helps to straighten the rectum). Use hands to motion around the stomach.
  • Yoga comprises a variety of postures and movements which stimulate and encourage the bowel functions.
  • Going to the bathroom at the same time each morning (colonic motor activity highest at this time) adjusts your body to this daily routine and brings excellent results.
  • Don't ignore the “urge to go” since peristalsis of the bowel (movements that trigger a bowel movement) come and go. The urge to defecate increases after mealtime, so watch your body’s signals.

OVER-THE-COUNTER (OTC) MEDICATIONS:

Laxatives purchased OTC is also available to increase the frequency and ease of passing stool (mild/moderate, occasional, at medical request). If constipation becomes severe or does not respond to OTC products, a doctor should be consulted. Dependence on OTC laxatives for passing stools is to be avoided or a condition called lazy bowel syndrome can develop (individual becomes incapable of passing any bowel movements without consuming laxatives.

Most OTC laxatives are safe, effective and well tolerated. There are distinct classes of laxatives, which function differently and have varying degrees of effectiveness and potential side effects:


  • Bulk-forming laxatives are the most commonly recommended initial treatments for constipation (works as quickly as 12 hours or can take up to 3 days to work). Some are derived from natural sources such as agar, psyllium (Metamucil), kelp (alginates), and plant gum (guar gum/Benefiber). Others are synthetic cellulose compounds such as methylcellulose (Citrucel) and carboxymethylcellulose. Natural & synthetic products act similarly. They dissolve or swell in the intestines, lubricate and soften the stool, and make the passage of stool easier and more frequent. Many of these products are available as powders and are mixed with fluids (fruit juices best to mask the gritty taste), tablets or wafers.

    Bulk-forming laxatives are not absorbed from the intestines into the body and are safe for long-term use (excellent for elderly patients). It is important to take full glasses of water (8oz. +) with supplements to avoid the possibility of choking. Also recommended to take with food to reduce stomach problems and to take prescription medications at least 2 hours before or 2 hours after taking bulk-forming laxative (binding of drug into product gel/ lowers absorption). Abdominal bloating, discomfort and flatulence (gas) can be bothersome to some patients.

    Bulk-forming products are excellent for patients with irritable bowel syndrome, diverticulosis & colostomies. Some products are used as dietary fiber supplements (Benefiber). Some products are high in sugar and diabetics should request a sugar-free supplement.
  • Stool softeners (emollient laxatives) prevent hardening of the feces by adding moisture to the stool. The active ingredient in most stool softeners is a medicine called docusate (Colace; Surfax). Docusate doesn't stimulate or increase the number of bowel movements (used to prevent constipation not treat it). Highly recommended to prevent straining while defecating, including those: who are recovering from abdominal, pelvic, or rectal surgery, childbirth or heart attack; who are challenged with high blood pressure or abdominal hernias or who are suffering with painful hemorrhoids and/or anal fissures. Some products (Peri-Colace) combine a stool softener with a stimulant laxative to activate bowel movements.

  • Stool softeners are generally safe and well tolerated. They should not be combined with mineral oil, a lubricant laxative; because stool softeners may increase the absorption and toxicity of mineral oil (could cause inflammation in the lymph glands, liver and spleen).
  • Lubricant laxatives (mineral oil/liquid petrolatum) coats & softens stool similar to stool softeners. Mineral oil should be avoided in individuals taking blood thinners (Warfarin/Coumadin) since it decreases the absorption of clotting factor Vitamin K. Mineral oil should not be taken during pregnancy (decreases vitamin K to developing fetus). Mineral oil should not be given at bedtime to individuals who are prone to aspirate. Mineral oil should only be used for short periods of time.
  • Stimulant laxatives induce bowel movements by increasing the contraction of muscles in the intestines, and are effective when used on a short-term basis. One common stimulant laxative is Bisacodyl (Dulcolax; Correctol) available in pill form (takes 6-10 hours to work), suppository or enema. Bisacodyl is used in cleansing the colon for colonoscopies, barium enemas and intestinal surgeries. While effective for occasional constipation, it should not be taken for more than a week without medical supervision.  Other common stimulant laxatives include senna (Ex-Lax, Senokut), cascara sagrada (Nature's Remedy) and casanthranol. These laxatives are converted by the bacteria in the colon into active compounds which then stimulate the contractions of colon muscles. Bowel movements occur after 8 to 24 hours. Prolonged, chronic use of these laxatives can cause the lining of the colon to darken and could lead to loss of colon function.

    The intensity of stimulant laxatives is dose related (never take more than the recommended dose). A large dose can produce serious adverse effects including severe cramps, excess fluid loss and dehydration, blood electrolyte disturbances such as low levels of blood potassium and malnutrition with chronic use. At special risk, are patients suffering with anorexia nervosa, bulimia nervosa or binge-eating disorders.

    Castor oil is a liquid stimulant laxative that causes accumulation of fluid in the small intestine and promotes evacuation of the bowels. It works rather quickly, within 2 to 6 hours, and it should not be taken with food. Castor oil today is usually used to cleanse the colon for surgery, barium enema or colonoscopy.

  • Saline and osmotic laxatives are mostly magnesium, sulfate, citrate and phosphate ions. These ions draw water into the intestines which increase pressure within the intestines and increases intestinal contractions resulting in softer stools. Fleet Phospho-Soda, milk of magnesia and magnesium citrate are examples of saline laxatives. Saline laxatives should not be used in individuals with impaired kidney function or patients that need to limit their sodium intake.

    Oral doses of saline laxatives should be taken with 1 or 2 glasses of water. Onset of bowel response is usually 1/2 to 3 hours after consuming the laxative. Large doses can produce complete evacuation of the intestine which is very useful in preparing for colonoscopy, sigmoidoscopy and barium enema.

    Active ingredient in osmotic-type laxatives such as GlycoLax and MiraLax is polyethylene glycol (PEG). These work by holding water in the stool to soften the stool and increasing the number of bowel movements. It is also used to cleanse the bowel prior to colonoscopies or colon surgery. Side effects include nausea, abdominal cramping or gas. Caution is advised when using drug in the elderly since they may be more sensitive to side effects, especially diarrhea.

    Rectally administered enemas and suppositories are commonly used to cleanse the rectum and the sigmoid colon prior to surgery, childbirth and flexible sigmoidoscopy. Enemas and suppositories include docusate (Microenema), bisacodyl (Dulcolax Suppository) and sodium phosphate (Fleet Enema). These products are only used occasionally to relieve constipation and are not recommended for chronic use. Evacuation occurs within minutes to an hour.

PRESCRIPTION MEDICATION:

If after a change in diet, natural remedies and OTC products constipation continues, two prescription drugs are used for the treatment of chronic constipation:


  • Amitiza (lubiprostone) is used when there is no known cause for the constipation. It works by softening the stools (increasing its water content), so that the stool can pass easily.
  • Lactulose draws water into the bowel to soften and loosen the stool. Side effects include gas, diarrhea, upset stomach & stomach cramps.