Constipation

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 * Associate Editor-In-Chief:

Overview
Constipation or irregularity, is a condition of the digestive system where a person (or animal) experiences hard feces that are difficult to egest. It may be extremely painful, and in severe cases (fecal impaction) lead to symptoms of bowel obstruction. The term obstipation is used for severe constipation. Causes of constipation may be dietary, hormonal, anatomical, a side effect of medications (e.g. some painkillers), or an illness or disorder. Treatments consist of changes in dietary and exercise habits, the use of laxatives, and other medical interventions depending on the underlying cause.

Signs and symptoms
Constipation is one of the most common digestive complaints. It varies greatly between different people, as each person's bowel movements differ. Rate of defecation is not in itself a problem, as infrequent defecation without problems is not abnormal. Constipation is most common in children and older people, and affects women more than men. In children, constipation can lead to soiling (enuresis and encopresis).

In common constipation, the stool is hard and difficult and painful to pass. Usually, there is an infrequent urge to void. Straining to pass stool may cause hemorrhoids and anal fissures, which are themselves painful. In later stages of constipation, the abdomen may become distended and diffusely tender and crampy, occasionally with enhanced bowel sounds.

The definition of constipation includes the following:
 * infrequent bowel movements (typically 3 times or less per week)
 * difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools), or
 * the sensation of incomplete bowel evacuation.

Severe cases ("fecal impaction") may feature symptoms of bowel obstruction (vomiting, very tender abdomen) and "paradoxical diarrhea", where soft stool from the small intestine bypasses the impacted matter in the colon.

Diagnosis
The diagnosis is essentially made from the patient's description of the symptoms. Bowel movements that are difficult to pass, very firm, or made up of small rabbit-like pellets qualify as constipation, even if they occur every day. Other symptoms related to constipation can include bloating, distention, abdominal pain, or a sense of incomplete emptying.

Inquiring about dietary habits may reveal a low intake of dietary fiber or inadequate amounts of fluids. Constipation as a result of poor ambulation or immobility should be considered in the elderly. Constipation may arise as a side effect of medications (especially antidepressants and opiates). Rarely, other symptoms suggestive of hypothyroidism may be elicited.

During physical examination, scybala (manually palpable lumps of stool) may be detected on palpation of the abdomen. Rectal examination gives an impression of the anal sphincter tone and whether the lower rectum contains any feces or not; if so, then suppositories or enemas may be considered. Otherwise, oral medication may be required. Rectal examination also gives information on the consistency of the stool, presence of hemorrhoids, admixture of blood and whether any tumors or abnormalities are present.

X-rays of the abdomen, generally only performed on hospitalized patients or if bowel obstruction is suspected, may reveal impacted fecal matter in the colon, and confirm or rule out other causes of similar symptoms.

Chronic constipation (symptoms present for more than 3 months at least 3 days per month) associated with abdominal discomfort is often diagnosed as irritable bowel syndrome (IBS) when no obvious cause is found. Physicians caring for patients with chronic constipation are advised to rule out obvious causes through normal testing.

Causes
The main causes of constipation include:
 * Hardening of the feces
 * Improper mastication (chewing) of food
 * Insufficient intake of dietary fiber
 * Dehydration from any cause or inadequate fluid intake
 * Medication, e.g. diuretics and those containing iron, calcium, aluminium
 * Paralysis or slowed transit, where peristaltic action is diminished or absent, so that feces are not moved along
 * Hypothyroidism (slow-acting thyroid gland)
 * Hypokalemia
 * Injured anal sphincter (patulous anus)
 * Medications, such as loperamide, opioids (e.g. codeine & morphine) and certain tricyclic antidepressants
 * Severe illness due to other causes
 * Acute porphyria (a rare inherited condition)
 * Lead poisoning
 * Dyschezia (usually the result of suppressing defecation)
 * Constriction, where part of the intestine or rectum is narrowed or blocked, not allowing feces to pass
 * Stenosis (Strictures)
 * Diverticula
 * Tumors, either of the bowel or surrounding tissues
 * Retained foreign body or a bezoar
 * Psychosomatic constipation, based on anxiety or unfamiliarity with surroundings.
 * Functional constipation
 * Constipation-predominant irritable bowel syndrome, characterized by a combination of constipation and abdominal discomfort and/or pain
 * Smoking cessation (tobacco smoking has a laxative effect)
 * Abdominal surgery, other types of surgery, childbirth

