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Abstract
Over two million Americans visit their health care providers each year for constipation-related problems. We'll help you understand this common gastrointestinal complaint and let you know what you can do to help your patients manage and prevent it from recurring.
CONSTIPATION CAN AFFECT adults of any age, with an estimated prevalence ranging from 2% to 28%. The incidence of constipation increases with age and is as high as 20% in older adults (see Constipation in older patients). Twenty to thirty percent of people over age 65 use some form of laxative therapy to treat this problem. Constipation can also affect pregnant women (see Constipation and pregnancy), postoperative patients, and even children.
In this article, I'll discuss how and why constipation occurs, the signs and symptoms to watch for, diagnostic testing and treatment options, and what you need to teach your patients about coping with and overcoming this problem.
But first, let's briefly define constipation.
Irritable irregularity
Constipation is defined as infrequent or irregular defecation (less than three times per week) with hardened stool that's difficult or painful to pass, decreased stool volume, stool retention, or the feeling of incomplete bowel evacuation. It can be further defined as either primary or secondary. Let's take a closer look.
Primary constipation is caused by problems that affect the bowels, such as:
* immobility
* a low-fiber diet
* inadequate fluid intake
* lack of regular exercise
* pregnancy
* overuse of laxatives
* ignoring the urge to have a bowel movement
* changes in life or routine
* stress.
Many medications may also cause constipation (iatrogenic constipation), including:
* opioids
* tranquilizers
* anticholinergics
* antidepressants
* antihypertensives
* antacids with aluminum.
Secondary constipation is caused by rectal or anal disorders, such as:
* hemorrhoids or fissures
* bowel obstruction
* metabolic, neurologic, or neuromuscular diseases, such as diabetes, Parkinson's disease, and multiple sclerosis
* endocrine disorders like hypothyroidism
* connective tissue disorders like lupus
* diseases of the colon, such as irritable bowel syndrome and diverticulitis.
Many people become constipated because they either ignore the urge to defecate or don't take the time to do so. "Perceived" constipation can also be a problem. The belief that one's bowel habits aren't normal may lead to chronic laxative use, especially among older patients.
Now that you know some of the possible causes of constipation, what's actually going on with the patient? Let's take a look at the inner workings of this problem next.
When it's time to go
Constipation occurs when the colon absorbs too much water or the colon's muscle contractions become sluggish, causing the stool to pass through too slowly.
Normally, defecation results from the defecation reflex, a sensory and parasympathetic nerve-mediated response, along with the voluntary relaxation of the external anal sphincter. Regularly ignoring this urge can lead to chronic constipation-the rectal mucous membrane and muscles become insensitive to the presence of fecal masses, so a stronger stimulus is needed to trigger the urge to defecate. If stool is retained, the colon will become irritated over time and may go into spasm, causing colicky midabdominal or low abdominal pain. After several years of chronic retention, the colon will lose muscle tone and won't respond to normal stimuli.
How does all of this stack up for your patient? Let's review the signs and symptoms of constipation to watch out for.
All backed up
Signs and symptoms of constipation include:
* abdominal distension, bloating, or pain
* gurgling or rumbling sounds in the abdomen
* indigestion
* nausea or vomiting
* decreased appetite
* headache
* fatigue
* sensation of incomplete evacuation at least 25% of the time
* sensation of fullness at least 25% of the time
* the need to strain during a bowel movement at least 25% of the time
* elimination of small, hard, dry stool at least 20% of the time.
If the patient consistently exhibits two or more of these symptoms for more than 3 months, it's safe to say he's suffering from constipation.
Besides being irritating, constipation can also be dangerous. Potential complications include:
* hemorrhoids
* fecal impaction
* bowel obstruction
* bowel perforation
* electrolyte disturbances.
Chronic constipation is also associated with an increased risk of colon and rectal cancer. In chronic constipation there's a prolonged buildup of toxins and harmful bacteria in the colon. Minor cell damage can occur and progress, leading to abnormal cell proliferation.
Straining to defecate results in the Valsalva maneuver (forcibly exhaling with the glottis closed), which increases systemic blood pressure. Active straining increases intrathoracic pressure and temporarily slows down venous blood flow, leading to decreased cardiac output and a drop in arterial pressure. Arterial pressure then rebounds, momentarily rising to a point far above the original level. In someone with hypertension, this rebound pressure may be high enough to rupture a major artery in the brain.
If you suspect your patient is constipated, what's next? Obtain a detailed health history and help him prepare for diagnostic testing.
Assessing the problem
First, you'll need to obtain a detailed health history. Discussing bowel patterns may make your patient (and you!!) feel nervous or embarrassed. Reassure him and explain why you need to collect this information. Ask these questions:
* What time of day do you usually have a bowel movement? What's your normal stool consistency (hard or soft)?
* Have you noticed any blood in your stool?
* Does having a bowel movement hurt?
* Do you have trouble making it to the toilet at home or do you use a commode?
* Do you feel as if you've completely emptied your bowel after having a bowel movement?
Ask your patient about his exercise and activity level and about his normal fluid intake and diet. Note any medications he's taking, what he does to relieve the constipation, and if he's been using a laxative to help relieve it. Look for routines he carries out when he has a bowel movement and identify any recent changes that may contribute to constipation, such as surgery, opioid use, and changes in diet.
Tests to take
To rule out more serious conditions such as cancer and possibly determine the cause of constipation, the health care provider may perform or order these tests:
* digital rectal exam to determine the presence of stool
* abdominal X-ray to rule out bowel obstruction
* sigmoidoscopy, in which a lighted, flexible tube is used to examine the sigmoid colon and rectum
* barium enema, where the lining of the bowel is coated with a contrast dye (barium) so the rectum, colon, and part of the small intestine can be seen clearly on an X-ray
* testing the stool for occult blood
* bowel transit study, in which the patient takes a radio-opaque tablet and has a series of X-rays taken to measure the time it takes the tablet to work its way through the bowel.
