India’s No 2 problem
By: Altaf Patel
Our concern over bowel habits stem from the fact that many decades ago, docs attributed a host of diseases to constipation.
We are a bowel centric society. We are unduly concerned about our bowel habits. Over the years taking care of critically ill patients in ICUs, my first question to them is whether they have any complaints. They always complain of constipation. I guess this stems from the fact that several decades ago physicians attributed a host of diseases to constipation. The mistaken concept was that the stools in the intestine if not passed would poison you by passing their toxins into the blood. Hence, it is not surprising that patients brought up in that era are so bowel conscious.
International committees have proposed a Rome 2 criteria for chronic functional constipation and if you have had at least 12 weeks in the preceding 12 months, two or more of the following symptoms – lumpy or hard stools in 25% of the defecation, sense of incomplete evacuation 25% of the time, straining 25% of the time, a sense of anal blockage 25% of the time or require manual manoeuvres to evacuate your stool 25% of the time or have less than 3 stools per week, then you fit the criteria for chronic functional constipation.
Constipation increases with age. Females are affected more than males. The causes of constipation can be many- disorders like diabetes, Parkinson’s disease, spinal cord injury, sluggish thyroid, increased serum calcium and prescription medications often overlooked by the physician.
If there is associated weight loss or bleeding then the patient must be evaluated first for a cancer by colonoscopy (an endoscopy that looks into the large intestine).
When a physician decides that detailed investigation is unnecessary, he embarks on therapy with laxatives. It is important to provide adequate hydration and dietary fibre to produce a proper stool. Exercise is important and helps bowel move. Common sources of dietary fibre are fruits and vegetables, wheat and oat bran.
The bacteria present in the colon to a small extent digest dietary fibre and produce gas and this often causes flatulence. The ability of the bacterial digestion of fibre varies from person to person and it is worth a trial of various fibres to find the ideal one that produces a good quality stool with minimal flatulence. It is worthwhile beginning with small quantity fibre and increasing every week till the desired stool is obtained or troublesome flatulence makes it appearance.
The dose of fibre can be reduced and slowly increased again and then if found to be unsatisfactory, change to a different fibre. It is always advisable to drink plenty of water to prevent hardening of the stool. Laxatives are of various types, the bulk forming laxatives like psyllium and synthetic ones like methyl cellulose increase the bulk volume, decrease transit time through the colon, increase stool weight and consistency.
Hyperosmolar laxatives like sorbitol and lactulose are poorly absorbed sugars and are metabolised in the colon into lactic, acetic and formic acids. These acids produce an osmotic effect to form soft and formed stools. Polyethylene glycol is also a similar laxative having the advantage of less flatulence. Docusates reduce the surface tension and allow the stools to be penetrated by water, relieving constipation. Mineral oil is often used as a laxative.
Aword of caution for the elderly is that aspiration in the lungs producing a pneumonia sometimes occur. Anal seepage also occurs when mineral oil is first started. When these bulk or osmotic laxatives fail, the physician will use stimulant laxatives. Because of such laxative abuse it is recommended that they not be taken more than a few weeks. Continuous daily use can produce low sodium and potassium in the blood and dehydration. When used 2 or 3 times a week they can be used for longer periods. These laxatives act within 2 to 8 hours as opposed to bulk laxatives which require 1 to 3 days to begin action. Senna, Cescora are examples of stimulant laxatives. Phenolphthalein commonly used in the old days and no longer used because of its tendency to produce cancer in animals. When there is failure of oral laxatives the option is enemas and such enemas are available pre-packaged in today’s times. Suppositories can also be tried and stimulant and glycone suppositories which irritate the rectum are useful. The insertion of a finger into the anus may itself stimulate a bowel movement. Several other prescription drugs are also available to the physician to combat constipation.
Less than 5% of patients have severe intractable constipation and require more detailed investigations. Radioactive markers are swallowed and an x-ray film taken after 5 days should show 80% of these markers have exited, for the colon transit time to be normal. Tests for pelvic floor function may also be done.
Measurements of descent of the pelvic floor with the patient lying on his left side and straining shall show more than 1.5 cms of descent to be called normal. Measurement of pressure in the anorectal area if more than 80 mmHg suggest anal sphincter spasm called anismus. Defecography when an enema of barium is put in the rectum and its expulsion studied on x-rays has also been useful in selected cases. Various imaging studies during defecation called proctography and neurological testing (electromyography) can also be useful.
Our concern over bowel habits stem from the fact that many decades ago, docs attributed a host of diseases to constipation.
