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Constipation

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Related Terms
  • Adverse reaction, Barium, bloating, bowel, carboxymethylcellulose, Chagas disease, colonic inertia, colon, colonoscope, colonoscopy, constipated, constipation, defecation, defecography, dehydration, diabetes, diarrhea, digestion, digestive, enema, encopresis, fecal impaction, fiber, fissures, gastrointestinal, glycerin, hemorrhoid, Hirschsprung's disease, irritable bowel syndrome (IBS), laxative, lazy bowel syndrome, methylcellulose, movement, multiple sclerosis, Parkinson's disease, pelvic floor dysfunction, polycarbophil, rectum, saline, scleroderma, side effect, sigmoidoscope, sigmoidoscopy, stool, stricture, suppository.

Background
  • Constipation is the infrequent passage of small amounts of hard, dry bowel movements, usually fewer than three times a week. Some individuals who are constipated find it painful to have a bowel movement and often experience straining, bloating, and the sensation of a full bowel.
  • The colon (part of the large intestine) absorbs water from food as it moves through the colon. The colon forms waste products, or stool, from this material. Muscle contractions in the colon then push the stool toward the rectum (final part of the large intestine). The stool is normally solid by the time it reaches the rectum, because most of the water has been absorbed back into the body.
  • Constipation is a symptom, not a disease. Almost everyone experiences constipation at some point in their life, and most periods of constipation are temporary, self-treatable, and not serious health issues. Understanding the causes, prevention, and treatment of constipation will help most individuals find relief.
  • Common causes of constipation include prescription medications, hormonal changes, bowel habits, diet, dehydration (lack of sufficient water), lack of exercise, laxatives, diseases such as colon cancer and irritable bowel syndrome (IBS), and stress.
  • Bowel movements are different for each individual, depending on the body, what the person eats and drinks, and the amount of exercise. Bowel movements do not have to occur daily. Normal stool elimination may range from three times a day to three times a week.
  • Constipation is one of the most common gastrointestinal (dealing with the digestive tract) complaints in the United States. More than 4 million Americans have frequent constipation, accounting for 2.5 million physician visits a year. Constipation most often occurs in women (during hormonal changes, pregnancy, and childbirth), and in adults ages 65 and older.
  • It is reported that 12% of people worldwide suffer from constipation. The prevalence of childhood constipation in the general population worldwide ranges from 0.7 to 29.6%.
  • The number of bowel movements generally decreases with age. Approximately 95% of adults have what is considered "normal" bowel movements - between three and 21 times per week. The most common pattern is one bowel movement a day, but this pattern occurs in less than 50% of people. Most people in the U.S. have irregular bowel movements and do not have bowel movements every day or the same number of bowel movements each day.
  • Most cases of constipation can be self-treated with over-the-counter (OTC) laxatives. According to the American Gastroenterological Association, around $725 million is spent on laxative products each year in the U.S. However, the overuse of laxatives may also cause constipation along with other problems such as fluid imbalances and nutrient (vitamins and minerals) deficiencies.
  • Constipation can also alternate with diarrhea in some cases. This pattern is more commonly associated with irritable bowel syndrome (IBS). Fecal impaction (a condition in which stool hardens in the rectum and prevents the passage of any stool) is when constipation becomes a serious condition.

Risk factors and causes
  • Medications: Many medications commonly cause constipation. Some of the most common ones include anticonvulsants such as and carbamazepine (Tegretol®), phenytoin (Dilantin®), and valproic acid (Depakote®), aluminum-containing antacids such as Alternagel®, Amphojel®, Basaljel®, Gaviscon®, Maalox®, and Mylanta®, Riopan®, and Tums®, certain antidepressants (called TCA or tricyclics) such as amitriptyline (Elavil®), doxepin (Sinequan®), and imipramine (Tofranil®), antihistamines such as diphenhydramine (Benadryl® and cetirizine, Zyrtec®), calcium channel blocking drugs such as amlodipine (Norvasc®) and diltiazem (Cardizem®), diuretics such as hydrochlorothiazide and furosemide (Lasix®), iron supplements, and narcotic pain medications such as hydrocodone (Vicodin®, Lortab®), hydromorphone (Dilaudid®), meperidine (Demerol®), morphine (MS Contin®), and oxycodone (Percocet®, Oxycontin®).
