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McXtra Care Newsletter | January 2020

Section A

MAIN FEATURE

Understanding Risk factors and types of Constipation

Constipation is a difficulty in passing stool, which includes infrequent bowel evacuations, straining to pass stool, hard or lumpy stools, prolonged duration to evacuate, or a feeling of not having evacuated fully or adequately.

Everyone goes through such episodes once in a while but when this is present for most days in the month, for at least 3 months or longer, the person is said to have chronic constipation. Associated symptoms include feeling of abdominal discomfort, bloating, cramps, appetite loss and an overall feeling of decreased well-being.

RISK FACTORS

Risk of developing constipation increases with Age (risk doubling >75 years) due to weakening of muscles and decreased physical activity. Women are 3-4 times at higher risk of developing constipation. Constipation is more common in Asian and African Ethnicity.

Lifestyle factors such as type of Diet (decreased fiber and increased processed items), low fluid and water intake, Physical inactivity and sedentary lifestyle, improper bowel habits, psychological stress and intake of certain substances/medicines, all can lead to development of constipation. Long term illnesses and weakness, or prolonged bed rest and periods of recovery from surgeries/illnesses also predispose to developing constipation.

The term Post Prandial glucose, refers to blood glucose 2 hours after a regular meal. Though this has importance in monitoring and assessing response to treatment in diabetics, it has low evidence of strong correlation with diagnosis of Diabetes and is not used for the same. Blood sugar fasting, OGGT and Post meal (Post Prandial: PP) show current blood glucose status, and HbA1C gives the blood sugar over past 2-3 months.

TYPES OF CONSTIPATION

These are based on the probable cause and mechanism of constipation.

Normal transit constipation

Also called Functional constipation, as here the Bowel movements and the transit time of stool is normal. Constipation occurs due to reduced bulk of stool (seen with low fiber and fluid intake), suppressing urge or avoiding to pass stool (rushing to work/busy schedules, avoiding unpleasant/unhygienic toilets) or if there is a painful body condition making one avoid sitting for passing stools (hip/knee arthritis, injuries, recurrent boils, fissures in the anus, breathlessness on sitting/straining etc.)

Slow Transit Constipation

Bowel movement (Motility) here is decreased leading to increased transit time of stools. This is the result of reduced contracting ability of the abdominal and bowel muscles as seen with Ageing, injuries/trauma, nerve related diseases, hormonal imbalances- pregnancy, and certain drugs/medicines. Sometimes the reduced motility maybe even seen throughout the gut leading to symptoms of indigestion (like acidity, early fullness after meals) along with constipation.

Lack of synergy (co-ordination) of Muscles

Even though strength and contracting ability of muscles may be intact, there may be incoordination in their action. For effective bowel evacuation, muscles of the abdomen (just below the chest around the belly button/navel) contract, while the pelvic floor (group of muscles supporting the lower organs like urinary bladder, large bowels, and uterus), and the anal sphincter (a ring like group of muscles surrounding the anus to control stool release) relax, in synergy. Absence of synergy and coordination may occur due to trauma and injury to the muscles and nerves during childbirth, sexual abuse, accidents, and spinal cord injuries. Such patients may have additional symptoms like urinary complaints (frequency, pain or leakage), pain in lower back or area of genitals, or pain during intercourse. The constipation in such people is typically a feeling of incomplete evacuation even after prolonged strain.

Mechanical obstruction to passage of stools

It is important to rule out a local partial (stenosis) or complete obstruction (stricture and stenosis) which prevents stools from passing out. Such cases usually present with almost sudden and complete constipation and a feeling of stools getting stuck. This happens due to inflammation and scarring following injury, ulcers, infections (like STD, TB), instrumentation/surgery/radiation. A tumor or cancerous growth is a cause to be explored in elderly patients presenting with sudden constipation, accompanied by weight loss, and blood in stools or presence of paleness/anemia. Sometimes a hard piece of stool (fecal impaction) may cause the obstruction. There may sometimes be localized ‘pouches’ in the bowel which accumulate the stool and cause obstruction (rectoceles).

Secondary to other diseases

Constipation can be one of the manifestations of several body diseases therefore it is wise to consider these conditions and treat the primary cause along with managing the constipation per se. These include Diabetes, Thyroid disorders, Imbalances in calcium-magnesium-potassium levels, increase in blood urea due to liver disorders, Neurological conditions like Parkinson’s, Multiple sclerosis or post stroke, heavy metal poisoning (can be from sea food, occupational or industrial sources) and long term use of some medicines.

Irritable bowel syndrome (IBS)

This is a bowel condition comprising of abdominal pain as hallmark symptom, related to (relieved or brought on by) passing of stool, accompanied by change in form and frequency of stool. The cause is related to disruptions in the gut brain connections whereby there may be alterations (increase or decrease) in the sensitivity of the gut to stretch/food, gut motility/transit time, and amount of fluid absorbed from the gut. Therefore, IBS can present as abdominal pain with constipation (50% cases IBS-C) or with diarrhea (IBS-D) or a mixed type (IBS-M) with alternate diarrhea and constipation. Sometimes sensitivity to a substance called Gluten found in wheat products can also cause constipation with or without alternating diarrhea and other abdominal symptoms.

