What is constipation?

Constipation means different things to different people. For many people, it simply means infrequent stools. For others, however, constipation means hard stools, difficulty passing stools (straining), or a sense of incomplete emptying after a bowel movement. The cause of each of these "types" of constipation probably is different, and the approach to each should be tailored to the specific type of constipation. Constipation also can alternate with diarrhea. This pattern commonly occurs as part of the irritable bowel syndrome (IBS). At the extreme end of the constipation spectrum is fecal impaction, a condition in which stool hardens in the rectum and prevents the passage of any stool. The number of bowel movements generally decreases with age. Ninety-five percent of adults have bowel movements between three and 21 times per week, and this would be considered normal. The most common pattern is one bowel movement a day, but this pattern is seen in less than 50% of people. Moreover, most people are irregular and do not have bowel movements every day or the same number of bowel movements each day. Medically speaking, constipation usually is defined as fewer than three bowel movements per week. Severe constipation is defined as less than one bowel movement per week. There is no medical reason to have a bowel movement every day. Going without a bowel movement for two or three days does not cause physical discomfort, only mental distress for some people. Contrary to popular belief, there is no evidence that "toxins" accumulate when bowel movements are infrequent or that constipation leads to cancer. It is important to distinguish acute (recent onset) constipation from chronic (long duration) constipation. Acute constipation requires urgent assessment because a serious medical illness may be the underlying cause (for example, tumors of the colon). Constipation also requires an immediate assessment if it is accompanied by worrisome symptoms such as rectal bleeding, abdominal pain and cramps, nausea and vomiting, and involuntary loss of weight. In contrast, the evaluation of chronic constipation may not be urgent, particularly if simple measures bring relief.

What causes constipation?

Theoretically, constipation can be caused by the slow passage of digesting food through any part of the intestine. More than 95% of the time, however, the slowing occurs in the colon.

Medications that cause constipation

A frequently over-looked cause of constipation is medications. The most common offending medications include: Narcotic pain medications such as codeine (for example, Tylenol #3), oxycodone(for example, Percocet), and hydromorphone (Dilaudid); Antidepressants such as amitriptyline (Elavil) and imipramine (Tofranil) Anticonvulsants such as phenytoin (Dilantin) and carbamazepine (Tegretol) Iron supplements Calcium channel blocking drugssuch as diltiazem (Cardizem) and nifedipine(Procardia) Aluminum-containing antacids such as Amphojel and Basaljel In addition to the medications listed above, there are many others that can cause constipation. Simple measures (for example, increasing dietary fiber) for treating the constipation caused by medications are often are effective, and discontinuing the medication is not necessary. If simple measures don't work, it may be possible to substitute a less constipating medication. For example, a nonsteroidal

antiinflammatory drug (for example, ibuprofen) may be substituted for narcotic pain
medications. Additionally, one of the newer and less constipating anti-depressant medications [for example, fluoxetine (Prozac)] may be substituted for amitriptyline and imipramine.

Other causes of constipation

Habit Bowel movements are under voluntary control. This means 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 (for example, when a bathroom is not available), doing this too frequently can lead to a disappearance of urges and result in constipation. Diet Fiber is important in maintaining a soft, bulky stool. Diets that are low in fiber can, therefore, cause constipation. The best natural sources of fiber are fruits, vegetables, and whole grains. Laxatives One suspected cause of severe constipation is the over-use of stimulant laxatives [for example, senna (Senokot), castor oil, and certain herbs]. An association has been shown between the chronic use of stimulant laxatives and damage to the nerves and muscles of the colon, and it is believed by some that the damage is responsible for the constipation. It is not clear, however, whether the laxatives have caused the damage or whether the damage existed prior to the use of laxatives and, indeed, has caused the laxatives to be used. Nevertheless, because of the possibility that stimulant laxatives can damage the colon, most experts recommend that stimulant laxatives be used as a last resort after non-stimulant treatments have failed. Hormonal disorders Hormones can affect bowel movements. For example: Too little thyroid hormone (hypothyroidism) and too much parathyroid hormone (by raising the calcium levels in the blood) can cause constipation. At the time of a woman's menstrual periods, estrogen and progesterone levels are high and may cause constipation. However, this is rarely a prolonged problem. High levels of estrogen and progesterone during pregnancy also can cause constipation. Diseases that affect the colon There are many diseases that can affect the function of the muscles and/or nerves of the colon. These include diabetes, scleroderma, intestinal pseudo-obstruction, Hirschsprung's disease, and Chagas disease. Cancer or narrowing (stricture) of the colon that blocks the colon likewise can cause a decrease in the flow of stool. Central nervous system diseases Some diseases of the brain and spinal cord may cause constipation, including Parkinson's disease, multiple sclerosis, 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. As a result, the contents of the colon are not propelled through the colon normally. The cause of colonic inertia is unclear. In some cases, the muscles or nerves of the colon are diseased. Colonic inertia also may be the result of the chronic use of stimulant laxatives as described above. In most cases, however, there is no clear cause for the constipation. 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 defecation (bowel movement). It is not known why these muscles fail to work properly in some people, but they can make the passage of stools difficult even when everything else is normal.

How is constipation evaluated (diagnosed)?

A careful history and physical examination is important in all patients with constipation. There are many tests that can be used to evaluate constipation. Most patients need only a few basic tests. The other tests are reserved for individuals who have severe constipation or whose constipation does not respond easily to treatment. Medical History A careful medical history from a patient with constipation is critical for many reasons, but particularly because it allows the physician to define the type of constipation. This, in turn, directs the diagnosis and treatment. For example, if defecation is painful, the physician knows to look for anal problems such as a narrowed anal sphincter or an anal fissure. If small stools are the problem, there is likely to be a lack of fiber in the diet. If the patient is experiencing significant straining, then pelvic floor dysfunction is likely. The history also uncovers medications and diseases that can cause constipation. In these cases, the medications can be changed and the diseases can be treated. A careful dietary history-which may require keeping a food diary for a week or two-can reveal a diet that is low in fiber and may direct the physician to recommend a high-fiber diet. A food diary also allows the physician to evaluate how well a patient increases his dietary fiber during treatment. Physical examination A physical examination may identify diseases (for example, scleroderma) that can cause constipation. 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 appropriate in evaluating patients with constipation. More specifically, blood tests for thyroid hormone (to detect hypothyroidism) and for calcium (to uncover excess parathyroid hormone) may be helpful. Abdominal X-ray Large amounts of stool in the colon usually can be visualized on simple X-ray films of the abdomen; the more stool that is visualized, the more severe the constipation. Barium enema A barium enema (lower GI series) is an x-ray study in which liquid barium is inserted through the anus to fill the rectum and colon. The barium outlines the colon on the X-rays and defines the normal or abnormal anatomy of the colon and rectum. Tumors and narrowings (strictures) are among the abnormalities that can be detected with this test. Colonic transit (marker) studies Colonic transit studies are simple X-ray studies that determine how long it takes for food to travel through the intestines. For transit studies, individuals swallow capsules for one or more days. Inside the capsules are many small pieces of plastic that can be seen on X-rays. The gelatin capsules dissolve and release the plastic pieces into the small intestine. The pieces of plastic then travel (as would digesting food) through the small intestine and into the colon. After 5 or 7 days, an X-ray of the abdomen is taken and the pieces of plastic in the different parts of the colon are counted. From this count, it is possible to determine if and where there is a delay in the colon. In non-constipated individuals, all of the plastic pieces are eliminated in the stool and none remain in the colon. When pieces are spread throughout the colon, it suggests that the muscles and/or nerves throughout the colon are not working, which is typical of colonic inertia. When pieces accumulate in the rectum, it suggests pelvic floor dysfunction. Defecography Defecography is a modification of the barium enema examination. For this procedure, a thick paste of barium is inserted into the rectum of a patient through the anus. X-rays then are taken while the patient defecates the barium. The barium clearly outlines the rectum and anus and demonstrates the changes taking place in the muscles of the pelvic floor during defecation. Thus, defecography examines the process of defecation and provides information about anatomical abnormalities of the rectum and pelvic floor muscles during defecation.

Ano-rectal motility studies Ano-rectal motility studies, which complement defecography tests, provide an assessment of the function of the muscles and nerves of the anus and rectum. For ano-rectal motility studies, a flexible tube, approximately an eighth of an inch in diameter, is inserted through the anus and into the rectum. Sensors within the tube measure the pressures that are generated by the muscles of the anus and rectum. With the tube in place, the patient performs several simple maneuvers such as voluntarily tightening the anal muscles. Ano-rectal motility studies can help determine if the muscles of the anus and rectum are working normally. When the function of these muscles is impaired, the flow of stool is obstructed, thereby causing a condition similar to pelvic floor dysfunction. Magnetic resonance imaging defecography The newest test for evaluating defecation and its disorders magnetic resonance imaging defecography and is similar to barium defecography. However, magnetic resonance imaging(MRI) is used instead of X-rays to provide images of the rectum during defecation. MRI defecography appears to be an excellent way to study defecation, but the procedure is expensive and somewhat cumbersome. As a result, it is used in only a few institutions that have a particular interest in constipation and abnormalities of defecation. Colonic motility studies Colonic motility studies are similar to ano-rectal motility studies in many aspects. A very long, narrow (one-eighth inch in diameter), flexible tube is inserted through the anus and passed through part or all of the 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. Colonic motility studies are most useful in defining colonic inertia. These studies are considered research tools, but they can be helpful in making decisions regarding treatment in patients with severe constipation.

What treatments are available for constipation?

There are many treatments for constipation, and the best approach relies on a clear understanding of the underlying cause. Dietary fiber (bulk-forming laxatives) The best way of adding fiber to the diet is increasing the quantity of fruits and vegetables that are eaten. This means a minimum of five servings of fruits or vegetables every day. For many people, however, the amount of fruits and vegetables that are necessary may be inconveniently large or may not provide adequate relief from constipation. In this case, fiber supplements can be useful. Fiber is defined as material made by plants that is not digested by the human gastrointestinal tract. Fiber is one of the mainstays in the treatment of constipation. Many types of fiber within the intestine bind to water and keep the water within the intestine. The fiber adds bulk (volume) to the stool and the water softens the stool. There are different sources of fiber and the type of fiber varies from source to source. Types of fiber can be categorized in several ways, for example, by their source. The most common sources of fiber include: fruits and vegetables, wheat or oat bran, psyllium seed (for example, Metamucil, Konsyl), synthetic methyl cellulose (for example, Citrucel), and polycarbophil (for example, Equilactin, Konsyl Fiber). Polycarbophil often is combined with calcium (for example, Fibercon). However, in some studies, the calcium-containing polycarbophil was not as effective as the polycarbophil without calcium. A lesser known source of fiber is an extract of malt (for example, Maltsupex); however, this extract may soften stools in ways other than increasing fiber.

Increased gas (flatulence) is a common side effect of high-fiber diets. The gas occurs because the
bacteria normally present within the colon are capable of digesting fiber to a small extent. The bacteria produce gas as a byproduct of their digestion of fiber. All fibers, no matter what their source, can cause flatulence. However, since bacteria vary in their ability to digest the various types of fiber, the different sources of fiber may produce different amounts of gas. To complicate the situation, the ability of bacteria to digest one type of fiber can vary from individual to individual. This variability makes the selection of the best type of fiber for each person (for example, a fiber that improves the quality of the stool without causing flatulence) more difficult. Thus, finding the proper fiber for an individual becomes a matter of trial and error. The different sources of fiber should be tried one by one. The fiber should be started at a low dose and increased every one to two weeks until either the desired effect on the stool is achieved or troublesome flatulence interferes. (Fiber does not work overnight.) If flatulence occurs, the dose of fiber can be reduced for a few weeks and the higher dose can then be tried again. (It generally is said that the amount of gas that is produced by fiber decreases when the fiber is ingested for a prolonged period of time; however, this has never been studied.) If flatulence remains a problem and prevents the dose of fiber from being raised to a level that affects the stool satisfactorily, it is time to move on to a different source of fiber. When increasing amounts of fiber are used, it is recommended that greater amounts of water be consumed (for example, a full glass with each dose). In theory, the water prevents "hardening" of the fiber and blockage (obstruction) of the intestine. This seems like simple and reasonable advice. However, ingesting larger amounts of water has never been shown to have a beneficial effect on constipation, with or without the addition of fiber. (There is already a lot of water in the intestine and extra water that is digested is absorbed and excreted in the urine.) It is reasonable to drink enough fluids to prevent dehydration because with dehydration there may be reduced intestinal water. Because of concern about obstruction, persons with narrowings (strictures) or adhesions (scar tissue from previous surgery) of their intestines should not use fiber unless it has been discussed with their physician. Some fiber laxatives contain sugar, and patients with diabetes may need to select sugar-free products. Lubricant laxatives Lubricant laxatives contain mineral oil as either the plain oil or an emulsion (combination with water) of the oil. The oil stays within the intestine, coats the particles of stool, and presumably prevents the removal of water from the stool. This retention of water in the stool results in softer stool. Mineral oil generally is used only for the short-term treatment of constipation since its long-term use has several potential disadvantages. The oil can absorb fat-soluble vitamins from the intestine and, if used for prolonged periods, may lead to deficiencies of these vitamins. This is of particular concern in pregnancy during which an adequate supply of vitamins is important for the fetus. In the very young or very elderly in whom the swallowing mechanism is not strong or is impaired by strokes, small amounts of the swallowed oil may enter the lungs and cause a type of pneumonia called lipid pneumonia. Mineral oil also may decrease the absorption of some drugs such as warfarin (Coumadin) and oral contraceptives, thereby decreasing their effectiveness. Despite these potential disadvantages, mineral oil can be effective when short-term treatment is necessary. Emollient laxatives (stool softeners) Emollient laxatives are generally known as stool softeners. They contain a compound called docusate (for example, Colace). Docusate is a wetting agent that improves the ability of water within the colon to penetrate and mix with stool. This increased water within the stool softens the stool. Although studies have not shown docusate to be consistently effective in relieving constipation. Stool softeners often are used in the long-term treatment of constipation. It may take a week or more for docusate to be effective. The dose should be increased after one to two weeks if no effect is seen. Although docusate generally is safe, it may increase the absorption of mineral oil and some medications from the intestine. Absorbed mineral oil collects in tissues of the body, for example, the lymph nodes and the liver, where it causes inflammation. It is not clear if this inflammation has any important

consequences, but it generally is felt that prolonged absorption of mineral oil should not be allowed. The use of emollient laxatives is not recommended together with mineral oil or with certain prescription medications. Emollient laxatives are commonly used when there is a need to soften the stool temporarily and make defecation easier (for example, after surgery, childbirth, or heart attacks). They are also used for individuals with hemorrhoids or anal fissures. Hyperosmolar laxatives Hyperosmolar laxatives are undigestible, unabsorbable compounds that remain within the colon and retain the water that already is in the colon. The result is softening of the stool. The most common hyperosmolar laxatives are lactulose (for example, Kristalose), sorbitol, and polyethylene glycol (for example, MiraLax). and are available by prescription only. These laxatives are safe for long-term use and are associated with few side effects. Hyperosmolar laxatives may be digested by colonic bacteria and turned into gas, which may result in unwanted abdominal bloating and flatulence. This effect is dose-related and less with polyethylene glycol. Therefore, gas can be reduced by reducing the dose of the laxative. In some cases, the gas will decrease over time. Saline laxatives Saline laxatives contain non-absorbable ions such as magnesium, sulfate, phosphate, and citrate [for example, magnesium citrate (Citroma), magnesium hydroxide, sodium phosphate). These ions remain in the colon and cause water to be drawn into the colon. Again, the effect is softening of the stool. Magnesium also may have mild stimulatory effects on the colonic muscles. The magnesium in magnesium-containing laxatives is partially absorbed from the intestine and into the body. Magnesium is eliminated from the body by the kidneys. Therefore, individuals with impaired kidney function may develop toxic levels of magnesium from chronic (long duration) use of magnesium-containing laxatives. Saline laxatives act within a few hours. In general, potent saline laxatives should not be used on a regular basis. If major diarrhea develops with the use of saline laxatives and the lost fluid is not replaced by the consumption of liquids, dehydration may result. For constipation, the most frequently-used and mildest of the saline laxatives is milk of magnesia. Epsom Salt is a more potent saline laxative that contains magnesium sulfate. Stimulant laxatives Stimulant laxatives cause the muscles of the small intestine and colon to propel their contents more rapidly. They also increase the amount of water in the stool, either by reducing the absorption of the water in the colon or by causing active secretion of water in the small intestine. The most commonly-used stimulant laxatives contain cascara (castor oil), senna (for example, Ex-Lax, Senokot), and aloe. Stimulant laxatives are very effective, but they can cause severe diarrhea with resulting dehydration and loss of electrolytes (especially potassium). They also are more likely than other types of laxatives to cause intestinal cramping. There is concern that chronic use of stimulant laxatives may damage the colon and worsen constipation, as previously discussed. Bisacodyl (for example, Dulcolax, Correctol) is a stimulant laxative that affects the nerves of the colon which, in turn, stimulate the muscles of the colon to propel its contents. Prunes also contain a mild colonic stimulant. Tegaserod (Zelnorm) Tegaserod (Zelnorm) was approved in 2002 by the FDA specifically for the treatment of abdominal pain and constipation in women with irritable bowel syndrome. In March of 2007, the FDA asked Novartis, the company manufacturing tegaserod, to suspend sales of tegaserod in the U.S. because a retrospective analysis of data by Novartis from more than 18,000 patients showed a slight difference in the incidence of cardiovascular events (heart attacks, strokes and angina) among patients taking tegaserod compared to placebo. The data showed that cardiovascular events occurred in 13 out of 11,614 patients treated with tegaserod (.11%), compared to one cardiovascular event in 7,031 (.01%) placebo-treated patients. However, it is unclear whether tegaserod actually causes heart attacks and strokes. Doctors and scientists will be scrutinizing the data to determine the long-term safety of tegaserod. The mechanism whereby tegaserod relieves constipation (and abdominal bloating and pain) is interesting

