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Diagnostic and Treatments |
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What Diagnostic Tests Are Used?Most people do not need extensive testing and
can be treated with changes in diet and exercise. For example, in young
people with mild symptoms, a medical history and physical examination may
be all the doctor needs to suggest successful treatment. The tests the
doctor performs depends on the duration and severity of the constipation,
the person's age, and whether there is blood in stools, recent changes in
bowel movements, or weight loss.
Medical History
The doctor may ask a patient to describe his or
her constipation, including duration of symptoms, frequency of bowel
movements, consistency of stools, presence of blood in the stool, and
toilet habits (how often and where one has bowel movements). Recording
eating habits, medication, and level of physical activity or exercise also
helps the doctor determine the cause of constipation.
Physical Examination
A physical exam may include a digital rectal
exam with a gloved, lubricated finger to evaluate the tone of the muscle
that closes off the anus (anal sphincter) and to detect tenderness,
obstruction, or blood. In some cases, blood and thyroid tests may be
necessary. Extensive testing usually is reserved for people with severe symptoms,
for those with sudden changes in number and consistency of bowel movements
or blood in the stool, and for older adults. Because of an increased risk
of colorectal cancer in older adults, the doctor may use these tests to
rule out a diagnosis of cancer:
- Barium enema x-ray
- Sigmoidoscopy or colonoscopy
- Colorectal transit study
- Anorectal function tests.
Barium Enema X-Ray
A barium enema x-ray involves viewing the
rectum, colon, and lower part of the small intestine to locate any
problems. This part of the digestive tract is known as the bowel. This
test may show intestinal obstruction and Hirschsprung's disease, a lack of
nerves within the colon.
The night before the test, bowel cleansing, also called bowel prep, is
necessary to clear the lower digestive tract. The patient drinks 8 ounces
of a special liquid every 15 minutes for about 4 hours. This liquid
flushes out the bowel. A clean bowel is important, because even a small
amount of stool in the colon can hide details and result in an inaccurate
exam.
Because the colon does not show up well on an x-ray, the doctor fills
the organs with a barium enema, a chalky liquid to make the area visible.
Once the mixture coats the organs, x-rays are taken that reveal their
shape and condition. The patient may feel some abdominal cramping when the
barium fills the colon, but usually feels little discomfort after the
procedure. Stools may be a whitish color for a few days after the exam.
An examination of the rectum and
lower colon (sigmoid) is called a sigmoidoscopy. An examination of the
rectum and entire colon is called a colonoscopy.
The night before a sigmoidoscopy, the patient usually has a liquid
dinner and takes an enema at bedtime. A light breakfast and a cleansing
enema an hour before the test may also be necessary.
To perform a sigmoidoscopy, the doctor uses a long, flexible tube with
a light on the end called a sigmoidoscope to view the rectum and lower
colon. First, the doctor examines the rectum with a gloved, lubricated
finger. Then, the sigmoidoscope is inserted through the anus into the
rectum and lower colon. The procedure may cause a mild sensation of
wanting to move the bowels and abdominal pressure. Sometimes the doctor
fills the organs with air to get a better view. The air may cause mild
cramping.
To perform a colonoscopy, the doctor uses a flexible tube with a light
on the end called a colonoscope to view the entire colon. This tube is
longer than a sigmoidoscope. The same bowel cleansing used for the barium
x-ray is needed to clear the bowel of waste. The patient is lightly
sedated before the exam. During the exam, the patient lies on his or her
side and the doctor inserts the tube through the anus and rectum into the
colon. If an abnormality is seen, the doctor can use the colonoscope to
remove a small piece of tissue for examination (biopsy). The patient may
feel gassy and bloated after the procedure.
Colorectal Transit Study
This test, reserved for those with
chronic constipation, shows how well food moves through the colon. Transit time studies may help differentiate colonic from pelvic floor
dysfunction causing constipation. The colonic transit test qualifies the transit
time of small radiopaque markers through the colon. Subjects ingest one capsule
(in which 20-24 markers have been placed) each morning for 3 days, abdominal
x-rays are taken on days 4 and 7. Transit through the right, left and
rectosigmoid segments of the colon can be calculated. The patient follows a high-fiber diet during the course of this
test. By this method, transit
time through each segment is about 11.5 hours, and a total transit time is
approximately 36 hours. Men have significantly shorter whole colon transit times
than women (334 hours Vs 474 hours; p<0.05), but age has no effect on colonic
transit. The exam is considered normal if 80% of markers are expelled within
5 days. Small bowel transit time
Small bowel transit time is more difficult to assess, the Mayo Clinic
protocol appears to be the best at present. The dual radioisotope transit
test concomitantly assesses transit through the stomach and small bowel (with
the use of Tc99-Amberline pellets) as well as the colon (with use of In
111-labeled resin particles in a methacrylate-coated capsule designed to
dissolve at the pH found in the ileum). This test can be completed within 24
hours and is less expensive than standard gastric emptying tests.