Section B

TRENDING FEATURE

Diet solutions for Constipation

The general principles are to include more fiber like whole grains, vegetables and fruits and less of processed and refined food. This is also the key to general good health, weight, sugar and fat management, and keeping many lifestyle and metabolic conditions at bay.

Fibers (Roughage) – These maybe insoluble (remain unchanged in gut but add bulk to stool to help it move more easily) or soluble (absorb water, swelling into a gel making the stools move slowly but steadily and smoothly). A balanced mix of insoluble fibers (whole grains, wheat bran, brown rice, prunes) and soluble fibers (oat bran, beans, lentils, peas, and flaxseeds) should be incorporated in the diet.

Vegetables and fruits are good sources of both insoluble and soluble fibers with the former being more in the outer skin, peel and leafy parts and the latter more in the inner fleshy parts. Fruit like apples, pears, citrus fruits and berries have good amounts of soluble fibers while tomatoes, nuts, raisins, grapes have good amounts of insoluble fibers. Figs are a great balanced source of both fibers.

Soluble fibers provide additional health benefits like managing cholesterol, sugar and weight. Some of these fibers are fermented by gut bacteria to additional useful products, but the byproduct gases liberated may temporarily aggravate the feeling of bloating or abdominal discomfort especially in IBS patients. This may also be experienced with too much of insoluble fiber intake increasing stool bulk.

Therefore, fiber intake should be kept to around 20-25g/day in women and 30-35g/day in men out of which 25-30% should come from soluble fibers. The fiber content of the food should be gradually raised. IBS patients should especially avoid FODMAP foods in their diet.

Water and Fluid intake – At least 1.5 to 2 liters/day is the recommended norm (this does not include beverages/other drinks). Beverages/alcohol/aerated and carbonated drinks – these should be kept to a minimum). Alcoholic, sugary, aerated and carbonated drinks should be avoided/restricted as they increase tendency to constipation. A morning warm/hot milk, coffee or tea works well to stimulate bowel movement, but it is advisable to restrict them later in the day or evening as they are likely to constipate the next day. Fruit juices work well for people with tendency to constipation.

Constipating food items – These include meats, cheese, butter, fried foods, frozen foods, ice creams, processed grains and foods, high salt foods, and sweetened sugary food items (cookies, cakes, pastries etc). Unripe bananas tend to constipate so go for ripe bananas which has good amount of soluble fibers.

Yogurt is very beneficial for constipation as well as to maintain gut bacteria (probiotic). Olive oil has a mild laxative effect so is a good option to use for cooking for constipated people

Section C

SPECIAL FEATURE

Lifestyle changes and Medicines for Constipation

Lifestyle

A few habits go a long way to improve functional constipation. It’s prudent to ensure adequate time for passing stool by setting time for waking and not suppressing urge to go to the toilet.

Include half hour of exercise (5 days/week) in your lifestyle – swimming, brisk walking, cycling, jogging, yoga, or aerobics. If sitting for prolonged periods of time, take a short walk and do some stretching every 2 hours. Squatting exercises help to build abdominal muscle strength and aid in managing constipation.

The brain and gut have an intricate connection, so stress or depression can lead to release of chemical mediators which increase acid release and slow down gut movement. Including de-stressing and relaxation techniques in daily routine like deep breathing exercises, indulging in hobbies like reading, music, dance, crafts, gardening, and sports, can also contribute to smooth bowel functioning.

Medicines for Constipation

Laxative medicines are recommended in chronic and resistant constipation and are best used after medical consultation and investigations which may include blood and stool testing. A colonoscopy may also be performed to rule out certain causes, and sometimes specific tests for gluten sensitivity or lactose intolerance maybe advised.

Even though many laxatives are available over the counter, it is best to start in accordance with medically recommended amount and duration. Irregular, inappropriate or overuse of laxatives can actually worsen the symptoms or condition in many people.

Laxatives act by various mechanisms like increasing stool bulk or water content, lubricating or softening stools, stimulating the gut muscle contraction, or irritating the gut lining to mobilize stools. Combinations of laxatives are also available (Ispaghula+Lactulose, PEG+Ispaghula, Milk of Magnesia+Liquid paraffin) as powders, liquids and capsules (and sometimes as enemas in hospital setting for emptying bowel before surgery/procedure or in acute severe constipation).

Some of the side effects of Laxative medicines include nausea, bloating, abdominal cramps, diarrhea and imbalance of mineral salts in the body. Palatability is also an issue which is often solved by flavouring the powder and liquid preparations. In elderly, leakage of stools (fecal incontinence) maybe a disturbing side effect. Many of the over the counter preparations start to decrease in effectiveness over a period of time in chronic constipation cases, and the need for larger and multiple doses may arise. Newer drugs like Prucalopride have shown effectiveness in chronic constipation not responding satisfactorily to conventional laxatives, and also have the advantage of once daily dosing.

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