The term constipation defines the infrequent or difficult evacuation of faeces.
Patients also complain of constipation if they experience the subjective
sensation of transit of hard stools.
Constipation often represents the grave of the gastroenterologist, because after
prescribing the evacuative enema or lactulose or fiber, the problem is not
solved.
For this reason, before doing your own thing, remember that behind constipation
there are very serious problems, such as for example. cancer of the left colon
or rectus sigma and that you should always contact your doctor for treatment and
diagnosis of constipation.
What you read below is just an article, even if written in an accurate and
scientific way.
The normal frequency of bowel movements varies from 3 times a week to 2 times a
day; if, on the other hand, a subject evacuates only twice a week or less, then
we can speak of constipation which, however, is always a condition associated
with difficulty in evacuation with the need to ponz, that is to push.
Constipation, again, can be associated with other pathological conditions, for
example pain in the abdomen, meteorism, rectal bleeding.
Approximately 1000 ml of fluids pass from the terminal ileum into the cecum,
mainly consisting of salt water and fiber, i.e. undigested carbohydrates. The
passage to the colon occurs slowly, requiring 24 to 30 hours for the transit of
this material from the cecum to the rectum; during this step the water is
absorbed and the fiber is fermented with the production of gas and short-chain
fatty acids.
These substances are absorbed by the mucous membrane of the colon and the
quantity of faeces represents only a small fraction of what has entered the
colon, i.e. only 80-120 g / 24 hours. For the fecal material to be expelled it
is necessary that other obstacles are overcome and that is that the pelvic floor
muscles are able to release and thus the anal sphincters, in a complex mechanism
of contraction, relaxation, and traction of the rectum.
Constipation can be idiopathic or secondary.
The pathological conditions that cause constipation are:
- Endocrine conditions: hypothyroidism, panhypopituitarism, hypeparathyroidism,
pheochromocytoma, glucagonoma
- Metabolic conditions: diabetes mellitus, hypercalcemia, hypokalaemia,
porphyria
- Neurological disorders: autonomic neuropathy, amyloidosis, diabetes,
paraneoplastic diseases, Chagas disease, neurofibromatosis, ganglioneuromatosis,
Hirschprung's disease and variants, lumbar disc disease, dorsal tabe, multiple
sclerosis, Parkinson's disease, stroke, brain neoplasms
- Disorders of the anorectal region and colon: to investigate Constipation
functional causes
- Drug constipation: Loperamide, Codeine, Buprenorphine, Fentanyl, Hydrocodone,
Hydromorphone, Meperidine, methadone, Morphine sulfate, Oxycodone, Oxymorphone,
Tramadol, verapamil, benzodiazepines, statins,
- Painful anorectal lesions: anal fissures, thrombosed hemorrhoids, prolapse of
the mucosa, ulcerative proctitis.
- Stenotic lesions: neoplasms, diverticulitis, inflammatory stenosis, ischemia,
volvulus, endometriosis
Idiopathic constipation
The mechanisms that determine constipation can be slowed transit, inadequate
propulsion along the colon, with dysfunction of the enteric nerve fibers or
smooth muscle of the colon.
The slowing down of the transit is the most frequent mechanism, which affects
75% of the subjects, ie in the colon the transit time must be a maximum of 30
hours, if it is longer then the feces become dehydrated.
People with functional expulsion obstruction generally complain of evacuation
difficulties or dyschezia. The causes of the slow transit time are to be found
in alterations of the enteric nervous system or smooth muscle.
The presence of functional obstruction or dysergia or anism is due to a
paradoxical contraction of the pelvic floor muscles or the external anal
sphincter that occurs during the attempt to defecate. Every person with
constipation should be carefully evaluated from an anamnestic point of view and
subjected to an objective examination to understand the reported symptoms and
rule out causes of secondary constipation.
Local physical examination
Assessment of the tone of the sphincter
Research of hypokalaemia, TSH, hypothyroidism, hypercalcemia
Anoscopy and rectosigmoidoscopy or pancoloscopy to rule out tumors
Direct abdominal x-ray to rule out the presence of neoplasms or double-contrast
barium enema
Balloon ejection test
Defecography: it consists in the introduction of barium into the rectum and with
videofluoroscopy the movements of the pelvic floor are detected and signs of
prolapse and intussusception are sought and the rectal angle with the pelvic
floor is detected;
Intestinal transit time with 24-ring Sitzmarks capsule and execution of a plate
at 24-72 and 120 hours.
Increasing the daily intake of fiber to 20-30 g / day is the main goal of the
dietary treatment of constipation; this can be achieved with the introduction of
an ad hoc diet, with psyllium, and other fiber-based products.
The fiber, however, can cause flatulence and, therefore, at the beginning it is
necessary to go slowly, in order not to have abdominal pain and bloating.
Biofeedback techniques. Patients with functional obstructive constipation due to
pelvic floor dysfunction may benefit from defecation techniques, including
maneuvers such as small warm water enemas or suppositories or micro-enemas. The
biofeedback technique uses electromyography to visualize the relaxation of the
spasm of the muscles during defecation.
Laxatives: magnesium salts, lactulose, polyethylene glycol (PEG), to be used
sparingly because they can give the colon cathartic
Systemic agents: tagaserod (not on the market in Italy), betanechol,
misoprostyol, colchicine, with action on local nervous function and enteric
muscles.
Surgery: subtotal colectomy in patients with colonic inertia.