Are you constipated?

Chronic constipation is a very common problem. I see patients with stomach and bowel problems all the time and constipation is high on their list of complaints. Usually, it has been present for many years. We usually tell patients with chronic constipation to take high fiber diet, do regular exercise and drink plenty of fluids. But what really works for constipation?

Let us start by defining what chronic constipation is. Unfortunately, there is no simple definition. Most people complain of constipation if they do not have a bowel movement for a few days or if they have difficulty emptying. Generally speaking, constipation is defined as having a bowel movement fewer than three times a week. The bowel movements are usually hard, dry, and small in size.

We do not need a daily bowel movement to be healthy. We do not have to spend money on bowel cleansing with laxatives and enemas to get rid of so called toxins. Daily bowel movements are not important for overall health.

As part of my research for this column, I came across an article in the American Journal of Medicine (AJM) titled: Constipation in the Primary Care Setting: Current Concepts and Misconceptions. The article reviews what works and what does not work in patients with chronic constipation. Here are some important points discussed in the article.

Regular exercise, high fiber diet and fluids are good choices for a healthy life style. But if one of these choices is missing in your life then it would not be a major factor in causing chronic constipation.

High fiber diet increases stool weight and frequency in healthy individuals and decreases the time it takes for the stool to travel to the rectum. Increase intake of fiber has shown to help some chronically constipated individuals. High fiber diet does not help patients who have irritable bowel syndrome where constipation is the dominant symptom, patients who have slow large bowel transit time or have problem with emptying the rectum due to muscle weakness. That means all constipated patients will not benefit from high fiber diet.

What about fluid intake and exercise? The article says that adequate fluid intake and regular exercise improves general health but there is no evidence to support the use of these measures in treating constipation

What about the laxatives? Laxatives are among the most widely used medications in Western countries, says the AJM article. Laxatives are designed to increase the frequency and ease of bowel movement. They are easily accessible and sometimes abused as most of them can be purchased over-the-counter. There are three categories of laxatives:
-Bulk agents: psyllium, methylcellulose, Calcium polycarbophil
-Osmotic agents: polyethylene glycol, lactulose, sorbitol, glycerine suppositories magnesium citrate, magnesium sulfate
-Bowel stimulants: bisacodyl, senna

Bulk agents like psyllium work in similar fashion to high fiber diet. Studies have shown that osmotic laxatives like lactulose, sorbitol and polyethylene glycol are effective. Stimulant laxatives are also effective in many patients with constipation, although certainly not all. Except for bloating and flatulence, laxatives have few side effects. Once daily dosage should be encouraged for better compliance. There is no evidence to support the belief that stimulant laxatives like senna can damage colonic nerves if chronically used.

The article says that although tolerance to laxatives has not been studied extensively in humans, it seems to be uncommon in the majority of laxative users. Tolerance to stimulant laxatives occurs in patients who have constipation due to slow transit time and whose colons have poor neurological function. Can you get addicted, habituated or dependent on laxatives? The answer is no. Most laxatives are not absorbed in the system so there is no risk of addiction.

So, high fiber diet, adequate fluid intake, regular exercise and psyllium should work for most patients with chronic constipation. If you are resistant to these measures then you can add something like lactulose or a stool softener. If that does not work then add senna.

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