  • Bowel Habits: Bowel movements are under voluntary control, meaning that the normal urge people feel when they need to have a bowel movement can be suppressed. Although occasionally it is appropriate to suppress an urge to defecate, such as during a meeting or in a car, doing this too frequently can lead to a disappearance of urges and result in constipation.
  • Diet: Lack of fiber in the diet may cause constipation. Fiber is important in maintaining a soft, bulky stool. Americans eat an average of 5 to 14 grams of fiber daily, which is short of the 20 to 35 grams recommended by the American Dietetic Association. Both children and adults often eat too many refined and processed foods from which the natural fiber has been removed. The best natural sources of fiber are fruits (apples, plums), vegetables such as green leafy vegetables and cruciferous vegetables (broccoli, cabbage), and whole grains. A diet high in fat including foods such as cheese, eggs, and meats may contribute to constipation, due to the difficulty in digesting these foods.
  • Dehydration: Dehydration (or lack of water) can also cause constipation. Liquids add fluid to the colon and bulk to stools, making bowel movements softer and easier to pass. However, liquids that contain caffeine, such as coffee and cola drinks, may worsen symptoms (caffeine tends to dehydrate the body). Alcohol is another beverage that causes dehydration. It is important to drink fluids that hydrate the body, the main one being water.
  • Lack of exercise: A lack of physical activity can lead to constipation. Exercise may increase the muscular contractions of the intestine, thus helping bowel movements. Exercise is also important for relieving stress, which contributes to constipation. Lack of physical activity is thought to be one of the reasons constipation is common in older people.
  • Laxatives: One suspected cause of severe constipation is the over-use of stimulant laxatives such as aloe, castor oil, rhubarb, and senna. An association has been reported between the chronic use of stimulant laxatives and damage to the nerves and muscles of the colon, resulting in constipation. The body may actually become physically dependent upon the laxative in order to have a bowel movement. Potassium (a mineral that is crucial for heart and muscle function) imbalances, from long-term use of laxatives (especially at high dosages) has been blamed for deaths of apparently otherwise healthy women. Stimulant laxatives are the most likely laxative to cause side effects. These can include abdominal discomfort, stomach cramps, diarrhea, upset stomach, vomiting, and yellow-brown urine.
  • Hormonal disorders: Hormonal changes can affect bowel movements. For example, menopause causes estrogen levels to decline, resulting in constipation in many individuals. High levels of female hormones during a woman's menstrual periods and pregnancy may also cause constipation. Thyroid hormone imbalances such as hypothyroidism (too little thyroid hormone) and hyperparathyroidism (too much parathyroid hormone, which raises calcium levels) can cause constipation.
  • Diseases of the colon: There are many diseases that can affect the function of the muscles and/or nerves of the colon. These include diabetes, scleroderma (excessive deposits of connective tissue in organs), intestinal pseudo-obstruction (decreased ability of the intestines to move stool), Hirschsprung's disease (enlargement of the colon that stops the flow of stool), irritable bowel syndrome (IBS), diverticulitis (formation of pouches in the colon), and Chagas disease (tropical disease caused by a parasite). Cancer with tumors that block the colon can also cause constipation.
  • Central nervous system diseases: A few diseases of the brain and spinal cord may cause constipation, including Parkinson's disease, multiple sclerosis (loss of muscle control and coordination), and spinal cord injuries.
  • Colonic inertia: Colonic inertia is a condition in which the nerves and/or muscles of the colon do not work normally resulting in a decrease in the evacuation of stool from the body. The cause of colonic inertia is unclear. Colonic inertia can be the result of the chronic use of stimulant laxatives, or diseased muscles and nerves in the colon.
  • Pelvic floor dysfunction: Pelvic floor dysfunction (also known as outlet obstruction or outlet delay) refers to a condition in which the muscles of the lower pelvis that surround the rectum (the pelvic floor muscles) do not work normally. These muscles are critical for normal bowel movements. The causes of why these muscles fail to work properly in some people are not known.
  • Psychosomatic: Psychosomatic problems, such as anxiety and stress, may cause constipation.
  • Others: Some individuals will experience constipation during colds and the flu, possibly due to dehydration and lack of proper diet. Lead poisoning may also cause constipation.

