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New guidelines for severe or persistent constipation

Doctors often have one hand on the door knob when they learn about a patient's constipation. It's the problem no one wants to talk about, but it affects more than three million Americans -- many of them 60 and older -- and it can cause significant misery. 

Everyone gets constipated from time to time and recognizes the symptoms: Hard, dry stools; difficult and painful bowel movements; and a bloated, sluggish, uncomfortable feeling. Some individuals, however, wrongly think they are constipated simply because they do not have a bowel movement every day. Everyone's system is different, and normal frequency of bowel movement ranges from three a day to three a week. 

In most cases, constipation is temporary -- often following a change of routine or diet -- and not serious. Frequent constipation is another matter. Considering the brisk sales of over-the-counter remedies, the two million doctor visits each year reflect only a small percentage of those affected by this frustrating, uncomfortable condition. 

Constipation is no more likely in a healthy senior than in a young person, but many illnesses and medications that are common with aging can contribute to bowel problems. 

Stroke, irritable bowel syndrome, hypothyroidism, diverticulosis, diabetes, multiple sclerosis and Parkinson's disease are among diseases that can contribute to constipation. Medications include pain killers (particularly those containing codeine), antacids, calcium channel blockers, diuretics, antidepressants, anticonvulsants, antiparkinson drugs and iron supplements. Taking numerous drugs is a specific risk. Persons who have had surgery in the lower abdomen or bowels also have an increased risk. 

New treatment guidelines 
In the very recent past, persons suffering from constipation were given straightforward lifestyle advice: 1) Eat more fiber, 2) drink more water and 3) get regular exercise. Following a review by four international experts, these recommendations were found to have no basis in research. Dramatically different guidelines were issued in the American Journal of Gastroenterology [April, 2005]. 

There's no question, however, that the old advice is good for overall health and should help a healthy individual avoid digestive and other problems.

As digested food moves through the intestine, water is absorbed through the walls, leaving behind a solid waste product to be eliminated as stool. If the muscle contractions of the colon are too slow or too much water is removed, the result can be constipation. 

Even a small change in the water content can make a considerable difference in the consistency of the stool, and dehydrated individuals often become constipated. But, according to the panel, no reliable study has shown that constipation can be treated by increasing fluid intake.

It's well established that fiber increases bulk in the stool and boosts the frequency of bowel movements. A high fiber diet may be good preventive practice and offer some help for mild constipation. But for someone with severe or frequent constipation, more fiber may actually make things worse. In one study, fewer than 50 percent of constipated patients responded to an over-the-counter fiber supplement.

Physical activity tends to speed the body's metabolism and digestive processes, but only vigorous or extended exercise (such as long distance running) has been found to significantly change bowel function, according to the review study. While severe constipation in an older person may be associated with poor mobility or extended periods of bed rest, such a patient usually requires more comprehensive therapy, focusing on cognitive function, mood, medications and diet as well as physical activity. 

Although the review study found no evidence that stimulant laxatives are habit-forming or harmful to the colon if taken at recommended doses, their data indicated that these products are ineffective on their own in treating chronic constipation. High doses can lead to metabolic problems, and frequent use is associated with severe cramping, dehydration and malnutrition. 

Newer drugs such as PEG 3350 and tegaserod, the reviewers noted, "appear to be beneficial." 

If you're bothered by mild or occasional constipation, of course, the old lifestyle recommendations will do no harm and may help. Bowel function is heavily tied to routine, so try to get back to a regular, well balanced diet and a healthy exercise pattern. Set aside time for undisturbed and unrushed visits to the toilet, and don't ignore the urge to have a bowel movement because of inconvenience, embarrassment or stress. 

For severe or persistent constipation or even a sudden, unexplained change in bowel habits, it's best to see a doctor and find out what's causing the problem. Decreased muscle and nerve activity can cause slowed transit of waste through the colon. The problem might also be associated with obstruction, scar tissue or tumors that are squeezing or narrowing the intestine. An abnormality in the structure of the anus and rectum can make it difficult to relax the muscles that allow stool to exit. 

Straining can cause what is known as rectal prolapse -- a protrusion of a portion of the intestinal lining into the anal opening. This in turn can make normal bowel movements more difficult. 

Occasionally, hard stool can become packed so tight that it's virtually impossible to expel. A doctor may soften this fecal impaction through mineral oil, taken by mouth and enemas, then break up the stool and remove the outer part by inserting one or two fingers into the anus. 

In addition to a physical examination, a doctor may ask the patient to keep a seven-day stool diary and a record of diet, exercise, medication and fluid intake. 

Various tests can be used to evaluate the functioning of the anal sphincter muscle, the contractions and relaxation of the rectum and the speed of passage of wastes through the colon. A sigmoidoscopy or colonoscopy allows more thorough examination of the colon to check for polyps and cancer. 

Whatever you do, don't wait until the doctor's hand is on the doorknob before you discuss constipation. Better yet, make a special appointment to deal with the problem before it escalates into something worse. 


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