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Definition: It is a medical condition in which the number of bowel movements is reduced to the extent that stools come out hard and dry and in much smaller quantities than expected. According to American and British medical guidelines, the patient is diagnosed with constipation if the number of bowel movements is less than 3 times a week.

It is worth noting that the number of times one goes to the toilet in order to pass stool varies greatly from one person to another, but there is an average rate, as the number ranges from 3 times a day to 3 times a week, and the complaint of constipation is one of the most common symptoms among the symptoms of the digestive system.

How common is constipation and at what age?

Constipation is classified as one of the most common symptoms of digestive disorders. In a country such as the United States of America, 2.5 million people suffer from constipation annually.

As for age, constipation can occur in all ages (at least once), while chronic constipation is more prevalent in the elderly, and it has several factors that contribute to its occurrence, including:

• Age: the elderly tend to exert less movement and less activity, and thus the rates of  metabolism in their bodies decrease, and the strength of muscle contraction, including smooth muscles in the digestive system, is weakened, and consequently constipation occurs.
• Gender: Women are more likely to suffer from constipation than men, especially women during pregnancy and the postpartum period due to hormonal changes. in addition to that during pregnancy the weight of the fetus puts pressure on the intestines, which slows its movement.
• The nature of food: Eating foods rich in fiber reduces the incidence of constipation, and people who eat small amounts of fiber and vegetables in their daily food are more prone to constipation.

How does constipation occur?

Constipation occurs when the colon reabsorbs large amounts of water from the stool again, making the stool dry, hard, and more difficult to move through the rectum.

Under normal circumstances, the small intestine absorbs the nutrients necessary for the body, and pass  waste products and undigested food to the large intestine (also called the "colon").

The large intestine absorbs specific amounts of water from waste and undigested food, turning it into lumps of consistency between liquid and solid, which is "faeces" or "stool", which travels to the rectum and exits through the anus during defecation.

If there is a change that makes the bowel movement slower than normal, this gives the colon more time to reabsorb more water from the waste (feces), making it drier, more solid and more difficult to pass, and constipation develops.

What are the causes of constipation?

Constipation is one of the diseases that have large number of causes, so they are divided into 3 groups as follows:

a. Lifestyle: Common Unhealthy Habits that cause constipation include:

• Consuming foods low in fiber
• Not drinking enough water (dehydration)
• Lack of exercise
• A stagnant lifestyle and lack of physical activity
• Constant change in the daily routine, such as constantly changing the times of the main meals, or changing the bedtime or traveling a lot.
• Eating large amounts of dairy products (milk and cheese)
• Stress and stress
• Resisting the urge, which means not going to the toilet when feeling the urge to defecate

b. Medications that cause constipation:

• Narcotic pain relievers such as tramadol, codeine, and oxycodone
• Non-steroidal pain relievers such as ibuprofen, ketolac and voltaren
• Antidepressants, especially serotonin reuptake inhibitors, such as "Cipralex", "Joy Box", "Dapoxetine" and others
• Antacids such as Rani effervescents and others
• Iron tablets that are used to treat anemia
• Anti-allergic drugs such as Telfast, Zyrtec, Aureus, and others
• Certain types of high blood pressure medications, such as diltiazem and Bistol
• Medications for mental illness (psychosis), such as clozapine and olanzapine
• Anti-epileptic drugs such as gabapentin and phenytoin
• Medications for nausea and vomiting, such as Zofran and Ondalenz

c. Diseases and medical conditions that cause constipation:

• Endocrine diseases such as hypothyroidism, diabetes mellitus, high blood calcium and high blood urea
• colorectal cancer
• Irritable Bowel Syndrome
• Weakness of the pelvic muscles, whose function is to squeeze the colon to expel stool
• Parkinson's Disease
• Spinal injuries
• Multiple Sclerosis
• Brain strokes and spinal cord diseases
• Lazy bowel syndrome, where the force of contraction of the muscles of the colon is weakened
• Intestinal obstruction
• Congenital defects in the colon, such as fistula, atresia, intussusception, and children born with obstruction of the anus
• Autoimmune diseases that affect more than one organ in the body, such as lupus erythematosus, scleroderma, and amyloidosis

What are the symptoms of constipation?

The symptoms of constipation include:

• The patient goes to the toilet to pass stool less than three times a week
• Stools are dry, hard, and large lumps
• The patient feels pain and difficulty when passing stool
• Constant aches and pains with stomach and abdominal cramps
• flatulence
• feeling nauseous
• Every time he goes to the toilet, he feels like he hasn't completely emptied his bowels

When to see a doctor, and what to expect?

If constipation persists for more than two weeks, it is considered chronic, and a specialist internist and gastroenterologist should be consulted, especially if the patient is elderly or suffers from other chronic diseases.

