Chronic Idiopathic Constipation (CIC) management involves some basic steps. The first step is to rule out other secondary causes that may be causing constipation. As the name suggests, chronic idiopathic constipation seldom has a definite cause. Some of the more serious secondary causes leading to constipation include colon cancers and rectal and anal pathologies.
The next step is to determine if the patient takes adequate amount of fluids and fibre in diet. Presence of other complications like urinary retention, gastroesophageal reflux disease, vomiting and abdominal pain is also checked for.
Treatment for severe impaction of faeces
When there is severe impaction of faeces due to chronic idiopathic constipation, the preferred regimen is:-
- The first step is to clean out the lower bowels using PEG (Polyethylene glycol) taken in fluids over 2 to 3 hours along with stimulant purgatives like senna 25-50 mg or bisacodyl 10 mg. For younger children the dose is halved or as an alternative Magnesium citrate may be given along with fluids.
- A dose of 17gms (once daily) of PEG may be given as maintenance along with Senna or Bisacodyl every other day.
- Once a month the bowels need to be cleaned with PEG and bowel movements are monitored.
If the constipation does not respond to this therapy, it has to be discontinued. The dose of Senna and Bisacodyl may be raised but PEG should not be given at doses over 34 gms daily.
Enemas every alternate day may be started with normal saline with castille soap, mineral oil etc. Enemas with phospho-soda, milk and molasses should be avoided since it may lead to life threatening complications like electrolyte imbalance.
Mineral oil intake orally should also be avoided for clearing constipation, as these may lead to aspiration pneumonia.
Once the acute constipation is cleared laxatives may be advised. These agents help pass stools more comfortably. They lead to soft formed stools after a couple of days of use and ease the process of passing stools.
Types of laxative
There are three major classes of laxatives. These include –
These agents increase the bulk of the stools formed and soften them to ease passage. They soften the stools by retaining the fluids within the stools. Softening the stools help in their passage and prevents stool impaction or fecal impaction.
Commonly prescribed bulk-forming laxatives include ispaghula husk or psyllium, polycarbophill, methylcellulose and sterculia. These should be taken with plenty of water. These agents take around two to three days to be effective.
Osmotic laxatives work by drawing the water into the intestines and thus make the stools soft. These are prescribed if the bulk laxatives fail to work. Commonly prescribed osmotic laxatives include lactulose.
These laxatives are used if the other two agents have failed to cause softening and passage of stools. These agents stimulate the muscles of the gut to contract and expel the faeces.
The most commonly prescribed stimulant laxatives are senna, bisacodyl and sodium picosulphate. These agents take around 6 to 12 hours to work and should be used on short term basis only.
They are also useful for clearing the bowel in patients who are to undergo surgery (especially abdominal surgery) or radiological investigations and imaging of the abdomen.
Other medications and therapies that may be used include:-
- Newer medications like Lubiprostone, serotonin agonists like Cisapride and Tegaserod, Prucalopride, Linaclotide (a guanylate cyclase C receptor agonist) and Naloxone (opioids antagonist).
- Anal Botox Injections may be given under general anesthesia to release the anal sphincter. This injection is followed with anal dilatation.
- Surgical intervention - some surgical options for chronic idiopathic constipation include colostomy, subtotal or total colectomy. These are used if there is no response to maximum pharmacological therapy.
Dietary and lifestyle changes
Patients are advised several dietary and lifestyle changes as well. These include:-
- Fibres in diet - fibres are available in fruits, vegetables, whole grain rice, whole wheat bread, whole wheat pasta, seeds, nuts, oats, pulses etc. It is recommended that a person needs at least 18 to 30g of fibre a day.
- Fluids in diet - fluids like water and fruit juices help prevent dehydration and help in softening the stools as well. Certain fluids like caffeine, alcohol and fizzy drinks are not good for bowel motions and may aggravate constipation.
- Regular physical activity and exercise.
- Good toilet habits and not suppressing or ignoring the urge to go to the toilet. The best time for passing stools is first thing in the morning or around half an hour after a full meal. The toilet should be used with adequate time and privacy.