When a person passes less than three bowel movements a week or has difficult bowel movements.
Basic Constipation Myths debunked
Chronic idiopathic constipation also called functional constipation is common and encounter across multiple demographics. It is important to have a broad view of the symptoms to adequately diagnose and manage this condition. Here we bring to you few myths and facts associated with Constipation.
Chronic idiopathic constipation and irritable bowel syndrome with constipation IBS-C are similar conditions.
One of the criteria for chronic idiopathic constipation is insufficient evidence to make a diagnosis of IBS-C which implies that these conditions are categorically distinct. It is suggested to consider them on a continuum rather than exclusive disease entities. The differentiation, according to the Rome 4 criteria is abdominal pain associated with abnormal bowel habits in IBS-C while all other defecatory symptoms of the conditions are otherwise identical.
Colonoscopy is required for the evaluation of chronic idiopathic constipation.
In the absence of alarming features or suspicion of organic gastrointestinal disease it is recommended to initially evaluate patients with symptoms of chronic idiopathic constipation with a colonoscopy if the patient presents with rectal bleeding, heme positive stool, iron deficiency anemia, weight loss or obstructive symptoms, a colonoscopy should be performed.
Chronic idiopathic constipation can be corrected with Lifestyle changes alone.
Many patients believe that their symptoms are caused by inadequate fluid intake, poor dietary choices or inadequate exercise. Although moderate physical activity and increase fluid intake may be associated with easing the symptoms. Most data suggest that few patients with chronic idiopathic constipation benefit from it. One of the best symptoms of chronic idiopathic constipation improve the quality of life, that is best treated with active medical therapy rather than Lifestyle changes alone.
Chronic idiopathic constipation is due to delayed colonic transit.
Most patients with chronic idiopathic constipation have normal transit constipation. Chronic idiopathic constipation is complex and includes slow transit as well as disorders of rectal evacuation such as dyssynergic defecation. To make it even more complex, the pathophysiology may coexist in individual patients, which may explain the lack of response to laxatives.
A daily bowel movement is the goal of constipation treatment.
There is a range of normal bowel movement frequency and it is a myth that a daily bowel movement is healthier than other frequencies. Individual treatment plan should take into account patient preferences and management should not target a daily bowel movement as the success of treatment.
All osmotic laxatives work similarly.
Osmotic laxatives include saline osmotic (magnesium and sodium Salts), saccharides (lactulose, sorbitol) and PEG(Polyethylene glycol). All osmotic laxatives are not the same in terms of their mode of action. Some work by drawing water into the colon where as polyethylene glycol work differently to assist the natural bowel movement. Saline osmotic laxatives such as magnesium citrate and sodium phosphate have a rapid onset of action but are intended for short term intermittent relief. Long term use can result in hypermagnesemia, hyperphosphatemia and dehydration.
Patient compliance is an issue with lactulose as it is metabolized by the colonic flora resulting in Side Effects such as abdominal pain, bloating and flatus. However, PEG is biologically inert and is not metabolised by colonic bacteria. As a result, PEG exerts its adequate osmotic effect with minimal side effects in comparison to the non absorbable disaccharide (lactulose). Thus PEG has become the mainstay therapy for functional constipation.
PEG may not be safe for constipation in pregnancy.
PEG is approved by the American gastroenterology Association as the treatment of choice for chronic constipation in pregnancy.
PEG are inert Polymers of Ethylene glycol which sequester fluids in the bowel. PEG is licensed for use in pregnancy as the effects on the foetus are negligible because the drug does not get absorbed in systemic circulation. As per American gastroenterological Association(AGA) PEG meets the criteria for an ideal laxative during pregnancy which is effective, not absorbed (Non teratogenic), well-tolerated. PEG is also considered a low risk treatment option and is the first choice for the treatment of constipation in pregnancy.
In fecal impaction, manual evacuation or enema is the preferred treatment approach.
Extreme and severe cases of constipation can lead to fecal impaction. standard treatment include stimulant laxatives, enema, suppositories or manual evacuation. However, these treatments are associated with Side Effects sometimes causing discomfort and distress to the patient and even hospitalization for the procedure. PEG given as a treatment does equivalent to 1 l daily for up to three days is Highly Effective and acceptable oral therapy for fecal impaction. PEG effectively resolves the fecal impaction and maybe used to soften or wash out proximal stool.
PEG is quite effective without an unpleasant invasive procedure and can be used in elderly and vulnerable patients. Even NICE recommends PEG as the first line treatment for disimpaction.
PEG 4000 is better than PEG 3350+ electrolytes.
PEG 3350 is more hygroscopic than PEG 4000 due to its lower molecular weight, suggesting a higher potenct on a per gram basis. The major disadvantage of the use of PEG, without the addition of electrolytes, is the potentially poor safety due to plasma electrolyte loss. The electrolyte is combined with PEG 3350 exchange through the intestinal mucosa with serum electrolyte and are excreted in fecal water without net gain or loss of sodium, potassium or water.
It is proven to be the most effective and best tolerated treatment for the relief of symptoms and has also shown to induce the first motion within the first day of treatment in the majority of patients.
PEG is primary use for bowel wash, in constipation management it should be used as a reserve therapy.
Polyethylene glycol has been used as a bowel wash for past many decades. However the low molecular weight PEG due to its dose-dependent laxative action resulting in colon hydration favouring colon transit, has been recommended for the treatment of constipation and fecal impaction.
PEG is more efficacious than other laxative for the treatment of functional constipation with grade safety and tolerability. This preparations constitutes the most efficacious osmotic laxatives (more than lactulose) and are the first line treatment for functional constipation in the short and long-term as per the recommendations of various scientific bodies.
In summary, there are several misconceptions about Chronic idiopathic constipation that needs to be understood when diagnosing or treating the symptoms. Frequency of bowel movement is individual, and management should consider the patient and their preferences when defining treatment success.