Constipation

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Classification according to ICD-10
K59.0 Constipation
ICD-10 online (WHO version 2019)

As constipation or constipation , and constipation , an aggravated in medicine and less than three times a week is defecation with passage disorders of the small or large intestine, respectively. The symptom of absent or reduced bowel movements is sometimes referred to as constipation (as opposed to long-term constipation) or sluggishness . In contrast, when the transport of stool has come to a complete standstill, one speaks of coprostasis . About 20% of the residents of Germany suffer from constipation at least occasionally, about 75% of them women. In old age, constipation affects approximately 26% of men over 84 years of age and 34% of women. Causes are pathological changes in the intestine , e.g. B. Increase in the storage of collagen in the intestinal wall, malnutrition , insufficient fluid intake , metabolic disorders or disorders of the electrolyte balance (often potassium deficiency ); little physical exercise has a beneficial effect. Even after abdominal surgery, there may be obstructions to the passage of stool due to adhesions or a lack of peristalsis . Another form of constipation is constipation-predominant irritable bowel syndrome .

The word constipation comes from the Latin ob , “to”, “against” and stipare , “(full) stuff”, “to crowd together”, but also obstipatio , “to be crowded”, “to pile up”.

Historical

Digestive disorders were demonstrably described as early as ancient Egypt and the Middle Ages. There are numerous references to constipation in medical writings from those times as well as in literature and art.

Intestinal passage

Complete digestion through to bowel movements is subject to strong fluctuations over time and usually takes eight hours to three days.

to form

Acute constipation

Acute constipation occurs relatively rarely and must be clarified. In most cases, the causes of acute constipation are to be found in the personal circumstances of those affected. The symptoms are similar to those of chronic constipation. In addition to the symptoms of constipation, symptoms such as

on, these symptoms can be due to an intestinal obstruction (ileus). These patients require immediate medical attention, sometimes immediate surgical treatment is necessary. Acute constipation can also be the result of a stroke or a herniated disc .

Chronic constipation

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One speaks of chronic constipation if

  • There is no bowel movement for four days for more than three months
  • heavy pressing is required
  • a feeling of incomplete emptying remains

According to its causes, chronic constipation is divided into three groups, ecological constipation, anorectal constipation and idiopathic constipation, for which no clear physical cause can be found.

Ecological constipation

Ecological constipation is a form of chronic constipation, which is also known as slow-transit constipation . Due to the lack of mobility of the intestine, the intestinal contents are only moved slowly forward. Since water is constantly withdrawn from the intestinal contents, hard stools develop. Elimination can be delayed by up to two weeks. The following causes can be responsible:

Anorectal constipation

Anorectal constipation is a form of chronic constipation that is attributed to changes or disorders in the rectum and anus . The causes include:

  • Narrowing of the bowel outlet (anal stenosis)
  • Part of the rectal tissue slipping out of the anus ( rectal prolapse , anal prolapse )
  • Bulging of the rectum ( rectocele )
  • congenital thickening of the internal sphincter muscle (sphincter internus)
  • impaired motor function of the rectum and anus
  • decreased rectal sensitivity
  • impaired coordination of the internal and external sphincters

Idiopathic constipation

In idiopathic constipation, no pathological changes in bowel function or bowel anatomy can be diagnosed by a doctor. This constipation is common. A distinction is made between so-called slow transit constipation (disturbed stool propagation through the colon) and pelvic floor dysfunction (disturbance of defecation from the rectum, so-called outlet obstruction ). Since no organic causes can be found, this form of constipation is determined on the basis of the patient's complaints and with the help of a transit time measurement. Transit time is the period from ingestion to excretion of food. A sigmoidoscope and Sphinktermanometrie (pressure measurement ( manometry ) of the sphincter (sphincter)) should be performed to ensure the diagnosis. Common causes are:

