Constipation

Constipation: Overview

Constipation, either acute or chronic, can be described as difficult, infrequent, or incomplete bowel movements.  The stool tends to be small and/or hard.  Bowel movements should, under normal circumstances, occur at least daily.

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Do not ignore the urge to defecate.  Doing so can reduce the reflex and cause constipation to worsen.  The delayed bowel movement becomes more difficult to pass and the unpleasant experience starts a negative feedback cycle.

Incidence; Causes and Development

Chronic constipation is more common in women.

Acute constipation generally results from a change in diet and/or lifestyle, significant stress, drug side-effects, or some organic cause.

Chronic constipation is usually due to diet, colon health problems, insufficient dietary fiber and roughage, a sedentary lifestyle, ignoring defecation urges, or frequent traveling.  Chronic constipation is also associated with some disease conditions such as hypothyroidism, dehydration and nerve injury.  Psychogenic constipation is described as an obsessive-compulsive fixation on frequency and quality of bowel movements.

Diagnosis and Tests

Check your transit time by consuming charcoal or beets.  It should take from 18 to 24 hours to see evidence in the toilet (black or red).  Longer times may result in bowel toxicity symptoms and increase the burden on your liver.  If constipation does not improve using the above methods then professional help may be needed.

Treatment and Prevention

Saline oral preparations and enemas, Epsom salts, or magnesium citrate preparations can be safely used if necessary for acute constipation.

The use of laxatives should be avoided unless the problem cannot be dealt with otherwise.

General rules for treating constipation
Before using laxatives, try first to remove any underlying cause.  Make sure you are:

  • Getting regular aerobic exercise
  • Having or trying to have your movement at the same time each day
  • Drinking enough water.  Increase water consumption to 8 glasses per day
  • Avoiding refined foods that have had fiber taken out of them (white flour, white rice, peeled vegetables, etc.)
  • Increase fiber (both water-soluble and non-water-soluble types) in the diet with more fruits and vegetables.  If too difficult for now, try supplementing natural fibers such as flax, psyllium, pectin or guar gum.  These possess a mild laxative action due to their ability to attract water and form a gelatinous mass.
  • Consider the possibility of food allergies, especially milk, when you see diarrhea, alternating constipation and diarrhea, anal fissures, or other general allergy signs.  A recent study found that 10 of the 86 patients allergic to milk showed "very delayed reactions" to a cow's milk challenge averaging over 13 days (range 4-26 days).  These "very delayed" reactions included constipation, wheezing, and dermatitis.

Stimulant laxatives act on the large intestine by increasing peristalsis.  The most common stimulant laxatives are derived from either Cascara sagrada or senna.  Both plants have long been used as laxatives and although extremely effective in promoting bowel movements, the use of stimulant laxatives should be avoided.

Dietary fibre is the treatment of choice for constipation.  However the side-effects of a high-fibre diet (including bloating, flatulence and irregular bowel movements) may reduce patient compliance.  Fibre intake is generally lower in the northern countries than in the countries of southern Europe.

Since low fluid intake also plays an important role in constipation, the patient should drink at least 1.5 liters of fluid a day, with increased intake in the summer.

Regular bowel movement and physical exercise are important.  In case of limited mobility, simply maintaining an upright position may be helpful.

Application of Vaseline to the anal region before defecation is a useful measure to reduce the pain and irritation caused by passage of the dry hard feces.

Signs, symptoms & indicators of Constipation:

Symptoms - Abdomen

Symptoms - Bowel Movements

Counter-indicators
Counter-indicators

Conditions that suggest Constipation:

Circulation

Varicose Veins

Constipation is a leading cause of varicose veins.

Digestion

Hemorrhoids

The hemorrhoidal plexuses drain through veins without valves, so factors that increase the pressure inside these veins – such as straining while on the toilet – can lead to hemorrhoids.

Infections

Yeast / Candida Infection

Chronic constipation can lead to Candida overgrowth.

Organ Health

Enlarged Prostate

Chronic constipation has been implicated as a contributing factor to prostatic discomfort when there is an already enlarged gland.  A correction of the constipation will bring some relief of symptoms since the rectum puts pressure on the prostate gland when it is enlarged.  In addition, there is a buildup of waste products in the circulation with chronic constipation.  This will indirectly have an effect on the function of the prostate.

