Constipation

What causes constipation

Constipation is the infrequent passage of stool that may be hard, dry, and leads to straining. There may be a feeling of incomplete evacuation and pressure on the rectum. The abdomen may feel bloated and the colon distension can cause abdominal pain. More than 20 % of Americans suffer from constipation at some point. It is more common in women and the elderly.
You should have an easy to pass, moist formed stool at least every two to three days. This will decrease your risk of symptomatic enlarged hemorrhoids. Time on the commode should be less than two minutes. Straining should be avoided.

Causes?

In most cases there is no obvious cause. A low fiber diet without enough fluid will make constipation worse. Increasing fiber, water, and exercise will help. Eating large amounts of dairy products may cause constipation. Slow transit time or colonic inertia is due to the colonic muscles not moving the stool through the colon normally. Pregnancy can make constipation worse and is a good time to increase fiber and water. Irritable bowel syndrome may be associated with constipation and diarrhea. Hemorrhoids can add to the obstruction of stool which may cause a flattening of the stool.

Constipation may be caused by high calcium, low thyroid, diabetes mellitus, low potassium, or renal failure. Neurological conditions such as Parkinson’s disease, spinal cord lesions, stroke, multiple sclerosis, Hirschsprung’s disease, or autonomic neuropathy can lead to constipation as well. The muscle disorders of amyloidosis or scleroderma are associated with constipation. Anxiety, depression, and somatization may exacerbate it as well. Constipation is frequently worse around menstrual periods.

Antacids that contain calcium (Tums) or aluminum (Amphojel or Basaljel), calcium supplements, anticholinergics, antidepressants (Elavil and Tofranil), cholestyramine, catapres, sinemet, narcotic pain medicines (codeine, oxydodone, hydrocodone, hydromorphone), diuretics, NSAID’s, psychotropics, sympathomimetics, anticonvulsants (Dilantin or Tegretol), iron supplements, or calcium channel blockers ( Cardizem or Procardia) may all lead to constipation.

The pelvic floor muscles may fail to relax causing difficulty with passage of the stool. This may be helped by biofeedback.

Colon or rectal cancer can lead to a smaller stool, no stool, or blood in the stool. The acute onset of constipation, weight loss, severe pain, or change in the caliber of the stool demands immediate medical attention.

An acute bowel obstruction may cause abdominal pain, cramps, bloating, nausea, vomiting, distension, decreased stools and also requires immediate medical evaluation.

Complications

Chronic constipation may lead to bloating, abdominal pain, nausea, cramps, rectal pain or pressure, or rectal bleeding. The passage of a large or dry stool can cause a tear or anal fissure.

Evaluation

A rectal exam, sigmoidoscopy, or colonoscopy should be done. For chronic constipation that does not respond to dietary changes the workup may include a physical exam, history, blood work, rectal exam, colonoscopy, barium enema, rectal manometry and transit time or motility studies.

Treatment

$800 million dollars are spent each year on laxatives. The chronic use of stimulants such as mineral oil, cascara sagrada, Ex-lax, Senokot, Correctol, Dulcolax, Feen-a-mint may lead to a dependency and should be avoided.
Avoid the frequent use of stimulant laxatives such as Bisacodyl (Ducolax or Correctol), castor oil, Perdiem (Psyllium and Senna), Senna (Senokot or Ex-Lax), cascara sagrada, mineral oil, or saline osmotic laxatives such as magnesium citrate and sodium phosphate. Renal failure patients cannot use magnesium products. Milk of magnesia usually works within a few hours but should not be used on a regular basis. The abuse of the stimulants can lead to the weakening of the intestinal muscles and a worsening of the constipation.

No one product is perfect and trial and error is required. Usually, it takes 1-2 weeks to see the full benefit of the additive. Foods rich in fiber include whole grains, beans, fruits and vegetables. Many cereal products or snack bars now have good fiber content. Read the product contents and look for cereals with four or more grams of fiber. A trial of fiber and water may be helpful. An occasional prune may be helpful.

Drink up to 6 glasses of water and add 5 grams of fiber per day for the first 5 days. You may add an additional 5 grams of fiber per day every five days or so until you reach 15 grams of fiber per day. Fiber may cause gas or bloating. This may be decreased by adding the increased amounts of fiber over a weeks’ time to allow you intestines to get use to the slower transit time and increased bacterial load that fiber may cause. Fiber helps make a soft bulky stool that stretches the rectum and gives you a signal to go to the bathroom. Smaller stool can lie in the rectum undetected and obstruct blood flow leading to worsening of the hemorrhoids. Increasing fiber in your diet will help lower cholesterol, decrease the risk of heart disease and diverticulosis, and may decrease the risk of colon cancer.

Safe laxatives include stool softeners such as Colace which contains docusate sodium, fiber, or the osmotic laxative Miralax. Stool softeners are wetting agents and may be taken with fiber. Docusate sodium (Colace or Surfak) 100 mg may be taken one to three per evening to help the morning motion. Do not take mineral oil with Colace as it may increase the absorption leading to inflammation of lymph nodes or liver. Miralax may cause less bloating and gas. It pulls water into the intestines. Take 17 grams per day. Adjust dose or frequency downward if stools are too loose.

Flaxseed and Flaxseed oil are helpful but may reduce the absorption of some medications such as Digitalis. They may potentiate the anticoagulation effect of Coumadin or aspirin.

Lactulose may occasionally be prescribed for constipation that does not respond to other measures.

Linzess is now available for chronic constipation that does not respond to any of the other measures.

If the stool is dry you may apply Vaseline, with your finger, inside the rectum to try and aid the passage of the stool and help prevent a fissure. Chronic constipation will exacerbate hemorrhoids and can cause an anal fissure.

Reducing the size of internal hemorrhoids with the banding procedure helps many patients have a more normal bowel movement. If you are having trouble with constipation and hemorrhoids or fissures call our office today-find nearest location.

Very large dry stools may lead to and obstructing ball of stool in the rectum. This may lead to pain, lack of normal stool, and leakage. This impaction requires careful removal with lubricants, enemas, and gentle digital breaking up of the impaction. This may require the help of a medical professional.

Enemas should not be used on a regular basis as they may injure the rectum or disturb the electrolyte balances. Fleet phosphosoda enemas stimulate the muscles of the colon. Mineral oil enemas lubricate and soften hard stools.
Suppositories work by stimulating the rectum. They may occasionally be used for constipation. Dulcolax contains bisacodyl and is a stimulant. Glycerin works by irritating the rectum. Do not use laxatives on a regular basis without having your colon evaluated by a physician. A consultation with an internist or gastroenterologist may be helpful.

If you are having constipation that aggravates your hemorrhoids please seek help from an expert in the non-surgical treatment of hemorrhoids. We hope this has been helpful.

OTC Treatments

*This is not an endorsement of any particular product.

Read the ingredients of herbal treatments carefully as many of them have stimulants. There is no proven benefit to colonics or colon cleansing routines.

At HCA we only use disposable ligation systems. Dr. Goldman introduced disposable banding to the Southeastern United States in 2006. Dr. Alan Goldman is the Medical Director of Hemorrhoid Centers of America. At HCA we have helped thousands of patients avoid surgery and get the relief they deserve. We will start you on our special hemorrhoid compounds as needed for immediate relief and help you get rid of your hemorrhoids with our ligation system.