Complete Differential Diagnosis of the Causes of Constipation
(In alphabetical order)


 * 5-HT3 antagonist
 * 5-Hydroxytryptophan
 * Acamprosate (patient information)
 * Acebutolol (patient information)
 * Actiq
 * Acute Intermittent Porphyria
 * Adhesion
 * Adjustable gastric band
 * Aldesleukin (patient information)
 * Alendronate (patient information)
 * Alfentanil Hydrochloride Injection (patient information)
 * Alfuzosin (patient information)
 * Alosetron
 * Aluminium hydroxide
 * Amantadine
 * Amiodarone Oral (patient information)
 * Amitriptyline (patient information)
 * Amobarbital (patient information)
 * Amyloidosis
 * Amyotrophic Lateral Sclerosis
 * Anagrelide (patient information)
 * Anal atresia
 * Anastrozole (patient information)
 * Anorexia nervosa
 * Aprepitant (patient information)
 * Aripiprazole (patient information)
 * Ascites
 * Atorvastatin
 * Atovaquone (patient information)
 * Atropine
 * Auranofin
 * Autonomic neuropathy
 * Barium Sulfate (patient information)
 * Batten disease
 * Belladonna Alkaloid Combinations and Phenobarbital (patient information)
 * Benign colonic tumors
 * Benzatropine
 * Benzonatate (patient information)
 * Bepridil (patient information)
 * Berdon syndrome
 * Bezafibrate
 * Bile acid sequestrant
 * Bismuth Subsalicylate, Metronidazole, and Tetracycline Combination (patient information)
 * Blastocystosis
 * Bortezomib (patient information)
 * Botulism
 * Bowel obstruction
 * Bromocriptine
 * Buspirone (patient information)
 * Butabarbital (patient information)
 * Cabergoline
 * Calcitriol
 * Calcium carbonate (patient information)
 * Capecitabine (patient information)
 * Carbamazepine (patient information)
 * Carboplatin (patient information)
 * Carteolol (patient information)
 * Celiac disease
 * Cerivastatin (patient information)
 * Cetuximab Injection (patient information)
 * Chagas Disease
 * Chlordiazepoxide (patient information)
 * Chlorpheniramine
 * Chlorpromazine
 * Chloropyramine
 * Chlorpropamide
 * Cholestyramine
 * Choline Magnesium Trisalicylate (patient information)
 * Chronic amebiasis
 * Cidofovir Injection (patient information)
 * Cimetidine Hydrochloride Injection (patient information)
 * Cimicifuga racemosa
 * Cilansetron
 * Cinnarizine
 * Cisapride (patient information)
 * Cladribine (patient information)
 * Clofarabine Injection (patient information)
 * Clomipramine
 * Clonazepam (patient information)
 * Clonidine
 * Clorazepate (patient information)
 * Clozapine
 * Codeine (patient information)
 * Colesevelam (patient information)
 * Colestipol (patient information)
 * Colofac
 * Colonic stricture
 * Colorectal cancer
 * Colestyramine
 * Conn's Syndrome (primary aldosteronism)
 * Cornelia de Lange Syndrome
 * Corrosive enema
 * Crohn's disease
 * Cystic fibrosis
 * Daptomycin
 * Darbepoetin Alfa Injection (patient information)
 * Darifenacin (patient information)
 * Darunavir (patient information)
 * Dehydration
 * Descending perineum syndrome
 * Desipramine (patient information)
 * Dextroamphetamine and Amphetamine (patient information)
 * Dextropropoxyphene
 * Diabetes Mellitus
 * Diacetyldihydromorphine
 * Diazepam (patient information)
 * Dicyclomine (patient information)
 * Diethylcathinone
 * Diflunisal
 * Dihydroetorphine
 * Diltiazem (patient information)
 * Diphenhydramine
 * Diphenoxylate
 * Disopyramide (patient information)
 * Diuretic
 * Diverticular stricture
 * Diverticulosis
 * Dolasetron Mesylate Injection (patient information)
 * Doripenem
 * Dosulepin hydrochloride
 * Doxepin (patient information)
 * Duloxetine
 * Enfuvirtide Injection (patient information)
 * Enteric Neuropathy
 * Eosinophilic colitis
 * Epoetin Alfa Injection (patient information)
 * Esomeprazole (patient information)
 * Estazolam (patient information)
 * Estradiol Topical (patient information)
 * Ethcathinone
 * Ethosuximide
 * Ethylmorphine
 * Etodolac (patient information)
 * Etoposide
 * Extrinsic compression
 * Famotidine (patient information)
 * Felbamate (patient information)
 * Felodipine (patient information)
 * Fenofibrate (patient information)
 * Fenoprofen (patient information)
 * Fentanyl Citrate Injection (patient information)