Skin-Hair-Nails

Adult Acne

Bowel toxins from poor digestion or a prolonged transit time may contribute to acne.

Adolescent Acne

Bowel toxins from poor digestion or a prolonged transit time may contribute to acne.

Symptoms - Female

Cysts in breasts

Women who have less than three bowel movements a week increase the risk of cystic breasts by 400%.  Regular bowel movements help the body eliminate toxins more efficiently.

Risk factors for Constipation:

Allergy

Circulation

Diet

Effects of a Low Carbohydrate Diet

Authorities recommend that Americans get "at least 30-35 grams" [Gastroenterology 118 (2000): p.1233] of fiber each day "from foods, not from supplements." [Circulation.  102 (2000): p.2284] The initial phase of Atkins' diet, which dieters may have to repeatedly return to, has about 2gm of fiber per day.  [Atkins, RC.  Dr. Atkins New Diet Revolution.  Avon Books, 1999]

The May 2004 Annals of Internal Medicine study showed once again that most of the Atkins Dieters are constipated and headachy.

Digestion

Environment / Toxicity

Fluoride Toxicity

Chronic constipation is an early sign of fluorosis.

Hormones

Hypothyroidism

Constant constipation is a sign of hypothyroidism.

Mental

Stress

In a study of 34 women with chronic constipation, investigators led by Dr. Anton Emmanuel and colleagues at St.  Mark's Hospital in Middlesex linked emotional distress with changes in the nerve pathway that helps control gut function.  They say the findings suggest a specific path through which psychological factors directly influence the digestive system.

The researchers compared the patients, who had suffered bouts of constipation for an average of 21 years, with a group of women with no history of gastrointestinal illness.  All took standard tests that measure psychological symptoms such as anxiety and depression, self-image, social functioning and ability to form intimate relationships.

Women with chronic constipation were more likely than healthy women to report anxiety, depression and feeling less "feminine".  They also found it harder to form close relationships.  [Gut Aug 2001;49: pp.209-213]

Anxiety

This connection is discussed in the link between constipation and stress.

Metabolic

Musculo-Skeletal

Muscular Dystrophy

Constipation can be a symptom for anyone who is not mobile.

Nervous System

Guillain-Barre Syndrome

Constipation is often a problem, due to the reduced activity of the intestines, change of diet, weakened stomach muscles that resist efforts by the patient to express the intestinal content.

Symptoms - Female

History of cysts in breasts

Women who have less than three bowel movements a week increase the risk of cystic breasts by 400%.  Regular bowel movements help the body eliminate toxins more efficiently.

Tumors, Benign

Fibroids

Mural fibroids (located in the uterine wall) and subserous fibroids (protrude outside the uterine wall) may reach a large size before causing symptoms.  These symptoms may include pressure on the bladder with difficulty voiding or urinary frequency and urgency, pressure on the rectum with constipation, lower back and abdominal pain, as well as heavy or irregular bleeding during periods.

Tumors, Malignant

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Constipation suggests the following may be present:

Autoimmune

Counter-indicators
Counter-indicators

Circulation

Diet

Effects of a Low Carbohydrate Diet

Authorities recommend that Americans get "at least 30-35 grams" [Gastroenterology 118 (2000): p.1233] of fiber each day "from foods, not from supplements." [Circulation.  102 (2000): p.2284] The initial phase of Atkins' diet, which dieters may have to repeatedly return to, has about 2gm of fiber per day.  [Atkins, RC.  Dr. Atkins New Diet Revolution.  Avon Books, 1999]

The May 2004 Annals of Internal Medicine study showed once again that most of the Atkins Dieters are constipated and headachy.

Hormones

Counter-indicators

Tumors, Malignant

Constipation can lead to:

Circulation

Varicose Veins

Constipation is a leading cause of varicose veins.

Digestion

Hemorrhoids

The hemorrhoidal plexuses drain through veins without valves, so factors that increase the pressure inside these veins – such as straining while on the toilet – can lead to hemorrhoids.

Environment / Toxicity

Organ Health

Enlarged Prostate

Chronic constipation has been implicated as a contributing factor to prostatic discomfort when there is an already enlarged gland.  A correction of the constipation will bring some relief of symptoms since the rectum puts pressure on the prostate gland when it is enlarged.  In addition, there is a buildup of waste products in the circulation with chronic constipation.  This will indirectly have an effect on the function of the prostate.