Signs and symptoms
  • Signs and symptoms of constipation include difficult bowel movement, dry bowel movement, painful bowel movement, dry feces, small feces, hard feces, absent bowel movement, infrequent bowel movements, fecal straining, abdominal pain and bloating, nausea, vomiting, weight loss, uncomfortable feeling, fatigue, and diarrhea.

Diagnosis
  • History: An individual's medical history is very important in determining the diagnosis of constipation. A medical history from a patient with constipation will find out about a patient's dietary habits, physical activity level, medications, and existing diseases that can contribute to constipation. The doctor may ask a patient to describe his or her constipation, including duration of symptoms, frequency of bowel movements, consistency of stools, presence of blood in the stool (which may also indicate colon cancer), and toilet habits (how often and where one has bowel movements).
  • Physical examination: A physical examination may identify diseases that can cause constipation such as scleroderma (excessive deposits of connective tissue in organs), intestinal pseudo-obstruction (decreased ability of the intestines to move stool), Hirschsprung's disease (enlargement of the colon that stops the flow of stool), irritable bowel syndrome (IBS), diverticulitis (formation of pouches in the colon), and Chagas disease (tropical disease caused by a parasite). A rectal examination with the finger may uncover a tight anal sphincter that may be making defecation difficult. If a stool-filled colon can be felt through the abdominal wall, it suggests that constipation is severe. Stool in the rectum suggests a problem with the anal, rectal, or pelvic floor muscles.
  • Blood tests: Blood tests may be used to evaluate underlying conditions in constipation. Blood tests include thyroid hormone (to detect hypothyroidism), blood glucose levels (to determine if diabetes is present) and calcium (to uncover excess parathyroid hormone). Other blood tests can include serum cortisol levels (the stress hormone), that may indicate Addison's disease (a disease of the adrenal gland), myeloma (cancer of the bone marrow), and porphyria (blood disorder dealing with iron content).
  • Abdominal x-ray: Large amounts of stool in the colon usually can be seen on simple x-ray films of the abdomen. The more stool that is found, the more severe the constipation.
  • Barium enema: A barium enema, also called a lower GI or gastrointestinal series, is an x-ray study in which liquid barium is inserted into the rectum and colon through the anus. The barium outlines the colon on the x-rays and defines the normal or abnormal anatomy of the colon and rectum. Barium enema can detect tumors and narrowings (strictures) in the colon.
  • Sigmoidoscopy or colonoscopy: An examination of the rectum and lower (sigmoid) colon is called a sigmoidoscopy. An examination of the rectum and entire colon is called a colonoscopy. The individual will have a liquid dinner the night before a colonoscopy or sigmoidoscopy. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soft drinks. Whole bowel irrigation with large quantities of fluid (usually 1 gallon) is performed using a solution of polyethylene glycol and electrolytes (GoLYTELY®). Then an enema (Fleet's Enema®) is used early the next morning to ensure all contents are out of the colon. An enema an hour before the test may also be necessary. During a sigmoidoscopy, a long, flexible tube with a light on the end (called a sigmoidoscope) is used to view the rectum and lower colon. The patient may be lightly sedated before the exam (usually Versed® or midazolam) and can even watch the procedure on a screen. The procedure may cause abdominal pressure and a mild sensation of wanting to have a bowel movement. Air injected into the colon can cause cramping and gas.
  • During a colonoscopy, a flexible tube with a light on the end (called a colonoscope) is used to view the entire colon. This tube is longer than a sigmoidoscope. The patient lies on his or her side sedated, and a tube is inserted through the anus and rectum into the colon. If an abnormality is seen, the doctor can use the colonoscope to remove a small piece of tissue for examination (biopsy). Gas and bloating are common side effects with a colonoscopy.
  • Colorectal transit study: This test shows how well food moves through the colon. The patient swallows capsules containing small plastic markers that are visible on an x-ray. The movement of the markers through the colon is monitored by abdominal x-rays taken several times 3 to 7 days after the capsule is swallowed. The patient eats a high-fiber diet during the course of this test.
  • Defecography: Defecography is a modification of the barium enema examination. A thick, pasty preparation of barium is inserted into the rectum of the patient through the anus. X-rays then are taken while the patient expels the barium. The barium clearly outlines the rectum and anus, demonstrating the changes taking place in the muscles of the pelvic floor (connective tissue directly under the pelvis) during defecation.
