Constipation

Medical Conditions

Author, Frank W. Jackson MD
Updated 2014

Introduction

Constipation can be defined as infrequent or hard pellet stools, or difficulty in evacuating stool. Passing one or more soft, bulky stools every day is a desirable goal. While troublesome, constipation is not usually a serious disorder. However, there may be other underlying problems causing constipation and, therefore, testing is often recommended.

What Causes Chronic Constipation?

The stomach churns and mixes food so it can be digested. The near-liquid food then enters the small intestine which extracts calories, minerals and vitamins. The small intestine ends in the right-lower abdomen where it enters the colon. The colon, or large bowel, is 5 to 6 feet long. Its function is to withdraw water from the liquid stool, so that by the time it reaches the rectum, there is a soft formed stool. If an excessive amount of water is extracted, the stool can become hard and difficult to expel.

A major cause of chronic constipation is a lazy colon that does not contract properly and fails to move the stool to the rectum. The colon also can become spastic and remain contracted for a prolonged time. In this case, stool cannot move along. Too much water is absorbed and hard pellet-like stool develops. Constipation also can result from a mechanical obstruction, such as tumors or advanced Diverticulosis, a disorder which can distort and narrow the lower left colon. Other conditions that can produce a sluggish, poorly contracting bowel include Irritable Bowel Syndrome, pregnancy, certain drugs such as antidepressants, blood pressure medicines and narcotic painkillers, thyroid hormone deficiency, chronic abuse of laxatives, travel, and stress.

More Causes of Chronic Constipation

Although many people can make simple dietary or lifestyle changes and improve chronic constipation, some conditions that may not seem related to lower bowel health can negatively affect regularity. Hypothyroidism, for example, causes constipation – even though the thyroid is located in the neck. Some people suffering from constipation report that certain foods such as bananas, dairy products and chocolate cause it, as does adding an iron or calcium supplement to your diet. Depression, which slows down all of the body’s functions, can result in constipation. And if you’re accustomed to taking an antacid after dinner and you also suffer from regularity problems, your calcium-rich, post-meal antidote may be causing your issues.

If none of these causes sound familiar, it’s time to add more fiber to your diet slowly and schedule an appointment for a lower gastrointestinal checkup. Read the labels on the boxed, bagged, and canned foods you purchase, and record their fiber contents; you can also read our fiber content of foods chart. Fiber-rich cereals, fruits such as apples and strawberries, and dark leafy vegetables are all important elements of a high fiber diet. You can also try a prebiotic supplement, such as Prebiotin.

Diagnosis

The patient’s medical history is most important in diagnosing the cause of constipation. The physician will perform a physical exam and obtain certain blood tests. A barium x-ray exam of the lower bowel or colon may be warranted. In addition, a sigmoidoscopy exam (using a lighted, flexible endoscope) is necessary to rule out a mechanical blockage of the lower bowel, such as a tumor. This exam allows the physician to view the bowel wall and obtain biopsies (tissue samples) of any suspicious areas. Colonoscopy may be indicated. This is the visual exam of the inside of the entire colon using a flexible endoscope. The exam is usually performed under mild sedation. A marker test may be done whereby the patient swallows a capsule containing markers. Some days later an x-ray is taken to analyze the pattern and distribution of markers in the colon. In some cases, pressure measurements of the rectum and lower colon can provide valuable information. This exam is called manometry.

Guidelines for Treating Constipation

Because there are many causes of constipation, treatment depends on the physician’s findings and diagnosis. After serious problems are excluded, chronic constipation usually responds to simple measures, such as adding fiber, bran or a bulking agent to the diet.

Chronic constipation treatment guidelines include: eating regularly, drinking plenty of liquids each day, and regular walking or aerobic exercise. In particular, individuals should respond to the urge to defecate. Retaining stool at this point will aggravate the condition.

The Importance of Fiber When Treating Constipation

Fiber is the material that the lower gut depends on to create soft, bulky and regular stools and the beneficial bacteria that affect overall health and well being. Insoluble fibers that are part of foods such as whole wheat bread pass through the colon without breaking down and form the basis for stool. Soluble fibers, including the beneficial prebiotics inulin and oligofructose, produce gases that fertilize the healthy bacteria that live in the lower gut. Together and when consumed in adequate quantities, soluble and insoluble fibers help improve constipation, mineral absorption, immunity to disease, the symptoms of other lower gut conditions such as IBS and IBD, anxiety, appetite control and more.

Unfortunately, most people don’t eat nearly enough fiber. Certain foods also seem to trigger constipation. In general, ingesting upward of 25 grams of fiber per day is necessary for a healthy lower gut. For the best results, eat foods such as apples and potatoes with the skins on. Choose whole grain breads and pastas over their refined (white) flour cousins. Make leafy green vegetables and legumes such as beans a regular part of your diet. Also, read the labels of everything you eat – some breakfast cereals, for example, that advertise the benefits of fiber may actually include little if any fiber at all, while other cereals provide everything you need in one bowl.

