Although the number of defecations per day varies depending on the societies, individuals and eating habits, constipation can be called 3 times a week or less frequently, hard and difficult defecation. Some people may express that they do not complain when they defecate 2 or 3 times a week, but in a normal consistency and without difficulty. The most important characteristic of constipation is that the stool consistency is hard, the amount of stool is low and there is strain during defecation. Absence of defecation, inability to defecate when going to the toilet despite the feeling of defecation, straining to defecate, defecating in small and hard pieces, the feeling of not being able to empty completely after defecation are other findings that can be seen in constipation. Some patients try to assist defecation with their fingers.
In chronic constipation, no underlying organic cause is usually found and this type of constipation is called functional constipation. However, it should be kept in mind that constipation is not a disease but a symptom that may develop secondary to another disease. Rarely, constipation may be caused by a narrowing that prevents stool from moving through the bowel (such as a tumor, inflammatory bowel disease, or a deformity of the bowel). This type of constipation is called constipation due to organic causes. For this reason, some examinations are usually required in patients who apply with the complaint of constipation.
WHAT CAUSES CONSILENCE?
The large intestines are 140-180 cm long and their main task is to absorb the water and electrolytes in the watery intestinal contents from the small intestines. The large intestines can absorb up to 4 liters of water per day. Passing water above this amount from the small intestines to the large intestines causes diarrhea. The intestinal contents, whose water is absorbed, solidify and are stored in the form of feces, especially in the last 40-50 cm of the large intestines. If the stool stays in the large intestine for a long time, it causes more water in it to be absorbed and harden more.
The large intestines have different movements that allow the contents to move forward. Some of these movements are in the form of segmental contractions and they are movements that increase the movement of the stool back and forth and the absorption of water in it, causing the stool to become small pieces (Segmentary contractions). These movements do not contribute to the progress of stool in the intestine. Another form of movement in the large intestines is in the form of progressive contractions that follow each other from proximal to distal, allowing the stool in the intestine to move towards the exit (Peristaltic contractions). When the stool reaches the last 15 cm of the large intestine, which we call the rectum, it is expelled by creating a feeling of defecation.
Three basic mechanisms generally play a role in the formation of functional constipation;
1- Constipation due to excessive contraction of the large intestine (Hyperkinetic constipation):
Increased segmental contractions in the large intestine; In this type, segmental (local) contractions that do not contribute to the progress of stool in the intestine have increased, the stool is hard and in small pieces. It is usually associated with irritable bowel disease (See Irritable bowel disease).
2- Constipation due to the decrease in contractions that allow the forward movement of stool in the large intestines (Hypokinetic constipation- lazy large intestine):
In this type, the laziness of the large intestines is in question. Neurological diseases (Parkinson’s disease, stroke, etc.), underactive thyroid gland (hypothyroidism), long-term diabetes, fasting and fiber-free diet, pregnancy, long-term travels, stress, use of certain drugs (Psychiatric drugs, for the treatment of constipation) long-term and unconscious use of drugs used, etc.) can lead to this type of constipation.
3- Disruption of the defecation mechanism (Dyschesia):
In this type of constipation, there is a malfunction in the perception of the stool coming to the last part of the large intestine (Rectum) near the exit and in the formation of coordinated movements that allow the stool to be thrown out by opening the anus. It is usually seen in rectal diseases and neurological diseases.
DIAGNOSIS
A detailed history should be taken from every patient who applies to the physician due to constipation, a physical examination should be performed, and the medications used should be reviewed. Although the probability of an organic cause is very low in patients with long-standing constipation, biochemical blood tests, including thyroid function tests, and stool examination should be performed. The method that should be preferred for the examination of the large intestine in a constipated patient is ‘double contrast barium radiography of the large intestine’. Colon X-ray has almost the same sensitivity as colonoscopy when taken by an experienced radiologist using a good device.
In addition, in this method, it is possible to obtain information about the length of the large intestines and, if any, deformities (excessive folds, stenosis, etc.). Another radiological method is defecography. Especially in the elderly population, it is preferred to be done together with a colon radiography. This method is also applied like barium enema radiography, however, more detailed imaging is performed during the discharge of barium from the intestine to obtain information about the physiology of defecation. When an additional pathology is seen in the large bowel X-ray, colonoscopy can also be performed if necessary. Endoscopy (colonoscopy) is not the first method to be applied in patients who apply for constipation.