  • Anorectal manometry: In this procedure, a narrow, flexible tube is inserted into the anus and rectum. A small balloon is then inflated at the tip of the tube, allowing a measure of the coordination of the muscles in the bowel.
  • Colonic motility studies: Colonic motility studies are similar to anorectal motility studies in many aspects. A very long, narrow, flexible tube is inserted through the anus and passed through part or the entire colon during a procedure called colonoscopy. Sensors within the tube measure the pressures that are generated by the contractions of the colonic muscles. These contractions are the result of coordinated activity of the colonic nerves and muscles. If the activity of the nerves or muscles is abnormal, the pattern of colonic pressures will be abnormal.

Complications
  • Constipation is not usually serious and will self-resolve, although it can be very uncomfortable. Constipation can lead to abdominal pain, rectal discomfort, abdominal fullness and bloating, nausea, fatigue (tiredness), and loss of appetite. Persistent straining can cause hemorrhoids or fissures (tears in the anus). As a result, rectal bleeding may occur, appearing as bright red streaks on the surface of the stool.
  • Severe constipation (chronic) can cause fecal impaction, or a mass of hard stool unable to be eliminated by normal bowel movement. An impaction can cause serious consequences if left untreated, such as ulceration and death of anal tissue.
  • The over use of laxatives use can cause the bowels to become dependent upon the laxatives (lazy bowel syndrome). Poor absorption of vitamins and minerals may also occur with laxative use.
  • Constipation has been linked with colon cancer, stroke, headaches, heart attacks, and varicose veins.

Treatment
  • There are several approaches to the treatment of constipation. The first is to distinguish between acute (recent) and chronic (long time) constipation. With acute constipation or constipation that is getting worse, it is necessary to find the cause early so as not to overlook a serious illness that should be treated urgently. The second principle is to prevent the constipation from worsening, and also to prevent potential damage to the colon that can be caused by the frequent use of stimulant laxatives. The third is to know when it is time to evaluate the cause of chronic constipation. Evaluation for the cause of chronic constipation needs to be done if there is no response to the simple treatments. The goal of treatment in constipation should be a bowel movement every 2 to 3 days without difficulty.
  • Occasional constipation: For occasional, short-lived, or mild constipation, the best treatment is prevention. Regular exercise and dietary measures such as increasing fiber (20 to 35 grams each day including more fruits and uncooked vegetables), more water, and more whole grain breads and cereals are helpful. For individuals that get gas or bloating from whole grains, a fiber substitute such as psyllium (a natural soluble fiber) may help. If gas is still a problem, methylcellulose (Citrucel®) or polycarbophil (FiberCon®) may be beneficial. These products do not undergo bacterial fermentation, therefore creating less gas. Laxatives may also be used, but should be reserved for temporary constipation due to illness, incapacity, or travel.
  • Chronic constipation: If constipation becomes chronic (persistent), consulting with a doctor is necessary. Diseases of the colon or rectum will be evaluated along with discontinuing constipating medicines. Increasing fiber and water will also be recommended.
  • Laxatives: Laxatives are medicines taken orally or rectally to relieve and prevent constipation. Oral laxatives come in many different forms, including liquids, tablets, wafers, gums, or powders that are dissolved in water. Rectal laxatives include suppositories and enemas. Before turning to laxatives, lifestyle changes (such as diet, plenty of water, and exercise) can be used to help manage occasional irregularity.
  • There are many different types of laxatives available for the treatment of constipation. Laxatives include bulk forming, stimulant, osmotic, stool softeners, lubricating, and saline agents.
  • Medical history and other medications an individual is taking may limit laxative options. Laxatives can interact with many medications, including blood thinners such as warfarin (Coumadin®), digoxin, antibiotics as tetracycline and ciprofloxacin (Cipro®), diabetes, and anti-seizure medications.
  • Laxative use can be dangerous if constipation is caused by a serious condition such as appendicitis (inflammation of the appendix) or a bowel obstruction (blockage in the colon). If laxatives are used frequently over a period of weeks or months, they can decrease the colon's natural ability to function (contract) and actually worsen constipation. In severe cases, overuse of laxatives can damage nerves, muscles, and tissues of the large intestine. Laxatives should not be abused. Children under age 6 should not take laxatives without a doctor's recommendation. If pregnant or breast feeding, seek a doctor's advice before using laxatives.