Expect your doctor to ask general questions about your medical history and questions about constipation.

General questions are as follows:

• Do you suffer from other acute or chronic diseases?
• Have you noticed a remarkable decrease or increase in your weight recently?
• Have you had surgery in any parts of the digestive system before?
• Have you had a gastroscopy or GI endoscopy before?
• What medications do you take? whether for constipation or for any other disease
• Does anyone in your family suffer from constipation or gastrointestinal tumors such as colon cancer?

Questions about constipation are:

• How many times do you go to the toilt for defecation per week?
• How does stool look and how is its consistency in the last couple of weeks?
• Have you noticed blood or a dark red color in your stool?
• What is your diet and your favorite foods?
• Do you make any kind of exercise?

After that, your doctor will make a full examination, including auscultating bowel sounds with a stethoscope, and may include Digital Rectal Examination in some cases, but not all.

Does the doctor order tests to diagnose the cause of constipation?

In some cases, the physician begins treating patients directly without investigations, especially the young patients and patients who do not suffer from chronic diseases.

In other cases, especially the elderly or those who have frequent constipation on an ongoing basis, the doctor orders a number of tests to determine the cause of constipation and treat it. These tests include:

• Laboratory tests: such as thyroid function tests if hypothyroidism is suspected, complete blood count analysis to exclude anemia, blood sugar and stool analysis.
• Diagnostic x-rays: In some cases, the doctor may order a CT scan or an MRI.
• Gastrointestinal endoscopy: In cases where the doctor suspects the presence of a tumor or inflammation in the colon, the patient is asked to perform a colonoscopy, and a sample is taken and examined in a pathology lab.
• Contrast: such as a barium x-ray.

Treatment methods

a. Home management:

Many cases of constipation are mild and can be treated at home with some easy procedures and tips such as:

• Drink an extra 3-4 cups of water daily
• Add plenty of vegetables that contain large amounts of fiber to your food
• Avoid drinks that can cause dehydration, such as alcohol
• Eat more prunes and bran grains
• Avoid foods that contain large amounts of fat, such as fatty meats, eggs, and cheese
• Commit to exercising for at least half an hour a day, 5 days a week
• [Important] Raising the feet off the ground while sitting on the toilet helps emptying the entire colon of stool and thus treats constipation and prevents its recurrence (the position as in the picture), knowing that the squatting pots in the old (baladi) toilets is the best for emptying the intestines.

The best position to empty the colon and prevent constipation

• You can add ready-made canned fibers to food
• If the above measures fail, treatment with laxatives (stool softener) can be started, whether tablets (pills) or drops such as "Minalax" or "Picolax", which is a fast-acting laxative drug for constipation, taking care not to use laxatives for more than two weeks without consulting a doctor.
• Do not read or use a mobile phone while you are in the toilet to pass stool.

b. Medications

There are a few medications available for the symptomatic treatment of constipation, which are laxatives. Examples include Lactulose, Picolax, Menalax, and some other alternatives.

An enema is used in cases that do not respond to laxative therapy.

c. Surgical treatment

It is rare to resort to surgery in cases of constipation, but surgeries may be the only solution to treat cases where the cause is congenital anomalies.

What foods that help treat and prevent constipation?

Here is a list of the known foods that contain a large proportion of fiber that help relieve and prevent constipation as well.

Food category	Moderate amount of fibers	High amount of fibers
Bread	Brown bread made from wheat granola bread White bran bread Bread made of corn flour Wheat pancakes	None
Grains	barley grains oats Raisin Bran (Corn Flakes) Wheat with milk Wheat grain oatmeal		All types of bran contain large amounts of fiber	Like corn bran and barley
Vegetables	beet Cabbage and cauliflower carrots and corn Peas and green beans Green Beans Pumpkin and walnut Spinach, potatoes with peel and avocado	None
Fruits	Non-peeled apple Dates mango and plum Orange, tangerine and guava kiwi and strawberry Raspberries and raisins	Cooked peaches and dried figs
Meat alternatives	Peanut Butter nuts	White Beans black peas Beans

When should you visit a doctor?

You should see a doctor as soon as possible in the following cases:

• If constipation occurs for the first time and without predisposing factors
• If blood or red streaks appear in the urine
• If you notice your weight suddenly dropping
• If you have severe abdominal pain with a bowel movement or when defecating
• If constipation persists for more than three weeks

What are the complications of Constipation?

Constipation can cause some complications, such as hemorrhoids, which occur as a result of repeated straining to expel stool.

An anal fissure is also a well-known complication of constipation. It occurs due to the passage of hardened (fossilized) stool through the rectum and anal canal, causing wounds and infections that form anal fissures.

Anal bleeding, rectal prolapse, and fecal impaction in the colon are also complications.

References

• Constipation: Evaluation and Management

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