Help for Constipation

Frederick R. Jelovsek MD, MS

" What causes a ripple in the colon? I have a problem trying to have a normal bowel movement. My doctor claims the rippling effect is causing blockage so the stool cannot come out. Is there anything that can be done for this problem?

I am age 69, with Non-Hodgkins Lymphoma (in remission), taking Estrace ® for hot flashes. " Lorrie

Constipation is only a symptom of many different diseases and conditions. Normal bowel movement frequency varies from 3 times a week to 3 times a day. The definition of constipation is a bowel movement 2 times a week or less. Some people are under the misconception that they must have a bowel movement every day and if not, they call themselves constipated. As many as 15-25% of women consider themselves as suffering from constipation (1).

In the normal situation, any food you eat is digested in the stomach into a liquid soup. It passes through the small bowel where the nutrients are absorbed. When it gets to the large colon, all the water that is left is absorbed into the blood stream through the colon wall. This leaves dry, undigestible waste products that form the stool. If you do not drink enough water or eat enough fiber, the stool is turned into very hard lumps. To avoid constipation normally, you do not have to drink excessive water but you have to make sure your are not at all dehydrated because any excess water in the stool will be resorbed in the colon. If you eat mostly food made from refined white flour instead of foods with whole grains and fiber-rich foods, you will have a tendency toward being constipated.

I believe your doctor is using the term rippling to refer to the peristaltic waves of colon muscle contractions that move stool down to the rectum. If there is a section of colon that does not "ripple", you become constipated. At the point of blockage of the peristalsis, there may develop excess "rippling" that causes discomfort and pain because gas and liquid behind the solid stool distend the colon. Thus it is not the ripple that causes constipation, but the lack of "rippling" or peristalsis of a section of colon is one of the causes. The only way you would know for sure if you have this problem is to have had a bowel transit time xray in which you swallow some dye capsules and they are followed through the bowel by xray.

Most chronic constipation can be treated with dietary and activity change. Sometimes current medical therapy needs to be altered or temporary laxative therapy started. In a very small percent of cases there is a section of colon that has a nerve dysfunction that cannot be overcome with non surgical therapy (2). These suspected cases need further diagnostic work up including colonoscopy and bowel transit studies. If colonic inertia, or slow transit constipation is found, there may be a need for surgical intervention to remove part of the colon that does not peristalt (3). The removal of a section of the colon (colectomy) for constipation has a variable success rate (40-100%) so it should only be considered after all other causes have been ruled out and non surgical treatments tried (4).

Many different medicines can decrease bowel motility and lead to constipation. While certain classes of drugs that are known to cause constipation are listed below, every prescribed and over-the-counter medication you are taking should be looked up to see if it is associated with causing constipation.

• Antacids such as aluminum hydroxide
• Calcium Carbonate
• Anticholinergics (Ditropan ®, Detrol ®)
• Antidiarrheals
• Antiparkinson's
• Antidepressants (especially tricyclics and lithium)
• Antihypertensives/Antiarrhythmics (calcium channel blockers especially verapamil)
• Metals such as bismuth and iron
• Opioid (narcotic) pain medicines
• Laxatives (used chronically)
• NSAIDs (ibuprofen, naproxen)
• Sympathomimetics such as pseudoephedrine in decongestant medications

If your doctor is unable to substitute a non constipating medication for the above medications you are taking, you will need to make an extra effort with dietary and lifestyle changes.

We have discussed why adequate, but not excessive water intake is necessary to avoid constipation. The other major dietary component is undigestible fiber which forms the bulk of the stool. If a woman is dieting, or in the case of elderly women who just have a decreased appetite or require dental soft foods, the lack of a usual volume of food will lead to constipation. This may also occur at the time of surgery or hospitalization for illness when the amount of food is restricted.

A diet consisting of breads, rolls, pastries, bagels, pretzels, noodles, desserts and dairy products leads to very hard stools, while one with fruits, green vegetables, whole grains, beans and nuts will soften the stool. Coffee stimulates the colon. Flaxseed is a good natural laxative and there are even some cereals that have it added. Vitamin C and magnesium supplements may also help with constipation but you have to be careful not to take too much.

At your age of 69, you have to be careful that the constipation problem is not just due to eating too small amounts of food and drinking too few liquids. If you are not already doing so, you may want to go for a couple of weeks and:

• drink eight glasses of liquid a day
• cut out all simple carbohydrates
• eat added small amounts of fiber such as celery, popcorn, beans, nuts, flaxseed
• make sure you are getting 30 minutes of brisk physical activity each day

Sometimes the stool seems to get to the rectum and the feeling of a need to defecate is present, but an individual just cannot move their bowels at all. In general there a two possible causes for this type of "outlet" obstruction. One is where there is a herniation of the rectal wall through the pelvic diaphragm muscles called a rectocele. In this condition there is a loss of sensation and an overfilling of the rectum with stool, while at the same time there is muscle weakness in initiating the defecation mechanism. About 50% of women with rectoceles have constipation and difficulty with defecation and when they undergo surgical repair of the hernia, about half of those are significantly cured (5).

A second type of "outlet obstruction" is a nerve or muscle dysfunction called anismus or anal sphincter dyssynergia. Basically when the sphincter muscle is supposed to be relaxed, it is closed. It is parallel to a urine voiding condition called detrusor sphincter dyssynergia and a vaginal condition called vaginismus in which there is an involuntary contraction of the vaginal opening muscles. Everyone has experienced this defecation difficulty, perhaps in a crowded public restroom like at an airport, or just the occasional inability to relax the sphincter when it is needed. The woman who has this constantly ends up being constipated and uncomfortable most of the time. This condition is best treated with biofeedback techniques in which a person is taught to consciously relax the anal sphincter. Kegel exercises are also used to help learn relaxation (6).

There can be causes of constipation other than the ones discussed above although they are somewhat uncommon. Other causes are:

• stricture due to cancer of colon
• chronic laxative abuse (destroys innervation of colon)
• colon or rectal ulcers
• congenital or acquired aganglionosis (lack of nerve connections)
• hypothyroidism
• irritable bowel syndrome (see IBS)
• lupus erythematosis
• megacolon
• multiple sclerosis
• Parkinson's disease
• scleroderma
• stroke

Several weeks of constipation should always respond to dietary change, increased physical activity and mild bulk laxatives such as psyllium (Metamucil ®), methylcellulose(Citrucel ®), calcium polycarbophil (FiberCon ®), and bran (in food and supplements) and herbal supplements (Irritable Bowel Support). If it does not, then you should see your physician to see if investigation should be started for some of the other causes of constipation.

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