INTRODUCTION
Definition of Chronic Constipation
Chronic constipation (Psora) is a disorder characterized by unsatisfactory defecation (Psora) that results from infrequent stools, difficult stool passage (Psora), or both over a time period of at least 12 weeks.
The diagnosis is primarily symptom-based, relying on the patient’s self-report of symptoms; however, the description of constipation symptoms varies significantly among patients. Common symptoms may include infrequent bowel movement (Psora), hard stool (Psora), too small stool (Tubercular/ Psora), difficulties with stool expulsion (excessive straining) (Tubercular/ Psora), feeling of incomplete evacuation (Psora) or simply a patient description of “a feeling of being constipated” without any of these constipation-related symptoms.
Symptom-based criteria for chronic functional constipation
1- Rome II Criteria
At least 12 weeks, need not be consecutive, in past 12 months of > 2 of:
• Straining in >25% of defecations (Psora)
• Sensation of incomplete evacuation in >25% of defecations (Psora)
• Sensation of anorectal obstruction/blockade in >25% of defecations (Psora/ Psora)
• Manuel maneuvers to facilitate >25% of defecations (Psora)
• Fewer than three defecations per week (Psora)
• Loose stools should not be present and there are insufficient criteria for IBS (Tubercular/ Syphilis)
2- ACG CC Task Force
Symptoms for at least 3 of the last 12 months consisting of:
• Infrequent stools: less than 3 per week, or (Psora)
• Difficult stool passage, which may include: (Psora)
• Straining (Psora)
• Sense of difficulty passing stool (Psora)
• Incomplete evacuation (Psora)
• Hard/lumpy stools (Psora/ Syphilis)
• Prolonged time to stool (Psora)
• Need for manual maneuvers to pass stool (Psora/ Sycosis)
• Can be a combination of both
Abbr. – ACG: American College of Gastroenterology; CC: chronic constipation; IBS: Irritable Bowel Syndrome
Incidence
Chronic constipation (Psora) appears to be very common in the general population although its prevalence varies depending on the diagnostic criteria used. Chronic constipation disproportionately affects women compared with men (2.2:1), and the prevalence increases with age.
Symptoms
Symptoms may be benign but chronic constipation can significantly reduce life quality, and, if left untreated, can result in fecal impaction (Psora), incontinence (Psora/ Syphilis), and, very rarely, bowel perforation (Psora/ Syphilis).
Irritable Bowel Syndrome (IBS) (Tubercular/ Syphilis) is the most common and best studied functional gastrointestinal (GI) disorder.
Irritable Bowel Syndrome
IBS symptoms (Psora/ Tubercular) are heterogeneous in their expression. The clinical presentation is abdominal pain (Psora) or discomfort associated with altered bowel habits (e.g., diarrhea, constipation, or a combination of both at times (Sycosis)) and with a change in the consistency or frequency of stools. Other associated symptoms may include bloating, urgency, and/or a feeling of incomplete evacuation (Psora). Although symptoms tend to occur in clusters, individual symptoms may also occur sequentially and they may vary in type, location, and severity over time.
Classification of IBS
IBS is classified as diarrhea-predominant (IBS-D) (Tubercular/ Sycosis), constipation-predominant (IBS-C) (Tubercular/ Psora), or mixed—a combination of both (IBS-M), depending on the most prevalent bowel pattern. This sub-classification is determined by stool frequency, form, and passage. However, because the predominant symptom often changes over time, it is not uncommon for a patient to alternate between these IBS subgroups or between different functional bowel disorders such as IBS-C or IBS-D and functional constipation or functional diarrhea.
Diagnosis of IBS
There are no biological markers or specific tests for the diagnosis of IBS. The diagnosis is therefore based on identifying a cluster of clinical symptoms that are consistent with the disorder and excluding other conditions by looking for clinical alert signs and performing limited diagnostic testing.
Management of IBS
Since the pathophysiological mechanisms underlying the disorder are not known, the current approach to management is based primarily on the patients’ predominant symptoms and overall wellbeing rather than on a specific underlying etiological mechanism. The treatment is determined on basis of totality and the peculiars- whether pain, diarrhea, or constipation is predominant and the targeted symptom is treated using the same medications as in other conditions.
Etiology of constipation
There are many causes for constipation. The disorder may be secondary to systemic diseases (e.g., hypothyroidism (Psora/ Syphilis), hyperparathyroidism (Psora/ Sycosis), diabetes mellitus (Tubercular)), gastrointestinal diseases (e.g., mechanical obstruction due to colon or rectal cancer), neurological disorders (e.g., autonomic neuropathy (Syphilis), Parkinson’s disease (Psora/ Syphilis), multiple sclerosis (Syphilis)). Another common etiology is the use of prescription or over the counter (OTC) medications that slow down the intestinal transit.