We are a bowel centric society. We are unduly concerned about our bowel habits. Over the years taking care of critically ill patients in ICUs, my first question to them is whether they have any complaints. They always complain of constipation. I guess this stems from the fact that several decades ago physicians attributed a host of diseases to constipation. The mistaken concept was that the stools in the intestine if not passed would poison you by passing their toxins into the blood. Hence, it is not surprising that patients brought up in that era are so bowel conscious.
Normal bowel movements vary from 3 a day to 3 per week and so one must understand what a patient means by constipation. It refers to difficult, infrequent and seemingly incomplete defecation. Many patients have a normal frequency of stools, but complain of a feeling of incomplete evacuation of the bowel. Psychological factors also play an important part in constipation.
International committees have proposed a Rome 2 criteria for chronic functional constipation and if you have had at least 12 weeks in the preceding 12 months, two or more of the following symptoms – lumpy or hard stools in 25% of the defecation, sense of incomplete evacuation 25% of the time, straining 25% of the time, a sense of anal blockage 25% of the time or require manual manoeuvres to evacuate your stool 25% of the time or have less than 3 stools per week, then you fit the criteria for chronic functional constipation.
Constipation increases with age. Females are affected more than males. The causes of constipation can be many- disorders like diabetes, Parkinson’s disease, spinal cord injury, sluggish thyroid, increased serum calcium and prescription medications often overlooked by the physician.
If there is associated weight loss or bleeding then the patient must be evaluated first for a cancer by colonoscopy (an endoscopy that looks into the large intestine).
When a physician decides that detailed investigation is unnecessary, he embarks on therapy with laxatives. It is important to provide adequate hydration and dietary fibre to produce a proper stool. Exercise is important and helps bowel move. Common sources of dietary fibre are fruits and vegetables, wheat and oat bran.
The bacteria present in the colon to a small extent digest dietary fibre and produce gas and this often causes flatulence. The ability of the bacterial digestion of fibre varies from person to person and it is worth a trial of various fibres to find the ideal one that produces a good quality stool with minimal flatulence. It is worthwhile beginning with small quantity fibre and increasing every week till the desired stool is obtained or troublesome flatulence makes it appearance.
The dose of fibre can be reduced and slowly increased again and then if found to be unsatisfactory, change to a different fibre. It is always advisable to drink plenty of water to prevent hardening of the stool. Laxatives are of various types, the bulk forming laxatives like psyllium and synthetic ones like methyl cellulose increase the bulk volume, decrease transit time through the colon, increase stool weight and consistency.
Hyperosmolar laxatives like sorbitol and lactulose are poorly absorbed sugars and are metabolised in the colon into lactic, acetic and formic acids. These acids produce an osmotic effect to form soft and formed stools. Polyethylene glycol is also a similar laxative having the advantage of less flatulence. Docusates reduce the surface tension and allow the stools to be penetrated by water, relieving constipation. Mineral oil is often used as a laxative.
Aword of caution for the elderly is that aspiration in the lungs producing a pneumonia sometimes occur. Anal seepage also occurs when mineral oil is first started. When these bulk or osmotic laxatives fail, the physician will use stimulant laxatives. Because of such laxative abuse it is recommended that they not be taken more than a few weeks. Continuous daily use can produce low sodium and potassium in the blood and dehydration. When used 2 or 3 times a week they can be used for longer periods. These laxatives act within 2 to 8 hours as opposed to bulk laxatives which require 1 to 3 days to begin action. Senna, Cescora are examples of stimulant laxatives. Phenolphthalein commonly used in the old days and no longer used because of its tendency to produce cancer in animals. When there is failure of oral laxatives the option is enemas and such enemas are available pre-packaged in today’s times. Suppositories can also be tried and stimulant and glycone suppositories which irritate the rectum are useful. The insertion of a finger into the anus may itself stimulate a bowel movement. Several other prescription drugs are also available to the physician to combat constipation.
Less than 5% of patients have severe intractable constipation and require more detailed investigations. Radioactive markers are swallowed and an x-ray film taken after 5 days should show 80% of these markers have exited, for the colon transit time to be normal. Tests for pelvic floor function may also be done.
Measurements of descent of the pelvic floor with the patient lying on his left side and straining shall show more than 1.5 cms of descent to be called normal. Measurement of pressure in the anorectal area if more than 80 mmHg suggest anal sphincter spasm called anismus. Defecography when an enema of barium is put in the rectum and its expulsion studied on x-rays has also been useful in selected cases. Various imaging studies during defecation called proctography and neurological testing (electromyography) can also be useful.
Disclaimer: The views expressed here are the author's own. The opinions and facts expressed here do not reflect the views of Mirror and Mirror does not assume any responsibility or liability for the same.