and is related to its effects on the intestinal serotonin, a chemical that controls contractions of intestinal muscles. The contractions of the intestinal muscles control transit of digesting food through the intestine. More contractions speed transit, fewer contractions slow transit. In constipated patients, contractions are fewer. Serotonin is a chemical manufactured by nerves in the intestine that is released and then binds to muscle cells. Depending on which receptor it binds to on the muscle, serotonin can either promote or prevent contractions. The serotonin 5-HT4 receptor is a receptor that prevents contractions when serotonin binds to it. Tegaserod blocks the 5-HT4 receptor, prevents serotonin from binding to it, and thereby increases contractions of the intestinal muscles. The increased contractions speed the transit of digesting food and reduces constipation. In addition, tegaserod reduces the sensitivity of the intestinal pain-sensing nerves and can thereby reduce abdominal pain. In large placebo controlled trials involving men and women with chronic constipation, tegaserod was more effective than placebo in increasing the number of spontaneous bowel movements and reducing straining, abdominal bloating, abdominal pain, and abdominal discomfort. The most common side effect of tegaserod was diarrhea, which was usually mild or moderate and generally resolved within a few days while continuing treatment. Lubiprostone (Amitiza) Lubiprostone (Amitiza) is a selective chloride channel activator that increases secretion of chloride ions from the cells of the intestinal lining into the intestinal lumen. Sodium ions and water then follow the chloride ions into the lumen, and the water softens the stool. The FDA approved lubiprostone for the treatment of chronic constipation in both men and women in February 2006. At a dose of 24 micrograms twice a day, lubiprostone significantly and promptly increased bowel movements, improved stool consistency, and decreased straining. The most common side effect of initial clinical studies was mild to moderate nausea in 32% of patients treated with lubiprostone, compared to 3% of the controls. More long term studies of efficacy and side effects are needed to determine the place of lubiprostone in the treatment of constipation. Enemas There are many different types of enemas. By distending the rectum, all enemas (even the simplest type, the tap water enema) stimulate the colon to contract and eliminate stool. Other types of enemas have additional mechanisms of action. For example, saline enemas cause water to be drawn into the colon. Phosphate enemas (for example, Fleet phosphosoda) stimulate the muscles of the colon. Mineral oil enemas lubricate and soften hard stool. Emollient enemas (for example, Colace Microenema) contain agents that soften the stool. Enemas are particularly useful when there is impaction, which is hardening of stool in the rectum. In order to be effective, the instructions that come with the enema must be followed. This requires full application of the enema, appropriate positioning after the enema is instilled, and retention of the enema until cramps are felt. 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. This is especially true of tap water enemas. Soapsuds enemas are not recommended because they can seriously damage the rectum. Suppositories As is the case with enemas, different types of suppositories have different mechanisms of action. There are stimulant suppositories containing bisacodyl (for example, Dulcolax). Glycerin suppositories are believed to have their effect by irritating the rectum. The insertion of the finger into the rectum when the suppository is placed may itself stimulate a bowel movement. Combination products There are many products that combine different laxatives. For example, there are oral products that combine senna and psyllium (Perdiem), senna and docusate (Senokot-S), and senna and glycerin (Fletcher's Castoria). One product even combines three laxatives, senna-like casanthranol, docusate, and glycerin (Sof-lax Overnight). These products may be convenient and effective, but they also contain stimulant laxatives. Therefore, there is concern about permanent colonic damage with the use of these products, and they probably should not be used for long-term treatment unless non-stimulant treatment

fails. Miscellaneous drugs Several prescribed drugs that are used to treat medical diseases consistently cause (as a side effect) loose stools, even diarrhea. There actually are several small studies that have examined these drugs for the treatment of constipation. Colchicine

Colchicine is a drug that has been used for decades to treat gout. Most patients who take colchicine
note a loosening of their stools. Colchicine has also been demonstrated to relieve constipation effectively in patients without gout. Misoprostol (Cytotec) Misoprostol (Cytotec) is a drug used primarily for preventing stomach ulcers caused by nonsteroidal antiinflammatory drugs such as ibuprofen. Diarrhea is one of its consistent side-effects. Several studies have shown that misoprostol is effective in the short term treatment of constipation. Misoprostol is expensive, and it is not clear if it will remain effective and safe with long-term use. Therefore, its role in the treatment of constipation remains to be determined. Orlistat (Xenical) Orlistat (Xenical) is a drug that is used primarily for reducing weight. It works by blocking the enzymes within the intestine that digest fat. The undigested fat is not absorbed, which accounts for the weight loss. Undigested fat is digested by bacteria within the intestine and the products of this bacterial digestion promote the secretion of water. The products of digestion also may affect the intestine in other ways, for example, by stimulating the intestinal muscles. In fact, in studies, orlistat has been shown to be effective in treating constipation. Orlistat has few important side effects, which is consistent with the fact that only very small amounts of the drug are absorbed from the intestine. It is unclear if these prescribed drugs should be used for the treatment of constipation. Although it is difficult to recommend them specifically just for the treatment of constipation, they might be considered for constipated individuals who are overweight, have gout, or need protection from nonsteroidal antiinflammatory drugs. Exercise People who lead sedentary lives are more frequently constipated than people who are active. Nevertheless, limited studies of exercise on bowel habit have shown that exercise has minimal or no effect on the frequency of bowel movements. Thus, exercise can be recommended for its many other health benefits, but not for its effect on constipation. Biofeedback Most of the muscles of the pelvis surrounding the anus and rectum are under some degree of voluntary control. Thus, biofeedback training can teach patients with pelvic floor dysfunction how to make their muscles work more normally and improve their ability to defecate. During ano-rectal biofeedback training, a pressure-sensing catheter is placed through the anus and into the rectum. Each time a patient contracts the muscles, the muscles generate a pressure that is sensed by the catheter and recorded on a screen. By watching the pressures on the screen and attempting to modify them, patients learn how to relax and contract the muscles more normally. Surgery For individuals with problematic constipation that is due to diseases of the colon or laxative abuse, surgery is the ultimate treatment. During surgery, most of the colon, except for the rectum (or the rectum and part of the sigmoid 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. Electrical pacing

Electrical pacing is still in its experimental phases. Electrical pacing may be done using electrodes implanted into the muscular wall of the colon. The electrodes exit the colon and are attached to an electrical stimulator. Alternatively, stimulation of the sacral skin can be used to stimulate nerves going to the colon. These techniques are promising, but much more work lies ahead before their role in treating constipation, if any, has been defined.

What is the approach to the evaluation and treatment of constipation?

There are several principles in approaching the evaluation and treatment of constipation. The first principle is to differentiate between acute (recent onset) and chronic (long duration) constipation. Thus, with acute constipation or constipation that is worsening, it is necessary to assess for the cause early so as not to overlook a serious illness that should be treated urgently. The second principle is to start treatment early and use the treatments that have the least potential for harm. This will prevent constipation from worsening, and it also will prevent potential damage to the colon that can be caused by the frequent use of stimulant laxatives. The third principle 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 not be a bowel movement every day, but a bowel movement every two to three days without difficulty (without straining). Start with the simple things. Don't suppress urges to defecate. When the urge comes, find a toilet. With the assistance of your physician and pharmacist, determine if there are drugs that you are taking that could be contributing to the constipation. See if the drugs can be discontinued or changed. Increase the fiber in your diet by consuming more fruits, vegetables, and whole grains. (There are other health benefits from this recommendation as well.) It may be difficult to get enough fiber in the diet to effectively treat constipation, so don't hesitate to take fiber supplements if necessary (wheat bran, psyllium, etc.). Use increasing amounts of fiber and/or change the type of fiber consumed until there is a satisfactory result. Don't expect fiber to work overnight. Allow weeks for adequate trials. What if constipation does not respond to these simple, safe measures? These efforts should not be discontinued but other measures should be added. If the constipation is infrequent, that is, every few weeks (as it can be when due to the menstrual cycle), it probably doesn't matter what other measures are added-emollient, saline, or hyper-osmolar laxatives, enemas, and suppositories. Even stimulant laxatives every four to six weeks are unlikely to damage the colon. Unfortunately, the tendency when using stimulant laxatives is to unconsciously increase the frequency of their use. Before you know it, you're taking them every week, or more often, and permanent damage might result. If constipation is a continuous rather than an intermittent problem, probably the safest laxatives to take on a regular basis are the hyper-osmolar laxatives. Their use should be supervised by a physician. As with fiber, increasing doses of different hyper-osmolar laxatives should be tried over several weeks until a satisfactory type and dose of laxative is found. Hyper-osmolar laxatives, however, can be expensive. Milk of magnesia is the mildest of the saline laxatives, is inexpensive, and provides a good alternative. Most patients can adjust the dose of milk of magnesia to soften the stool adequately without developing diarrhea or leakage of stool. Prunes and prune juice have been used for many years to treat mild constipation. There is no evidence that the mild stimulant effects of prunes or prune juice damage the colon. Stronger stimulant laxatives usually are recommended only as a last resort after non-stimulant treatments have failed. Many people take herbs to treat their constipation because they feel more comfortable using a "natural" product. Unfortunately, most of these herbal preparations contain stimulant laxatives and their long term

use raises the possibility that they also may damage the colon.

When should I seek medical care for chronic constipation?

If the main problem is straining to push the stool out, chronic constipation should probably be evaluated early. This difficulty might be due to pelvic floor dysfunction, and the treatment of choice is biofeedback training, not laxatives. If the constipation is not responding to the simple measures discussed previously with the addition of hyper-osmolar laxatives or milk of magnesia, it is time to consult a physician for an evaluation. If a primary doctor is not comfortable performing the evaluation or does not have confidence in doing an evaluation, he or she should refer the patient to a gastroenterologist. Gastroenterologists evaluate constipation frequently and are very familiar with the diagnostic testing described previously.

What's new in the treatment of constipation?

Each part of the intestine (stomach, small intestine, and colon) has a network of nerves that controls its muscles. A great deal of research is being done in order to gain an understanding of how these nerves control each other and ultimately the muscles. Much of this research involves the study of neurotransmitters. (Neurotransmitters are chemicals that nerves use to communicate with each other.) This research is allowing scientists to develop drugs that stimulate (and inhibit) the various nerves of the colon which, in turn, cause the muscles of the colon to contract and propel the colonic contents. Such drugs have great potential for the treatment of constipation that is due to colonic inertia. The first of these drugs is in clinical trials and is likely to be available soon. These drugs are an exciting development because they offer a new treatment for a difficult-to-treat form of constipation. Nevertheless, there are many questions about these types of drugs that must be answered. How effective are they? Will they work in many or only a few patients? Will they work in patients who have damaged their nerves with stimulant laxatives? Since these medications are likely to be used for a lifetime, how safe will they be with many years of use? Will they be used indiscriminately in situations for which simple treatments (for example, fiber) or more appropriate treatments (for example, biofeedback training) should be used?

Constipation is the most common digestive complaint in the United States. It is a symptom rather
than a disease and, despite its frequency, often remains unrecognized until the patient develops sequelae, such as anorectal disorders or diverticular disease. No widely accepted clinically useful definition of constipation exists. Health care providers usually use the frequency of bowel movements (ie, less than 3 bowel movements per week) to define constipation. However, the Rome criteria, initially introduced in 1988 and subsequently modified twice to yield the Rome III criteria, have become the research-standard definition of constipation.[1] According to the Rome III criteria for constipation, a patient must have experienced at least 2 of the following symptoms over the preceding 3 months: Fewer than 3 bowel movements per week Straining Lumpy or hard stools Sensation of anorectal obstruction Sensation of incomplete defecation Manual maneuvering required to defecate The Rome III criteria also stipulate that a patient should not meet the suggested criteria for irritable bowel syndrome (IBS) and that loose stools are rarely present without the use of laxatives. For surgical purposes, the most useful definition of constipation is simply a change in bowel habits or

defecatory behavior that results in acute or chronic symptoms or diseases that would be resolved with relief of the constipation. Acute or subacute constipation in middle-aged or elderly patients should prompt a search for an obstructing colonic lesion. Acute constipation must be carefully distinguished from ileus secondary to intra-abdominal emergencies, including infections. Constipation is frequently chronic, can significantly affect an individuals quality of life, and may be associated with significant health care costs. It is considered chronic if it occurred for at least 12 weeks (in total, not necessarily consecutively) during the previous year. Chronic constipation may be associated with psychological disturbances, and the reverse is true as well. However, these issues are beyond the scope of this article. Laboratory evaluation does not play a large role in the initial assessment of the patient. Imaging studies are used to rule out acute processes that may be causing colonic ileus, to evaluate causes of chronic constipation, or to rule out sources of sepsis or intra-abdominal problems. Lower gastrointestinal (GI) endoscopy, anorectal manometry, electromyography (EMG), and balloon expulsion may be used in the evaluation of constipation. Medical care should focus on dietary change and exercise rather than laxatives, enemas, and suppositories, none of which really addresses the underlying problem. Surgical care is generally restricted to the evaluation of underlying causes; it may also be indicated for the management of acute complications of constipation. Once acute constipation has resolved and the associated medical or surgical conditions have been ruled out, additional inpatient care is rarely indicated.

Pathophysiology
Constipation is divided, with considerable overlap, into issues of stool consistency (hard, painful stools) and issues of defecatory behavior (infrequency, difficulty in evacuation, straining during defecation). Although hard stools frequently result in defecatory difficulties, soft bulky stools may also be associated with constipation, particularly in elderly patients with anatomic abnormalities and in patients with impaired colorectal motility. Constipation may originate primarily from within the colon and rectum or may originate externally. Processes involved in constipation originating from the colon or rectum include the following: Colon obstruction(neoplasm, volvulus, stricture) Slow colonic motility, particularly in patients with a history of chronic laxative abuse Outlet obstruction (anatomic or functional) - Anatomic outlet obstruction may derive from intussusception of the anterior wall of the rectum on straining, rectal prolapse, and rectocele; functional outlet obstruction may derive from puborectalis or external sphincter spasm when bearing down, shortsegment Hirschsprung disease, and damage to the pudendal nerve, typically related to chronic straining or vaginal delivery Hirschsprung diseasein children

Chagas disease
Factors involved in constipation originating outside the colon include poor dietary habits (the most common factor, generally involving inadequate fiber or fluid intake and/or overuse of caffeine or alcohol), medications, systemic endocrine or neurologic diseases, and psychological issues. Constipation results in various degrees of subjective symptoms and is associated with abnormalities (eg, colonic diverticular disease, hemorrhoidal disease, anal fissures) that occur secondary to an increase in colonic luminal pressure and intravascular pressure in the hemorrhoida l venous cushions. Nearly 50% of patients with diverticular or anorectal disease, when asked, deny experiencing constipation. On careful questioning, however, nearly all of these patients report having symptoms suggestive of defecatory straining or infrequency, mostly constipation related, although occasionally diarrhea related in patients with irritable bowel or other chronic diarrheal disorders.

