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Fact File - Signs and symptoms of constipation: Part one

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VOL: 102, ISSUE: 47, PAGE NO: 48

Gaye Kyle, BA, DipEd, RGN, is senior lecturer, Faculty of Health and Human Science, Thames Valley University, Slough, Berkshire

Constipation is an unpleasant and often distressing symptom that can happen to anyone at any time. Its severity may vary from the slight, causing no disruption to life, to the severe, impacting upon an individual’s physical, psychological and social well-being. Constipation affects both genders but there is a higher prevalence among females (Thompson et al, 1999; Campbell et al, 1993). Females of all ages are at greater risk of developing constipation than their male counterparts (Richmond and Wright, 2004; Harari et al, 1996) due to a slower colonic transit time (Taylor, 1990).

Constipation is an unpleasant and often distressing symptom that can happen to anyone at any time. Its severity may vary from the slight, causing no disruption to life, to the severe, impacting upon an individual’s physical, psychological and social well-being. Constipation affects both genders but there is a higher prevalence among females (Thompson et al, 1999; Campbell et al, 1993). Females of all ages are at greater risk of developing constipation than their male counterparts (Richmond and Wright, 2004; Harari et al, 1996) due to a slower colonic transit time (Taylor, 1990).

It is suggested that older women suffer from constipation because of changes in the musculature of the pelvic floor following childbirth resulting in problems relaxing pelvic floor muscles (Ross, 1995; Campbell et al, 1993). Hormonal imbalance between progesterone and motilin (a polypeptide hormone secreted by the small intestine) has been suggested as a cause of constipation among young women (Heaton et al, 1992). Petticrew et al (1997) speculate that a higher prevalence of constipation in women is documented because women seek medical advice more often than men.

Constipation may become a major healthcare issue for patients who are older, less mobile, have neurological problems or live in care homes. Despite a commonly held belief that constipation is an inevitable consequence of ageing, it is vital to stress that constipation is not synonymous with the ageing process (Petticrew et al, 1997; Ross, 1995).

The increased prevalence of constipation in older people probably reflects changes associated with reduced mobility, polypharmacy, poor diet and chronic illness (Harari, 2004; Petticrew et al, 1997; Campbell et al, 1993).

Patients with a chronic illness have a prolonged total gut transit time associated with general debility, with evacuation being delayed through the sigmoid colon and the rectum (Walton and Miller, 1998; Talley et al, 1996; Abrams et al, 1995) leading to difficulty in bowel evacuation rather than a decline in frequency of bowel movements.

Process of defecation

The process of rectal emptying is usually initiated voluntarily. Movement of faeces into the rectum causing rectal distension evokes the desire to defecate, known as the ‘call to stool’. Under the appropriate circumstances defecation is completed when the patient adopts a posture that allows abdominal pressure to rise by contraction of the diaphragm and abdominal muscles. This is followed by relaxation of the puborectalis muscle and external anal sphincter muscles.

Coordination between the abdominal contraction and pelvic floor relaxation is vital for the process of defecation. Any abnormality or impairment of the nerve supply to the colon and pelvic floor will lead to a reduction in colonic propulsion or poor pelvic floor coordination, resulting in decreased defecation or excessive straining.

Definition and classification of constipation

Constipation can occur for a variety of reasons including physical, psychological, physiological, emotional and environmental factors. Many of the underlying reasons for constipation remain poorly understood and symptoms are largely subjective, with the consequence that it has no universally accepted definition (Richmond, 2003). Thompson et al (1999) suggest that constipation is characterised by persistent difficult or incomplete defecation. This definition alone can include a huge variation in bowel habits especially if patients believe erroneously that they should have a bowel action at least once a day. Most definitions now include frequency of defecation, hardness of stools, abdominal fullness or bloating and abdominal pain (Petticrew et al, 1997).

The Rome II criteria is the most referred to definition (Thompson et al, 1999) in the literature. However, it is mainly used for inclusion criteria for research purposes and it has limited use in practice as many patients develop and require treatment for constipation before 12 weeks. The American College of Gastroenterology Chronic Constipation Task Force (2005) supports this view, stating that the widespread use of the Rome II criteria is impractical, as observation studies indicate that most patients who report constipation do not fulfil the criteria.

Bowel habits vary from one individual to another (Richmond, 2003), supporting the idea that any one definition of constipation will be difficult to work with in practice. This lack of clarity on what constitutes constipation could be one reason why constipation is usually addressed only when it has become a significant problem (Ross, 1998).