Travel Obstipation

Travel obstipation actually counts as ecological constipation (see above); Since it occurs for a limited time (usually at the beginning of the journey), it is not a chronic constipation. Sudden constipation can result from changes in diet and surroundings while traveling. The body is not familiar with the new situation and reacts with temporary constipation. Causes of travel obsession can be:

  • unfamiliar foods and spices
  • Lack of fluids due to high temperatures and dry air
  • Time change for long-distance travel
  • unusual everyday routine

Pseudo constipation

When the bowel is empty, it may take a few days for normal bowel movements to return. It is a natural process and not a blockage. There is no need to take a laxative. Reasons for such a bowel movement can be a change in diet, such as diet or previous fasting . Other reasons are severe diarrhea or abuse of laxatives, but also prior emptying during bowel examinations, such as a colonoscopy .

Causes of Constipation

  • Lack of physically effective nutritional stimuli, malnutrition, insufficient fluid intake
  • Vitamin deficiency
  • Diabetes mellitus
  • chronic inflammatory bowel disease (Crohn's disease> ulcerative colitis)
  • Colorectal cancer (associated with other symptoms such as blood in the stool, alternation with diarrhea or sudden constipation without any other cause)
  • Celiac disease
  • autonomic polyneuropathy
  • M. Addison
  • M. Parkinson
  • multiple sclerosis
  • Hyperparathyroidism
  • Hypercalcemia
  • Hypokalemia
  • Lack of movement in the abdomen due to weakening of diaphragmatic breathing
  • Lack of physical activity
  • Weakening of the core muscles
  • Spinal (vertebral) irritation
  • psychological influence
  • Dulling of bowel excitability through laxative abuse
  • after abdominal surgery with disturbance of reflex play or due to adhesions
  • Accumulation of fat or lymph congestion in the abdomen
  • toxic nerve damage (alcohol, nicotine, drugs)
  • chronic inflammation e.g. B. Colonitis, adnexitis , gallbladder inflammation
  • Food intolerance ( hereditary fructose intolerance )
  • Long-term therapy with drugs from the active ingredient group of opioids or opiates (e.g. morphine , oxycodone , fentanyl )
  • Volvulus (rotation of a section in the digestive tract) (extremely rare)
  • Hypothyroidism (underactive thyroid)

Symptoms

One constipated. By Franz Xaver Messerschmidt , 1775, Germanisches Nationalmuseum Nürnberg

Constipation can show itself in different symptoms depending on the severity. The patients initially suffer from a feeling of fullness and general malaise, and the stomach may be bloated. Often, stool is difficult, often painful, and many small and hard portions of feces are passed out. Constipation is linked to a number of symptoms or abnormal sensations, which can show up to different degrees:

  • Infrequent bowel movements with evacuation of only small amounts of stool ("rabbit dumplings", "sheep dumplings")
  • hard chair
  • strong pressing when emptying the bowel
  • Feeling of incomplete bowel movement
  • very painful bowel movements
  • Flatulence
  • Chill, sometimes stomach pain and loss of appetite

Health consequences

Chronic constipation can have various health consequences if not treated in a timely manner. The most common complications of chronic constipation include:

The formation of a megacolon or the development of a mechanical ileus are rare consequences .

Diagnosis

As part of a particularly detailed anamnesis , an attempt is first made to narrow down the large number of possible causes of constipation.

Physical examination

The clinical examination follows the anamnesis. It begins with listening (auscultation using a stethoscope ), palpation of the abdomen or palpation of the rectum ( palpation ) and tapping ( percussion ) of the abdomen. This is followed by further investigations to rule out organic causes.

Examination of blood and urine

Laboratory testing of blood and urine samples is required to determine the mineral and electrolyte status of the patient. These values ​​provide information on whether, for example, a metabolic disease or laxative abuse is present. The results indicate the direction for further investigations and can provide an initial indication of the reason for the constipation.

Check for blood in your stool

The stool blood test is also used to detect hidden blood in the stool. If there is blood in the stool, this indicates an inflammation of the intestine, a polyp or other tumor in the intestine.

