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Constipation: causes and cures

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Constipation should be considered as the passing of small, hard stools with difficulty. The most popular definition is described by Pfeifer and Wexner (1996) as two or more of the following:



VOL: 99, ISSUE: 25, PAGE NO: 26

Ruth Christer, RN, Dip HE, BA

Liz Robinson, RGN, BSc, and Clare Bird, RGN, Dip NSc, are colorectal nurse specialists, Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Trust



Constipation should be considered as the passing of small, hard stools with difficulty. The most popular definition is described by Pfeifer and Wexner (1996) as two or more of the following:



- Straining at defaecation at least 25 per cent of the time;



- Lumpy or hard stools at least 25 per cent of the time;



- A sensation of incomplete defaecation at least 25 per cent of the time;



- Less than two bowel motions per week.



Medical and nursing staff classify constipation as the above, but patients’ interpretation of constipation may be quite different. The term is often used when people experience symptoms such as difficult or incomplete evacuation, pain, hard stools, straining, nausea and bloating, even if the patient defaecates daily.



Incidence and causes



According to the 1991 National Health Interview Survey, about half a million people in the USA said they were constipated most or all of the time. Symptoms were commonly reported by women, children, and adults aged over 65 years. Pregnant women often complain of constipation and it is a common problem following childbirth or surgery. Within the UK, it is estimated that three million GP consultations relating to constipation take place each year.



Extra-colonic constipation is often referred to as simple constipation because it results from factors outside the bowel and usually responds well to simple treatment. It therefore does not warrant further investigation. Causes of extra-colonic constipation can include:



- Dietary factors. The modern Western diet is generally low in fibre and high in fats. There is also an increasing consumption of refined and convenience foods, which are low in fibre. A low fluid intake can also lead to constipation. Liquids add fluid to the colon and bulk to stools, making stools softer and easier to pass;



- Lack of exercise. Colonic motor activity is reduced during periods of diminished physical activity. Lack of exercise can therefore lead to constipation. It is a common problem after an accident or during an illness when prolonged bed rest is necessary;



- Medication. Analgesics, antacids that contain aluminium, antispasmodics, antidepressants, iron supplements, diuretics and anti-convulsants for epilepsy can slow down bowel movements;



- Underlying medical conditions, such as irritable bowel syndrome, tumours (pelvic and bowel), diabetes and hypothyroidism, slow down the metabolic rate through hormonal changes. This also occurs within the menstrual cycle and during pregnancy;



- Neurological disorders, including multiple sclerosis, Parkinson’s disease, chronic idiopathic intestinal pseudo-obstruction, stroke and spinal cord injuries;



- Metabolic and endocrine conditions, including diabetes, an underactive or overactive thyroid gland and uremia;



- Systemic disorders, including amyloidosis, lupus and scleroderma;



- Abuse of laxatives. When laxatives are used excessively, the colon begins to rely on them to bring on bowel movements. Over time, laxatives can damage nerve cells in the colon and interfere with the colon’s natural ability to contract. For the same reason regular use of enemas can also lead to a loss of normal bowel function.



Another common cause of constipation is ignoring the call to pass a stool. This can eventually lead to feeling no urge at all and subsequent constipation as a result. Some people may delay having a bowel movement because they do not want to use toilets outside their home. Some may ignore the urge due to emotional stress or being too busy. Children may postpone because of stressful toilet training or because they do not want to interrupt their play.



Some people have structural abnormalities in the back passage, known as anorectal dysfunction or anismus. It results in an inability to relax the rectal and anal muscles that allow stools to exit. It can lead to constipation as stools remain in the rectum and become dry and hard.



Treating constipation



Most people do not need extensive treatment for constipation and can resolve the matter through changes in diet and exercise. The type of treatment is decided upon after a general assessment. In young people with mild symptoms, a medical history and physical examination may be all that is necessary. Further investigations depend upon the duration and severity of the constipation, the patient’s age, evidence of blood in the stools, recent changes in bowel habit or weight loss.



Increasing fibre intake



The first-line treatment of simple constipation is to increase the fibre content of the diet accompanied by an increased fluid intake. According to government guidelines the recommended daily intake of fibre is 18g. Much of the food we eat is digested in the stomach and small intestine but fibre is not digested and passes into the colon. It draws water in to the stool and increases the number of bacteria in the colon; both of which make the stool larger, softer and easier to pass.