 * Ferrous Sulfate (Iron) (patient information)
 * Fludarabine Phosphate (patient information)
 * Fluphenazine (patient information)
 * Flurazepam (patient information)
 * Fluvoxamine
 * Food allergy
 * Food intolerance
 * Fructose malabsorption
 * Fulvestrant Injection (patient information)
 * Furosemide (patient information)
 * Gabapentin (patient information)
 * Ganciclovir (patient information)
 * Gastroptosis
 * Gatifloxacin (patient information)
 * Gemcitabine Hydrochloride (patient information)
 * Gemfibrozil (patient information)
 * Glucagonoma
 * Glycopyrrolate (patient information)
 * Granisetron (patient information)
 * Guanethidine (patient information)
 * Guanfacine
 * H2 antagonist
 * Haloperidol
 * Hashimoto's thyroiditis
 * Hernia
 * Heroin
 * Hexamethonium
 * Hirschsprung's disease
 * Hookworm
 * Hydralazine (patient information)
 * Hydroxyurea (patient information)
 * Hydroxyzine
 * Hyoscyamine (patient information)
 * Hypercalcemia
 * Hypervitaminosis D
 * Hypokalemia
 * Hypothyroidism
 * Hypotonia
 * Ibandronate (patient information)
 * Ileus
 * Imatinib (patient information)
 * Imipramine (patient information)
 * Imperforate anus
 * Indomethacin (patient information)
 * Inflammatory Bowel Syndrome
 * Insulin lispro injection (patient information)
 * Interferon Beta-1b Injection (patient information)
 * Internal intussusception
 * Intestinal pseduoobstruction
 * Intraabdominal/pelvic tumors
 * Intussusception
 * Iron deficiency anemia
 * Iron supplements
 * Irritable bowel syndrome
 * Ischemic colitis
 * Isocarboxazid (patient information)
 * Itraconazole (patient information)
 * Kaolin and Pectin (patient information)
 * Ketogenic diet
 * Ketorolac
 * Lack of fiber
 * Lamivudine and Zidovudine (patient information)
 * Lamotrigine (patient information)
 * Lanthanum (patient information)
 * Lassa fever
 * Laxative abuse
 * Lead poisoning
 * Letrozole (patient information)
 * Leuprolide (patient information)
 * Lerisetron
 * Levomepromazine
 * Levalbuterol Oral Inhalation (patient information)
 * Levetiracetam (patient information)
 * Levodopa and Carbidopa (patient information)
 * Levomethadyl (patient information)
 * Levorphanol Oral (patient information)
 * Linezolid
 * Lofepramine
 * Lomotil
 * Loperamide
 * Loprazolam
 * Lorazepam (patient information)
 * Lovastatin (patient information)
 * Low fluid intake
 * Low-residue diet
 * Lysuride
 * Loxapine Oral (patient information)
 * Lymphogranuloma venereum
 * Magaldrate
 * Meclofenamate (patient information)
 * Mefenamic Acid (patient information)
 * Meningocele
 * Meperidine (patient information)
 * Meropenem Injection (patient information)
 * Mesalamine (patient information)
 * Mesoridazine Oral (patient information)
 * Metformin (patient information)
 * Methadone
 * Methsuximide Oral (patient information)
 * Methyprylon
 * Metoclopramide
 * Metoprolol (patient information)
 * Milk-alkali syndrome
 * Misoprostol
 * Modafinil (patient information)
 * MOPP (medicine)
 * Morphine
 * Motofen
 * Multiple endocrine neoplasia (MEN 2b)
 * Multiple sclerosis
 * Muscular dystrophies
 * Mycophenolate (patient information)
 * Myxedema
 * Nabumetone (patient information)
 * Nateglinide oral (patient information)
 * Nefazodone (patient information)
 * Neuroblastoma
 * Nialamide
 * Nicardipine (patient information)
 * Nifedipine (patient information)
 * Nilutamide (patient information)
 * Nimodipine (patient information)
 * Nizatidine (patient information)
 * Nortriptyline (patient information)
 * Olanzapine (patient information)
 * Omeprazole (patient information)
 * Ondansetron
 * Opisthorchis infection
 * Osteitis fibrosa cystica
 * Ovarian cancer
 * Oxaliplatin injection (patient information)
 * Oxazepam (patient information)
 * Oxcarbazepine (patient information)
 * Oxybutynin (patient information)
 * Oxycodone
 * Pamidronate injection (patient information)
 * Pancrelipase (patient information)
 * Panhypopituitarism