Anorectal Function Tests Balloon expulsion/Anorectal manometry
These tests diagnose constipation caused
by abnormal functioning of the anus or rectum (anorectal function). Failure to expel the balloon is commonly associated with pelvic floor
dysfunction, anatomic defects of the rectum, or anismus. The overall
defecatory process and relaxation of the puborectalis muscle is assessed by
placing a urinary catheter in the rectum, inflating the balloon to 50-60 ml, and
determining if it can be expelled. Two approaches to this test have been
described: in one the patient is sitting on a toilet and asked to pass the 60ml
balloon, in the second the patient is in the left lateral decubitus
position, and a bucket is suspended from the end of the catheter over a pulley
at the level of the anal verge - the weight needed to facilitate expulsion of
the balloon (0 to 200g) is determined.
Anorectal manometry evaluates anal sphincter muscle function. A catheter
or air-filled balloon inserted into the anus is slowly pulled back through
the sphincter muscle to measure muscle tone and contractions.Anorectal manometry is not often
contributory in patients with severe constipation. This test identifies the
presence of occult incontinence or rare syndromes, such as adult Hirschsprungs
Disease, by the absence of the rectoanal inhibitory reflex. An excessively
high resting and squeeze anal sphincter tone suggests anismus. Defecography is an x-ray of the anorectal area that evaluates
completeness of stool elimination, identifies anorectal abnormalities, and
evaluates rectal muscle contractions and relaxation. During the exam, the
doctor fills the rectum with a soft paste that is the same consistency as
stool. The patient sits on a toilet positioned inside an x-ray machine and
then relaxes and squeezes the anus and expels the solution. The detection of rectal intussusception (occult rectal
prolapse) is arguably the most important use of defecating proctography. In
addition, defecating proctograms are used to calculate resting and straining
anorectal angles. Proctography should be interpreted with care and always in the
context of the clinical problem. False positive "abnormalities" are common,
with some "positive findings" occurring in healthy individuals.
Videoproctography may be most useful in the assessment of patients with rectal
inertia, occult prolapse and anismus.
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Although treatment depends on the cause,
severity, and duration, in most cases dietary and lifestyle changes will
help relieve symptoms and help prevent constipation.
Diet
A diet with enough fiber (20 to 35 grams each day) helps form
soft, bulky stool. A doctor or dietitian can help plan an appropriate
diet. High-fiber foods include beans; whole grains and bran cereals; fresh
fruits; and vegetables such as asparagus, brussels sprouts, cabbage, and
carrots. For people prone to constipation, limiting foods that have little
or no fiber such as ice cream, cheese, meat, and processed foods is also
important.
Lifestyle Changes
Other changes that can help treat and prevent
constipation include drinking enough water and other liquids such as fruit
and vegetable juices and clear soup, engaging in daily exercise, and
reserving enough time to have a bowel movement. In addition, the urge to
have a bowel movement should not be ignored.
Laxatives
Most people who are mildly constipated do not need
laxatives. However, for those who have made lifestyle changes and are
still constipated, doctors may recommend laxatives or enemas for a limited
time. These treatments can help retrain a chronically sluggish bowel. For
children, short-term treatment with laxatives, along with retraining to
establish regular bowel habits, also helps prevent constipation.
A doctor should determine when a patient needs a laxative and which
form is best. Laxatives taken by mouth are available in liquid, tablet,
gum, powder, and granule forms. They work in various ways:
- Bulk-forming laxatives generally are considered the safest but can
interfere with absorption of some medicines. These laxatives, also known
as fiber supplements, are taken with water. They absorb water in the
intestine and make the stool softer. Brand names include
Metamucil®, Citrucel®, and Serutan®.
- Stimulants cause rhythmic muscle contractions in the intestines.
Brand names include Correctol®,
Dulcolax®, Purge®, Feen-A-Mint®,
and Senokot®. Studies suggest that
phenolphthalein, an ingredient in some stimulant laxatives, might
increase a person's risk for cancer. The Food and Drug Administration
has proposed a ban on all over-the-counter products containing
phenolphthalein. Most laxative makers have replaced or plan to replace
phenolphthalein with a safer ingredient.
- Stool softeners provide moisture to the stool and prevent
dehydration. These laxatives are often recommended after childbirth or
surgery. Products include Colace®,
Dialose®, and Surfak®.
- Lubricants grease the stool enabling it to move through the
intestine more easily. Mineral oil is the most common lubricant.
- Saline laxatives act like a sponge to draw water into the colon for
easier passage of stool. Laxatives in this group include Milk of
Magnesia®, Citrate of Magnesia®, and Haley's M-O®.
