Constipation

Causes of constipation

• Diet and activity level.
• Not drinking enough.
• Social and emotional problems.
• Medications.
• Medical conditions.
• A combination of these.

Diet, liquid, and activity

• Eating less means the body makes less stool.
• Eating food that is greasy or low in fibre can make you constipated.
  • The fibre in food helps to keep liquid in the gut. This liquid keeps stool from drying out, which helps it to travel more quickly through the digestive system. 
• Drinking less can result in hard stools that are difficult to pass.
• Being inactive or not exercising makes the gut less active – which slows the stool’s journey through the digestive system.

Social and emotional problems

• Difficult access to a bathroom (the bathroom may be occupied, hard to get to or not very private).
• Needing help in the bathroom because of a physical or medical condition.
• Needing to use a bedpan or bedside toilet (commode).
• Being in unfamiliar surroundings or a stressful atmosphere.
• Feeling depressed or anxious.

Medications

• Opioids.
  • These are used for symptoms such as pain and shortness of breath.
• Diuretics.
  • These help remove excess fluid from the body. They increase the amount of urine.
• Anti-convulsants.
  • These prevent seizures and treat many other symptoms, including pain.
• Iron supplements.
  • These are used to treat anemia (a condition where a person lacks enough healthy red blood cells).
• Anti-depressants and anti-anxiety medications.
  • These improve mood and treat many other symptoms, including pain.
• Antacids.
  • These relieve irritation in the stomach.
• Laxatives and stool softeners.
  • If these are used often or long-term, the gut starts to depend on them and becomes less active on its own. A gut that isn’t active leads to constipation.

Medical conditions 

• Tumours in the bowel.
• Irritable bowel syndrome (IBS).
• Crohn’s disease (chronic inflammatory condition).
• Poor functioning of the bowel nerves due to:
  • Diabetes.
  • Multiple sclerosis (MS).
  • Spinal cord injuries.

Constipation at end of life

Constipation and emotions

• The physical discomfort can leave people feeling tired and sad.
• Most people are private about their body functions, so the location of bathrooms can cause anxiety. For example:
  • Bowel movements in unfamiliar places such as hospital washrooms.
  • Lack of privacy in shared bathrooms.
  • The loss of dignity to have a bowel movement in a four-bed hospital room.
• Someone who is already anxious can find themselves constantly worrying about their bowel movements.

Assessing and diagnosing

To learn more about your constipation, your healthcare provider will ask questions, do a physical exam, and may order tests. This will help them decide how best to manage the constipation.

Questions

• How bad is the constipation?
  • Mild, moderate, or severe?
  • Rate the constipation on a scale from 0 to 10. Zero means no constipation and 10 the worst possible constipation.
• How often do you normally have a bowel movement?
  • Once a day? Twice a day? Every two days?
• When was your last bowel movement?
• What was the last bowel movement like?
  • Hard or soft?
  • How much?
  • What colour?
  • Any signs of blood? If so, was it bright or dark? Was it in the toilet or on the toilet paper or both?
  • Was the bowel movement painful?
• Have you felt the push to have a bowel movement but had no stool?
• Have you been nauseated or vomiting? 
• What about pains or cramps in the stomach?
• Are you passing gas?
  • How many times a day?
• Are you taking medication now to help with bowel movements?
  • Is it working?
  • How long does it work for?
  • How often do you take it?
• What medication have you taken in the past to help with bowel movements?
  • Did it work?
  • How long did they work for?
  • How often did you take it?
• What has helped with constipation in the past?
• How is constipation affecting your quality of life?
  • What kinds of things does it stop you from doing?
  • Do you feel discouraged or depressed?

Physical exam

• Pressing on your abdomen, feeling for tenderness or masses. 
• Listening to bowel sounds with a stethoscope in different areas of the abdomen.

• Your healthcare provider will insert a gloved finger into the rectum, feeling for stool or hard masses. 
• A pressure will be felt in the rectum like the pressure felt during a bowel movement.

Tests

• X-rays take pictures of the inside of your body.
• This type of X-ray can show where stool is sitting in your bowel.

• These check for levels of calcium and thyroid hormones. 
• Changes to the amount of these in the blood can lead to constipation.

Medications and other treatment

Oral laxatives

• They may also be prescribed if your illness keeps you from drinking enough or being physically active. 
• Certain medications cause constipation. (Opioids, for example, used to manage pain or shortness of breath).
  • In most circumstances, laxatives should be prescribed with constipating medications in an effort to keep the bowels moving. Your healthcare provider will know if this is right for your circumstance.

• Stimulant laxatives.
• Osmotic laxatives.

• Senna.
• Sennosides.
• Cascara.

• Cramps.
• Diarrhea (if too much of this medication is used).

• Potential side effects and myths about opioids in Managing Pain.
• Common concerns about use of opioids in palliative care.

• PEG (polyethylene glycol). 
• Lactulose. 
• Saline.

• These help to soften stool and empty the bowels by pulling water into the bowels. 
• They cause less bloating and cramping than lactulose.
• There are several brands in this group. Some have electrolytes (salts) and some do not.

• This is a type of sugar that isn’t absorbed into the body (so it’s safe for people with diabetes). 
• It helps soften stools by drawing water into the bowels, and it helps the bowels to empty. 
• Lactulose makes some people feel bloated and gassy, and its sweet taste can be nauseating.
  • It may taste better mixed with juice or ice.