Etiology

The etiology of constipation is usually multifactorial, but it can be broadly divided into 2 main groups: primary constipation and secondary constipation.

Primary constipation
Primary (idiopathic, functional) constipation can generally be subdivided into the following 3 types: Normal-transit constipation (NTC) Slow-transit constipation (STC) Pelvic floor dysfunction (ie, pelvic floor dyssynergia) NTC is the most common subtype of primary constipation. Although the stool is passing through the colon at a normal rate, patients find it difficult to evacuate their bowels. Patients in this category sometimes meet the criteria for IBS with constipation (IBS-C). The primary difference between chronic constipation and IBS-C is the prominence of abdominal pain or discomfort in IBS. Patients with NTC usually have a normal physical examination. STC is characterized by infrequent bowel movements, decreased urgency, or straining to defecate. It occurs more commonly in female patients. Patients with STC have impaired phasic colonic motor activity. They may demonstrate mild abdominal distention or palpable stool in the sigmoid colon. Pelvic floor dysfunction is characterized by dysfunction of the pelvic floor or anal sphincter. Patients often report prolonged or excessive straining, a feeling of incomplete evacuation, or the use of perineal or vaginal pressure during defecation to allow the passage of stool, or they may report digital evacuation of stool.

Secondary constipation
Dietary issues that may cause constipation include inadequate water intake; inadequate fiber intake; overuse of coffee, tea, or alcohol; a recent change in bowel habit paralleled by changes in the diet; and ignoring the urge to defecate. Reduced levels of exercise may play a role as well. Structural causes of secondary constipation include anal fissures, thrombosed hemorrhoids, colonic strictures, obstructing tumors, volvulus, and idiopathic megarectum. Systemic diseases that may cause constipation include the following: Endocrinologic and metabolic disorders -Hypercalcemia, hyperparathyroidism, hypokalemia, hypothyroidism, pregnancy, and diabetes mellitus (constipation is the most common gastrointestinal problem affecting the diabetic population) Neurologic disorders - Stroke, Hirschsprung disease, Parkinson disease, multiple sclerosis, diabetic autonomic neuropathy, spinal cord lesion, head injury, cerebrovascular accident, Chagas disease, and familial dysautonomia Connective-tissue disorders -Scleroderma, amyloidosis, and mixed connective-tissue disease Often, what appears to be acute or subacute constipation may represent a colonic or small bowel ileus from systemic or intra-abdominal infection or other intra-abdominal emergencies. In appropriate settings, this should be addressed and not missed, lest the patients condition deteriorate acutely. Medications that may contribute to constipation include the following: Antidepressants (eg, cyclic antidepressants and monoamine oxidase inhibitors [MAOIs]) Metals (eg, iron and bismuth) Anticholinergics (eg, benztropine and trihexyphenidyl) Opioids (eg, codeine and morphine) Antacids eg, (aluminum and calcium compounds) Calcium channel blockers (eg, verapamil) Nonsteroidal anti-inflammatory drugs (NSAIDs; eg, ibuprofen and diclofenac) Sympathomimetics (eg, pseudoephedrine) Many psychotropic drugs[2] Cholestyramine and stimulant laxatives (long-term use) - Although laxatives are frequently used to treat constipation, chronic laxative use becomes habituating and may lead to the development of a dilated

atonic laxative colon, which necessitates increasing laxative use with decreasing efficacy Inadequate thyroid hormone supplementation Constipation may be of toxicologic origin, as with lead poisoning. Psychological issues (eg, depression, anxiety, somatization, and eating disorders) may also contribute to the development of constipation.

Prognosis
Most active patients do well with medical management and appropriate dietary management. Recurrence depends on the patients long-term compliance to therapy. A small percentage of patients are quite debilitated as a result of constipation. Some patients with functional (primary or idiopathic) constipation (ie, colonic inertia) require total abdominal colectomy with ileorectal anastomosis. After a careful preoperative workup that includes physical and psychological assessment, patients with outlet obstruction generally respond well to surgical correction and have a good prognosis. Dyskinesias of the pelvic floor musculature and of the sphincter mechanism may be managed via biofeedback therapy, but the results are mixed. Patients who are chronically dependent on increasing doses of self-prescribed laxatives are perhaps the most difficult patients to treat. Most such patients can be treated with a combination of fiber, water, and osmotic agents (eg, polyethylene glycol ,sorbitol). However, the need for increasing doses of laxatives and the intermittent use of other agents becomes problematic. In rare situations in which patients are virtually refractory to laxatives, total abdominal colectomy may be performed after careful workup. Postoperatively, these patients often experience a greatly improved quality of life. A careful preoperative evaluation and a detailed informed consent discussion are required.

Patient Education
Patient education typically involves instructions for improving dietary management. Dietary deficiency requires increased fluid and fiber supplementation for life. For patients who implement recommended dietary changes, the prognosis is excellent. For patient education resources, see the Esophagus, Stomach, and Intestine Center, as well as Constipation in Adults and Constipation in Children.

Background
Constipation is a common condition about which there are many widespread notions that have no basis in fact. The purpose of this article is to summarize current scientific knowledge on the subject.

Methods
Selective review of the literature.

Results
Diagnostic evaluation usually fails to reveal the cause of constipation. It is due to medications in some patients, while endocrine disorders are the cause in only a small minority. Abnormal defecation may be due to dysfunction of the pelvic floor. Most patients complain of abdominal fullness and of needing to strain to pass stool; low stool frequency is a rare symptom. The symptoms alone determine the indication for treatment. Constipation usually poses no threat to health. Some patients are helped by a diet rich in fiber, others by laxatives. A number of laxatives with different modes of action are available; all are safe and generally well tolerated. In some patients, dysfunctional defecation may be an indication for proctological surgery.

Conclusions

The Rome criteria are useful for establishing a specific diagnosis of constipation. Most patients can be helped with laxatives and patient education. Keywords:constipation, defecation, laxatives, dietary fiber Chronic constipation goes under a number of alternative designations, including "irregularity," "costiveness," "sluggishness of the bowels," and "intestinal hypomotility." The treatment of constipation with bowel movementinducing procedures and medications has a long history. Many unproven notions, some of them demonstrably false, are in circulation even today regarding the causes and treatment of constipation. When polled, 10% to 20% of persons in the general population state that they suffer from constipation (1). The learning objectives of this article for the reader are the following: knowing the symptoms to which the term "constipation" refers, and understanding their causes; knowing which diagnostic studies are indicated (and which are superfluous); being able to identify incorrect notions about the significance of constipation and about its treatment; being able to advise sufferers about the significance and treatment of constipation. This review article is based on a search of the PubMed database for articles containing the key word "constipation."

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Definition
The term "constipation" refers to a constellation of symptoms. Only one-quarter of all patients who consider themselves constipated state that they have fewer than three bowel movements per week (2). Some patients are worried that their stool frequency is too low because they fear self-poisoning in consequence of the long time that the stool remains in the body; this fear has no basis in fact (3). For most patients, the chief complaint is either a feeling of fullness and/or the need to strain in order to have a bowel movement.

Definition
The term "constipation" refers to a constellation of symptoms.

Symptoms
Low stool frequency is only one of the symptoms of constipation. There is no minimum stool frequency required for good health. The "Rome criteria" are a useful set of diagnostic criteria for constipation that highlight the chronicity of the disorder and the importance of symptoms other than infrequency of bowel movements. They serve the purpose of cutting back on unnecessary ancillary diagnostic testing (Box 1). They are also intended to enable more uniform reporting of therapeutic trials (2).
Box 1

The diagnosis of constipation according to the current version of the "Rome criteria"
At least two of the following symptoms are required to have been present for at least three of the past six months (2): Straining at stool at least 25% of the time Hard stools at least 25% of the time A feeling of incomplete evacuation at least 25% of the time*1 A feeling of anal blockage at least 25% of the time*1 Manual maneuvers for rectal emptying at least 25% of the time*1 Two stools or less per week

*1

These symptoms indicate an impairment of defecation

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Pathogenesis
A variety of pathogenetic mechanisms can cause constipation (Box 2). The distinction between organic and functional types of chronic constipation has no practical relevance in the treatment of patients.
Box 2

The pathophysiological components of chronic constipation

Abnormal intrinsic motility Lack of luminal factors (stretching, chemical and tactile stimuli) Medications (see Table 1) Hormones (very rarely, e.g., in pheochromocytoma) Lack of extrinsic innervation (in paraplegia) Impaired defecation

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General lifestyle and nutrition

In a normal, non-constipated individual, physical activity can serve as a stimulus to bowel emptying. Ambulatory patients suffering from constipation are, however, no less physically active than healthy persons (3). Thus, telling a constipated patient to exercise more is illogical. Neither are such recommendations founded in any demonstration of efficacy. Although it is true that a diet including little dietary fiber is associated with low stool volume in healthy persons, dietary analysis does not reveal any difference in the amount of dietary fiber consumed by constipated and non-constipated persons (3). Bacterially non-degradable dietary fiber, such as wheat bran, has been found in meta-analyses to improve transit time and stool weight, yet constipated persons have, on the average, low stool weight and prolonged transit times regardless of whether their diet contains a large amount of fiber (4).

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Prolonged colonic transit time

Some constipated persons can be shown to have a prolonged colonic transit time that cannot be normalized even by the consumption of large amounts of dietary fiber. This is true of about half of all patients (5) in specialized centers, but presumably fewer in general practice.

Possible causes of secondary constipation

Secondary forms of constipation are often due to neurological causes and only rarely due to endocrine causes. In occasional cases, constipation is due to an underlying endocrine or, more commonly, neurological disease; in other cases, it is an undesired effect of medication (Table 1). Opiate-induced constipation, in particular, should be treated as soon as it arises (6). In most cases, however, the cause remains unclear. The importance of hormonal causes is generally overestimated (except during pregnancy). About half of all premenopausal women report having less frequent bowel movements in the second half of their cycles, but the objectively measurable transit delay is only slight (3). Parkinsons disease and

paraplegia are the main neurological causes.

Table 1
Medications that commonly cause constipation, and the appropriate therapeutic management

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Impairment of defecation
Unlike mechanical obstruction of the intestinal lumen by neoplasms (for example), changes in the shape of the anorectum and pelvic floor and abnormalities of sphincter function can lead to a functional obstruction of the defecation pathway, and thus to constipation (8). Such changes can only be detected with functional diagnostic testing, e.g., by functional proctological examination and defecography, rather than with traditional morphological techniques such as colonoscopy and positive-contrast colonic enema. Some patients involuntarily contract the external anal sphincter while straining at stool and thereby block the defecation pathway (dyssynergy of the pelvic floor; anismus; so-called "outlet obstruction"). This is a case of faulty use of a muscle that is, in and of itself, normal. It is still unclear when or how this problem arises. Paradoxical contraction of the external sphincter can be demonstrated by a number of methods, including manometry, electromyography (EMG), and defecography, but any "pathological" finding of this type may be an artifact, because the patient is not as relaxed in the laboratory setting as he or she would be at home.

Impaired defecation
Possible impairment of defecation should be sought by specific questioning of the patient and directed physical examination. If the rectum is not held adequately in place while the patient strains at stool, invagination of the rectum can result (internal rectal prolapse). The invaginated segment of the bowel may then simulate a full rectum, so that the patient feels the need to defecate (feeling of incomplete emptying) and strains further. Mechanical damage of the invaginated bowel wall is thought to be the cause of solitary rectal ulcers. With larger rectoceles, and in cases of abnormal lowering of the pelvic floor, the pressure of straining serves only to expand the rectocele or push the pelvic floor further downward, rather than being employed, as it is normally, to widen the anal canal and expel the stool. These two pathological conditions are caused by trauma during childbirth and by chronic straining.

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Diagnostic evaluation
Causes of impaired defecation
Impaired defecation may be due to dysfunction of the anal sphincter or a pathological change in the architecture of the pelvic floor.

It is important that the patients history should be taken actively, because patients often do not report certain symptoms spontaneously (Box 2). Apart from history-taking, diagnostic testing can be kept to a bare minimum for the vast majority of patients. A digital rectal examination is part of the basic physical work-up, particularly when the symptoms point to a possible functional disturbance of the rectum (Box 2). Colonoscopy is indicated only if an organic disease of the colon is suspected, or if it is due to be performed anyway for carcinoma screening. It is not an essential element of the diagnostic evaluation of chronic constipation. Laboratory studies, too, are superfluous in most cases. The next step is high-dose trial therapy with bacterially non-degradable dietary fiber, for a period of about two weeks. The most suitable substances for this purpose are wheat bran and psyllium preparations. Bran is less expensive, but also less well tolerated (9). If a trial of non-degradable fiber results in adequate improvement of the symptoms, then no further diagnostic assessment is needed (5). Measurement of the transit time mainly serves to objectify the patients symptoms, as subjective reports of low stool frequency are often not very accurate. If the transit time is normal, for example, then this will effectively disprove a patients claim of having had "practically no bowel movements at all for a week." Suspected impairment of defecation is best evaluated by defecography. In this testing technique, a viscous barium suspension is instilled into the rectum, and rectal emptying is documented with lateral pelvic fluoroscopy while the patient defecates into a radiolucent plastic commode (10). This test involves a certain amount of exposure to radiation that must be borne in mind, particularly when the patient is a woman of child-bearing age.

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Treatment
Chronic constipation is generally harmless, but it often impairs the patients quality of life (11). Diagnostic evaluation and treatment are needed only when the patients subjective degree of suffering calls for it.

Basic treatment
Patient education is important. The physician should explain to the patient that there is no minimum required frequency of bowel movements, and that rarity of bowel movements is not known to be associated with any health problems (there is no such thing as "autointoxication" or self-poisoning with unpassed stool) (3). If trial therapy with dietary fiber is successful and well tolerated, it is reasonable to recommend a high-fiber diet with whole wheat products. Fruit and vegetables are relatively ineffective, because most of the dietary fiber they contain is degraded by bacteria (12).

Psyllium
High-dose trial therapy with bacterially non-degradable dietary fiber can be carried out, for example, with psyllium preparations. A number of proposed treatments for chronic constipation continue to be uncritically recommended, in textbooks as well, even though they have not been shown to be effective or have actually been shown to be ineffective. While plausible physiological mechanisms can be adduced for some of these recommendations (eat breakfast to induce colonic motility, then allow sufficient time for a visit to the toilet), others lack even this degree of plausibility (drink more than "normal" persons, e.g., more than 1.5 liters per day; engage in vigorous exercise) (3). It is likewise incorrect to imagine that bran and other high-fiber foods need to be taken with additional liquid (3).

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Laxatives

It is not known how many patients can be adequately treated with the measures discussed above. Undoubtedly, some patients do need pharmacotherapy; many obtain laxative medications themselves without a prescription. Once basic therapy has been tried and found to be unsuccessful, there is no medical objection to the long-term use of laxatives. The "laxative colon" that was observed in an earlier era was probably due to the neurotoxic substance podophylline (13). An overview of the laxatives in use today is provided in Table 2.

Table 2
The most important laxatives and their main advantages and disadvantages

Water-binding laxatives
Some osmotic salts, such as Carlsbad salt, are found in natural sources and have been used to treat constipation for many years. They have hardly been studied systematically but are probably safe, except in the presence of chronic renal failure or congestive heart failure (14). If they are used over the long term, their bad taste may be a problem.

Unsupported hypotheses
A number of proposed treatments for chronic constipation continue to be uncritically recommended, in textbooks as well, even though they have not been shown to be effective or have actually been shown to be ineffective. In recent years, polyethylene glycol (molecular weight 33504000, macrogol), which has long been used to cleanse the bowel in preparation for diagnostic and therapeutic procedures, has been found to be effective for the long-term treatment of constipation (15). Macrogol should be taken daily. Its onset of action is relatively slow, and tolerance does not appear to develop. The electrolytes found in many preparations are not an advantage. The sugar alcohol sorbite and the disaccharide lactulose are also often used to treat constipation. They produce a considerable degree of bloating, however, and are not very effective if the colonic transit time is prolonged (15, 16).