  • The misuse of laxatives can cause significant and severe medical complications. These complications include abdominal pain, bloating, and fullness, dehydration, esophageal tears (Mallory-Weiss Syndrome), electrolyte abnormalities, irritable bowel syndrome (colon disorder), ulceration of the bowel, a decreased absorption of nutrients leading to hypoproteinemia (low protein), hypoalbuminemia (low albumin) and calcium deficiency, fatty infiltration of the liver, pancreatitis (inflammation of the pancreas), hemorrhoid symptoms, esophagitis (inflammation of the esophagus), melanosis coli (pigment disorder of the colon), gastritis (inflammation of the stomach), gastric ulceration, gastric bleeding, and intestinal injury.
  • Bulk-forming laxatives: Bulk-forming laxatives are the most commonly recommended initial treatments for constipation. Bulk-forming laxatives may work as quickly as 12 hours after first use or take as long as three days to be effective. Some bulk-forming laxatives are derived from natural sources such as agar, psyllium, kelp, and plant gum. Others are synthetic cellulose compounds such as methylcellulose and carboxymethylcellulose. Natural and synthetic bulk-forming laxatives act similarly. They dissolve or swell in the intestines, lubricate and soften the stool, and make the passage of bowel movements easier and more frequent. Bulk-forming laxatives are not absorbed from the intestines into the body and are safe for long-term use. These agents must be taken with water or they can cause obstruction. Many people also report no relief after taking bulking agents and suffer from a worsening in bloating and abdominal pain. They are also safe for elderly patients to use. Brand names include psyllium (Metamucil® and Fiberall®), methylcellulose (Citrucel®), and polycarbophil (Konsyl®).
  • Stimulant laxatives: Stimulant laxatives cause regular muscle contractions in the intestines. Agents in this class include bisacodyl (Correctol®, Dulcolax®), and senna (Senokot®). Stimulant laxatives can cause dehydration and electrolyte problems, in addition to structural and muscular changes in the colon (such as cathartic colon) over long-term use. In some products, stimulant laxatives are combined with bulk-forming laxatives. Studies suggest that phenolphthalein, an ingredient in some stimulant laxatives, might increase a person's risk for cancer. The U.S. Food and Drug Administration (FDA) has proposed a ban on all over-the-counter products containing phenolphthalein.
  • Osmotic laxatives: Osmotic laxatives work by increasing the amount of water in the small intestine and colon, which increases the size and softness of the stool. When ingested on an empty stomach, they may take only one to two hours to take effect. Osmotic laxatives include lactulose (Cephulac®), sorbitol, and polyethelyne glycol (Miralax®). Osmotic laxatives can cause cramping, nausea, fluid loss and electrolyte imbalances, including sodium and potassium.
  • Stool softeners: Stool softeners moisten the stool and prevent dehydration. These laxatives are often recommended after childbirth or surgery. Examples include docusate sodium (Colace® and Surfak®). These products are suggested for people who should avoid straining in order to pass a bowel movement. The prolonged use of this class of drugs may result in an electrolyte imbalance. It may be three days before a patient experiences results. Stool softeners should not be used exclusively but may be useful in combination with stimulant laxatives.
  • Lubricant laxative: Lubricants grease the stool, enabling it to move through the intestine more easily. Lubricants typically stimulate a bowel movement within eight hours. Mineral oil is the most common example, often being used to prevent straining in patients for whom it would be dangerous to strain (such as patients who have suffered from a stroke). Absorbed mineral oil may collect in tissues of the body, for example, the lymph nodes and the liver, where it can cause inflammation.
  • Saline laxatives: Saline laxatives act like a sponge to draw water into the colon for easier passage of stool. Saline laxatives are used to treat acute constipation if there is no indication of bowel obstruction. Electrolyte imbalances have been reported with extended use, especially in small children and people with renal (kidney) deficiency. Saline laxatives include magnesium citrate and Fleet Phospho-soda®.
  • Enemas: Saline enemas cause water to be drawn into the colon. Phosphate enemas (Fleet Phospho-soda®) stimulate the muscles of the colon. Mineral oil enemas lubricate and soften hard stool. Emollient enemas (Colace Microenema®) contain agents that soften the stool.