 * Papaverine
 * Paralytic ileus
 * Paroxetine
 * Peginterferon alfa-2b (patient information)
 * Pemetrexed injection (patient information)
 * Perazine
 * Pergolide (patient information)
 * Perphenazine oral (patient information)
 * Pethidine
 * Phenelzine (patient information)
 * Phentermine (patient information)
 * Phenytoin oral (patient information)
 * Pheochromocytoma
 * Pholcodine
 * Pimozide (patient information)
 * Piperacillin sodium and tazobactam sodium
 * Pipothiazine
 * Piroxicam (patient information)
 * Piribedil
 * Pizotifen
 * Polio
 * Polyp (medicine)
 * Posaconazole (patient information)
 * Pramipexole (patient information)
 * Prazepam (patient information)
 * Prazosin and polythiazide (patient information)
 * Prednisolone
 * Pregabalin (patient information)
 * Pregnancy
 * Primary hyperparathyroidism
 * Procarbazine (patient information)
 * Prochlorperazine
 * Procyclidine (patient information)
 * Progressive supranuclear palsy
 * Propafenone (patient information)
 * Propantheline
 * Propoxyphene (patient information)
 * Propranolol Oral (patient information)
 * Protriptyline (patient information)
 * Pseudocyesis
 * Pseudohypoparathyroidism
 * Quetiapine
 * Rabeprazole (patient information)
 * Ranitidine (patient information)
 * Ranolazine (patient information)
 * Rasagiline (patient information)
 * Reboxetine
 * Rectal carcinoma
 * Rectocele
 * Renal cell carcinoma
 * Repaglinide (patient information)
 * Rett syndrome
 * Ribavirin (patient information)
 * Rilmenidine
 * Risperidone (patient information)
 * Rivastigmine (patient information)
 * Ropinirole (patient information)
 * Rosuvastatin (patient information)
 * Sacrococcygeal teratoma
 * Saquinavir (patient information)
 * Scleroderma
 * Scopolamine
 * Secobarbital (patient information)
 * Selegiline (patient information)
 * Sevelamer (patient information)
 * Sibutramine
 * Sibutramine
 * Simethicone
 * Simvastatin (patient information)
 * Sirolimus (patient information)
 * Sitaxsentan
 * Smoking cessation
 * Solifenacin
 * Sorafenib (patient information)
 * Sotalol (patient information)
 * Spinal cord injury, chronic phase
 * SSRI discontinuation syndrome
 * Stomach cancer
 * Sucralfate
 * Sufentanil citrate injection (patient information)
 * Sulindac (patient information)
 * Sunitinib
 * Superior mesenteric artery occlusion
 * Suxamethonium chloride
 * Syphilis
 * Systemic sclerosis
 * Tamoxifen (patient information)
 * Tapentadol
 * Temazepam (patient information)
 * Temozolomide (patient information)
 * Terazosin
 * Teriparatide (rDNA origin) Injection (patient information)
 * Thalidomide
 * Thioridazine (patient information)
 * Thiothixene Oral (patient information)
 * Tianeptine
 * Tiludronate (patient information)
 * Tinidazole (patient information)
 * Tiotropium
 * Tolterodine
 * Topiramate
 * Topotecan Hydrochloride (patient information)
 * Toxic megacolon
 * Tranylcypromine (patient information)
 * Travel constipation
 * Triazolam (patient information)
 * Triclofos
 * Trifluoperazine Oral (patient information)
 * Trihexyphenidyl (patient information)
 * Trimethadione (patient information)
 * Trimipramine (patient information)
 * Tropisetron
 * Trospium (patient information)
 * Tuberculosis
 * Typhoid fever
 * Ulcerative colitis
 * Upper gastrointestinal series
 * Valproic Acid (patient information)
 * Venlafaxine
 * Verapamil
 * Vicodin
 * Vigabatrin
 * Viloxazine
 * Vinblastine (patient information)
 * Vincristine
 * Vinorelbine
 * Visceroptosis
 * Volvulus
 * Vorinostat (patient information)
 * Wandering spleen
 * Zaleplon (patient information)
 * Zidovudine Injection (patient information)
 * Zileuton (patient information)
 * Ziprasidone (patient information)
 * Zoledronic Acid Injection (patient information)
 * Zolpidem (patient information)
 * Zonisamide (patient information)
 * Zotepine