Stimulating laxatives Melanosis coli

Brown discoloration of the colonic mucosa after the ingestion of anthraquinones (melanosis coli) is of no functional importance. The generic term "stimulating laxatives" includes the anthraquinones as well as the diphenylmethanes bisacodyl and sodium picosulfate. These agents have a dual mechanism of action. They inhibit fluid resorption from the small and large intestines and induce fluid secretion in dose-dependent fashion; they also have a marked prokinetic effect. The latter may cause cramp-like abdominal pain. These medications take effect 6 to 12 hours after they are consumed, causing one to three bowel movements

(17). Stimulating laxatives (bisacodyl, picosulfate, anthraquinones) need not be taken daily, and one or two doses per week may suffice. Chronic overdosing can be expected to produce side effects, but administration in the recommended dose will not cause any untoward effects. In particular, proper dosing does not cause hypokalemia, even though this concern is often voiced. Some patients say that they develop tolerance to these preparations and therefore switch to a different one every so often, but this matter has not been systematically studied. A Swedish study involving a retrospective questionnaire revealed that about half of all patients moderately increased the dose of picosulfate over years of use, but they did not take more than the maximum recommended dose. Some patients, however, were actually able to lower the dose (18). Anthraquinones are naturally present in the form of glycosides. These compounds cannot be resorbed from the small intestine and thus have no effect on it. The pharmacologically active rhein anthrones arise only in the colon as the result of bacterial degradation of the drug (Figure 1). A number of different anthraquinone preparations are now commercially available; the pure sennosides have been the most thoroughly studied (16). The "purely natural" origin of these substances is often stressed in advertisements but confers no known advantages or disadvantages. No association between the use of anthraquinones and colon carcinoma was found in any of the epidemiological studies that have addressed this question (19). Nor is there any danger of damage to the autonomic nervous system. The brown discoloration of the colonic mucosa that is seen after anthraquinone use (melanosis coli) is of no functional significance (3). Epithelial cells migrating toward the submucosa in the process of apoptosis obtain a black color from anthraquinone and are then phagocytosed; the macrophages take on the black pigment, then migrate away by way of the lymphatic vessels, so that melanosis resolves some time after anthraquinone use is discontinued (Figure 2).

Figure 1
The pharmacology of stimulating laxatives. BHPM; bis-(p-hydroxyphenyl)-pyridyl-2-methane

Figure 2
Melanosis coli: epithelial cells migrating toward the submucosa in the process of apoptosis obtain a black color from anthraquinone and are then phagocytosed. The macrophages take on the black pigment and then migrate away by way of the lymphatic vessels. (more ...) The synthetic laxative bisacodyl is converted into the active substance BHPM (bis-[p-hydroxyphenyl]pyridyl-2-methane) by hydrolases of the colonic mucosa. Because an effect on the small intestine is not wanted, this medication is given only in tablet form, and not in liquid form. An elegant alternative is to administer the sulfate ester of bisacodyl, i.e., sodium picosulfate (17). This substance is enzymatically activated by hydrolases only after it is degraded by bacteria in the colon. It can thus be given in drop

form and can be more finely dosed.

Prokinetic agents
A direct prokinetic effect on the colon has been demonstrated for: senna preparations bisacodyl pruclaopride, tegaserod, and cisapride Rectal varieties of constipation can be treated with bisacodyl and, for example, glycerine in suppository form. The patients preference is determinative, however, not just regarding the mode of administration, but also regarding the substance used. When the problem is an impairment of defecation that has been unambiguously demonstrated by defecography, a proctological surgical intervention can be considered. Colectomy can be considered in rare cases of slow colonic transit that does not respond to treatment with laxatives.

Effectiveness
At present, the stimulating laxatives and macrogol have the best ratio of beneficial effects to side effects.

Prokinetic agents Successful treatment

Most patients can be treated satisfactorily with dietary fiber and/or laxatives. Because chronic constipation is usually a hypomotile disorder, it would seem logical to attempt to treat it with purely prokinetic agents. In accordance with our current state of knowledge, the main purely prokinetic agents coming into consideration are 5-HT4 agonists. In this class of medications, cisapride, prucalopride, and tegaserod have been well studied in randomized, controlled trials and have been found to be moderately effective against chronic constipation (20). Cisapride and tegaserod have, however, been taken off the market in the meantime because of safety concerns. It is possible that prucalopride will be approved within the coming year.

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Disimpaction
Fecal impaction (coprostasis) deserves special mention because it is a common problem, especially among elderly inhabitants of nursing homes. Particularly in immobile patients, large quantities of stool may clump together in solid masses (coproliths) in the lower colon. Stretching of the rectum causes relaxation of the internal anal sphincter, and fluid stool flows out past the solid fecal bolus. The problem often goes unrecognized or misdiagnosed for a long time, even though digital rectal examination immediately reveals the diagnosis. The "traditional" treatment is by manual disimpaction, for which intravenous sedation of the patient is often required. The oral administration of macrogol (ca. 100 g in 1 liter of fluid per day) can also alleviate the problem in two to three days. It is important to prevent recurrent coprostasis thereafter by regular treatment of the underlying chronic constipation with suitable laxatives. Bran is not appropriate for this purpose.

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New developments
Lubiprostone stimulates intestinal chloride secretion and has been shown effective against chronic constipation in randomized, controlled studies (21), but it has not yet been approved for use in Europe. Linaclotide, a guanylate cyclase C agonist that stimulates intestinal secretion and transit (22), also still awaits approval.

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Psychophysiological techniques
Pelvic floor dyssynergy was improved with the aid of biofeedback training in about half of all patients studied in randomized, controlled trials (23). The effectiveness of this method in non-rectal constipation is difficult to assess, because only uncontrolled trials have been published (24). Biofeedback training is also highly labor-intensive. Women complaining of constipation show an elevated degree of psychological morbidity, with an abnormal perception of self and an increased prevalence of partnership problems (25). No systematic studies have yet been performed, however, regarding the possible effect of psychotherapy on constipation (although such studies have been done for irritable bowel syndrome).

Psychophysiological techniques
Pelvic floor dyssynergy was improved with the aid of biofeedback training in about half of all patients studied in randomized, controlled trials.

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Overview
Constipation can be reliably diagnosed with the aid of the Rome criteria (Figure 3). Organic disease of the colon usually does not manifest itself as chronic constipation. Colonoscopy can, therefore, be dispensed with if there is no other reason to perform it. There is no reason whatever for multiple colonoscopies. The "general measures" that are often recommended are of dubious efficacy. Dietary fiber is worth trying, but it is not a magic bullet, and some patients cannot tolerate it. The available laxatives are effective and safe. The choice of laxative is based on the type of constipation that is present, as well as on the patients individual tolerance profile and preferences. The stimulating laxatives and macrogol have the best ratio of beneficial effects to side effects. Purely prokinetic agents are not yet on the market. Even thoughor precisely becauselaxatives are available without a prescription, the physician has a very important role to play in advising the patient about the best ones to use and the proper doses to take them in.

Figure 3
Recommended diagnostic and therapeutic algorithm for constipation

Further Information on CME

This article has been certified by the North Rhine Academy for Postgraduate and Continuing Medical Education. Deutsches rzteblatt provides certified continuing medical education (CME) in accordance with the

requirements of the Chambers of Physicians of the German federal states (Lnder). CME points of the Chambers of Physicians can be acquired only through the Internet by the use of the German version of the CME questionnaire within 6 weeks of publication of the article, i.e., by 31 July 2009. See the following website: cme.aerzteblatt.de Participants in the CME program can manage their CME points with their 15-digit "uniform CME number" (einheitliche Fortbildungsnummer, EFN). The EFN must be entered in the appropriate field in the cme.aerzteblatt.de website under "meine Daten" ("my data"), or upon registration. The EFN appears on each participants CME certificate. The solutions to the following questions will be published in volume 3132/2009. The CME unit "Differential Diagnosis of Food Intolerance" (issue 21/2009) can be accessed until 3 July 2009. For issue 2829/2009 we plan to offer the topic "Endocarditis Prophylaxis." Solutions to the CME questionnaire in volume 17/2009: Brmswig J, Dbbers A: Disorders of Pubertal Development. Solutions: 1c, 2d, 3b, 4a, 5e, 6e, 7d, 8c, 9b, 10a Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate. Question 1 Which of the following pieces of information is most important for establishing the diagnosis of "chronic constipation"? Measurement of the colonic transit time Measurement of the stool volume Stool coloration The patients description of the symptoms and their duration Stool consistency Question 2 Which of the following medications can promote constipation? Opiates, corticosteroids, and calcium antagonists Opiates, calcium antagonists, and tricyclic antidepressants Calcium antagonists, proton-pump inhibitors, and antibiotics Proton-pump inhibitors, tricyclic antidepressants Opiates, beta-blockers, and antihistamines Question 3 Which of the following is an indication for treating chronic constipation? The danger of autointoxication from prolonged retention of stool in the colon The elevated risk of colon carcinoma in persons suffering from constipation The patients subjective complaints The low frequency of bowel movements There is no valid indication for treating chronic constipation Question 4 The dietary-fiber component of which of the following foods has a particularly marked influence on stool volume? Apples Chocolate Whole-wheat products Fruit juices Whole milk Question 5 Which of the following substances are considered "stimulating laxatives"? Anthraquinones and macrogol (polyethylene glycol) Lactulose and Glaubers salt (decahydrated sodium sulfate) Epsom salt (heptahydrated magnesium sulfate), Glaubers salt, and bisacodyl Bisacodyl, picosulfate, and anthraquinones Macrogol and picosulfate

Question 6 Which of the following substances have been shown to have a direct prokinetic effect on the colon? Senna preparations, bisacodyl, and prucalopride Lactulose, bisacodyl, and prucalopride Bisacodyl, wheat bran, and prucalopride Glaubers salt, senna preparations, and tegaserod Macrogol, lactulose, and Epsom salt Question 7 What side effects can be expected from the use of anthraquinones, even when taken as recommended? Hypokalemia Colon carcinoma Increased gas formation Diminished resorption of other glycosides, e.g., digitoxin Abdominal discomfort Question 8 What is melanosis coli? Irreversible discoloration of the colonic mucosa Epithelial damage due to anthraquinones A precancerous condition A regular sequela of the use of laxatives Discoloration of submucosal macrophages Question 9 Which of the following laxatives has the named side effect even when taken in the correct dose? Glaubers salthypokalemia Lactuloseincreased gas formation Macrogolabdominal cramps Bisacodyldependence Sennosidescolon carcinoma Question 10 What is/are the usual cause(s) of large rectoceles and/or abnormal lowering of the pelvic floor? Excessive consumption of laxatives in high doses Long-term, (almost) daily laxative consumption Trauma during childbirth and chronic straining at stool The consumption of constipating medications Crohns disease and ulcerative colitis Home Care Children and adults should get enough fiber in their diet. Vegetables, fresh fruits, dried fruits, and whole wheat, bran, or oatmeal cereals are excellent sources of fiber. To reap the benefits of fiber, drink plenty of fluids to help pass the stool. For infants with constipation: Over 2 months old -- try 2 - 4 ounces of fruit juice (grape, pear, apple, cherry, or prune) twice a day. Over 4 months old -- if the baby has begun solid foods, try baby foods with high-fiber content (peas, beans, apricots, prunes, peaches, pears, plums, spinach) twice a day. Regular exercise may also help establish regular bowel movements. If you are confined to a wheelchair or bed, change position frequently and perform abdominal contraction exercises and leg raises. A physical therapist can recommend exercises appropriate for your physical capabilities. Stool softeners (such as those containing docusate sodium) may help. Additionally, bulk laxatives such as psyllium may help add fluid and bulk to the stool. Suppositories or gentle laxatives, such as milk of magnesia liquid, may establish regular bowel movements. Enemas or stimulant laxatives should be reserved for severe cases only. These methods should be used only if fiber, fluids, and stool softeners do not provide enough relief.

Do NOT give laxatives or enemas to children without first asking your doctor. Prevention Avoiding constipation altogether is easier than treating it, but involves the same lifestyle measures: Eat lots of fiber. Drink plenty of fluids each day (at least 8 glasses of water per day). Exercise regularly. Go to the bathroom when you have the urge. Don't wait.

Clinical manifestations of constipation

BY tcmwell.com

Friday, Dec 25,2009, 4:36:34 PM Click: 500 Constipation itself is not an independent disease but many diseases can be manifested in the digestive tract a group of symptoms, so it is constipation symptoms, its clinical manifestations can be recognized from the following three aspects. I led to the corresponding incidence of constipation of the original performance: such as colorectal cancer may have mucous bloody stool, tumor; chronic intussusception may have abdominal pain, mass; anal fissure may have bowel pain, blood will be; spinal cord tumor location can have neurological signs; thyroid dysfunction may have Wei Leng, mucus edema. Ii performance of defecation disorders: 1. Naturally plays a small, less than 3 times per week, less waste, natural defecation interval extension, and may gradually the weight. 2. Discharge difficult. Can be divided into two kinds of situations. Way for the fecal dry hard, such as the chestnut-shaped, it is difficult to leach out; The other is a hard stool is not dry and difficult to discharge. Some patients with a sense of conscious obstruction above the anus and defecation force the greater the sense of this obstruction of the more intense, forcing patients with excessive force, and even loud groan, very painful. Some female patients have fecal Preshoot a sense of the direction of consciously fecal anal not to fall, this is the direction of forward setting to the vagina; have experience stretching from the vagina with your fingers to the posterior wall of the pressure, make it easier for fecal discharge. Some patients feel fullness in the rectum, tail sacral pain, bowel dysfunction, with fingers, rolls, soap of the anus after defecation can be easier. The group of symptoms known as outlet obstruction syndrome. These patients, the majority (90.0%) had normal rectal-type it is intended, and they intended to frequent, prolonged defecation time, with an average of 23 16 minutes, the most common bowel movement each time up to 2 hours. Iii associated with symptoms. In addition to the aforementioned characteristic features of the original disease, the routine checks for those who found no obvious abnormality in patients with common symptoms associated with abdominal distension, abdominal pain, thirst, nausea and perineal pain. Most patients had felt uneasy, and some patients have mouth pain, headache, skin rash. Showed a small number of patients with neurotic individual has suicidal tendencies. Points from the perspective of medicine, the authors believe that chronic constipation cards are mainly lack of fluid, air-Yu Zhi, spleen and three pairs of virtual patients.

ABSTRACT

Various agents are used for the medical management of chronic constipation, but few of these have been adequately studied. This article specifically examines the medical treatment of chronic constipation and the available data concerning bulk agents, lubricating agents, stimulants, and osmotic laxatives, used alone and in combination. Most experts consider dietary fiber or medicinal bulk agents to be the initial therapeutic option for the treatment of chronic constipation. If fiber is not successful or poorly tolerated, subsequent treatments may include saline osmotic laxatives, lactulose, 5-hydroxytryptamine4 (5-HT4) agonists (tegaserod), or stimulants such as senna or bisacodyl. Recent data also demonstrate both polyethylene glycol laxative and tegaserod to be safe and effective as initial therapy for chronic constipation. Keywords:Constipation, laxatives, fiber, osmotic agents, polyethylene glycol, 5-HT4 agonists Although there are many remedies and treatments available for the symptomatic improvement of constipation, only tegaserod (Zelnorm, Novartis Pharmaceuticals, East Hanover, NJ) is approved by the United States Food and Drug Administration (FDA) for the chronic treatment of chronic constipation for individuals younger than 65. All other currently available agents are indicated only for short-term use in occasional constipation.1 Although few agents have been carefully studied, even fewer have been adequately studied in the arena of chronic constipation. Initial management of patients with chronic constipation should include education of the patient, dietary evaluation, and consideration of medical options. Education of the patient is critical and should include explanation of normal physiologic bowel patterns. The focus of this review is on available therapeutic options utilizing lifestyle modifications, medications, and biofeedback.