  • Enemas are particularly useful when there is impaction (hardening of stool in the rectum). Defecation usually occurs between a few minutes and one hour after the enema is inserted. Enemas are meant for occasional rather than regular use. The frequent use of enemas can cause disturbances of the fluids and electrolytes in the body.
  • Suppositories: Different types of suppositories have different mechanisms of action. Bisacodyl (Dulcolax®) is an example of a stimulant laxative suppository. Glycerin suppositories are believed to have their effect by irritating the rectum. They are commonly used in infants and children with constipation. The insertion of the finger into the rectum when the suppository is placed may itself stimulate a bowel movement.
  • Drug Therapies: Tegaserod (Zelnorm®) is a serotonin partial agonist for patients who have chronic constipation. Tegaserod treatment produces significant improvements in the symptoms of chronic constipation and is safe and well tolerated.
  • Chloride channel activators: These medications increase intestinal fluid and motility to help stool pass, thereby reducing the symptoms of constipation. Lubiprostone (Amitiza®) has been reported to be safely used for up to six to 12 months. This drug has a U.S. Food and Drug Administration (FDA) pregnancy warning category C: "this medication may be harmful to an unborn baby." Patients should not use Amitiza® without telling their doctor in cases of pregnancy, and should inform their doctor if they become pregnant during treatment. Patients may be asked to have a pregnancy test before taking Amitiza®.
  • Surgery: For individuals with problematic constipation that is due to diseases of the colon or laxative abuse, surgery may be a treatment alternative. During surgery, most of the colon, except for the rectum (or the rectum and part of the sigmoid or lower colon), is removed. The cut end of the small intestine is attached to the remaining rectum or sigmoid colon. In patients with colonic inertia, surgery is reserved for those who do not respond to all other therapies. If the surgery is to be done, there must be no disease of the small intestinal muscles. Normal small intestinal muscles are evidenced by normal motility studies of the small intestine itself.
  • Behavioral treatments: Bowel retraining may be necessary for some individuals with constipation. Such training involves sitting on the toilet for 15 to 20 minutes at the same time each day so the body can get into the habit of having regular bowel movements. The ideal time is following breakfast. Elevation of the feet by placing a footstool before the toilet may simulate the bowels. Biofeedback therapy is sometimes helpful to treat a variety of bowel disorders including constipation and pelvic floor dysfunction. In this procedure, special sensors measure bodily functions of which we are usually unaware of. A therapist helps use this information to modify or change abnormal responses to more normal patterns.
  • Constipation in children: Constipation in children (less than six years of age) may be treated with increasing fluids (water or diluted fruit juices such as apple or prune) and increasing the amount of fiber (such as cereals, prunes, or apricots) if the infant is over four months old. Glycerin suppositories are commonly used for constipation in infants.

Integrative therapies
  • Strong scientific evidence:
  • Phosphates, phosphorus: Phosphates are the naturally occurring form of the element phosphorus. In the body, phosphate is the most abundant intracellular (in the cell) anion (negatively charged particle). Occasional constipation is an approved use of phosphates in adults and children, both in oral form and as an enema (for example, Fleet Enema®). Sodium phosphate taken orally or as an enema may also be used for bowel preparation for procedures, such as imaging studies, or endoscopy (for example, Fleet Phospho-soda®, Fleet Enema®). As a laxative, phosphates appear to increase peristalsis (movement of the gastrointestinal tract) and cause an entry of fluids into the intestine. Aluminum phosphate is used orally to neutralize gastric acid.
  • Avoid if allergic or hypersensitive to any ingredients in phosphorus/phosphate preparations. Use phosphorus/phosphate salts cautiously with kidney or liver disease, heart failure, unstable angina (chest pain), recent heart surgery, hyperphosphatemia (high phosphate blood level), hypocalcemia (low calcium blood level), hypokalemia (low potassium blood level), hypernatremia (high sodium blood level), Addison's disease, intestinal obstruction or ileus, bowel perforation, severe chronic constipation, acute colitis, toxic megacolon, hypomotility syndrome, hypothyroidism, scleroderma, or gastric retention. Avoid sodium phosphate enemas with abnormalities of the intestine. Too much phosphorus may cause serious or life-threatening toxicity.