If counting grams of fiber isn’t possible, you can also try taking a prebiotic supplement. Prebiotin Prebiotic Fiber comes from plants, is safe for vegan and gluten-free diets, and is tasteless. You can add it to water, your breakfast cereal or anything else and get your fiber intake for the day in one easily-tolerated setting. Prebiotic fiber supplements provide all the health benefits of the fibers contained in fruits, vegetables and legumes.

A High Fiber Diet for Constipation

Increased dietary fiber is almost always an important part of any dietary program. You are referred to High Fiber Diet for details. The short version is that there are two main types of fiber, insoluble and soluble, and almost every plant has some of each. Insoluble fiber does not dissolve in water, is not acted on by colon bacteria and does not create colon gas. It is an important fiber because it hangs on to water within the colon, promoting a large, bulky stool and improved regularity. The second type of fiber is soluble, meaning it does dissolve in water and is fermented by colon bacteria. Some of these bacteria create colon gas.

Most plants have both fibers to varying degrees. As examples, the fibers in wheat are mostly insoluble while those in oats and beans are mostly soluble. Prebiotics, especially inulin and oligofructose, are recently discovered soluble fibers.  These fibers have had a great deal of research done on them lately and multiple, significant health benefits have been found to occur. Still, they are soluble and, as such, do produce colon gas just like all soluble fibers will if too much is taken.

The key is to get a good balance of these fibers. The recommended fiber diet for constipation sufferers, as well as for general health, total fiber intake per day is 25-35 grams, depending on your sex, age and weight. At this level, multiple health benefits occur. However, if excess colon gas and flatus are problems, then cut back on soluble fiber first.

The section on Fiber Content of Foods lists the amount of soluble and insoluble fiber in most foods. You can also try a prebiotic supplement, which is an easy way of getting comfortable levels of fiber without recording the fiber content of everything you eat. The prebiotics inulin and oligofructose, which are all natural plant fibers, keep the entire colon spectrum healthy by fertilizing the beneficial bacteria that live there. These beneficial bacteria help produce regular, soft stools as well as a diverse variety of important health improvements, which include better immunity to disease, stronger appetite control, improved mineral absorption, reduced anxiety and more. Foods such as onions, chicory root, Jerusalem artichoke, bananas and leeks also contain prebiotic fiber.

Prebiotics

Prebiotics are the soluble food fibers that feed the healthy bacteria in the colon. The term was coined in 1995, so the field is rather new. Researchers are evaluating many prebiotics, but only inulin and oligofructose have shown consistent results. Please refer to my essay, Introduction to Prebiotics for details. The key thing that these two prebiotics (and hopefully, others) do is stimulate the colon’s good bacteria to grow. Inulin and oligofructose can also make the colon more acidic.

Methane Constipation

There is some early research that suggests that the colon gas, methane, may promote constipation. Prebiotic plant fibers can increase the acidity of the colon to an extent that these particular methane producing bacteria
may stop growing. Were I still in practice, I would encourage my constipation patient to eat foods containing prebiotics or use a prebiotic supplement in gradually increasing doses – 1 gram a day for several days, then 2 grams and so forth. If excessive colon gas and bloating or cramps occur before constipation improves, then the diet test did not work. If it did, then you should find the amount of prebiotic soluble fiber that works for you by evaluating the malodorous sulfide smell of your flatus. The bacteria that make methane do not grow in an acid environment. Likewise, those that make the malodorous sulfide gases in colon gas do not grow in an acid environment. If your flatus has no or little smell, your colon may be at the right acidity to prevent the methane producing bacteria from growing. See references at end.

Exercise

Regular exercise, even walking, can help prevent constipation.

Do Laxatives Help?

There are two types of laxatives: stimulants (chemical) and saline (liquid or salt). They occasionally help temporary constipation.  However, chronic use of laxatives, especially stimulant laxatives is discouraged because the bowel becomes dependent upon them. Bowel regularity should occur without laxatives. An occasional enema is preferable over the chronic use of laxatives.

Bowel Retraining Program

  1. Do not use laxatives long term.
  2. Eat a diet high in roughage, such as bran cereals, fruits and leafy vegetables (click Fiber Content of Foods).
  3. Drink six (6) ounces of prune or apricot juice each morning.
  4. Eat two (2) large servings of stewed fruit each day.
  5. Eat a normal breakfast.
  6. Set aside 15 minutes after breakfast to sit on the toilet, but do not strain to have a bowel movement.
  7. If you do not have a bowel movement by the third day, use an enema and repeat the above steps.
  8. Consider the use of a fiber prebiotic preparation.

Pregnancy

If you are considering pregnancy, your physician will want to know and advise you. There are risks to the mother and to the fetus as well, both with the disease and from some of the medications that are used to treat the disorder. If you are already pregnant at the time of diagnosis, close consultation with a physician with expertise in this situation is needed.

Summary

Constipation usually is a short-term disorder which can be controlled by simple measures. However, the condition may reflect a more serious underlying disorder that can only be detected and treated by the physician. For chronic constipation, it is important that the patient understands how this occurs. Adequate dietary fiber is usually the first and perhaps the only step that needs to be taken.