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LIFESTYLE MODIFICATIONS
Following education and the initial assessment, patients should be encouraged to recognize and respond to the call to defecate. Although modest exercise is clearly of benefit for several reasons, increases in physical activity and fluid intake appear not to relieve chronic constipation except in situations of dehydration.2,3 Patients may be encouraged to monitor their bowel habits by using a diary to record bowel movements, stool characteristics, and associated abdominal symptoms. Such diaries can be useful when assessing responses to treatment interventions.

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LAXATIVES
With so many potential options available, the choice of initial laxative is subject to much personal opinion and consensus.4,5 There are also conflicting opinions about the initial approach to diagnosis before treatment. A useful classification is presented in Table Table1.1. Algorithmic treatment approaches have been developed on the basis of whether constipation is slow transit or normal transit.5 Because response to biofeedback is inconsistent5 and typical initial algorithms are similar regardless of transit status, laxative therapy can be initiated before additional diagnostic evaluation. Most empirical regimens begin with fiber (Table 2).

Table 1
Laxatives

Table 2
Treatment Algorithm for Chronic Constipation

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SELECTED LAXATIVE OPTIONS

Bulk Laxatives
The average American diet contains relatively low levels of fiber, and many consider this to contribute to the high prevalence of chronic constipation in the United States. There is a clear dose response between daily fiber intake and fecal output.6 Increased fluid intake enhances the effect provided by the increased fiber intake.7 Although it is not indicated in patients with pelvic floor dysfunction or anal outlet obstruction, patients with normal or slow transit constipation should increase their fiber intake to 20 to 35 g daily. Many types of insoluble fiber, such as bran, may cause significant amounts of abdominal bloating and discomfort. It is possible, however, to minimize these symptoms by starting with low doses and increasing amounts over time. Bulk-forming laxatives such as methylcellulose, calcium polycarbophil, and psyllium seed are polysaccharides or cellulose derivatives that absorb water into the colonic lumen and increase fecal mass.8 This, in turn, stimulates motility and reduces colon transit time.8 Psyllium, a naturally occurring agent, has been demonstrated to delay gastric emptying and depress appetite in some patients.8 In addition, esophageal and intestinal obstruction and asthmatic reactions from psyllium have been reported.9 Methylcellulose10 and calcium polycarbophil11 are synthetic fiber polymers that are metabolically inert and resistant to bacterial fermentation. In patients unresponsive to bulk agents alone, the addition of other laxatives is often the next logical choice. Laxatives come in many forms, each having its own mechanism of action. The particular laxative chosen should be based on both the symptoms experienced and the patient's preferences. Stool softeners such as docusate sodium lower the surface tension of stool, facilitating the passage of water into the stool. There is, however, little evidence to support their use in chronic constipation.

Osmotic Agents
SALINE AGENTS

Saline laxatives are poorly absorbed or nonabsorbed osmotic preparations that result in the secretion of water in the intestines to maintain isotonicity with plasma.12 The choice of which saline laxative (magnesium hydroxide, magnesium sulfate, magnesium citrate, sodium phosphate, sodium sulfate) is largely arbitrary.4 In patients with either cardiac or renal dysfunction, excessive absorption of sodium, phosphorus, or magnesium may lead to electrolyte and volume overload, and if the laxative is overused, dehydration may occur.12 For the most part, however, even when these laxatives are ingested as hypertonic solutions, the hypertonicity does not persist, as there is rapid osmotic equilibration.8 Electrolytes are not absorbed and an osmotic gap between stool and plasma forms, reflecting the unmeasured substances in stool water. Although the laxative action of magnesium is thought to be due to a local effect in the intestinal tract, it is also possible that released hormones such as cholecystokinin13 or activation of constitutive nitric oxide synthase14 may contribute to this pharmacological effect. Oral phosphates, given in large doses for bowel preparation, can have biochemical side effects of hyperphosphatemia and hypocalcemia.15 The oral phosphate products are not recommended for use in patients with renal failure or cardiac insufficiency. Sodium sulfate is an effective component of some gut lavage solutions for colon cleansing prior to diagnostic and surgical procedures,16 but significant absorption may occur in the jejunum. POORLY ABSORBED SUGARS Lactulose, a poorly absorbed sugar, is a galactose-fructose disaccharide. As humans lack an intestinal fructosidase, the unabsorbed carbohydrate becomes a substrate for colonic bacterial fermentation with resultant production of hydrogen, methane, carbon dioxide, water, acid, and short-chain or volatile fatty acids.1 These products act as osmotic agents but also stimulate intestinal motility and secretion. Lactulose increases stool frequency in chronically constipated patients17 and is best suited for gentle catharsis. Abdominal bloating, discomfort, and flatulence often result from its use and may decrease patients' acceptance. Sorbitol and mannitol, poorly absorbed sugar alcohols, may produce effects similar to those of lactulose if taken in sufficient dosages. Glycerin also has osmotic effects, but its significant absorption in the small bowel prevents its regular use for the treatment of chronic constipation. Some patients who are lactose maldigestors simply adjust their consumption of lactose-containing foods to regulate their bowel habits. POLYETHYLENE GLYCOL High-molecular-weight polyethylene glycol (PEG) is a large polymer with substantial osmotic activity that obligates intraluminal water.18 PEG is used with balanced electrolytes in solutions for colon cleansing as polyethylene glycol electrolyte lavage solution (PEG-ELS) and sulfate-free electrolyte lavage solution (SF-ELS).1 These solutions have been shown to be safe and effective for preparation for colonoscopy, barium x-ray examinations, and colon surgery.16 PEG-ELS and SF-ELS reach a steadystate equilibrium when given in large volumes at high infusion rates (1.5 L/hr) and pass through the gastrointestinal tract with no net water or electrolyte absorption or secretion.1 However, this is not necessarily the case when they are given in small amounts or ingested at slow rates. PEG 3350 laxative (MiraLax, Braintree Laboratories, Braintree, MA) is a chemically inert polymer composed of PEG 3350 that does not contain any salt that can be absorbed. DiPalma and colleagues presented data confirming efficacy of MiraLax in a placebo-controlled, randomized, multicenter, parallel-group trial that compared 17 g of PEG 3350 laxative with a dextrose placebo.19 The greatest efficacy for PEG 3350 was noted during the second week of therapy,19 but higher doses have been used successfully for the overnight treatment of constipation.20 In this overnight efficacy study, 24 constipated adults were randomly assigned to receive either placebo or a single dose of 51, 68, or 85 g of PEG 3350. The 68-g dose provided the most reliable and safe relief within 24 hours.20 There were no adverse effects and no incontinence, cramps, or diarrhea with any of the doses. There were no changes in

measured electrolytes, calcium, glucose, blood, urea, nitrogen (BUN), creatinine, or serum osmolality.

Stimulant Laxatives
Stimulant laxatives, such as bisacodyl and senna, exert their primary effects through alteration of electrolyte transport by the intestinal mucosa8 and generally work within several hours. In his classification, Schiller refers to this class of drugs as secretagogues and agents with direct effects on epithelial, nerve, or smooth muscle cells.8 Following their use, it is not uncommon for patients to report symptoms of abdominal discomfort and cramping.21 This grouping includes surface-active agents, diphenylmethane derivatives, ricinoleic acid, and anthraquinones (Table 1). Although stimulant laxatives may be associated with occasional side effects such as salt overload, hypokalemia, and proteinlosing enteropathy, data do not support the theory that they cause a so-called cathartic colon.22 Melanosis coli, a pigmentation of the colonic mucosa caused by the accumulation of apoptotic epithelial cells phagocytosed by macrophages, may develop in patients who chronically ingest anthraquinonecontaining stimulant laxatives.23 Despite prior theories to the contrary, neither anthranoid laxative use nor macroscopic or microscopic melanosis coli is associated with any significant risk for the development of colorectal adenoma or carcinoma.24 Phenolphthalein, no longer marketed in the United States, has been associated with fixed-drug eruption, protein-losing enteropathy, Stevens-Johnson syndrome, and lupus reactions.8 Castor oil, containing ricinoleic acid, alters intestinal water absorption and motor function,8 and side effects often include cramping and nutrient malabsorption.25

Lubricating Agents
Mineral oil is not chemically altered in the body but emulsifies into the stool mass, coating the rectum and providing lubrication.8 Side effects include lipid pneumonia (resulting from aspiration), malabsorption of fat-soluble vitamins, foreign-body reactions in tissue, and anal seepage.

5-HT4 Agonists
Tegaserod, a partial peripheral 5-hydroxytryptamine4 (5-HT4) receptor agonist, is approved by the FDA for the treatment of irritable bowel syndrome with constipation and has proved relatively safe is numerous trials.26,27 It has also been approved by the FDA for the treatment of chronic constipation in both men and women younger than 65. By agonizing 5-HT4 receptors, tegaserod probably acts by enhancing the peristaltic reflex. Although it was designed to mimic serotonin, chemical alteration decreases its peripheral effect by enhancing passage through the blood-brain barrier.28 Several reports of intestinal ischemia have been noted in postmarketing reports, leading to changes in product labeling. Health care providers are advised to evaluate quickly patients receiving tegaserod who present with worsening diarrhea or symptoms suggestive of intestinal ischemia, including abdominal pain or rectal bleeding.

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LAXATIVE USE IN SPECIAL CIRCUMSTANCES

Children
The treatment options for children are similar to the options for adults.29 Although constipation is a common problem, there are few clear treatment guidelines with evidence-based analysis.30 Recent data concerning PEG 3350 laxative show safety, efficacy, and preference by children and parents in studies of short- and long-term use in comparison with agents such as milk of magnesia and lactulose.31,32,33 PEG 3350 laxative is not yet approved by the FDA for use in children. Although constipation in adults and children is a chronic condition that warrants chronic therapy, no

agent has approval for chronic use. Therefore, guidelines reviewed here describe off-label use. There are data to support chronic PEG use in children,33 and studies are in progress evaluating the chronic use of PEG in adults.

Pregnancy
Most obstetricians advise avoiding laxatives in pregnancy and prescribe stool softeners instead. Dietary fiber and bulk laxatives such as psyllium, methylcellulose, and polycarbophil are most physiologic and safest during pregnancy.34 Stimulant laxatives can be used but are reserved for those who do not respond to these initial measures. PEG, lactulose, sorbitol, glycerin, bisacodyl, and senna have been cited as being preferred.33 Safety is not established for PEG 3350 laxative (FDA Pregnancy Category C), but PEG is chemically inert, with minuscule absorption, and toxicity has been thought to be unlikely.33 A consensus panel felt that PEG laxative met the criteria for the ideal treatment for pregnancy constipation.35 Tegaserod is Pregnancy Category B. Misoprostol (Pregnancy Category X) and colchicine (Pregnancy Category D) should not be used in pregnancy. Castor oil should be avoided during pregnancy because of the possibility of stimulating premature uterine contractions. The saline osmotic laxatives, such as magnesium salts and monobasic and dibasic sodium phosphate (Phospho-Soda), should also be avoided because of unwanted sodium and water retention.34 Nardulli and colleagues evaluated PEG for constipation in the puerperium, randomly assigning 225 subjects in a prospective, open-label trial,36 and found PEG to be effective and without side effects.

Treatments and drugs

By Mayo Clinic staff
In most cases, simple changes in your diet and lifestyle can help relieve symptoms and manage constipation. Less often, you may need medical treatment. Above all, recognize that a successful treatment program can take time and effort. Diet and lifestyle changes The following simple changes can go a long way toward reducing constipation: A high-fiber diet.A diet with at least 20 to 35 grams of fiber each day helps your body form soft, bulky stool. High-fiber foods include beans, whole grains, and fresh fruits and vegetables. Limit foods that have little to no fiber, such as cheese, meat and processed foods. Regular exercise.Physical activity can help stimulate intestinal activity. Adequate fluid intake.Drinking plenty of water and other fluids will help soften your stool. Take the time for bowel movements.Set aside sufficient time to allow undisturbed visits to the toilet. And don't ignore the urge to have a bowel movement. Laxatives These over-the-counter medications should be considered only when diet and lifestyle changes aren't effective. Some can become habit-forming. There are several different types of laxatives: Fiber supplements,or bulk laxatives, are generally considered the safest of laxatives. Examples include FiberCon, Metamucil, Konsyl, Serutan and Citrucel. These agents must be taken with plenty of water. Stimulantscause rhythmic contractions in the intestines. Examples include Correctol, Dulcolax and Senokot. Lubricantsenable stool to move through your colon more easily. Examples include mineral oil and Fleet. Stool softenersmoisten the stool and help prevent dehydration. Examples include Colace and Surfak. Osmoticshelp fluids to move through the colon. Examples include Cephulac, Sorbitol and

Miralax. Saline laxativesact like a sponge to draw water into the colon for easier passage of stool. Examples include milk of magnesia and Haley's M-O. Other medications If lifestyle changes and over-the-counter medications don't improve your symptoms, your doctor may recommend prescription medications, such as: Chloride channel activators.The agent lubiprostone (Amitiza) is available by prescription and increases fluid content of stool. 5-HT-4 agonists.These agents stimulate release of compounds in your body that increase fluid secretion in the intestines and decrease colonic transit time. Prucalopride is one such 5-HT-4 agonist. These drugs are not available in the U.S., and there have been some concerns about the safety of their use. Procedures If your constipation doesn't respond to changes in lifestyle or medical treatment, your doctor may recommend in-office or, rarely, surgical procedures. Manual procedures.To help clear your colon of retained, impacted stool if laxatives are not effective, your doctor may first gently insert a gloved finger and manually break up the impacted stool (disimpaction). Next, you'll be given a laxative enema to soften the stool and provide lubrication for a bowel movement. Surgical procedures.If you have chronic, severe constipation and other treatments haven't helped, surgical removal of part of your colon may be recommended. In this procedure, the problem segment or segments of the anal sphincter or rectum are removed. Treating underlying causes If an underlying disorder is causing your constipation, treatment will be aimed at the specific cause. If pelvic floor dysfunction is the cause of your constipation, your doctor may suggest biofeedback as a treatment. This retraining technique may help you learn to better coordinate the muscles you use to have a bowel movement. If you're pregnant and have constipation, try eating lots of high-fiber foods, such as fruits, vegetables and whole grains. Drink plenty of fluids and get as much exercise as you can. Discuss with your doctor any plan, including exercise, to treat your constipation. Swimming and walking may be good choices.Dietary

Measures

The key to treating most patients with constipation is correction of dietary deficiencies. This generally involves increasing intake of fiber and fluid and decreasing the use of constipating agents, such as milk products, coffee, tea, and alcohol.

Increased fiber intake

Dietary fiber is available in diverse natural sources, such as fruits, vegetables, and cereals. Ingestion of natural fiber sources is nutritionally superior to supplementation with purified fiber. However, advising patients to eat more fruits and vegetables is frequently unsuccessful, at least in American patients. American patients do respond reasonably well to prescriptions and often seek them; accordingly, prescribing a fiber supplement, such as wheat, psyllium, or methylcellulose, is often useful. Many of the available products vary substantially in their potency. For instance, sugar-free Metamucil (psyllium) has twice the potency of standard Metamucil on a volume basis because the latter is half sugar. Pharmaceutical companies may argue that one type of fiber is better tolerated or more effective than another. This may not make much difference in treatment or in fiber tolerance in most patients as long as the fiber supplementation doses start low and are slowly titrated upward. Theoretical considerations suggest that the use of a fermentable fiber, which increases short-chain fatty acid concentrations in the colonic lumen, may have other health benefits (as opposed to methylcellulose). However, this suggestion remains controversial and awaits further exploration. Because no convincing reason exists to pick one product over another, a single brand of choice should

be prescribed until the patients constipation resolves. The patient may then switch to generic or other brands with appropriate dose adjustments. The authors experience has been that some patients have preferences based on the taste of the product or other subjective reasons. In particular, those rare patients who cannot tolerate fermentable fiber supplementation because of resulting gas or bloating may do better with methylcellulose, whereas others may find that the quality of the stool, taste preferences, or both favor psyllium supplementation. To prevent patient noncompliance resulting from the cramping and bloating that may accompany changes in dietary fiber, fiber supplementation should be started at a low subtherapeutic dose and titrated upwards on a weekly basis until the desired effect is achieved. Patients should continue to increase the dose on a weekly basis until they experience daily bowel movements with no straining or until they reach the maximum dose. Patients should be cautioned that these products are not laxatives, will not induce a bowel movement, and must be taken daily regardless of their perceived need. Patients may increase or decrease their dose on a week-to-week basis. In particular, the author advises patients who have arrived at what they believe to be an appropriate and successful dose to increase the dose 1 additional step for at least a week and then back down if they wish. Some patients find that they actually prefer the higher dose. To ensure long-term compliance, the author believes that patients should titrate the doses in case of changes in potency between fiber supplement brands or changes in diet, fluid intake, or exercise. Patients should be cautioned that, although various stool softeners, such as docusate sodium, appear much more palatable than fiber, they are not suitable for long-term use. Tachyphylaxis to stool softeners develops over time.