Slow bowel transit time and/or impairment of rectal emptying (Thompson et al, 1999) are the physiological characteristics of constipation. As a result faeces remain in the colon for a prolonged period leading to water absorption from the stool with the effect that it becomes hard and dry. Patients with a slow bowel transit time will present with a history of infrequent bowel actions, whereas patients with evacuation difficulties will complain of difficulty with defecation. As evacuation difficulties and slow bowel transit time can coexist in the same patient, a mixture of symptoms may be reported. Constipation therefore results from faeces being lodged in any part of the large bowel but it is most frequently experienced in the sigmoid colon and rectum.

Constipation can be clinically classified into three categories and may result from one or more of these types of conditions. Primary constipation is associated mainly with lifestyle changes and where there is no underlying pathophysiology causing constipation. Table 1 outlines the factors attributed to primary, secondary and iatrogenic constipation (Richmond, 2003; Moriarty and Irving, 1992).

Symptoms and features

A patient with constipation may experience a variety of symptoms. These can range from a headache and fatigue to feelings of bloating and loss of appetite leading to nausea and vomiting.

Constipation affects the overall well-being of a patient and the severity of symptoms correlate negatively with perceived quality of life (Glia and Lindberg, 1997). Patients who have difficulty with defecation may complain of a ‘full bottom’ and an inability to open their bowels. The consequence of persistent or poorly managed constipation can lead to disabling complications for the patient. Such complications may include haemorrhoids, faecal impaction, faecal impaction with spurious overflow, urinary incontinence, urinary tract infection, rectal bleeding, general weakness and psychological disorders (Prodigy, 2004).

Persistent straining at stool leads to increased intrathoracic pressure which can give rise to a reduction in coronary and peripheral circulation leading to other possible complications, such as development of hernias, worsening of gastro-oesophageal reflux and transient ischaemic attacks (Prodigy, 2004).

Clinical signs of constipation are a distended abdomen, reduction in bowel sounds and, on digital rectal examination (DRE), a gaping anus or impacted faeces in the rectum.

Assessment of constipation

Assessment of constipation should consider all the possible causes checking in particular that the constipation is not a consequence of an underlying undiagnosed medical condition. Care pathways for bowel care are now developed in most community trusts (Bayliss, 2000) but the following checklist should be considered in the assessment of a patient with constipation especially if a care pathway is not available:

- Age and gender of the patient;

- General health - severity of illness is a major factor related to constipation (Ross, 1995);

- Previous laxative use - an excessive use of stimulant laxatives in younger life may result in secondary changes to the mesenteric plexus (autonomic nerve supply to the intestine) resulting in a reduction of peristalsis leading to a slower bowel transit time (Campbell et al, 1993);

- Description of problem - does the patient have flatus, feelings of discomfort or incomplete evacuation?

- Frequency of normal and current bowel movement - ask the patient to complete a bowel diary for at least one week;

- Description of normal diet and fluid intake - ask the patient to complete a dietary and fluid intake diary for at least one week. Has there been any change to dietary pattern which may increase the risk of constipation. A reduction in normal fluid intake increases the risk of constipation (Ross, 1995);

- Change in mobility (Ross, 1995);

- Preparation of food - is the patient able to prepare food or do they rely on others for this?

- Dentures or bad teeth - lack of teeth, poorly fitting dentures and a reduction in saliva production can make chewing and swallowing more difficult (Ross, 1998);

- Medication - this has been found to be a risk factor in more than 50% of patients (Kamm, 1994). Sheehy and Richard-Hall (1998) state that all medications can affect normal bowel function in a variety of ways, such as decreasing gastric motility, decreasing absorption rates and limiting general physical mobility;

- The use of over-the-counter medicines;

- Description of stool - use the Bristol Stool Chart to assess colour and consistency;

- The stool’s odour - if this is offensive it may be due to diet or malabsorption;

- Pain or bleeding on defecation - causes of this include local injury, for example, haemorrhoids/anal fissure and colorectal cancer;

- Unexplained changes in bowel habit - this may indicate underlying pathology such as colorectal cancer;

- Any new urinary problems - constipation is associated with bladder instability and urinary tract infections (Ross, 1995);

- Psychological state needs to be explored - confused patients may ignore the sensation of stool in the rectum (Ross, 1995).

A DRE may be required as part of the nursing assessment, and must be carried out by a nurse who has received suitable training and instruction (RCN, 2000). A DRE should only be used to establish the presence of stools in the rectum and should not be part of the primary assessment (RCN, 2000).

Conclusion

Patients presenting with constipation require careful assessment to identify the cause. Part two in this series will discuss the management of constipation.

Part 2 will be published in the Continence Journal on 9 January 2007

This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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