However, colonoscopy should be the first method of choice in patients with additional findings other than constipation (bleeding, anemia, rapid weight loss, thinning of stool thickness, new onset constipation and change in defecation habits, etc.). Another examination that can be done in patients with double contrast colon radiography and no organic pathology is the ‘radiopaque marker study’. In this method, after a certain number of radiopaque marker particles are swallowed by the patient, direct abdominal films are taken to examine the progression of these particles in the intestine and to obtain information about the movements of the large intestines.
ATTENTION!!
If you feel that there have been some changes in your defecation habit in the last 6 months compared to the past, if you have started to have difficulty defecating and/or if you see a decrease in stool thickness compared to the past, this may be a sign of a serious illness. You should immediately consult a gastroenterologist.
HOW IS CONSILENCE PROBLEM SOLVE?
Since constipation can have many causes, treatment is shaped according to examination and laboratory findings. Regular and fiber-rich foods, adequate fluid intake (drinking at least 8-10 glasses of water a day), regular exercise (walking, aerobics, etc.) are the general measures that can be applied to alleviate functional constipation. When the feeling of defecation comes, it is necessary to go to the toilet without wasting time and wait for a sufficient time (about 15 minutes). Postponing going to the toilet when the feeling of defecation occurs leads to exacerbation of constipation.
Diet
Diet rich in fiber (fiber) is one of the most important steps in the prevention and alleviation of constipation. Fiber is the indigestible part of plant foods. There are two types of fiber, water-soluble and insoluble. Water-soluble fibers are digested by bacteria in the large intestine. Oat bran is an example of water-soluble fiber. Water-insoluble fibers are more useful in reducing constipation. Wheat bran, cereal grains, green vegetables and the skins of various fruits such as apples and pears are examples of insoluble fibers. Fibers increase the amount and water content of stool by holding water, and in this way, they help reduce constipation by increasing the movement of stool in the large intestine through the intestine. While the amount of fiber in a Western diet is about 10-20g in a day, it is recommended to take 30-35g of fiber per day for a good bowel movement. There are many foods rich in fiber. Fruits, vegetables, wholemeal bread and bran are examples of fibrous foods. Brown rice can be preferred instead of white rice.
Can defecation facilitators be helpful?
Stool softener and stool facilitating drugs can be basically divided into two main groups; Stimulants of bowel movements (such as Tegaserod, itopride, domperidone) and those that stimulate the secretion of fluid into the intestine and thus soften the stool (such as Ca, Mg salts, lactulose, some herbal medicines). Although drugs that stimulate bowel movements provide some benefit when they are first used, their effects decrease over time when the drug is continued to be used.
Herbal medicines and Mg salts generally continue to work as long as they are used. When used continuously, they can cause electrolyte disorders, osteoporosis, protein loss and addiction. Some (Laxophenol) may cause pigment accumulation in the intestinal mucosa when used for a long time, causing the mucosa to appear brown in color (melanosis coli). Especially when drugs that act by increasing bowel movements are discontinued after long-term use, severe constipation that does not easily improve may occur.
If constipation is a symptom of irritable bowel disease, then drug therapy for irritable bowel disease is administered. If the stool hardens in the last part of the intestine (rectum) near the exit and cannot be removed, it can be helped with an enema. Attempting to forcefully remove pieces of excessively hard stool can lead to hemorrhoids and very painful ruptures in the anus (anal fissure) over time (See Anal fissure).
In terms of helping to gain regular defecation habit, the following application can be recommended;
1- Do not use stool softener
2- Increase the amount of fiber in your diet
3- Drink plum or peach juice in the morning
4- Try to eat at least two meals a day of low-sugar fruit compote
5- Use a preparation containing up to one tablespoon of psyllium twice a day (Psyllium is a plant species that grows in the Mediterranean basin, its seeds swell in a humid environment and gain a gelatinous structure. It can be found in the market under the name Psyllium seed or Psyllium husk).
6- Do not skip breakfast. In the morning, after drinking 2 glasses of water on a few dried apricots, dried figs or prunes on an empty stomach, after breakfast, whether or not there is a need for the toilet, you go to the toilet for 15 minutes. Sit on the toilet for as long as possible, but don’t strain yourself to defecate. Taking time for this defecation attempt each morning can provide long-term relief from bowel habit.