Once a more serious condition is ruled out and the diagnosis of constipation is confirmed, your patient's treatment will be based on the underlying cause. Let's look at the available options.
Stopping stop-ups
Treatment for constipation focuses on:
* increasing fiber and fluid intake
* bowel habit training
* possible short-term laxative use.
Lifestyle modifications are important in dealing with and preventing constipation. Encourage your patient to take an active role in self-care and advise him to:
* increase the amount of fiber in his diet (adding 6 to 12 tablespoons of unprocessed bran to the daily diet is recommended, especially for older adults)
* increase the amount of fluids (water and juice) he drinks
* increase his daily activity as he's able.
Bowel-habit training is important to manage constipation and prevent it from recurring. Encourage your patient to:
* Discuss normal variations in bowel patterns. A person may have a bowel movement several times a day or once every 3 to 5 days. Emphasize that a daily bowel movement isn't necessarily the norm for every person. During the health history, establish what's "normal" for the patient and make it a goal to obtain that norm.
* Establish a regular time for defecation; the best time is usually right after breakfast. This will help him return to a bowel pattern that's as close to his normal as possible.
* Realize the importance of heeding the urge to defecate.
* Eat high-residue, high-fiber foods such as fresh, uncooked fruits and vegetables and whole-grain products. He can gradually add bran. Unless contraindicated, he should increase his fluid intake to at least 6 to 8 glasses of liquids such as water and fruit juice every day.
A bulk-forming laxative (psyllium [Metamucil]), saline laxative (magnesium hydroxide [milk of magnesia]), stool softener (docusate sodium [Colace]), stimulant laxative (bisacodyl [Dulcolax]), or osmotic laxative (Colyte) may be ordered for your patient. For information about the action of these laxatives and what to teach your patient about their use, see Laxatives to manage constipation.
Long-term laxative use isn't recommended because it may cause adverse effects such as:
* nausea
* vomiting
* abdominal cramps
* weakness
* diarrhea
* electrolyte imbalance
* dizziness
* confusion
* sweating.
If a patient must use laxatives long-term, a bulk laxative with an osmotic laxative may be prescribed, but laxative use should be monitored closely. Older patients who chronically use laxatives and stool softeners are at risk to develop the following problems:
* increased constipation
* diarrhea
* elevated magnesium levels in the blood (hypermagnesemia)
* elevated phosphate levels in the blood (hyperphosphatemia)
* low levels of albumin in the blood (hypoalbuminemia)
* poor response to bowel preparation for barium enema
* increased risk of fecal incontinence and perianal soiling.
If a laxative has been prescribed for your patient, make sure he understands the importance of avoiding excessive use. Stress that enemas and rectal suppositories aren't recommended to treat constipation.
A patient who's in a long-term care facility may have privacy issues related to the use of public restrooms or bedpans. This anxiety can create a predisposition to constipation. Remember to address these feelings and allow the patient to express his anxiety. Reassure him that his feelings are normal and that you'll help him maintain as much privacy as possible to perform this bodily function.
Regularity rules
Constipation affects various people for different reasons, so you're likely to come across patients with this problem on a regular basis. But with your expert care and guidance, your patients will be able to return to a healthy, balanced bowel pattern in no time.
Constipation in older patients
Patients age 65 and older report problems with constipation five times more frequently than their younger counterparts. Here's why:
* Loose-fitting dentures or loss of teeth makes chewing difficult, leading the patient to frequently choose soft, processed foods that are low in fiber.
* Convenience foods, which are also low in fiber, are often used by those who've lost interest in eating or have difficulty with food preparation.
* Some older patients reduce their fluid intake if they aren't eating regular meals, don't have the ability to get their own drinks, or fear frequent trips to the bathroom.
* Lack of exercise and prolonged bed rest decrease abdominal muscle tone, anal sphincter tone, and intestinal motility.
* Nerve impulses decrease with age, decreasing the sensation of the urge to defecate.
Constipation and pregnancy
Half of all pregnant women will experience constipation at some point during their pregnancy because of increased hormones relaxing intestinal smooth muscle and the expanding uterus putting pressure on the intestines. Iron supplements, frequently prescribed for pregnant women, may also cause constipation, so make sure your pregnant patient increases her fluid intake if she's taking iron pills. Laxative use isn't recommended during pregnancy because of the risk of uterine contractions and dehydration.
Source: American Pregnancy Association. http://www.americanpregnancy.org/pregnancyhealth/constipation.html
Laxatives to manage constipation
On the Web
International Foundation for Functional Gastrointestinal Disorders: http://www.aboutconstipation.org
MedicineNet.com's Constipation Center: http://www.medicinenet.com/constipation
National Digestive Diseases Information Clearinghouse: http://digestive.niddk.nih.gov/ddiseases/pubs/constipation
National Institute on Aging: http://www.niapublications.org/agepages/const.asp .
Selected references
Bisanz A. Chronic constipation. The American Journal of Nursing. 107(4):72B-H, April 2007.
Brown L, et al. Constipation: Patient perceptions compared to diagnostic tools. Palliative Medicine. 20(7):717-718, June 1, 2006.
Heitkemper M, Wolff J. Challenges in chronic constipation management. The Nurse Practitioner. 32(4):36-42, April 2007.
National Guideline Clearinghouse. Practice guidelines for the management of constipation in adults. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3687&nbr=2913 . Accessed May 8, 2007.
Smeltzer, SC, Bare BG. Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 11th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2007.