Recommendations for Constipation:

Botanical

Picrorhiza

Picrorhiza is used in India for people with constipation due to insufficient digestive secretions.  [Nadkarni KM, Nadkarni AK.  Indian Materia Medica.  Bombay, Popular Prakashan, 1976, pp.953-5]

Bladderwrack

Bladderwrack has historically been used as a bulk-forming laxative.

Cascara Sagrada

Parke-Davis recognized its use as an herbal laxative, and marketed it as such as early as 1877.  It is still one of the best herbal laxatives available today (along with Cape Aloes and Senna), because it is both quick and mild.

The US FDA in February of 2002 issued a final ruling that aloe and Cascara sagrada will not be included in the final monograph for over-the-counter (OTC) laxative drug products because they have not been shown to be generally safe and effective as stimulant laxatives.  According to the ruling, aloe extract, aloe flower extract, cascara fluid extract aromatic, Cascara sagrada extract, casanthranol, Cascara sagrada bark and Cascara sagrada fluid extract will no longer be allowed in OTC laxative drug products and are not GRAS (Generally Recognized As Safe).

Cascara Sagrada bark is "Approved" by the German Commission E for constipation.

Senna

Senna is used in the treatment of constipation and acts through stimulation of intestinal peristalsis (contractions).  It is important to recognize that constipation is sometimes caused by factors which should be corrected prior to the regular use of a strong cathartic like senna.  Short-term use only is recommended without a doctor's supervision, as cathartics can become habit-forming.

When stimulant laxatives such as senna or Cascara sagrada have been used for a long time, stopping the medication may result in severe constipation.  You may need to "retrain" your bowels in order for them to function naturally by gradually lowering the nightly dose of senna.  This may take longer than a month to accomplish.

Detoxification

Supplemental Fiber

Psyllium is a popular fiber supplement which cleanses the intestines and promotes softer stools.  It is a good source of both soluble and insoluble fiber.

Diet

High/Increased Fiber Diet

A diet with enough fiber (20 to 35gm each day either from food or supplements) helps form a soft, bulky stool.  High-fiber foods include beans, whole grains and bran cereals, fresh fruits, and vegetables such as asparagus, Brussels sprouts, cabbage and carrots.  For people prone to constipation, limiting foods that have little or no fiber such as ice cream, cheese, meat, and processed foods is also important.

Plant-Based Nutrition

A vegetarian diet is generally higher in fiber than non-vegetarian diets.  Constipation amongst those on vegan and raw-food diets is extremely rare.

Increased Water Consumption

Drinking water adds fluid to the colon and bulk to stools, making bowel movements softer and easier to pass.  People who have problems with constipation should drink enough water every day, at least eight 8-ounce glasses depending on weight.  Other liquids such as coffee and soft drinks contain caffeine and seem to have a dehydrating effect.

Soy Isoflavones

Amongst 65 children aged 11 to 72 months with chronic constipation, 68% had a positive response with regard to bowel movements while receiving soy milk.

Dairy Products Avoidance

A double-blind trial found that chronic constipation among infants and problems associated with it were triggered by intolerance to cows' milk in two-thirds of the infants studied.  Symptoms disappeared in most infants when cows' milk was removed from their diet.  [N Engl J Med 1998;339: pp,1100-4]

Dairy products are also devoid of fiber which is important in maintaining normal bowel movements.

Habits

Aerobic Exercise

Lack of exercise can lead to constipation, although doctors do not know precisely why.

Lab Tests/Rule-Outs

Test for Food Allergies

Constipation triggered by food allergies might be responsible for chronic constipation in some adults.  Individual foods, such as milk and milk-containing products, may be at fault in some individuals.

Mineral

Magnesium

When given orally in sufficient quantities, magnesium citrate or sulfate (Epsom salts) is not fully absorbed but attracts water into the colon and thus acts as an effective laxative.

MSM (Methyl Sulfonyl Methane)

Some patients with chronic constipation have experienced continuing relief with a daily supplement of 100-500mg of MSM.  The effect appears particularly strong in those who are older.

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