Ultrasound examination

The ultrasound examination of the abdomen ( abdominal sonography ) takes place without radiation exposure and without impairing the patient. Under good conditions, it is possible to display the organs of the abdomen on a screen. Pathological changes such as intestinal narrowing due to inflammation or unusual accumulations of air in the intestine can be noticed in this way, whereby the ultrasound images can only be evaluated to a limited extent by the doctor due to too much gas in the intestine.

Colonoscopy

The colonoscopy ( colonoscopy ) gives you the opportunity to view and assess the intestine from the inside. A colonoscopy is the best option to detect changes such as colon polyps, constrictions or tumors. In some cases, the aforementioned rectoscopy is sufficient . In this case, only the rectum is examined, whereas a colonoscopy can also examine the higher sections of the large intestine , and if necessary the ileum as well. Before this examination, the entire intestine must be emptied; a simple enema is usually sufficient for the rectoscopy - a cleansing enema is rarely necessary here. For a colonoscopy, patients drink several liters of a PEG rinsing solution a few hours before the examination until only clear liquid is excreted.

X-ray examination

The colon contrast enema can be used to examine the position of the large intestine in the abdomen and how it works. Since the entire large intestine is to be visualized, the intestine must be well emptied before the examination. Barium porridge is usually used as a contrast medium . A vascular examination can also be carried out under fluoroscopy if bleeding, injuries, thrombi (clots) or tumors are suspected. In order to be able to show the functioning of the large intestine radiologically, the whole large intestine is filled with a special contrast medium in which a strong laxative is dissolved ( irrigoscopy ). The bowel movements can then be seen as a film on the X-ray screen. This examination can cause colic- like abdominal cramps due to the laxative and is therefore only carried out in exceptional cases.

Colon transit test

This examination is only carried out if, for example, a dolichocolon (excessively long colon) is suspected . It can be used to determine the activity of the large intestine and the rhythm of elimination. In this test, patients swallow so-called biomarkers at the same time every morning for six consecutive days . These are small capsules that are filled with barium sulfate and are clearly visible on the X-ray. On the seventh day, an x-ray of the abdomen is taken. In this way it can be determined how many capsules are in the different sections of the colon. This allows the passage time through the intestine to be calculated. The tolerable upper limit is 64 hours for the entire intestinal passage; in the case of constipation, the passage time can be up to 120 hours.

Additional special examinations

In special cases, computed tomography (CT) or magnetic resonance imaging (MRI / MRI) can be useful to clarify the cause . With this procedure the whole colon and the sphincter system can be visualized. Sometimes it is advisable to complete the diagnosis with a gynecological, urological or neurological examination. If a neurological disorder is suspected, electromyography (EMG) may be useful. In the case of anorectal constipation, anorectal manometry can also provide information about the function of the rectum and the sphincter muscle.

Mental examinations

The psychological state of the patient must also be recorded when diagnosing constipation. Constipation is often psychosomatic in nature, especially in younger women . Questions are asked about living conditions, eating habits as well as about the family, professional or school situation. The answers can give clear indications of stress-related constipation or stool retention (especially in children).

treatment

Treatment is based on a graduated scheme: If the constipation is caused by nutritional errors or an unfavorable lifestyle, the main aspect of treatment is a change in diet to a high-fiber diet, adequate fluid intake and, if necessary, a change in lifestyle. Sufficient exercise and toilet conditioning support bowel function. If these measures of level 1 are not sufficient, the bowel activity is stimulated in a second step with the help of fillers and swelling substances. B. Macrogol . Level 3 sufferers, for whom neither changing their diet and lifestyle nor level 2 laxatives help, need so-called stimulating laxatives ( bisacodyl , sodium picosulfate , senna alexandrina ) in addition to a healthy diet and exercise . Treatment of stage 3 should be carried out with a medical consultation. It is also advisable to attempt venting in order to regularly check whether the laxative is actually still needed. The dosage of the laxative is correct if the bowel movement is soft and not runny. Diarrhea is a sign of overdose or overuse. Senna products are largely avoided in the medical field.