Increased fluid intake

Fluid intake is the key to treatment. Patients should be advised to drink at least 8 glasses of water daily. Counseling may be required to achieve this goal. Milk and milk products should be minimized if these prove constipating. In some patient populations, coffee, tea, and alcohol account for the majority of the fluid volume consumed. Patients should be made to understand that because of the diuretic effects of these products, this state of affairs is counterproductive. The author usually recommends that patients decrease their consumption of coffee, tea, and alcohol as much as possible and that they make a point of consuming an extra glass of water for every drink of coffee, tea, or alcohol.

Failure of high-fiber, high-water regimen

Failure to control constipation on a regimen of fiber supplementation and increased water intake should prompt an analysis of patient compliance and a search for other physical causes (eg, altered colonic transit time, outlet obstruction, and psychological causes). The authors experience is that early failures usually reflect inadequate water intake, whereas recidivism months to years later usually reflects a patients decision that fiber supplementation is no longer necessary. Counsel patients in advance to encourage them to avoid these inappropriate decisions. In selected patients who comply with a trial of a high-fiber, high-water diet but find that this approach does not successfully treat their constipation, a trial of a very-low-residue diet, or even a liquid diet, may be appropriate. Such a regimen is most successful in patients with outlet obstruction who are not candidates for surgical correction and in patients whose presentation is more characteristic of IBS with a chief complaint of abdominal pain. A low-residue diet may be effective in the latter group of patients if thorough mechanical cleansing of the bowel, such as is done for diagnostic endoscopy or barium enema, temporarily relieves their symptoms.

Pharmacologic Therapy

Medications to treat constipation include bulk-forming agents (fibers), emollient stool softeners, rapidly acting lubricants, prokinetics, laxatives, osmotic agents, and prosecretory drugs. Fiber is arguably the best and least expensive medication for long-term treatment, although enthusiasm for the use of polyethylene glycol as first-line therapy in chronic constipation is increasing. It is important to convey to patients that bulk-forming agents generally do not work rapidly and must be used on a long-term basis. Emollient stool softeners are easier to use, but they lose their effectiveness with long-term administration. These drugs are best used for prophylaxis in a short-term setting, as in patients receiving a postoperative narcotic prescription. Rapidly acting lubricants and laxatives, including over-the-counter products, are often used to treat acute and chronic constipation. A meta-analysis affirmed the efficacy of bisacodyl and sodium picosulfate, which share the same active metabolite, in short- to medium-term use in chronic idiopathic constipation. [12]However, their use for acute episodes should be limited, because of the long-term risk of habituation or toxicity. Polyethylene glycol is simple to use and is more effective than placebo in the management of chronic constipation; however, the effects of long-term therapy with polyethylene glycol over decades are still not well studied. Newer therapies for constipation include prucalopride, a prokinetic selective 5-hydroxytryptamine-4 (5HT4) receptor antagonist that stimulates colonic motility and decreases transit time, and the osmotic agents lubiprostone and linaclotide,[13]which stimulate intestinal fluid secretion by acting on the intestinal epithelial chloride channel and the guanylate cyclase receptor, respectively. Linaclotide was approved by the US Food and Drug Administration (FDA) in August 2012 to treat chronic idiopathic constipation and for irritable bowel syndrome with constipation (IBS-C) in adults. Approval was based on randomized controlled trials that showed significant improvement for each indication compared with placebo.[14, 15, 16] These drugs may be useful in chronic constipation when fiber, water, and polyethylene glycol fail, either alone in combination with simpler interventions. When moving a patient to such interventions after failing on fiber, water, and polyethylene glycol, reconsider whether mechanical issues (eg, tumors, pelvic floor problems) have been adequately ruled out. Other drugs that have been studied include the prokinetic agents cisapride and tegaserod.[17, 18]Although significant promise had been shown with this new class of drugs, these 2 agents were withdrawn from the US market. As of July 27, 2007, restricted use of tegaserod is permitted via a treatment investigational new drug (IND) protocol.[19]The treatment IND protocol allows tegaserod treatment of irritable bowel syndrome (IBS) with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years who meet specific guidelines. Its use is further restricted to those in critical need who have no known or preexisting heart disease. Renzapride, a mixed 5-HT4 receptor agonist and 5-HT3 receptor antagonist, has been tested to assess its efficacy and safety in the treatment of chronic constipation.[20] Neurotrophin-3 stimulates the development, growth, and function of the nervous system and has been used to treat functional constipation. Stem cells have been suggested as a means of repopulating dysfunction

Tests and diagnosis

By Mayo Clinic staff

Your doctor will take your medical history, perform a physical exam and ask about any prescription or over-the-counter medications you're taking. Your doctor will also want to rule out several conditions in diagnosing constipation. These include a blockage in your small intestine or colon (intestinal obstruction), a narrowing of the colon, an endocrine condition, such as hypothyroidism, or an electrolyte disturbance, such as excessive calcium in the blood (hypercalcemia). Extensive testing is usually reserved for people with severe symptoms or for older adults with new-onset constipation. You may undergo these diagnostic procedures:

 Barium enema X-ray.In this test, the lining of your bowel is coated with a contrast dye (barium) so that your rectum, colon and sometimes a part of the small intestine can be clearly seen on an X-ray. X-ray of the anorectal area (defecography).In this X-ray procedure, your doctor will fill your rectum with a soft paste with the same consistency as stool. As you expel the paste, X-rays are taken to evaluate the completeness of stool elimination and rectal muscle contractions. Examination of the rectum and lower, or sigmoid, colon (sigmoidoscopy).In this procedure, your doctor inserts a lighted, flexible tube into your anus to examine your rectum and the lower portion of your colon. Examination of the rectum and entire colon (colonoscopy).This diagnostic procedure allows your doctor to examine the entire colon with a flexible, camera-equipped tube. Evaluation of anal sphincter muscle function (anorectal manometry).In this procedure, your doctor inserts a narrow, flexible tube into your anus and rectum and then inflates a small balloon at the tip of the tube. The device is then pulled back through the sphincter muscle. This procedure allows your doctor to measure the coordination of the muscles you use to move your bowels. Evaluation of how well food moves through the colon (marker study or colorectal transit study).In this procedure, you'll swallow a capsule containing markers that show up on X-rays taken over several days. Your doctor will look for signs of intestinal muscle dysfunction and how well food moves through your colon. al neurons.

SURGICAL OPTIONS
Several procedures have been attempted to treat colonic inertia. These include segmental colectomy, subtotal colectomy with ileosigmoid or cecorectal anastomosis, and total abdominal colectomy with ileorectal anastomosis (TAC IRA). Segmental colectomy is appealing, but it is difficult to determine whether only part of the colon does not function properly rather than the entire colon. Transit studies have not been adequately specific or reproducible to document segmental dysmotility. Segmental and subtotal colectomy with ileosigmoid anastomosis frequently result in persistent or recurrent constipation, and up to 50% of patients who have undergone these procedures have required additional resectional surgery.5,6 A cecorectal anastomosis is not an operation performed frequently and has led to higher complication rates including cecal distention.5,7 Several studies (Table 2,8,9,10,11,12,13,14,15) have demonstrated that TAC IRA is the procedure of choice for colonic inertia. The anastomosis is usually performed at the upper rectum (at or slightly above the sacral promontory). An anastomosis at this level is easier to perform and eliminates the risks associated with rectal mobilization. The upper rectum has a good supply, and its size does not limit the size of the anastomotic lumen.

Table 2
Total Abdominal Colectomy and Ileorectal Anastomosis In an extremely select group of patients with colonic inertia and rectal dysmotility, a restorative proctocolectomy may be considered. Another option is a proctocolectomy and continent ileostomy. Finally, poorer risk patients may be best served with an ileostomy, with or without a colectomy.

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RESULTS
Bowel Function

The frequency of bowel movements following total colectomy varies from 0.5 to 6 bowel movements per day. Most patients average 1 to 3 movements per day. The frequency decreases with time because of intestinal adaptation.5 A summary of the recent published results with total abdominal colectomy and ileorectal anastomosis is presented in Table Table2.2. Several aspects of these reports merit additional discussion. The relatively small numbers of patients reflect the select preoperative criteria most surgeons use for this therapeutic option. The vast majority of patients were young to middle-aged females. Although the follow-up was variable, TAC IRS had an overall success rate exceeding 90%. Varying criteria were used to measure success. These included patients' opinions, bowel frequency, symptom relief, and measures of quality of life. A uniform measure has not been adopted.

Quality of Life
Several authors have documented the patients' quality of life after surgical management.14,16,17 FitzHarris and colleagues surveyed 75 patients who had undergone TAC IRA a mean of 3.9 years (range 0.5 to 9.6) prior to the survey.14 Using a 54-item validated questionnaire (Gastrointestinal Quality-ofLife Index), the authors found that 81% of the patients were at least somewhat pleased with their bowel frequency, but 41% cited abdominal pain, 21% incontinence, and 46% diarrhea at least some of the time. However, 93% stated that they would undergo subtotal colectomy again if given a second chance.

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COMPLICATIONS
Morbidity after surgery includes several factors. The risks of colonic resection are related to anastomosis (leak, stricture), infections (wound and intra-abdominal abscess), bleeding, and the anesthesia required to accomplish the procedure. The mortality related to the colectomy in this group of relatively healthy patients has been less than 1%. Postoperative small bowel obstruction has been the most frequent complication after total abdominal colectomy . The reported incidence ranges from 8% to 44% with surgical intervention having been required in 41% to 100%.1,18 The etiology for obstruction has been adhesions resulting from the extensive colectomy and a proposed neuropathic disorder of the myenteric plexus affecting bowel motility.1,19 The recent use of antiadhesive agents such as Seprafilm may reduce the incidence of this complication. Postoperative functional results remain a major issue. Recurrent or persistent constipation has been reported in 0% to 33% of patients.14 A review of published reports for the past two decades identified a mean of 41% of patients with persistent abdominal pain.14 Bloating and symptoms related to irritable bowel remain common. Diarrhea following colectomy is usually a short-term problem. However, in a few patients, the failure of intestinal adaptation can result in intractable diarrhea. The reported incidence of diarrhea has varied from 0% to 46%.14 During the adaptation phase, adjuvant measures such as fiber, motility agents (loperamide, diphenoxylate and atropine sulfate, or codeine), and binders (cholestyramine) may assist in reducing bowel frequency. Diarrhea that fails to resolve may necessitate conversion to an ileostomy or consideration of a revision to a pouch-rectal anastomosis. Postoperative incontinence has been reported in 0% to 52% of patients with a mean of 14%. The reported incidence of conversion to a permanent ileostomy has ranged from 0% to 28% with a mean of 5%.14 Diarrhea is the frequent passage of loose, watery, soft stools with or without abdominal bloating, pressure, and cramps commonly referred to as gas. Diarrhea can come on suddenly, run its course, and be helped with home care to prevent complications such as dehydration. o Diarrhea is one of the most common illnesses in all age groups and is second only to the common cold as a cause of lost days of work or school.

In the United States, each child will have experienced seven to 15 episodes of diarrhea by age 5. o People of all ages can suffer from diarrhea, and the average adult has approximately four episodes of acute diarrhea per year. Diarrhea and related complications can cause severe illness. The most significant cause of severe illness is loss of water and electrolytes. In diarrhea, fluid passes out of the body before it can be absorbed by the intestines. When the ability to drink fluids fast enough to compensate for the water loss because of diarrhea is impaired, dehydration can result. Most deaths from diarrhea occur in the very young and the elderly whose health may be put at risk from a moderate amount of dehydration. o Diarrhea can be further defined in the following ways:

chronic diarrhea is the presence of loose or liquid stools for over two weeks; o o o acute enteritis is inflammation of the intestine;

gastroenteritis(stomach flu) is diarrhea associated with nausea and vomiting; or

dysentery is diarrhea that contains blood, pus, or mucus.

Diarrhea Causes
Viral infections cause most cases of diarrhea and are typically associated with mild-to-moderate symptoms with frequent, watery bowel movements, abdominal cramps, and a low-grade fever. Diarrhea generally lasts approximately 3 to 7 days. The following are the common causes of diarrhea caused by viral infections: rotavirusis a common cause of diarrhea in infants; norovirus(for example, Norwalk virus, caliciviruses) is the most common cause of epidemics of diarrhea among adults and schoolage children (for example, cruise ship infection, schools, nursing homes, day care facilities, and restaurants); and adenovirus infections are common in all age groups. Bacterial infections cause the more serious cases of diarrhea. Typically, infection with bacteria occurs from contaminated food or drinks (food poisoning). Bacterial infections also cause severe symptoms, often with vomiting, fever, and severe abdominal cramps or abdominal pain. Bowel movements occur frequently and may be watery. The following are examples of causes of diarrhea caused by bacterial infections: In more serious cases, the stool may contain mucus, pus, or blood. Most of these infections are associated with local outbreaks of disease. Family members or others eating the same food may have similar illnesses.

Foreign travelis a common way for a person to contract traveler's diarrhea.

 Campylobacter, salmonellae, and shigella organisms are the most common causes of bacterial diarrhea. Less common causes are Escherichia coli (commonly called E coli) Yersinia, and listeria. Use of antibiotics can lead to an overgrowth of Clostridium difficile (C diff) bacteria in the intestines. Parasitescause infection of the digestive system by the use of contaminated water. Common parasitic causes of diarrhea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. Intestinal disorders or diseases including inflammatory bowel disease, irritable bowel syndrome (IBS), diverticulitis, microscopic colitis, and celiac disease can cause diarrhea. Reaction to certain medications can cause diarrhea. Common medications include antibiotics, blood pressure medications, cancer drugs, and antacids (especially ones containing magnesium). Intolerance to foods such as artificial sweeteners and lactose (the sugar found in milk) can cause diarrhea.

Diarrhea Symptoms
Watery, liquid stools:The stools may be any color. The passage of red stools suggests intestinal bleeding and could be a sign of a more severe infection. The passage of thick, tarry black stools suggests significant bleeding in the stomach or upper portions of the intestine and is not usually caused by acute infections. Abdominal cramps:Occasionally diarrhea is accompanied with mild-to-moderate abdominal pain. Severe abdominal or stomach pain is not common and, if present, may suggest more severe disease. Fever:A high fever is not common. If present, the affected person may have a more severe illness than acute diarrhea. Dehydration:If diarrhea leads to dehydration, it is a sign of potentially serious disease. o Examples of signs and symptoms of dehydration include: Adults may be very thirsty and have a dry mouth. o The skin of older people may appear to be loose. The elderly may also become very sleepy or have behavioral changes and confusion when dehydrated. o Dehydrated infants and children may have sunken eyes, dry mouths, and urinate less frequently than usual. They may appear very sleepy or may refuse to eat or drink.

When to Seek Medical Care

Diarrhea can usually be treated well with home care. In some cases, it may become more severe. A person should go to a hospital emergency department in the following situations: if the person has diarrhea along with high fever, moderate-to-severe abdominal pain, or dehydration that cannot be managed by drinking fluids; if the diarrhea appears to contain blood (it may be bright red or may look like black, thick tar); or If the person is very sleepy and is not acting like their usual selves (others may notice this and take the person to the emergency department). Call a health care practitioner if a person has any of these complications: vomiting and unable to tolerate any food or drink; signs of dehydration;

high fever, significant abdominal pain, very frequent loose bowel movements, or bloody diarrhea; if he or she is elderly or has serious underlying medical problems, particularly diabetes, heart, kidney, or liver disease, or HIV or AIDS (contact a health care practitioner when diarrhea first begins as the person may be at higher risk for developing complications); a parent or caregiver needs advice about preventing dehydration in newborns and infants; symptoms do not improve in two to three days or appear to become worse; or if he or she develops diarrhea after travel within their home country, or foreign travel.