  • Good scientific evidence:
  • Aloe: Dried latex from the inner lining of aloe leaves has been used traditionally as a laxative taken by mouth. Although few studies have been conducted to assess this effect of aloe in humans, the laxative properties of aloe components such as aloin are well supported by scientific evidence. A combination herbal remedy containing aloe was found to be effective for constipation (laxative), although it is not clear if this effect was due to aloe or to other ingredients in the product. Further study is needed to establish dosing and to compare the effectiveness and safety of aloe with other commonly used laxatives. Caution is advised when taking aloe supplements, as adverse effects including diarrhea and drug interactions are possible. Aloe supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor. Do not use for more than three days without consulting a doctor.
  • Psyllium: Psyllium is derived from the husks of the seeds of Plantago ovata or Plantago isphagula. Psyllium contains a high level of soluble dietary fiber, and is the chief ingredient in many commonly used bulk laxatives, including products such as Metamucil® and Serutan®. Psyllium has long been used for constipation as a chief ingredient in "bulk laxatives." Generally an increase in stool weight, an increase in bowel movements per day, and a decrease in total gut transit time has been observed in most studies. Use psyllium with caution, as psyllium may cause medications not to be absorbed properly. Do not use for more than three days without consulting a doctor.
  • Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantain (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Prescription drugs should be taken one hour before or two hours after psyllium. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.
  • Unclear or conflicting scientific evidence:
  • Aromatherapy: Early research in Guillian Barré syndrome patients show a possible benefit of aromatherapy massage for constipation. Additional study is warranted to differentiate the effects of essential oils vs. massage. Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
  • Art therapy: Art therapy involves the application of a variety of art modalities including drawing, painting, clay and sculpture. Art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible. It is not clear if play with modeling clay is an effective therapeutic intervention in children with constipation and encopresis (fecal incontinence associated with psychiatric disorders)). In one study, play with clay modeling therapy was associated with improvement in five of six children, but was limited by lack of a control group.
  • Art therapy may evoke distressing thoughts or feelings. Use under the guidance of a qualified art therapist or other mental health professional. Some forms of art therapy use potentially harmful materials. Only materials known to be safe should be used. Related clean-up materials (like turpentine or mineral spirits) that release potentially toxic fumes should only be used with good ventilation.
  • Ayurveda: Early evidence suggests that a liquid Ayurvedic herbal preparation called Misrakasneham, containing 21 different herbs, as well as castor oil, ghee, and milk, may be of benefit for constipation in advanced cancer treatment. Further studies are needed to evaluate this treatment for palliative care.
  • Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.
  • Barley: Barley (Hordeum vulgare) is a cereal used as a staple food in many countries. It is commonly used as an ingredient in baked products and soup in Europe and the United States. Barley has been used traditionally as a treatment for constipation, due to its high fiber content. However, there is limited scientific evidence in this area. Further research is necessary in order to establish safety and dosing. Do not use for more than three days without consulting a doctor. Avoid if allergic or hypersensitive to barley flour or beer. Use cautiously with diabetes, asthma or arrhythmia (irregular heartbeat). Contamination of barley with fungus has occurred. Traditionally, women have been advised against eating large amounts of barley sprouts during pregnancy. Infants fed with a formula containing barley water, whole milk, and corn syrup have developed malnutrition and anemia, possibly due to vitamin deficiencies.
  • Cascara sagrada: Cascara (Rhamnus purshianus), also known as cascara sagrada, is widely accepted as a mild and effective treatment for chronic constipation, however limited data is available. Early studies have examined the use of cascara for bowel cleansing. Evidence is insufficient to suggest effectiveness over conventional treatments for this indication. Caution is advised when taking cascara supplements, as adverse effects including diarrhea and drug interactions are possible. Cascara supplements should not be used if pregnant or breast feeding, unless otherwise directed by a doctor. Do not use for more than three days without consulting a doctor.
  • Clay: It is not clear if play with modeling clay is an effective therapeutic intervention in children with constipation and encopresis (fecal incontinence associated with psychiatric disorders). There is a lack of reports of allergy to clay in the available scientific literature. However, in theory, allergy/hypersensitivity to clay, clay products, or constituents of clay may occur. Avoid if pregnant or breastfeeding.