Diet change

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The aim is to improve the intestinal environment and regulate bowel activity. It is important to create physically effective food stimuli, avoid malnutrition and take in enough fluids. Fiber in food is supposed to create volume in the faeces and prevent excessive dehydration. Minerals and trace elements stimulate the secretion of the intestinal glands to form intestinal juice . The change in diet in combination with sufficient exercise has a long-term effect and is the method of choice in chronic cases.

Whole-grain bread ( whole grain bread, black bread, pumpernickel, barley bread) should be preferred in the normal diet , mixed and brown bread has only slightly more fiber than white bread. Especially bran bread, which has a softer rind than some wholemeal bread, is recommended. Likewise, offer loaves of barley , since barley fiber increases stool volume. Switching to whole foods with a high proportion of raw food can bring about long-term improvement in chronic constipation. Whole-grain pasta, whole rice , millet , oats , barley flakes and whole-grain muesli are suitable as filling bases . Tuber vegetables , yacon , potatoes and beta-glucan barley also serve as substitutes for rice and legumes . Among the types of fruit, pears , peaches, cherries and figs are suitable additional components. Fiber-rich foods such as celery and leeks create volume in the intestinal contents, while asparagus has a dehydrating effect. Dried fruit contains laxatives, but it is better to soak it in water and use it with this liquid. In principle, you should choose soft food, which can be boiled fruits, pureed figs, prunes and dried pears , cooked vegetables and potatoes or peeled barley products such as barley flakes. Salads made from cooked tuber vegetables or high-fiber beta-glucan barley complete the menu. Strawberry jam is suitable, and instant coffee , chocolate drinks and milk chocolate as drinks .

A laxative diet uses pickled plums, figs, and apricots. Well-known remedies with a laxative effect are rhubarb , sauerkraut , beetroot (also available as juice) and in particular Indian flea seeds . When eating bran and linseed , make sure you add plenty of liquid. In the case of insufficient fluid intake, gas and abdominal pain are observed and there is a risk of an intestinal obstruction. Beta-glucan barley can be consumed like rice, as a barley salad or in the form of barley flakes and already contains large amounts of liquid when cooked. A constipating diet is to be avoided for the given reason. So white bread and pasta are rather contradicting. Bananas, carrots and chocolate should be avoided.

Drinks such as red wine or black tea have a constipating effect . Instead, mineral water (two liters per day) or herbal tea are recommended. Mineral water that is particularly rich in sulphate binds water in the intestine and triggers a flushing effect that promotes bile production.

A nutrition counseling by a specialist is better for the change in diet can be as such address the individual problems of patients. Most clinics and health insurance companies offer such advice, and occasionally even special nutrition and cooking courses.

Change of lifestyle

Eliminating constipation should go hand in hand with lifestyle changes.

Behavior therapy

An important pillar in the treatment of constipation lies in changing daily life processes (normalization of the rhythm of life, regulated day-night rhythm with activity and rest phases at the same times of the day as possible, taking meals at the same times). Those affected should free themselves from the need to defecate every day. So it is also important to get the bowels used to a certain regularity, for example by going to the toilet in the morning after breakfast and trying to defecate, but if the attempt is unsuccessful, it is not longer than five minutes. The urge to defecate, even if it occurs spontaneously, should not be suppressed. Any conflicts that may exist should be resolved, and it can be helpful to come to terms with others and with yourself. Opposites to stress should be created, for example through relaxation exercises, meditation , yoga or autogenic training .

Exercise therapy

Since any form of physical movement promotes bowel activity (especially hiking, running, playing sports, gymnastics - especially exercises to strengthen the abdominal muscles), patients should expand their sporting activities accordingly. Isometric abdominal presses to strengthen the abdominal muscles (pull in the stomach vigorously for ten seconds and relax slowly, repeat five times) can be helpful. This exercise should be done three times a day. Intestinal massages, which are carried out in the right lower abdomen with firm circular massaging movements clockwise over the entire abdomen for five minutes in the morning, promote success and also stimulate the intestines. Even deep tissue should have a beneficial effect.

