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Constipation: The Cause and Yes, the Cures

September 30, 2013
By Dr. K. Steven Wiley, MD, FACS, FASCRS Ohio Valley Colon & Rectal Surgery , The Intelligencer / Wheeling News-Register

The most common bowel disorder is constipation. The American Society of Colon and Rectal Surgeons reports that 80 percent of the population will suffer from constipation at some point in their life. This is an alarming number. Also of all the over-the-counter medications, laxatives are one of the most abused products. And as we all know, laxatives don't treat the cause of the constipation, they treat the symptom of constipation.

So what is constipation?

Constipation is a symptom that has different meanings to different individuals. Most commonly, it refers to infrequent bowel movements, but may also refer to a decrease in the volume or weight of stool, the need to strain to have a movement, a sense of incomplete evacuation, or the need for enemas, suppositories or laxatives in order to maintain regularity.

For most people, it is normal for bowel movements to occur from three times a day to three times a week; others may go a week or more without experiencing discomfort or harmful effects but this is not considered normal bowel movements.

For us at Ohio Valley Colon & Rectal Surgery to be successful at treating constipation we first have to know what caused the problem to occur.

There are many different treatments and there are many different causes.

Pairing the appropriate treatment with the cause is the only way to insure success. You may be surprised at how many different things can produce constipation. Some are obvious some are not.

Functional Causes of Constipation:Hypertonic or spasm of the anal sphincter, stenosis of the anal canal; low intrarectal pressure generated when straining; paradoxical sphincter contraction when straining; collapse of anal canal from increased pelvic excursion when straining; mega-rectum or overly compliant rectum; lack of urge response; poor defecation mechanics; non-relaxing puborectalis muscle; other sensory abnormalities.

Dietary Cause of Constipation: Not enough fluid or water intake; not enough fiber in diet; or too much fiber in diet (yes to much can be a problem for some people); Diet high in breads and flour products; Not eating often enough to keep peristalsis activated; Not eating enough food; Not consuming the food that keep the bowels soft.

Also, some medications.

Yes, many medications, including pain killers, antidepressants, tranquilizers, and other psychiatric medications, blood pressure medication, diuretics, iron supplements, calcium supplements, and antacids containing aluminum can slow the movement of the colon and worsen constipation.

Therefore the question is: How can the cause of my constipation be determined?

Constipation may have many causes as we discussed earlier, and it is important to identify them so that treatment can be as simple and specific as possible.

We first check for any anatomic causes, such as growths or areas of narrowing in the colon. This is done with either digital examination or possibly a flexible lighted scope or a colonoscopy if necessary.

Other tests may identify specific functional causes to help direct treatment. For example, "marker studies," also called motility studies, in which the patient swallows a capsule containing markers that show up on x-rays taken repeatedly over several days this study may provide clues to disorders in muscle function within the large intestine.

However, most problems with constipation occur in the Anorectal area and are considered Functional Bowel disorders. Our Anorectal Physiology Lab was designed to test and evaluate functional bowel disorders through very specific physiological examinations. These tests involve measuring the pressures in the anal canal and rectum, and the reflexes of anal muscles that control bowel movements using a test called manometry. Sensory responses to stimuli are also evaluated for proper function and response. Complete examination also involves performing electromyography or EMG of the pelvic floor to evaluate the nervous systems functional role in defecation as well as continence.

Most time we can determine a cause of the constipation and resolve the problem. As an example, one of the causes listed above is a mega-rectum which can produce severe constipation and very large diameter stools. This diagnosis of megarectum is easily determined through manometric compliance testing. Now the standard OTC fix for constipation is to take fiber. Well if you have this problem and take bulking fiber you will make your condition worse. The size of the stool will get larger and the constipation will worsen. The standard method used to determine if you have a megarectum is through physiological testing like we have in our Lab to determine your rectal vault size and its ability to be compliant or by having a barium enema study. So here is an example of when taking fiber will make your constipation worse rather than better.

Another example of the need to have your treatment directed by your physiological examination results would be if you have an outlet obstruction in the form of a paradoxical sphincter contraction when straining. When you strain to have a bowel movement your sphincter muscle is supposed to relax to allow the stool to exit. If rather than relaxing it contracts, this creates an obstruction to having a bowel movement. It's like shutting a door then trying to walk through it. The door has to be open for you to pass through. If you have this problem as a patient you would only know that you have to strain very hard to have a bowel movement or even strain and not be able to have a bowel movement. This is occurring because when you strain your sphincter muscle is inadvertently contracting which makes it difficult to impossible to pass stool out. Once this is identified, you can go through a series of treatments to correct this issue.

In our office all patients with constipation undergo strict diet review and likely diet modification which is adjusted personally depending on the patient's presentation and diagnosis. Careful records of all symptoms and responses are recorded. Every patient plays an active role in their treatment.

Many patients say to us, "I have had this for many years how can it change now?" Well, the fact is, it can change and most often does provided that determine the cause and work together to resolve the problem.

As our Practice continues to grow and our Anorectal physiology lab continues to grow we are treating a wider scope of patients with all of the different causes of constipation listed above. The success rate is very high once we uncovered the causative factor/s that needs addressed.

If you are having any of these problems and wish to have them evaluated and hopefully treated and resolved please have your family doctor make a referral to our office and we will call you to schedule an appointment.

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