• These draw liquid into the bowel and help to get the bowels moving.
• Many of these also have magnesium, which stimulates the bowel. For example:
  • Milk of magnesia (magnesium hydroxide).
  • Magnesium hydroxide with mineral oil.
  • Magnesium citrate.
• Oral liquid sodium phosphate is a powerful and effective saline laxative. However, it can seriously affect fluid and chemical balance in frail people.
  • This should only be used with medical supervision in people with advanced serious illness.

• Bulk-forming laxatives.These often contain psyllium or wheat bran. Both of these can cause bloating and make the bowels work even slower in someone who can’t drink much or be physically active.
• Mineral oil. People who are weak and spend a lot of time lying down shouldn’t use mineral oil. Small amounts of the oil might seep into the lungs. This can cause inflammation in the lungs.
• Castor oil. This laxative can cause serious cramping. If it’s used for a long time, the body might lose the ability to absorb certain nutrients from food. 

Rectal medications

• If medication taken orally (swallowed) isn’t improving bowel movements, the dose will usually be increased. 
• If constipation continues, rectal medications may be needed. These are medications that are inserted into the rectum. There are two kinds:
  • Suppositories.
  • Enemas. 

• These melt at body temperature when pushed into the rectum with a gloved finger. 
• They help to move stool from the lower end of the intestine.
• Suppositories work in different ways. For example:
  • Bisacodyl triggers the bowel to move the stool.
  • Glycerin softens the stool to make it easier to pass.

• The solution is placed into a small plastic container with a tube attached. 
• The tube is gently inserted into the rectum and the liquid is slowly sent through the tube into the bowel. 
• After about 15 to 20 minutes, the enema solution triggers the bowels to empty, so the patient should plan to be sitting on a toilet or bedpan. 

• Oral laxatives are usually the preferred approach. A repeated need for enemas suggests that oral laxatives need to be increased. 
• Enemas can damage the rectum if they’re not done properly.
• They often don’t completely address the problem of constipation because they only deal with the lower part of the bowel. 

Other constipation treatment

• These medications aim to block the constipating effects of opioids in the bowel without affecting pain relief. 
• They’re generally only used for temporary constipation relief. They add to, not replace, oral and rectal laxatives.  
• Check with a healthcare provider about whether a prescription for these medications is suitable. 
• Examples include methylnaltrexone (an injection) or naloxegol (a tablet).

Complementary therapies

• Breathing and relaxation exercises.
• Distraction techniques.
• Massage.
• Mindfulness meditation.
• Music therapy. 

• Talk with your healthcare provider first in case they have concerns about a certain therapy and your particular health circumstances. For example:
  • Some herbal remedies may affect how well your prescribed medications work.
  • Heat therapies are best avoided with certain disorders, such as reduced ability to feel hot temperatures against the skin (risk of burns).
• Experiment with the different approaches until a helpful one is found.
  • A therapy that works for one person might not work for another. 

What you can do

When you are living with illness

• Simple lifestyle changes.
• How much and what you should eat and drink.
• When to exercise.
• When to take medication.
• Getting or affording constipation medication.

• Eating (filling the stomach) triggers the rectum to empty. Try to have a bowel movement 30 to 60 minutes after meals to take advantage of this.
• Eat foods that are high in fibre such as dried fruits, fresh fruit and vegetables, legumes, and whole grain breads and cereals. 
• Try making a natural fruit laxative to loosen your stool and increase your bowel movements.  
• Drink hydrating fluids throughout the day, as tolerated.
• Avoid foods that constipate such as greasy fried foods and hard cheeses.
• Try to be more physically active if possible. For example, try a gentle walk each day.
• If bowel movements are painful, talk with your healthcare provider. 
• If possible, try to have a bowel movement sitting rather than lying down.
• Try to make sure you have private time in the bathroom.
• If you need help going to the bathroom, work with your helpers to ensure you feel respected and you are treated with dignity.

• Talk with someone you trust, like a friend or family member. Sometimes just talking with someone can help you to feel better. 
• Ask your healthcare provider to refer you to a counsellor such as a psychologist or social worker. They can offer:
  • Counselling and emotional support.
  • Education.
  • Practical suggestions to help you manage your symptoms.
• Talk with a spiritual care specialist.
• Find information online.
  • Canadian Virtual Hospice has information on many topics related to serious illness and palliative care.
• Join a support group.
  • If you can manage it, join a support group where you can meet with people with the same health concerns.
• Join online discussion forums such as:
  • Canadian Virtual Hospice Discussion Forums.
  • Cancer Chat Canada.     
• Learn more about Programs and Services in your area.

When someone you care about is living with illness

• Talk with someone you trust. Sometimes just talking with a friend or family member can help.  
• Ask your healthcare provider to refer you to a counsellor such as a psychologist or social worker. They can offer:
  • Counselling and emotional support.
  • Education.
  • Practical suggestions to help with stress.
• Talk with a spiritual care specialist.
• Ask about a support group for caregivers.
• Find information online.
  • Canadian Virtual Hospice has information on many topics related to serious illness and palliative care.
• Join online discussion forums such as:
  • Canadian Virtual Hospice Discussion Forums.
  • Cancer Chat Canada.     
• Learn more about Programs and Services in your area.

• Various therapies such as relaxation techniques, meditation and yoga can be helpful to manage stress and the emotional impact associated with caregiving. 
• To learn more, go to: Complementary therapies.

• Regular exercise is important in managing stress. What physical activities do you enjoy? Walking? Biking? Something else?
• We’re all different so choose something you enjoy. It might be reading, praying, listening to music, watching sports – or something else.