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Concerned About Constipation?.

This fact sheet from the National Institute on Aging provides basic information about constipation. Readers are reassured that there is no correct number of daily or weekly bowel movements and being “regular” is different for each person. The fact sheet lists recommended questions to help readers determine whether they might have a constipation problem. These questions consider symptoms such as bowel movements fewer than three times per week, difficulty passing stools, lumpy or hard stools, and a feeling of being blocked or of not having fully emptied the bowels. The fact sheet discusses the causes of constipation, including diet; using too many laxatives or enemas; lack of exercise; holding back bowel movements; some medical conditions; some medications; treatment approaches such as adding fiber to the diet, drinking adequate fluids, and getting enough physical activity; and how to know when to consult a health care provider about constipation concerns. Readers are referred to three resource organizations for more information: the National Digestive Diseases Information Clearinghouse (www.niddk.nih.gov or 1–800–891–5389), the National Library of Medicine Medline Plus (www.medlineplus.gov), and the National Institute on Aging Information Center (www.nia.nih.gov or 1–800–222–2225). Readers are encouraged to go online to NIHSeniorHealth (www.nihseniorhealth.gov), a senior-friendly website that has health information for older adults.

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Constipation and Disorders of Pelvic Floor Function. IN: Hauser, S., ed. Mayo Clinic Gastroenterology and Hepatology Board Review. 3rd ed. New York, NY: Informa Healthcare USA. 2008. pp 257-270.

This chapter on constipation and disorders of pelvic floor function is from a comprehensive textbook that provides an in-depth examination of essential knowledge in gastroenterology, hepatology, and the related areas of pathology, endoscopy, nutrition, and radiology. In the section on constipation, the author reviews the salient aspects of colonic motor physiology and pathophysiology, including function, regional differences in colonic motor function, motor patterns, colonic contractile response to a meal, colonic relaxation, colocolonic inhibitory reflexes, and serotonin and the gut. Other topics covered in this section include the assessment of colonic transit, a definition of constipation, and the clinical assessment, classification, and management of constipation The next section reviews disorders of pelvic floor function, including functional defecatory disorders and fecal incontinence; the physiology of defecation; diagnostic tests that may be used to confirm the presence of functional defecatory disorders; anorectal manometry; treatment options for functional defecatory disorders; the definition and etiology of fecal incontinence; patient assessment and diagnostic tests used to confirm fecal incontinence; and treatment strategies. The author stresses the potential impact of functional defecatory disorders on quality of life, noting that much can be accomplished by regulating bowel habits in patients with diarrhea or constipation. Diarrhea should be managed by treatment of the underlying condition. Biofeedback may be useful for fecal incontinence. Scheduled rectal emptying with suppositories of enemas is often useful for fecal impaction and overflow incontinence. 6 figures. 3 tables.

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Constipation in Children. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2008. 4 p.

This fact sheet describes constipation in children. Constipation is a condition in which bowel movements occur less frequently than usual or stools tend to be hard, dry, and difficult or painful to pass. Constipation is common in children and is usually without long-term consequences. However, constipation can diminish a child’s quality of life, cause emotional problems, and create family stress. The fact sheet answers common questions about constipation in children, including its causes, symptoms, how to know when to see a doctor, and treatment strategies. Children often develop constipation as a result of withholding stool. A child with constipation should see a doctor if symptoms last for more than 2 weeks. A child should also see a doctor if constipation is accompanied by symptoms that may indicate a more serious health problem. Constipation is treated by changing diet, taking laxatives, and adopting healthy bowel habits. The fact sheet includes a brief description of current research in this area. Readers are referred to online publications and two resource organizations: the American Academy of Pediatrics at 847–434–4000 or www.aap.org and the International Foundation for Functional Gastrointestinal Disorders at 1–888–964–2001 or www.iffgd.org. The document concludes with a summary of the activities of the National Digestive Diseases Information Clearinghouse (NDDIC), a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). 1 figure.

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Hirschsprung’s Disease. Practical Gastroenterology. 32(6):42-46. June 2008.

