Constipation is one of the most frequent gastrointestinal complaints worldwide. In the United States it is one of the common reasons for a visit to the physician.
Definition of chronic idiopathic constipation
Constipation is defined as reduced stool frequency or less than 3 times per week or difficulty passing stools, or both. The frequency of 3 times per week is different from different individuals. For some this may be a normal habit and any change or reduction in frequency is considered to be constipation in these individuals.
Difficulty in passing stools include straining, incomplete bowel movements or a feeling of incomplete evacuation after defecation, passing hard/lumpy stools and a prolonged time interval between two bowel motions.
In severe cases there may be a need for manual removal of hardened and impacted stool and there may be injury and bleeding of the tissues around the anus due to passage of the hard stools.
Chronic Idiopathic Constipation (CIC) is defined as the chronic presence of these symptoms. It is called idiopathic because the cause of this type of constipation is unknown and it is not caused by underlying illness or medication.
Symptoms of chronic idiopathic constipation
Symptoms of chronic idiopathic constipation include:-
Constipation or difficulty in passing stools
Hard and lumpy stools
Straining when defecating
Feeling of incomplete evacuation after completion
Abdominal discomfort and bloating
Poorer physical functioning
Poor social functioning
Decreased quality of life and perception of health
Causes of Chronic Idiopathic Constipation
This is a condition that has no well defined underlying cause. However, there are several factors that are associated with chronic idiopathic constipation. This includes reduction in fluid and fibre intake in diet, changes in water balance, changes in motility in the colon etc.
Changes in motility means changes in the contractility and the rate at which the muscles in the colon contract to move the fecal matter pass through the colon to the rectum. As the movement slows down, more water is absorbed from the fecal mass. This makes it hard and dry and more difficult to pass. Furthermore these hard, dry stools may be small and lack the bulk to stimulate the urge to defecate and this result in infrequent bowel movements.
The symptoms of chronic idiopathic constipation are also aggravated when there are visceral sensory abnormalities or changes in the enteric nervous system. This pathology may also cause abdominal discomfort. Visceral hypersensitivity may result in diminished rectal sensation and this decreases the urge to defecate.
In the United Sates as many as 35 million adults may suffer from chronic idiopathic constipation. The numbers may be higher as all patients do not seek medical help. Studies have shown that only about 12% with the condition seek medical help. Now, however, over 40% of patients with chronic idiopathic constipation are under medication.
It is slightly more common in women (56%) and adults over the age of 35 years (84%). Caucasians are worst affected (82%) than other races and ethnicities.
Diagnosis of chronic idiopathic constipation
Diagnosis is made mainly on the basis of history and physical examination of the patient. Individuals with symptoms such as bloating, hard, infrequent stools, and straining are commonly seen initially.
Some of the warning signs or red flags are enquired and watched out for to rule out other more serious conditions that may mimic chronic idiopathic constipation like bowel cancers.
Warning signs for more serious conditions
These red flags include:-
Blood in the stool
Onset of symptoms after age 50
Family history of bowel cancer and inflammatory bowel disease like ulcerative colitis and Crohn's disease
Presence of fever and low blood count
Severe constipation not responsive to treatment
Unexplained weight loss
Confirming the diagnosis
Colonoscopy, imaging studies like MRI scans and anal manometry may be performed to confirm diagnosis.
Treatment of chronic idiopathic constipation
Treatment strategies are based on the severity of symptoms of the condition. Diet and life style changes including regular physical exercise are advised. The patient is asked to increase fibre and water intake in diet and take healthy and balanced diets.
A symptom diary may help identify triggers that exacerbate symptoms and possible diet and other triggers may be avoided.
Medications that may be used include over-the-counter laxatives and stool softeners.