  • Flaxseed: Flaxseed (Linum usitatissimum) is a rich source of the essential fatty acid alpha-linolenic acid. Early studies in humans suggest that flaxseed (not flaxseed oil) may be used as a laxative for constipation. However, more information is needed to compare effectiveness and dosing to more commonly used agents. Do not use for more than three days without consulting a doctor. Avoid if allergic to flaxseed, flaxseed oil or other plants of the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed with a history of esophageal stricture, ileus, gastrointestinal stricture, bowel obstruction, acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Use cautiously with history of a bleeding disorder or with drugs that cause bleeding risk (like anticoagulants and non-steroidal anti-inflammatories (like aspirin, warfarin, Advil®), or with high triglyceride levels, diabetes, mania, seizures or asthma. Avoid if pregnant or breastfeeding. Avoid with prostate cancer, breast cancer, uterine cancer or endometriosis. Avoid ingestion of immature flaxseed pods.
  • Iodine: Povidone-iodine bowel irrigation before large bowel resection has been suggested as a sterilization technique. Reactions can be severe, and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis or tuberculosis. Use cautiously when applying to the skin because it may irritate/burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is considered safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.
  • Massage: Various forms of therapeutic superficial (on the surface) tissue manipulation have been practiced for thousands of years across cultures. Chinese use of massage dates to 1600 BC, and Hippocrates made reference to the importance of physicians being experienced with "rubbing" as early as 400 BC. Touch is fundamental to massage therapy and is used by therapists to locate painful or tense areas, to determine how much pressure to apply, and to establish a therapeutic relationship with clients. A small number of human trials report that abdominal massage may be helpful in patients with constipation. Overall, these studies are not well designed or reported. Better quality research is necessary before a definitive conclusion can be reached.
  • Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with a history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
  • Probiotics: Probiotics are beneficial bacteria (sometimes referred to as "friendly germs") that help to maintain the health of the intestinal tract and aid in digestion. They also help keep potentially harmful organisms in the gut under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be consumed as capsules, tablets, beverages, powders, yogurts and other foods. The use of probiotics for constipation has had mixed results. More studies are needed to determine what forms of probiotics and which pathways of administration may be effective. Probiotics may cause diarrhea, but are otherwise safe.
  • Psyllium: Patients with new onset constipation or presumed hemorrhoid bleeding frequently require the use of both fiber supplements and diagnostic colonoscopy. Researchers have concluded that in non-constipated patients, psyllium-based fiber supplementation should not be initiated in the few days prior to endoscopy using a polyethylene glycol preparation. Instructions given by the appropriate healthcare professional and pharmacist should be followed for colonoscopy preparation.
  • Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantain (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Prescription drugs should be taken one hour before or two hours after psyllium. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.
  • Reflexology: Early study of reflexology in humans with constipation has not yielded definitive results. Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.
  • Rhubarb: Rhubarb (Rheum palmatum) has been used by Chinese herbalists for thousands of years for various health conditions. Although rhubarb has been used in multiple cultures as a laxative, only limited scientific study has reported positive effects for chronic constipation when using a combination of rhubarb and Glauber's salt (sodium sulfate).
  • Avoid if allergic/hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, pre-eclampsia, renal disorders, ulcerative colitis and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12 due to risk for water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking anti-psychotic drugs or oral drugs, herbs or supplements (including calcium, iron, and zinc). Avoid if pregnant or breastfeeding.

Prevention
  • Increase fiber intake. Add more fruits and vegetables, in addition to whole grains and bran, to the diet. Adding fiber to the diet gradually may help reduce gas and bloating.
  • Cut back on high sugar, high fat and low-fiber foods such as meats, cheeses, ice cream, and processed foods.
  • Drink plenty of water (about eight full glasses a day, filtered is best). As fiber intake is increased, fluid intake may also need to be increased as well.
  • Eat on a regular schedule to give the body a chance to regulate elimination.
  • Respond to the body's natural signals to pass stool. This will keep bowel movements regular.
  • Exercise is an important factor in the management of constipation. Regular exercise (especially abdominal muscle exercises) and brisk walking are recommended according to the age and physical condition of the individual.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. American Gastroenterological Association. . Accessed March 13, 2009.
  2. International Foundation for Functional Gastrointestinal Disorders. . Accessed March 13, 2009.
  3. National Institutes of Health. . Accessed March 13, 2009.
  4. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed March 13, 2009.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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