This article presents a discussion of Hirschsprung’s disease, an unusual but well recognized cause of chronic constipation in young children. Hirschsprung’s disease is characterized by an absence of ganglion cells in the distal bowel beginning at the internal sphincter and extending proximally for varying distances. The disease is diagnosed by rectal biopsy. The article reviews epidemiology, genetics, etiopathology, symptoms, signs, differential diagnosis, imaging, and treatment, including preoperative management and surgical techniques. The authors stress that early recognition of Hirschsprung’s disease before the onset of complications is essential in reducing morbidity and mortality. Multiple genetic abnormalities are associated with the disorder, Down’s syndrome being the most common. Hirschsprung’s disease is classified as ultra-short-segment Hirschsprung’s disease, which involves only a few centimeters proximal to the dentate line; short-segment disease, the most common type, which is absence of ganglion cells in the rectosigmoid area; and long-segment disease that can involve the entire colon. The authors conclude with a discussion of the recommended surgical techniques to be used in patients with differing types and levels of Hirschsprung’s disease and its complications. 2 figures. 8 references.

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Medication Induced Constipation And Diarrhea. Practical Gastroenterology. 32(5): 12-28. May 2008.

This article reviews the problems of constipation and diarrhea that occur as a side effect of medication use. The authors note that medication-induced constipation and diarrhea are frequent side effects that contribute to the costs of health care for evaluation and management and also contribute to patient morbidity. The diagnosis is often delayed due to poor association of symptom onset with the use of a medication. The authors define constipation; discuss its epidemiology, economic impact, and risk factors; consider diagnostic and treatment issues; and discuss the treatment of constipation in the setting of chronic opioid use. The next section covers the definition and mechanisms of medication-induced diarrhea, antibiotic-associated diarrhea, diarrhea associated with protease inhibitors, and chemotherapy-induced diarrhea. The authors conclude by encouraging health care providers to have a high index of suspicion when patients present with constipation or diarrhea and to obtain a detailed medication history of all medications taken in the past 2 months; this approach can avoid multiple diagnostic tests. High-risk patient populations for medication-induced diarrhea or constipation include the elderly, nursing home or long-term care residents, patients with chronic pain, those with prolonged hospitalization, and those being treated with broad spectrum antibiotics. 3 figures. 2 tables. 35 references.

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Pain Relief, Opioids, and Constipation. Harvard Health Letter. 33(5): 1-3. March 2008.

This article reviews the problem of complications associated with pain relief, notably opioids. The author explains why providing pain relief is important, including the interplay between pain and depression, the incidence of conditions that can prolong or amplify pain in older people, and the role of pain as a warning sign of potentially serious problems. The article reviews the different types of analgesics available, from acetaminophen (Tylenol), ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin to opioids, which are sometimes called narcotics. Besides morphine, some of the opioids currently in use are codeine; hydrocodone, which is available only combined with acetaminophen (Lortab, Vicodin); hydromorphone (Dilaudid); fentanyl (Duragesic); meperidine (Demerol); oxycodone, which is available alone or combined with aspirin (Percodan) or with acetaminophen (Percocet); and methadone. The article focuses on the problem of constipation, which commonly occurs with opioid use. The author stresses that taking a preventive approach to this problem is especially important for older people because they are more likely to be immobile and dehydrated, both of which can contribute to constipation. Preventive strategies, in addition to drinking plenty of water, can include use of stool softeners and laxatives in conjunction with the opioids. A final section briefly considers some newer drugs that may be used to block the opioids in the bowel and thus prevent constipation. However, these newer drugs have their own side effects that limit use. 1 figure.

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Pediatric Anorectal Disorders. Gastroenterology Clinics of North America. 37(3): 709-730. September 2008.

This article about pediatric anorectal disorders is from a special issue of Gastroenterology Clinics of North America that presents updates on disorders of the pelvic floor and anorectum. The authors report on the clinical, physiopathologic, diagnostic, and therapeutic aspects of the most common anorectal disorders in children, including constipation and fecal incontinence. They focus on the differential diagnosis between organic and functional constipation. Other clinical conditions are discussed, such as atopy, neurologic diseases, and anorectal malformations, in which chronic constipation may be an important clinical manifestation. Anorectal disorders are common in children and are usually mild and short-lived if the child receives prompt and adequate attention during the early phase of the disorder. Altered stool frequency and altered behavior with defecation are common presenting symptoms in children who have anorectal disorders. These alterations may be affected by several factors such as diet, social habit, convenience, parents’ cultural beliefs, interrelationships with the family, and daily timing of activities. In addition, the authors encourage clinicians to consider the age and degree of psychosocial development of the child for both diagnostic and treatment approaches. 3 figures. 2 tables. 92 references.

