Constipation

Constipation is defined as two or fewer bowel movements per week.  It may be due to slow progress of stool through the colon (‘colonic inertia’), or from an inability to expel the stool that has travelled through the colon to the rectum at a normal rate (‘expulsion constipation’), or various combinations of the above.   At the extreme, there are people who have a bowel movement every three months.  These individuals have profound abnormalities of colon and/or pelvic floor muscle function and often require surgery if they hope to improve.  Other people have one bowel movement or more every day, but with so much difficulty and straining that, for all intents and purposes, they may as well be considered to be constipated.  Constipation may be seen as a part of Irritable Bowel Syndrome (IBS) in which the colon muscles function in a discoordinated fashion.  With IBS, constipation may alternate with diarrhea or normal stools.

Nobody gets through this life without some episodes of constipation, although for most it is short-lived and not of any great concern.  Some people, however, have life-long trouble.  The significant forms of constipation are most often seen in women, some of whom suffer from it all of their lives.  Constipation, in general, is less common in men.  Women may find that their constipation varies with their menstrual cycle.  Some women can only have bowel movements when they are having their period.

Most constipation is a benign, albeit troubling, disorder.  A variety of treatments, with an escalating degree of effectiveness, are available and can be matched against the degree of constipation.  With experimentation, most patients can find a product that will work for them most of the time.  There is always the concern that strong laxatives will cause the colon to become ‘weaker’ and leave the patient forever dependent on them.  It is hard to know whether this actually happens, or if the natural history of that particular patient’s constipation was such that they were going to need them forever anyway.  We often see patients at the Clinic who have a routine that works for them, but who have been told they must stop it in order to prevent some ‘damage’ to the colon.  After many years of experience dealing with these issues, we have learned that there is not much point in changing a patient’s routine unless we can replace it with something better, and that is not always the case.

Nonetheless, there are some products that are considered much more aggressive than others.  The problem here is that most patients cannot distinguish the mild products from the strong ones.  Producers of the products do little to help the consumer in this regard.  Particularly in the health product industry in which there is little regulation of these products, one can generally predict that the gentler and more fanciful the images on the box containing the product, the harsher it is likely to be.  This also applies to ‘teas’ of obscure origin, some powerful enough to move an apartment building.  Such ‘mild’ laxatives have the ability to change the colour of the lining of the colon, making it appear black during scoping.  This is called ‘melanosis coli’.

In some patients, gentle intermittent enemas may be effective and may minimize the requirement for harsher oral products.  These types of regimens should be planned with the help of a physician.

For surgeons, the type of constipation that is worrying is the type that is fairly recent, say 4 months, and becoming increasingly severe.  In such cases an obstructing lesion such as a colon cancer must be ruled out urgently.  As opposed to benign constipation that may have been present for many years or constipation that comes and goes, constipation from a cancer will almost certainly represent a definite change from the patient’s previous pattern, and will become progressively worse as the tumor grows.  There may or may not be associated abdominal cramps and rectal bleeding.

© Pezim Clinic, Vancouver, British Columbia, Canada