Fibre should be sought from a variety of sources and intake should be spread throughout the day, not just taken at breakfast (Chiarelli and Markswell, 1992). It is therefore important that patients are aware of the foods that contain fibre and how to include these in their daily diets. Adequate fluids must accompany any increase in fibre. The recommended daily intake of fluid is at least two litres per day. Caffeine should be avoided since it is a diuretic.



The role of exercise



If possible people suffering from constipation should increase their participation in physical exercise as this will help to aid peristalsis. This does not have to be anything too vigorous and could involve some simple adjustments such as using the stairs instead of the lift.



Using laxatives



Laxatives may be necessary in some cases, but their use should always be viewed as a short-term measure and should be stopped once the increased intake of fibre and fluid begin to have an effect.



Stimulant laxatives act by irritating the colon and causing rhythmic muscle contractions, therefore increasing motility. Lubricants soften the stool and coat the lining of the bowel, which makes the passage of faeces easier.



Osmotic laxatives retain water in the bowel by osmosis and bulking agents increase the bulk of the stool in much the same way as fibre. Fluids must always be increased when taking bulking agents to avoid causing an obstruction of large, dry and hard faeces. Suppositories and enemas are the most effective pharmacological means of relieving simple constipation, but they can be distressing and embarrassing for the patient.



When individualised care is planned for the patient, all predisposing factors should be considered before offering any clinical treatment, such as oral laxatives or enemas. These will only deal with the symptoms and not the cause. Patient education is therefore crucial.



Learning bowel control through biofeedback



Biofeedback can be used to retrain the nerves and muscles in evacuation disorders. A balloon is inserted into the rectum, which produces the feeling of needing to defaecate and electrodes are placed near the external anal sphincter. These are then connected to a display screen and the patient is able to see the effects of attempts to contract and relax the anal sphincter. Patients are taught relaxation exercises and how to use their abdominal muscles effectively during defaecation. Ongoing support is crucial as it may take weeks before the exercises have any effect. Treatment is not always successful.



The last resort: surgical intervention



Surgical intervention should be used only when all other treatment has failed. Most commonly a sub-total colectomy and ileo-rectal anastomosis is performed. According to Pfeifer et al (1996) this has the highest success rate - 90 per cent. Another alternative is formation of ileostomy.



Nursing management



Nurses are in an ideal position to provide preventative care and health promotion/education in conjunction with the multidisciplinary team. The process of health education involves more than simply giving information: it empowers patients to cope with their own needs. In this way nurses can influence patients to make changes to their lifestyle by teaching them the advantages and disadvantages of taking the recommended action. This can also increase patients’ motivation to make changes.



Nurses have a unique role in helping patients to manage bowel function. The nurse is often the first person to be aware of the problem and in many cases the sensitive handling of the situation by the nurse can lead to a rapid improvement for patients. Successful management depends upon good assessment of the patient. Good assessment depends upon a good understanding of bowel function and the identification of contributing factors.



National strategies and research



The NHS Plan (DoH, 2000) reinforced the importance of getting the basics right. From this the Essence of Care (DoH, 2001) document evolved, which aims to improve the quality of patient care by introducing benchmarks in certain key areas, one of which is continence management, including bowel care.



Laxatives are the most widely used treatment for constipation. Pettigrew et al (1997) undertook a systematic review on the use of laxatives in older people with the York Centre for Reviews and Dissemination. This document raised a number of issues, for example, relative cost and effectiveness of different laxatives in use, as well as the importance of patient assessment. From this review certain trusts have developed guidelines for the treatment of constipation in adults.






Constipation is a common complaint, which can vary in severity and duration. It affects almost everyone at some time or another. There is a misconception among the general public and health professionals alike, that if the bowels are not opened on a daily basis then this is constipation. Passing a large, soft stool with ease either daily or two to three times a week is, however, classed as a normal bowel habit.



The most common causes of constipation are poor diet and lack of exercise. Prevention is obviously better than cure and nurses can play a major role through health education. A detailed assessment of a patient’s history will often highlight the source of their constipation and in most cases the use of simple measures will relieve symptoms and prevent recurrence. The effects and causes of constipation should never be underestimated and the informed nurse, therefore, has much to offer patients in the form of advice and support.
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