Chronic primary or idiopathic constipation is primarily a diagnosis of exclusion which is made when the other possible etiologies have been ruled out. Once primary idiopathic constipation has been diagnosed and “red flags” suggesting other serious diseases such as colon or rectal cancer have been eliminated, empiric treatment may be started with an appropriate follow-up to assess the response.
Medications associated with constipation
By Prescription
Opiates
Anticholinergics
Tricyclic antidepressants
Calcium channel blockers
Antiparkinsonian drugs
Sympathomimetics
Antipsychotics
Diuretics
Antihistamines
Over the counter (OTC)
Antacids, especially calcium containing
Calcium supplements
Iron supplements
NSAIDS
Antidiarrheal agents
Management of Chronic Constipation
I. Initial recommendations
In clinical practice patients with milder symptoms are usually offered behavioral, diet and lifestyle modifications as the first step of treatment. Patients are often encouraged to increase their fluid intake, get involved with moderate increase in exercise, and use the bathroom daily in response to feeling of urge for a bowel movement or at a specific time, particularly after meals. Patients with more severe symptoms or those who do not respond to this initial treatment are usually offered an empiric medication treatment with fiber supplements and Homoeopathic medicine.
II. Evaluation of chronic primary constipation
The initial evaluation is based on careful history and physical evaluation. Important historical features include bowel frequency, stool consistency, need for straining, and feeling of incomplete evacuation. Presence of abdominal pain/discomfort can suggest a diagnosis of other functional disorders (e.g., IBS-C). Identifying alarm symptoms (e.g., weight loss, reduced appetite, weakness) are important since they can suggest other underlying conditions which usually require further evaluation (e.g., abdominal imaging, colonoscopy). Patients’ medications should be reviewed carefully and initial limited laboratory tests should be performed to exclude medications (e.g., calcium channel blockers, anticholinergics) or diseases (e.g., hypothyroidism) to which constipation is secondary.
Patients with primary constipation can be further evaluated for the underlying pathophysiological mechanism(s) of their constipation. Using functional tests of the colon and anorectum, primary constipation can be divided into three separate subgroups:
1. Slow transit constipation
2. Normal transit constipation
3. Obstructed defecation
Slow transit Constipation refers to a decrease in colonic transit particularly in its proximal parts (i.e., the ascending and transverse colon).
Normal transit constipation refers to patients who meet the criteria for chronic functional constipation but testing of their colonic transit is between normal limits. These patients often have misperceptions of normal bowel movements and some may have psychosocial disorders.
Obstructed defecation refers to organic/mechanical obstruction at the level of the rectosigmoid colon or pelvic floor, or functional obstruction due to failure of the anorectal and pelvic floor muscles to relax during defecation.
Combinations of these three subtypes are possible.
III. Pharmacologic treatments for chronic constipation
Pharmacologic treatments for chronic constipation include several groups of medications with different mechanism/mode of action.
Bulk-forming agents are organic polymers that absorb water. These agents increase stool mass and water content thereby making it bulkier, softer and easier to pass. Examples include bran, psyllium and methylcellulose. These agents are often used as the first line treatment of constipation.
Stool softeners, like docusate sodium and docusate calcium, are surface-active agents that facilitate water interacting with the stool in order to soften the stool, make it more slippery, and easier to pass. These agents are often used as OTC medications for constipation.
Osmotic laxatives are poorly absorbed ions or molecules that create an osmotic gradient within the intestinal lumen, drawing water into the lumen and making stools soft and loose. Examples of this group of agents include poorly absorbed electrolytes such as milk of magnesia, magnesium citrate, and sodium phosphate; poorly absorbed disaccharides such as lactulose and sorbitol; and polyethylene glycol 3350 (PEG). These agents are usually used for short-term treatment of constipation or for intermittent use in chronic constipation. The PEG solution is also used for intestinal purges in preparation for diagnostic procedures (e.g., colonoscopy) or surgery.
Stimulant laxatives increase peristalsis in the large bowel and fluid and electrolyte secretion in the distal small bowel and colon. These agents include anthraquinones (senna, cascara, danthron), diphenylmethanes (bisacodyl and phenolphthalein) and castor oil. They are available in different OTC forms and are usually used for intermittent and short term treatment of constipation.
Secretory agents – this group is currently represented by Lubiprostone, a new agent that was recently approved by the US Food and Drug Administration (FDA) for the treatment of chronic idiopathic constipation in adults. It works by activating chloride channels on the small intestinal mucosa and thereby leading to chloride rich intestinal fluid secretion that increases luminal water content and stool hydration.
Prokinetic agents – These agents act by increasing intestinal motility and thereby accelerating intestinal transit. Tegaserod maleate is a 5-HT4 pre-synaptic receptor agonist that enhances the peristaltic reflex, increases colonic motility, decreases visceral hypersensitivity, and facilitates secretion into the colonic lumen.
Homoeopathic Treatment of Chronic Constipation
Top Ten Remedies for Constipation
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