Complete Differential Diagnosis of the Causes of Constipation
(By organ system)

Physical Examination

 * Complete physical examination including thyroid examination

Abdomen

 * Examination of abdomen:
 * Palpate for masses
 * Surgical scars
 * Hernias
 * Hepatosoplenomegaly
 * Examination results are usually normal

Other

 * Complete rectal examination with attention paid to:
 * Presence of stool
 * Masses
 * Fistulas
 * Hemorrhoids
 * Abscesses
 * Fissures
 * Squeezing and resting of sphincter tone
 * Palpable relaxation of anal tone and perineal descents

Laboratory Findings

 * Complete blood count (CBC)
 * Blood urea nitrogen (BUN) / creatinine
 * Phosphate
 * Glucose
 * Liver function tests (LFTs)
 * Fecal occult blood test
 * Thyroid function tests
 * Calcium

Echocardiography or Ultrasound

 * Ultrasound may be used to detect tumors, fibroids, ovarian cysts or pregnancy

Other Diagnostic Studies

 * Colonoscopy for patients:
 * Greater than 50 years old
 * Present with constipation with no apparent cause
 * Presence of blood in the stool
 * Sigmoidoscopy for all other patients
 * To rule out ova and parasites, a stool examination should be considered

Treatment
In people without medical problems, the main intervention is to increase the intake of fluids (preferably water) and dietary fiber. The latter may be achieved by consuming more vegetables and fruit and whole meal bread, and by adding linseeds to one's diet. The routine non-medical use of laxatives is to be discouraged as this may result in bowel action becoming dependent upon their use. Enemas can be used to provide a form of mechanical stimulation.

In alternative and traditional medicine, colonic irrigation, enemas, exercise, diet and herbs are used to treat constipation.

Laxatives
Laxatives may be necessary in people in whom dietary intervention is not effective or is inappropriate. Most laxatives can be safely used long-term, although some are associated with cramping and bloatedness and can cause the phenomenon of melanosis coli.

Physical intervention
Constipation that resists all the above measures requires physical intervention. Manual disimpaction (the physical removal of impacted stool) is done by patients who have lost control of their bowels secondary to spinal injuries. Manual disimpaction is also used by physicians and nurses to relieve rectal impactions. Finally, manual disimpaction can occasionally be done under sedation or a general anesthetic—this avoids pain and loosens the anal sphincter.

Many of the products are widely available over-the-counter. Enemas and clysters are a remedy occasionally used for hospitalized patients in whom the constipation has proven to be severe, dangerous in other ways, or resistant to laxatives. Sorbitol, glycerin and arachis oil suppositories can be used. Severe cases may require phosphate solutions introduced as enemas.

Prevention
Constipation is usually easier to prevent than to treat. The relief of constipation with osmotic agents, i.e. lactulose, polyethylene glycol (PEG), or magnesium salts, should immediately be followed with prevention using increased fiber (fruits, vegetables, and grains) and a nightly decreasing dose of osmotic laxative. With continuing narcotic use, for instance, nightly doses of osmotic agents can be given indefinitely (without harm) to cause a daily bowel movement.

Recent controlled studies have questioned the role of physical exercise in the prevention and management of chronic constipation, while exercise is often recommended by published materials on the subject.

In various conditions (such as the use of codeine or morphine), combinations of hydrating (e.g. lactulose or glycols), bulk-forming (e.g. psyllium) and stimulant agents may be necessary to prevent constipation.

Epidemiology
Depending on the definition employed, constipation occurs in 2% of the population; it is more common in women, the elderly and children

In animals
Hibernating animals can experience tappens that are usually expelled in the spring. For example, bears eat many foods that create a "rectal plug" before hibernation.