Diarrhea Diagnosis
In healthy people with diarrhea, and who appear well otherwise, the health care practitioner may elect to do no tests at all. Stool cultures (when a sample of the stool is taken and examined in the lab for certain bacteria or parasites) are not usually necessary unless there is high fever, blood in the stool, recent travel, or prolonged disease. In some cases, the health care practitioner may send a sample of the stool (or sometimes a cotton swab from the patient's rectum) to the laboratory to evaluate if the cause of diarrhea can be determined (such as certain bacteria or parasites present in the body). It usually takes approximately one to two days for the results of these tests. Blood tests are sometimes necessary for patients with other medical problems or with severe disease. A colonoscopy is an endoscope procedure that allows the physician to view the entire colon to evaluate for infections or structural abnormalities that could cause diarrhea. Imaging tests such as X-rays or CT scans are performed to rule out structural abnormalities as the cause of diarrhea, particularly when pain is a prominent symptom.

Diarrhea Treatment

Acute diarrhea may be treated at home. Diarrhea will generally subside in two to three days without specific medical therapy.

Diarrhea Self-Care at Home

Diarrhea Treatment in Adults Adults should drink plenty of fluids to avoid dehydration. Replenishing water loss (due to diarrhea) is important. Avoid milk as it can make diarrhea worse. Sports beverages (for example, Gatorade or Powerade) can be beneficial because they replenish electrolytes in addition to providing hydration. If the affected person is able to eat, avoid greasy or fatty foods. Adults, infants, toddlers, and children should be encouraged to follow the "BRAT" diet (bananas, rice, applesauce, and toast). The BRAT diet (diarrhea diet) is a combination of foods used for decades to treat diarrhea. If diarrhea is accompanied by nausea, have the person suck on ice chips until the nausea stops. After the diarrhea subsides, avoid alcoholic beverages and spicy foods for two additional days. Individuals should continue their usual activities if they are mildly ill with diarrhea; however, strenuous exercise should be avoided until they feel better because exercise increases the risk of dehydration. Pregnant womenwith diarrhea should make sure to rehydrate to avoid dehydration, and should consult their physician. Diarrhea Treatment inChildren Dehydration in children and toddlers can be a great concern. Infants and toddlers pose special problems because of their increased risk of dehydration. They should be offered a bottle frequently. Solutions such as Pedialyte may be more appealing than water. These fluids also contain necessary electrolytes lost with diarrhea. Never use salt tablets as they may worsen diarrhea. Children with frequent stools, fever, or vomiting should stay at home and avoid school and daycare until these symptoms go away. This allows the child to rest and recover and prevents other children from being exposed to the infection. As mentioned previously, infants, toddlers, and children should be encouraged to follow the "BRAT" diet (bananas, rice, applesauce, and toast). The BRAT diet (diarrhea diet) is a combination of foods used for decades to treat diarrhea.

Diarrhea Medical Treatment

To replace fluids, the health care practitioner will often start an IV line if the patient is dehydrated and cannot eat or drink. Solutions administered through IV replaces the lost fluids and electrolytes, and often brings quick relief to the patient. Antibiotics Antibiotics are not effective in diarrhea caused by viruses. Even the more severe diarrhea caused by bacteria will usually go away in a few days without antibiotics. In fact, antibiotics appear to make some bacterial diarrhea worse, specifically those caused by the E coli bacterium (often a source of food poisoning). In some cases, antibiotics may benefit some adults with diarrhea. If selected carefully, antibiotics may decrease the severity of illness and shorten the duration of symptoms. If a person has recently traveled to

another country or has been camping (and may have been exposed to contaminated water in the wilderness), a health care practitioner may prescribe specific medication used to treat traveler's diarrhea for certain intestinal parasites. Over-the-counter antidiarrheal medications The health care practitioner may recommend using over-the-counter antidiarrheal medications. These drugs, such as loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol, Kaopectate, etc.) may help some individuals with diarrhea, but should be avoided by others. Antidiarrheal medications are not usually recommended for infants and children with diarrhea. Hospitalization If a person has severe diarrhea, especially accompanied with dehydration, he or she may require hospitalization to receive IV fluids and to be observed.

Diarrhea Medications
The use of anti-motility medications, although controversial, do provide relief from diarrhea. These drugs slow down the intestinal movement. These medications include loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol, Kaopectate, etc). Such medications are not recommended for infants and children younger than 5 years of age. In otherwise healthy adults who are not severely ill with diarrhea, loperamide is probably safe and is effective in decreasing the number of stools per day and the total duration of the diarrhea. Bismuth subsalicylate is also useful and may be more effective than loperamide when

vomiting accompanies the diarrhea.

Adults with other serious medical problems and those with severe diarrhea (high fever, abdominal pain, or bloody stool) should see a health care practitioner before using either medication. Electrolyte solutions are available to prevent salt deficiency. Oral electrolyte solutions are available at grocery and drug stores (Pedialyte, Rehydralyte, Naturalyte Solution). Follow label directions, which may specify 1 teaspoonful every 15 minutes. If the child retains the initial doses, increase the dose to 1 tablespoonful every 15 minutes until the diarrhea stops.

Diarrhea Remedies
Certain plant leaves contain tannins that are considered to be diarrhea remedies. Notably blackberry, blueberry, and raspberry leaves when taken as tea may help diarrhea. Do not eat fresh blueberries because they may make the diarrhea worse. Pregnant women should avoid high doses of tannins. Chamomile tea may also act as a diarrhea remedy. NOTE:If remedies involving homeopathy, herbs, dietary and nutritional supplements, acupressure, aromatherapy, and other alternative or complementary healing methods are used, be advised that these products and techniques have not been scientifically proven to treat, prevent, or cure any disease. Serious interactions with prescription and nonprescription medications (OTC) are always a possibility. Keep the doctor informed about every prescription medication, OTC medication, and vitamins and supplements an individual uses, and seek medical advice for any health concerns prior to taking any medication or remedy. It is recommended to keep a log of all medications a person is taking; prescriptioDiarrhea Follow-up

Avoid becoming dehydrated. Follow the advice of the health practitioner.

Re-contact the health care practitioner if the diarrhea worsens, if the affected person develops a high fever, abdominal pain, or has bloody stools. n, OTC, vitamins, supplements, and herbs in your wallet or purse in case of emergency.

Diarrhea Prevention
Many cases of diarrhea are spread from person-to-person. The following precautions can help an individual avoid diarrhea and other viral or bacterial infections: Individuals caring for sick children or adults in any setting should carefully wash their hands after changing diapers, helping an individual use the bathroom, or assisting an individual around the home. Children should be instructed to wash their hands frequently, especially after using the bathroom. Practice safe food-handling. Always wash hands before and after handling food. Use care when preparing raw poultry or meat. Food should be cooked to the recommended temperatures. Avoid raw or rare meat and poultry. Utensils coming in contact with raw food should be cleaned in soap and hot water. Fruits and vegetables consumed raw should be thoroughly rinsed in clean water.

Unpasteurized (raw) milk may be contaminated with bacteria and should always be avoided. Unpasteurized fruit juice or cider should generally be avoided even if the source is not known because the fruit may have come in contact with contaminated animal feces in the orchard. Use caution when traveling, especially to foreign countries. Do not eat foods from street vendors. Don't drink water or drinks with ice cubes made from tap water if the country is deemed unsafe. Check the Travelers' Health Web site of the Centers for Disease Control and Prevention for travel information for your destination.

Diarrhea Prognosis
Symptoms should begin to improve two to three days after the original diarrheal episode. Loose stools may persist longer than other symptoms. Serious disease is usually seen in individuals who become severely dehydrated, particularly infants, the elderly, or other people with significant medical illnesses.

Diagram of Pathophysiology of Diarrhea

Pathophysiology is the study of how a body biochemically changes after it is affected by a disease. The pathophysiology of diarrhea is a widely discussed issue due to the dangerous attributes of the disease when left unchecked. The average amount of deaths caused by diarrhea is roughly two million people a year. The demographic of individuals who die from diarrhea is mostly composed of juveniles or people vulnerable to infection and sickness. Many people may wish to view a physical diagram of the exact process by which the affliction moves from pathogen to infection to disease.Diarrhea progresses by increasing the volume and fluidity of the stools that a human body makes. Generally as a result of excessive diarrhea, whether it comes from bacterial infection or food indigestion, is major dehydration of the body's resources. A diagram of such will indicate that the pathogenic molecule will be ingested

through the mouth and travel throughout the body. Once the bacteria or offending particle reaches the intestinal region it increases the permeability of the intestinal walls. By doing so, it increases the amount of water that normally resides within the intestines, causing both pressure and discomfort. The combination of water and pressure eventually results in the watery discharge of a stool, or what people traditionally accept to be diarrhea. This can be dangerous because the water that fills the intestines is pulled from the host's water supply thus dehydrating the cells within the body. Since there is a constant flushing mechanism it is absolutely vital that the victim suffering from the disease replenish their water supply constantly. Understandably this can be counter-intuitive when the water is filled with the very same bacteria that promote diarrhea, as was the case during the Civil War with cholera-infested waters. Poor, or soiled water conditions often contribute to the fatal cases of diarrhea. More reference links:

www.webmd.com www.healthcentral.com

Nursing Interventions for Diarrhea

April 28, 2010 | In: Nursing Interventions 1 Replace fluid and electrolyte losses 2 Provide good perianal care. Diarrheal stool is oftentimes highly acidic. This causes anal soreness and irritation in the perianal area. 3 Promote rest. To reduce peristalsis. 4 Diet

1 2 3 4 5 6 7 8

Small amounts of bland foods Low fiber diet BRAT Diet (banna, rice, apple, toast) Avoid excessively hot or cold fluids. These are stimulants. Potassium-rich foods and fluid (e.g. banana, Gatorade)
Antidiarrheal medications as ordered:

Demulcents mechanically coat the irritated bowel and act as protectives. Absorbents absorbs gas or toxic substances from the bowel Astringents Shrink swollen or inflamed tissues in the bowel.

Note: Do not administer antidiarrheal at the start of diarrhea. Diarrhea is the bodys protective mechanism to rid itself of bacteria and toxins.

What is fecal incontinence (FI)?

Fecal incontinence, commonly referred to as bowel control problems, is the inability to hold a bowel movement until reaching a bathroom. FI also refers to the accidental leakagefor example, while passing gasof solid or liquid stool. Feces is another name for stool. FI can be upsetting and embarrassing. Many people with FI feel ashamed and try to hide the problem. However, health care providers are experienced in talking about FI. People with FI should not be afraid or embarrassed to talk with their health care provider. FI is often caused by a medical problem and treatment is available. [Top]

Who gets FI?

Nearly 18 million U.S. adultsabout one in 12have FI.1 FI is not always a part of aging, but it is more common in older adults. FI is slightly more common among women. Having any of the following can increase the risk of FI: diarrhea a disease or injury that damages the nervous system

 poor overall healthmultiple chronic, or long-lasting, illnesses a difficult childbirth with injuries to the pelvic floorthe muscles, ligaments, and tissues that support the uterus, vagina, bladder, and rectum 1 Whitehead WE, Borrud L, Goode PS, et al. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology. 2009;137:512517. [Top]

How does bowel control work?

Bowel control relies on muscles and nerves of the rectum and anus working together to hold and release stool. The rectum, which is the lower end of the large bowel, also called the large intestine, stretches to hold stool. Stool is normally solid by the time it reaches the rectum. Circular muscles called sphincters close tightly like rubber bands around the opening at the end of the rectum, called the anus, until stool is ready to be released during a bowel movement. Pelvic floor muscles also help maintain bowel control. The digestive system The external and internal anal sphincter muscles [Top]

What causes FI?

Fecal incontinence has many causes, including. diarrhea constipation muscle damage or weakness nerve damage loss of stretch in the rectum hemorrhoids pelvic floor dysfunction Diarrhea Diarrhea can cause FI. Loose stools fill the rectum quickly and are more difficult to hold than solid stools. Diarrhea increases the chances of not reaching a toilet in time. Constipation Constipation, a condition in which a person has fewer than three bowel movements a week, can cause FI. Constipation can lead to large, hard stools that get stuck in the rectum. Watery stool builds up behind the hard stool and may leak out around the hard stool. Constipation can, over time, stretch and weaken sphincter muscles, reducing the rectums ability to hold stool. Muscle Damage or Weakness Injury to one or both of the sphincter muscles can cause FI. If these muscles, called the external and internal anal sphincter muscles, are damaged or weakened, they may not be strong enough to keep the anus closed and prevent stool from leaking. Trauma, cancer surgery, and hemorrhoid surgery are possible causes of injury to the sphincters. Hemorrhoids are inflamed veins around the anus or in the lower rectum.

Nerve Damage The anal sphincter muscles wont properly open and close if the nerves that control them are damaged. Likewise, if the nerves that sense stool in the rectum are damaged, a person may not feel the urge to go to the bathroom. Both types of nerve damage can lead to FI. Possible sources of nerve damage are giving birth, a long-term habit of straining to pass stool, stroke, injury, and diseases that affect the nerves, such as diabetes and multiple sclerosis. Loss of Stretch in the Rectum Normally, the rectum stretches to hold stool until a person has a bowel movement. Rectal surgery, radiation treatment, and inflammatory bowel diseases, such as Crohns disease and ulcerative colitis, can cause scarring that stiffens the rectal walls. The rectum then cant stretch as much to hold stool, increasing the risk of FI. Hemorrhoids External hemorrhoids, which develop under the skin around the anus, can prevent the anal sphincter muscles from closing completely. Small amounts of mucus or liquid stool can then leak through the anus. Pelvic Floor Dysfunction Abnormalities of the pelvic floor muscles and nervescalled pelvic floor dysfunctioncan lead to FI by impairing the ability to sense stool in the rectum decreasing the ability to contract muscles used during a bowel movement causing the rectum to drop down through the anus, a condition called rectal prolapse causing the rectum to protrude through the vagina, a condition called rectocele causing the pelvic floor to become weak and sag Giving birth sometimes causes pelvic floor dysfunction. Risk is greater if forceps are used to help deliver the baby or if an episiotomya cut in the vaginal area to prevent the babys head from tearing the vagina during birthis performed. FI related to childbirth can appear soon or many years after delivery. [Top]

How is FI diagnosed?
Health care providers diagnose FI based on a patients medical history, physical exam, and medical test results. Diagnosis is key to treatment. People with concerns about FI should see a health care provider, who may ask the following questions: When did FI start? How often does FI occur? How much stool leaks? Does the stool just streak the underwear? Does just a little bit of solid or liquid stool leak out? Or does complete loss of bowel control occur? Does FI involve a strong urge to have a bowel movement or does it happen without warning? For people with hemorrhoids, do hemorrhoids bulge through the anus? How does FI affect daily life? Do certain foods seem to make FI worse? Can gas be controlled? Based on answers to these questions, a health care provider may refer the patient to a doctor who

specializes in problems of the digestive system, such as a gastroenterologist, proctologist, or colorectal surgeon. The specialist will perform a physical exam and may suggest one or more of the following tests, which may be performed at a hospital or clinic: Anal manometryuses a pressure-sensitive tube to check the sensitivity and function of the rectum. Anal manometry also checks the tightness of the anal sphincter muscles and their ability to respond to nerve signals. Magnetic resonance imaging (MRI)uses radio waves and magnets to produce detailed pictures of the bodys internal organs and soft tissues without using x rays. MRI can be used to create images of the anal sphincter muscles. Anorectal ultrasonography,an ultrasound procedure specific to the anus and rectum, uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. Anorectal ultrasonography can be used to evaluate the structure of the anal sphincter muscles. Proctography,also known as defecography, is an x-ray test that shows how much stool the rectum can hold, how well the rectum can hold stool, and how well the rectum can eliminate stool. Proctosigmoidoscopyuses a lighted, flexible tube to see inside the rectum and the lower large intestine to look for potential FI-related problems such as inflammation, tumors, or scar tissue. Anal electromyographytests for pelvic floor and rectal muscle nerve damage. [Top]

How is FI treated?
Successful FI treatment relies on correctly diagnosing the underlying problem. Treatment may include one or more of the following: eating, diet, and nutrition medication pelvic floor exercises bowel training surgery electrical stimulation Eating, Diet, and Nutrition Food affects stool consistency and how quickly it passes through the digestive system. If stools are hard to control because they are loose, high-fiber foods may add bulk and make stool easier to control. However, some people find that high-fiber foods loosen stool and make FI worse. Foods and drinks that contain caffeine, such as coffee, tea, or chocolate, may relax the internal anal sphincter muscles and worsen FI. Dietary changes that may improve FI include Eating the right amount of fiber.For many people, fiber adds bulk to their stool and makes it softer and easier to control. Fiber can help with diarrhea and constipation. Fiber is found in fruits, vegetables, whole grains, and beans. Fiber supplements sold in a pharmacy or in a health food store are another common source of fiber to treat FI. A normal diet should include 20 to 30 grams of fiber a day. Fiber should be added to the diet slowly to avoid bloating. Getting plenty to drink.Eight, 8-ounce glasses of liquid a day may help prevent constipation. Water is a good choice. Drinks with caffeine, alcohol, milk, or carbonation should be avoided if they trigger diarrhea. Over time, diarrhea can prevent a persons body from obtaining enough vitamins and minerals. Health care providers can recommend vitamin supplements to help correct this problem and can give information about how changes in eating, diet, or nutrition could help with treatment.