People who are dependent on laxatives need to slowly stop
using the medications. A doctor can assist in this process. In most
people, this restores the colon's natural ability to contract.
Other Treatment
Treatment may be directed at a specific cause. For
example, the doctor may recommend discontinuing medication or performing
surgery to correct an anorectal problem such as rectal prolapse.
People with chronic constipation caused by anorectal dysfunction can
use biofeedback to retrain the muscles that control release of bowel
movements. Biofeedback involves using a sensor to monitor muscle activity
that at the same time can be displayed on a computer screen allowing for
an accurate assessment of body functions. A health care professional uses
this information to help the patient learn how to use these muscles.
Surgical removal of the colon may be an option for people with severe
symptoms caused by colonic inertia. However, the benefits of this surgery
must be weighed against possible complications, which include abdominal
pain and diarrhea.
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Can Constipation Be Serious?Sometimes constipation can lead to
complications. These complications include hemorrhoids caused by straining
to have a bowel movement or anal fissures (tears in the skin around the
anus) caused when hard stool stretches the sphincter muscle. As a result,
rectal bleeding may occur that appears as bright red streaks on the
surface of the stool. Treatment for hemorrhoids may include warm tub
baths, ice packs, and application of a cream to the affected area.
Treatment for anal fissure may include stretching the sphincter muscle or
surgical removal of tissue or skin in the affected area.
Sometimes straining causes a small amount of intestinal lining to push
out from the anal opening. This condition is known as rectal prolapse and
may lead to secretion of mucus from the anus. Usually, eliminating the
cause of the prolapse such as straining or coughing is the only treatment
necessary. Severe or chronic prolapse requires surgery to strengthen and
tighten the anal sphincter muscle or to repair the prolapsed lining.
Constipation may also cause hard stool to pack the intestine and rectum
so tightly that the normal pushing action of the colon is not enough to
expel the stool. This condition, called fecal impaction, occurs most often
in children and older adults. An impaction can be softened with mineral
oil taken by mouth and an enema. After softening the impaction, the doctor
may break up and remove part of the hardened stool by inserting one or two
fingers in the anus.
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Points to Remember
- Constipation affects almost everyone at one time or another.
- Many people think they are constipated when, in fact, their bowel
movements are regular.
- The most common causes of constipation are poor diet and lack of
exercise.
- Additional causes of constipation include medications, irritable
bowel syndrome, abuse of laxatives, and specific diseases.
- A medical history and physical examination may be the only
diagnostic tests needed before the doctor suggests treatment.
- In most cases, following these simple tips will help relieve
symptoms and prevent recurrence of constipation:
- Eat a well-balanced, high-fiber diet that includes beans, bran,
whole grains, fresh fruits, and vegetables.
- Drink plenty of liquids.
- Exercise regularly.
- Set aside time after breakfast or dinner for undisturbed visits to
the toilet.
- Do not ignore the urge to have a bowel movement.
- Understand that normal bowel habits vary.
- Whenever a significant or prolonged change in bowel habits occurs,
check with a doctor.
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Most people with mild constipation do not need laxatives. However,
doctors may recommend laxatives for a limited time for people with
chronic constipation.
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International Foundation for Functional
Gastrointestinal Disorders
P.O. Box 17864
Milwaukee, WI
53217
(414) 964-1799
Intestinal Disease Foundation
1323 Forbes Avenue, Suite
200
Pittsburgh, PA 15219
(412) 261-5888
Further reading: Constipation(National Institute of Diabetes and Digestive and Kidney Diseases)
Constipation: Keeping Your Bowels Moving Smoothly(American Academy of Family Physicians)
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National Digestive Diseases Information Clearinghouse 2 Information Way
Bethesda, MD 20892-3570
E-mail: National Digestive
Diseases Information Clearinghouse The National Digestive Diseases Information Clearinghouse (NDDIC) is a
service of the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK). The NIDDK is part of the National Institutes of Health
under the U.S. Department of Health and Human Services. Established in
1980, the clearinghouse provides information about digestive diseases to
people with digestive disorders and to their families, health care
professionals, and the public. NDDIC answers inquiries; develops, reviews,
and distributes publications; and works closely with professional and
patient organizations and Government agencies to coordinate resources
about digestive diseases.
Publications produced by the clearinghouse are reviewed carefully for
scientific accuracy, content, and readability.
This e-text is not copyrighted. The clearinghouse encourages users of
this e-pub to duplicate and distribute as many copies as desired.
Treatment for stomach and duodenal ulcers:
More information Digestive Disorders Foundation
Tel: +4420 7486 0341
http://www.digestivedisorders.org.uk Karolinska Institutet, Sweden
http://www.mic.ki.se |
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Austria, A-1190
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