Physical therapy

In the case of "flaccid" constipation, knees can be useful to stimulate the intestines, cold foot baths and half baths, cold rubbing hip baths (16 to 20 ° C, two to three minutes), cold abdominal washes three times a day (three minutes) bring an improvement in the symptoms . In the case of convulsive constipation, intensive heat applications such as hip baths once or twice a day (20 to 30 minutes) and hot pads (hot water bottle with a damp cloth on the left lower abdomen) can be helpful for relieving the convulsions. External colon massage (clockwise) can reduce transit time in the colon up to 47%.

Rectal evacuation aids (enema, irrigator)

Colon irrigation with pure water is a tried and tested, particularly gentle alternative to laxatives. Enemas are one of the oldest instruments in medicine and have always been used to bring about rapid, targeted emptying of the rectum. Their advantage is that the application only works locally, namely in the lower part of the intestine, so that the body and its organs are not stressed. This suitable and well-tried method is no longer known to many patients. The enema device used to play an important role in folk medicine and until a few decades ago belonged in every household and in every doctor's case.

Additional therapy

If the coordination of the internal and external sphincters is disturbed, biofeedback or electrical stimulation therapy is an option . These methods are mainly used for neurological disorders, but under certain circumstances they can also be useful when learning how to properly defecate as part of behavioral therapy.

Medication

In the case of ecological constipation, the cause is a sluggish bowel that can be stimulated with osmotic ( lactulose ) or motility and secretion-influencing laxatives ( bisacodyl or sennoside ). Laxatives are predominantly prescribed by a doctor, but they are also initiated by pharmacists, acquaintances and advertising. If, on the other hand, the cause of the constipation is a lack of fiber, fillers and bulking agents (such as psyllium husks ) are suitable .

Anorectal constipation is best eliminated with rectally administered remedies. Suppositories with the active ingredients glycerine or bisacodyl and enemas with sodium dioctyl sulfosuccinate are suitable for this .

When using painkillers as part of special pain therapy, constipation is one of the most common side effects. This leads to the recommendation that any use of e.g. B. Opiates should be accompanied by laxative intake at least in the first days of therapy. The most common preparation used and examined in pain therapy is macrogol (trade name Movicol). This active ingredient has long been known and has also been extensively commented on by the European Medicines Agency for Pain Therapy.

In the case of chronic constipation that has existed for a long time, a somewhat more complex procedure is necessary to stimulate the bowel. In some cases, laxatives that influence motility and secretion, such as bisacodyl or sennoside, have been used in excessive doses for a long time. As with laxative abuse, you must first switch from stimulating to osmotic laxatives. To do this, start with magnesium sulphate (Epsom salt) in a high dose of two tablespoons to ½ liter of water. If the stool is normal or thin, the dose is reduced or, if unsuccessful, lactulose syrup (one to three tablespoons) is added after breakfast. The individual dose should be selected so that smooth stools occur regularly (every one to three days). When the stool normalizes, the laxative tapering off begins slowly, which can take several months.

If laxatives are necessary due to intestinal paralysis and, in exceptional cases, must be given over a long period of time, macrogol and bisacodyl give the best results. Here only enough is given that a regular, soft but well-formed bowel movement exists. Diarrhea is a sign of taking too much or too much.

If the above treatment strategies are not sufficient, the use of prucalopride (trade name Resolor) is indicated. This is a prokinetic which was initially only approved for treatment of patients with chronic constipation, for whom treatment with laxatives is not sufficient. In June 2015, the manufacturer Shire received EU approval for men as well. For so-called enterokinetic drugs , no consistently positive recommendation for the treatment of constipation in old age can be given, since the literature describes that there is no representative cohort for tegaserod over 65 years of age in the usual randomized studies and prucalopride in Parkinson's patients was convincing.