Keeping a Food Diary

A food diary can help identify foods that cause diarrhea and FI. A food diary should list foods eaten, portion size, and when FI occurs. After a few days, the diary may show a link between certain foods and FI. Eating less of foods linked to FI may improve symptoms. A food diary can also be helpful to a health care provider treating a patient with FI. Common foods and drinks linked to diarrhea and FI include dairy products such as milk, cheese, and ice cream drinks and foods containing caffeine cured or smoked meat such as sausage, ham, and turkey spicy foods alcoholic beverages fruits such as apples, peaches, and pears fatty and greasy foods sweeteners in diet drinks and sugarless gum and candy, including sorbitol, xylitol, mannitol, and fructose

What Foods Have Fiber?

Examples of foods that have fiber include Beans, cereals, and breads Fiber cup of beans (navy, pinto, kidney, etc.), cooked 6.29.6 grams cup of shredded wheat, ready-to-eat cereal 2.73.8 grams cup of 100% bran, ready-to-eat cereal 9.1 grams 1 small oat bran muffin 3.0 grams 1 whole-wheat English muffin 4.4 grams Fruits 1 small apple, with skin 3.6 grams 1 medium pear, with skin 5.5 grams cup of raspberries 4.0 grams cup of stewed prunes 3.8 grams Vegetables cup of winter squash, cooked 2.9 grams 1 medium sweet potato, baked in skin 3.8 grams cup of green peas, cooked 3.54.4 grams 1 small potato, baked, with skin 3.0 grams cup of mixed vegetables, cooked 4.0 grams cup of broccoli, cooked 2.62.8 grams cup of greens (spinach, collards, turnip greens), cooked 2.53.5 grams Source:U.S. Department of Agriculture and U.S. Department of Health and Human Services, Dietary Guidelines for Americans,2010. Medication If diarrhea is causing FI, medication may help. Health care providers sometimes recommend using bulk laxatives, such as Citrucel and Metamucil, to develop more regular bowel patterns. Antidiarrheal medicines such as loperamide or diphenoxylate may be recommended to slow down the bowels and help control the problem.

Pelvic Floor Exercises Exercises that strengthen the pelvic floor muscles may improve bowel control. Pelvic floor exercises involve squeezing and relaxing pelvic floor muscles 50 to 100 times a day. A health care provider can help with proper technique. Biofeedback therapy may also help. Biofeedback therapy uses sensors to tell patients if they are exercising the right muscles. Success with pelvic floor exercises depends on the cause of FI, its severity, and a persons ability to perform the exercises. Bowel Training Developing a regular bowel movement pattern can help improve FI, especially FI due to constipation. Bowel training involves attempting to have bowel movements at specific times of the day, such as after every meal. Over time, the body becomes accustomed to a regular bowel movement pattern, thus reducing constipation and related FI. Persistence is key to successful bowel training. Achieving a regular bowel control pattern can take weeks to months. Surgery Surgery may be an option for FI that fails to improve with other treatments or for FI caused by pelvic floor or anal sphincter muscle injuries. Sphincteroplasty, the most common FI surgery, reconnects the separated ends of a sphincter muscle torn by childbirth or another injury. Sphincteroplasty is performed at a hospital by a colorectal, gynecological, or general surgeon. Another surgery involves placing an inflatable cuff, called an artificial sphincter, around the anus and implanting a small pump beneath the skin that the patient activates to inflate or deflate the cuff. This surgery is much less common and is performed at a hospital by specially trained colorectal surgeons. Electrical Stimulation Electrical stimulation, also called sacral nerve stimulation or neuromodulation, involves placing electrodes in the nerves to the anal canal and rectum and continuously stimulating these nerves with electrical pulses. This procedure requires a battery-operated stimulator placed beneath the skin. [Top]

Anal Discomfort
The skin around the anus is delicate and sensitive. Constipation and diarrhea or contact between skin and stool can cause pain or itching. The following steps can help relieve anal discomfort: Washing the anal area after a bowel movement.Washing with water, but not soap, can help prevent discomfort. Soap can dry out the skin, making discomfort worse. Ideally, the anal area should be washed in the shower with lukewarm water or in a sitz batha special plastic tub that allows a person to sit in a few inches of warm water. No-rinse skin cleansers, such as Cavilon, are a good alternative. Wiping with toilet paper further irritates the skin and should be avoided. Premoistened, alcohol-free towelettes are a better choice. Keeping the anal area dry.The anal area should be allowed to air dry after washing. If time doesnt permit air drying, the anal area can be gently patted dry with a lint-free cloth. Creating a moisture barrier.A moisture barrier cream that contains ingredients such as dimethiconea type of siliconecan help form a barrier between skin and stool. The anal area should be cleaned before applying barrier cream. Patients, however, should talk with their health care provider before using anal creams and ointments. Some can irritate the anus. Using nonmedicated powders.Nonmedicated talcum powder or cornstarch can also relieve

anal discomfort. As when moisture barrier creams are used, the anal area should be clean and dry before use. Using wicking pads or disposable underwear.Pads and disposable underwear with a wicking layer can pull moisture away from the skin. Wearing breathable clothes and underwear.Clothes and underwear should allow air to flow and keep skin dry. Tight clothes or plastic or rubber underwear that blocks air can worsen skin problems. Changing soiled underwear as soon as possible. [Top]

What are some practical tips for coping with FI?

Because FI can cause embarrassment, fear, and loneliness, taking steps to deal with it is important. Treatment can dramatically improve quality of life and help people with FI feel better about themselves. The first step is to contact a health care provider. The organizations listed at the end of this fact sheet can provide information, support, and resources to help find FI treatment specialists. The following tips can help people cope with FI: carrying a bag with cleanup supplies and a change of clothes when leaving the house finding public restrooms before one is needed using the toilet before leaving home wearing disposable underwear if loss of bowel control is suspected using fecal deodorantspills that reduce the smell of stool and gas; although fecal deodorants are available over the counter, a health care provider can help patients find them [Top]

What if a child has FI?

A child with FI who is toilet trained should see a health care provider, who can determine the cause and recommend treatment. FI can occur in children because of a birth defect or disease, but in most cases it occurs because of constipation. Children often develop constipation as a result of stool withholding. They may withhold stool because they are stressed about toilet training, embarrassed to use a public bathroom, do not want to interrupt playtime, or are fearful of having a painful or unpleasant bowel movement. Similarly to adults, constipation in children can cause large, hard stools that get stuck in the rectum. Watery stool builds up behind the hard stool and may unexpectedly leak out, soiling a childs underwear. Parents often mistake this soiling as a sign of diarrhea. [Top]

Points to Remember
Fecal incontinence (FI), commonly referred to as bowel control problems, is the inability to hold a bowel movement until reaching a bathroom. Nearly 18 million U.S. adultsabout one in 12have FI. People with FI should not be afraid or embarrassed to talk with their health care provider. FI is often caused by a medical problem. Bowel control relies on muscles and nerves of the rectum and anus working together to hold and release stool. Circular muscles called sphincters close tightly like rubber bands around the opening at the end of the rectum, called the anus, until stool is ready to be released during a bowel movement. The pelvic floorthe muscles, ligaments, and tissues that support the uterus, vagina, bladder, and rectumhelps maintain bowel control.

 FI has many causes, including diarrhea, constipation, muscle damage or weakness, nerve damage, loss of stretch in the rectum, hemorrhoids, and pelvic floor dysfunction. Health care providers diagnose FI based on the patients medical history, a physical examination, and medical tests. Successful FI treatment relies on correctly diagnosing the underlying problem. Treatment may include eating, diet, and nutrition; medication; pelvic floor exercises; bowel training; surgery; or electrical stimulation. A food diary can help identify foods that cause diarrhea and FI. Steps that can help relieve anal discomfort include washing the anal area after a bowel movement, keeping the anal area dry, wearing breathable clothes and underwear, and changing soiled underwear as soon as possible. Treatment for FI is available. The first step is to contact a health care provider. FI can occur in children because of a birth defect or disease, but in most cases it occurs because of constipation. [Top]

Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports research into many kinds of digestive disorders, including FI. The NIDDK is researching ways to create new anal sphincter muscles from patients own cells or tissues. The U.S. Food and Drug Administration is currently reviewing sacral nerve stimulation, a technique used in Europe to treat FI. Sacral nerve stimulation involves implanting a small electronic device to stimulate the sacral nerves, which run from the spinal cord to the anal sphincter muscles. Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.

Bowel Incontinence Introduction

Bowel incontinence is the inability to control bowel movements. It's a common problem, especially among older adults. Bowel incontinence is usually not a serious medical problem. But it can seriously interfere with daily life. People with bowel incontinence may avoid social activities for fear of embarrassment. Many effective treatments can help people with bowel incontinence. These include: medicine surgery minimally invasive procedures Talking to your doctor is the first step toward freedom from bowel incontinence.

Bowel Incontinence Causes

The most common cause of bowel incontinence is damage to the muscles around the anus (anal sphincters). Vaginal childbirth can damage the anal sphincters or their nerves. That's why women are affected by bowel incontinence about twice as often as men. Anal surgery can also damage the anal sphincters or nerves, leading to bowel incontinence. There are many other potential causes of bowel incontinence, including: Diarrhea(often due to an infection or irritable bowel syndrome) Impacted stool (due to severe constipation, often in older adults)

 Inflammatory bowel disease(Crohn's disease or ulcerative colitis) Nerve damage (due to diabetes, spinal cord injury, multiple sclerosis, or other conditions) Radiation damage to the rectum (such as after treatment for prostate cancer) Cognitive (thinking) impairment (such as after a stroke or advanced Alzheimer's disease)

Diagnosis of Bowel Incontinence

Discussing bowel incontinence may be embarrassing, but it can provide clues for a doctor to help make the diagnosis. During a physical examination, a doctor may check the strength of the anal sphincter muscle using a gloved finger inserted into the rectum. Other tests may be helpful in identifying the cause of bowel incontinence, such as: Stool testing.If diarrhea is present, stool testing may identify an infection or other cause. Endoscopy.A tube with a camera on its tip is inserted into the anus. This identifies any potential problems in the anal canal or colon. A short, rigid tube (anoscopy) or a longer, flexible tube (sigmoidoscopy or colonoscopy) may be used. Anorectal manometry.A pressure monitor is inserted into the anus and rectum. This allows measurement of the strength of the sphincter muscles. Endosonography.An ultrasound probe is inserted into the anus. This produces images that can help identify problems in the anal and rectal walls. Nerve tests.These tests measure the responsiveness of the nerves controlling the sphincter muscles. They can detect nerve damage that can cause bowel incontinence. MRI defecography.Magnetic resonance imagingof the pelvis can be performed, potentially while a person moves her bowels on a special commode. This can provide information about the muscles and supporting structures in the anus, rectum, and pelvis.

Treatments for Bowel Incontinence

Bowel incontinence is usually treatable. In many cases it can be cured completely. Recommended treatments vary according to the cause of bowel incontinence. Often, more than one treatment method may be required to control symptoms. Nonsurgical treatments are often recommended as initial treatment for bowel incontinence. These include: Diet.These steps may be helpful: Eat 20 to 30 grams of fiber per day. This can make stool more bulky and easier to control. Avoid caffeine. This may help prevent diarrhea. Drink several glasses of water each day. This can prevent constipation. Medications. Try these medicines to reduce the number of bowel movements and the urge to move the bowels: Imodium Lomotil Hyoscyamine Methylcellulose can help make liquid stool more solid and easier to control. For people with a specific cause of diarrhea, such as inflammatory bowel syndrome, other medications may also help. Exercises.Begin a program of regularly contracting the muscles used to control urinary flow (Kegel exercises). This builds strength in the pelvic muscles and may help reduce bowel incontinence. Bowel training.Schedule bowel movements at the same times each day. This can help prevent

accidents in between. Biofeedback.A sensor is placed inside the anus and on the abdominal wall. This provides feedback as a person does exercises to improve bowel control. Surgery may be recommended for people whose bowel incontinence is not helped by noninvasive treatments. The types of surgery include: Sphincter surgery.A surgeon can stitch the anal muscles more tightly together (sphincteroplasty). Or the surgeon takes muscle from the pelvis or buttock to support the weak anal muscles (muscle transposition). These surgeries can cure many people with bowel incontinence that's due to a tear of the anal sphincter muscles. Sacral nerve stimulator.A surgeon implants a device that stimulates the pelvic nerves. This procedure may be most effective in people with bowel incontinence due to nerve damage. Sphincter cuff device.A surgeon can implant an inflatable cuff that surrounds the anal sphincter. A person deflates the cuff during bowel movements and reinflates it to prevent bowel incontinence. Colostomy.Surgery to redirect the colon through an opening created in the skin of the belly. Colostomy is only considered when bowel incontinence persists despite all other treatments. Newer, nonsurgical procedures are also available to treat bowel incontinence, such as: Radiofrequency anal sphincter remodeling.A probe inserted into the anus directs controlled amounts of heat energy into the anal wall. Radiofrequency remodeling creates a mild injury to the sphincter muscles, which become thicker as they heal. Injectable biomaterials.Materials such as silicone, collagen, or dextranomer/hyaluronic acid can be injected into the anal sphincter to boost its thickness and function. These minimally invasive procedures can reduce bowel incontinence in some people, without the risks of surgery. Because they are relatively new, their long-term effectiveness and safety aren't as well known as other treatments.

Pathophysiology of adult fecal incontinence.

Rao SS. Source
Department of Internal Medicine, University of Iowa Carver Colege of Medicine, Iowa City 52242, USA. satish-rao@uiowa.edu

Abstract
Fecal incontinence occurs when the normal anatomy or physiology that maintains the structure and function of the anorectal unit is disrupted. Incontinence usually results from the interplay of multiple pathogenic mechanisms and is rarely attributable to a single factor. The internal anal sphincter (IAS) provides most of the resting anal pressure and is reinforced during voluntary squeeze by the external anal sphincter (EAS), the anal mucosal folds, and the anal endovascular cushions. Disruption or weakness of the EAS can cause urge-related or diarrhea-associated fecal incontinence. Damage to the endovascular cushions may produce a poor anal "seal" and an impaired anorectal sampling reflex. The ability of the rectum to perceive the presence of stool leads to the rectoanal contractile reflex response, an essential mechanism for maintaining continence. Pudendal neuropathy can diminish rectal sensation and lead to excessive accumulation of stool, causing fecal impaction, mega-rectum, and fecal overflow. The puborectalis muscle plays an integral role in maintaining the anorectal angle. Its nerve supply is independent of the sphincter, and its precise role in maintaining continence needs to be defined. Obstetric trauma, the most common cause of anal sphincter disruption, may involve the EAS, the IAS, and the pudendal nerves, singly or in combination. It remains unclear why most women who sustain obstetric injury in their 20s or 30s typically do not present with fecal incontinence until their 50s. There

is a strong need for prospective, long-term studies of sphincter function in nulliparous and multiparous women.