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Rectal Prolapse, Rectal Intussusception, Rectocele, Solitary Rectal Ulcer Syndrome, and Enterocele. Gastroenterology Clinics of North America. 37(3): 645-668. September 2008.

This article about rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele is from a special issue of Gastroenterology Clinics of North America that presents updates on disorders of the pelvic floor and anorectum. The authors note that these common pelvic floor disorders share many clinical features and have a common pathogenesis. Chronic constipation is often the underlying problem that leads to these abnormalities. Rectal prolapse is best diagnosed by physical examination and by having the patient strain as if to defecate; a laparoscopic rectopexy is the preferred treatment approach. Intussusception is more an epiphenomena than a defecatory disorder and should be managed conservatively. Solitary rectal ulcer syndrome is a consequence of chronic straining. Therapy for these patients should be aimed at restoring a normal bowel habit with behavioral approaches, including biofeedback therapy. Rectocele correction may be considered if it can be definitively established that it is a cause of defecation disorder and only after conservative measures have failed. An enterocele should only be operated when pain and heaviness are the predominant symptoms and it is refractory to conservative therapy. The authors conclude that, because these problems are interrelated, an integrated, multidisciplinary approach is required for their management. The chapter is illustrated with black-and-white photographs and drawings. 8 figures. 117 references.

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Surgical Treatment of Patients with Constipation and Fecal Incontinence. Gastroenterology Clinics of North America. 37(3): 605-626. September 2008.

This article about the surgical treatment of patients with constipation and fecal incontinence is from a special issue of Gastroenterology Clinics of North America that presents updates on disorders of the pelvic floor and anorectum. The authors note that patients with constipation and fecal incontinence usually come to the attention of the surgeon when conservative measures have failed to alleviate sufficiently severe symptoms. Following detailed clinical and physiologic assessment, particularly with the use of anorectal manometry, the surgeon should tailor the procedure to specific underlying physiologic abnormalities to restore function. This article describes the rationale, indications, patient selection issues, and results. Surgical procedures discussed include colectomy, anterograde colonic enema, fecal diversion, sacral nerve stimulation, sphincter repair, vertical reduction rectoplasty, and stapled transanal rectal resection (STARR). Another section reviews current controversies regarding surgical procedures for constipation and fecal incontinence, dividing these into those regarded as historical, contemporary, or evolving. The authors conclude that reported surgical outcome data must be interpreted with caution because, for most studies, the evidence is of low quality, making comparison of different procedures problematic and emphasizing the need for better designed and conducted clinical trials. 2 figures. 2 tables. 108 references.

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What I Need to Know About Constipation. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2008. 18 p.

This brochure provides basic information about constipation, defined as three bowel movements or fewer in a week. In addition, the stool is hard, dry, and painful or difficult to pass. Some people with constipation lack energy and feel full or bloated. Written in nontechnical language, with a pronunciation guide, the brochure answers common questions about constipation, including the causes, diagnostic tests, and practical treatment strategies. The brochure outlines simple steps to help prevent constipation, including: eat a variety of foods, especially vegetables, fruits, and grains; drink plenty of liquids; exercise regularly; and do not delay visiting the restroom whenever feeling the urge to have a bowel movement. Fiber pills and powders may help relieve constipation. Most people with mild constipation do not need laxatives. However, a health care provider may recommend a laxative for a limited time if the constipation does not improve with lifestyle and dietary changes. The brochure cautions that some medications can cause constipation. One chart lists some common high-fiber foods. Readers are referred to two resource organizations for more information: the American Gastroenterological Association (www.gastro.org or 301–654–2055); and the International Foundation for Functional Gastrointestinal Disorders (www.iffgd.org or 1–888–964–2001). The inside back cover briefly describes the work of the National Digestive Diseases Information Clearinghouse, which provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. 5 figures. 1 table.

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