In some cases, in which a disturbed coordination of the internal and external sphincter muscle shows in the form of a spasticity , an improvement of the symptoms can be achieved by injecting botulinum toxin ( Botox ) into the external sphincter muscle. Botox causes the closure force to be weakened by about 20-40 percent for about three to nine months, making it easier to defecate.

Laxatives with bisacodyl can help with travel obsession, as they work quickly (coated tablets overnight and suppositories within 30 to 60 minutes). Those who prefer phytotherapeutics (herbal medicines) can use senna preparations, as they also work reliably (about eight to twelve hours after ingestion, preferably overnight). An enema , which can be done with the help of a travel irrigator , works even faster . Patients who suffered from chronic constipation before starting their trip should continue to use their previously used laxatives in the usual dosage .

In the case of drug-induced constipation during pain therapy with opioids, this can be effectively reduced by an antidote that only works in the intestine. For this purpose, methylnaltrexone is injected subcutaneously. It cannot cross the blood-brain barrier and therefore has an antagonistic effect on the opioid receptors, which disturb the motility of the intestine through the opioid effect of the painkillers.

Operative treatment

Surgical treatment may be necessary in certain cases, especially in the case of anorectal constipation. This treatment method should only be used if all other treatment attempts, including digital clearing, have failed. Often, surgical treatment can clear or significantly improve the constipation. Indications for this are:

literature

Web links

Wiktionary: Constipation  - explanations of meanings, word origins, synonyms, translations
Wiktionary: constipation  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ↑ a b c d H. Krammer, C. Kolac, U. Köhler, Stephan C. Bischoff: Taboo topic constipation: What role do lifestyle habits, diet, prebiotics, probiotics and laxatives play. In: Aktuel Ernaehr Med. 34, 2009, pp. 38–49. doi: 10.1055 / s-2008-1067563
  2. ↑ JF Erckenbrecht: Epidemiology of Constipation. In: Z. Gastroenterol. Suppl. 1, 2000, pp. 3-5.
  3. ↑ D. Harari: Constipation. In: Hazzards Geriatric Medicin. 6th edition. 2009, ch.93.
  4. ↑ European Food Safety Authority (EFSA): Scientific Opinion on the substantiation of health claims related to oat and barley grain fiber and increase in faecal bulk (ID 819, 822) pursuant to Article 13 (1) of Regulation (EC) No 1924 / 2006. In: EFSA Journal No. 9 (6): 2207, 2011.
  5. ↑ R. Thiesemann: constipation. General practitioner geriatrics, Hesse Medical Association. November 2, 2013.
  6. ↑ R. Thiesemann: constipation. General practitioner geriatrics, Hesse Medical Association. November 2, 2013.
  7. ↑ Pubmed database; Search syntax “Pain AND macrogol” (611 publications); last accessed on January 21, 2016.
  8. ↑ HF Hammer, J. Hammer, C. Gasche: [Polyethylene glycol (Macrogol) - an overview of its use in diagnosis and therapy of gastrointestinal diseases]. In: Wien Klin Wochenschr. 112 (2), Jan 28, 2000, pp. 53-60.
  9. ↑ EMA: Overview of comments received on 'Guideline on the evaluation of medicinal products for the treatment of chronic constipation (including opioid induced constipation) and for bowel cleansing' (EMA / CHMP / 336243/2013)
  10. ↑ Shire Receives European Approval to Use Resolor® (prucalopride) in Men for the Symptomatic Treatment of Chronic Constipation , PM by Shire, June 3, 2015.
  11. ↑ Claudia Dellas: Pharmacology crash course: revision course with incorporation of the most important examination facts . Elsevier, Urban & Fischer, Munich et al. 2011, ISBN 978-3-437-43182-1 .
  12. ↑ Klaus Aktories, Ulrich Förstermann, Franz Hofmann, Klaus Starke: General and special pharmacology and toxicology . 10th edition. Elsevier, Urban & Fischer, Munich Jena 2009, ISBN 978-3-437-42522-6 .