Constipation: Why treatment matters — Prof Adekanle

Although constipation is very common, if it is overlooked, it can eventually cause complications, some of which may be serious, says Professor Olusegun Adekanle, a consultant gastroenterologist with the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile-Ife, Osun State, in this interview with SADE OGUNTOLA. Excerpts:

December was named Constipation Awareness Month. Is constipation really that important?

The idea is to raise awareness and let people know what it is all about, its manifestations and what people can do about it. This ensures people take responsibility for their health and present themselves in hospital in case they have constipation. Some of them might have been coping with it. But still, they need to be seen at the hospital for a proper evaluation, and then action can be taken.

 

What exactly is constipation in medical practice?

A person is said to have constipation when there is a departure from the normal number of times that person passes faeces and hard stools, which are difficult to pass.

The frequency of passing faeces varies across the world.

The white people pass stool like once a week, but in Africa, where people take high-fibre diets, it is about once a day. Some people even pass faeces twice a day. If a person is supposed to go to the toilet once or twice a day and now it has turned to once every three or four days, that is constipation for Africans. So, any departure from the usual frequency of passing stool is a problem; it is individualised. It is food that actually dictates the frequency of passing stools most of the time.

 

What is (are) its cause(s)?

Actually, constipation is a sickness with a wide range of reasons. Some are straightforward, such as dehydration from not drinking enough water, while others are really serious and should not be treated carelessly. Constipation can be caused by a number of common factors, such as taking certain drugs, exercising infrequently, drinking too little water, ignoring the urge to pass gas or holding onto waste, getting older and intestinal blockages

Of course, people hold on to their stool, say because they have travelled to an unfamiliar or uncomfortable environment or because they are staying in boarding houses with bad toilets, until they are back in their home zone. Similarly, as people get older, their activity level reduces, so older people then become more constipated compared with younger ones

When the food enters the mouth, it goes to the stomach and eventually into the large bowels as waste. By the time it gets into the large bowels, a lot of water would have been reabsorbed from them. One might take semi-solid food, but by the time it is passed out, it is in solid form because a lot of water has been removed from it.

On the other hand, many disease entities can result in constipation. People with conditions like stroke, Parkinson’s disease and spinal cord injuries may be constipated because the reflex to the large bowels that controls the movement of stool out of the body is affected.

Also, people with long-standing diseases like thyroid problems and diabetes may also have constipation as part of their manifestation. Cancer can cause a sudden obstruction to the flow of stool in the large bowel. It is the large bowel that receives the remnant of food that has been taken; water is absorbed from it, and the rest is passed out as stool. With cancer, the person is not only constipated but also losing weight. The stool, apart from becoming so hard, may take on the appearance of the stool of a goat. It may also have blood in it. In cases like these, a cancer of the large bowel, also called colorectal cancer, is suspected.

 

Can stress or anxiety contribute to constipation?

In medicine, there is never a no. Just as a person under stress will not remember that he wants to go and pass stool, it is only after the event has passed that he realises that he might have constipation because he has not gone to the toilet for the past three days. Also, stress can make somebody suddenly want to go to the toilet to stoop because the system is out of order. So, either of them can occur.

Should constipation be a thing of concern to make a person promptly seek medical help?

Everybody should know what his normal frequency of passing stool is, and once there is a departure, it is likely constipation. In my medical opinion, the person should seek medical advice because some of its causes shouldn’t be taken lightly. It could be due to many things, so a thorough examination by the physician at this stage will be important. It might not need medication, but a diet or even lifestyle modification, depending on its cause.

 

Are there specific foods that can help prevent constipation?

In Nigerian contexts, people go to the toilet almost every day and that is normal for us. But in recent years, we are copying people in westernised countries and eating a refined diet. These are processed foods with little or no fibre in them. Our usual foods are things like eba, amala, fufu and pounded yam, as well as vegetables and fruits that people just go to the farm to pick and eat. These are foods with high fibre content. It is our departure from this and our current intake of processed and junk food like bread, pasta and so on that is causing constipation.

In fact, the departure from our cultural norm is not only affecting our society in terms of increasing the possibility of constipation but also the development of many diseases like diabetes. The World Health Organisation (WHO) tells us that the burden of diabetes in developing countries will increase in the years to come. So, if somebody wants to go to the toilet normally every day or to normalise, they should go back to eating our natural foods— vegetables, cocoyam and so on. All these contain high fibre content.

Similarly, the atmospheric temperature is increasing. Sometimes, it is as high as 40 degrees Celsius in the afternoon due to climate change. This comes with its attendant problem, dehydration. People are dehydrated without their knowledge and many are also drinking less water. So, constipation can occur.

 

How much water should be taken to avoid constipation?

We cannot say that this is the amount of water that you should take or that this is the amount of water that you should not take. But let me answer the question in this way. At this time of the year, when the atmospheric temperature is high, adults lose between two and three litres of fluid, an amount of water they are unaware of because of the heat. This is called an insensible water loss.

So, if I want to prescribe how much water should be taken, I will say the minimum should be the amount of water people lose without being aware of it. If you don’t replace that baseline, the person is going to run into problems. The kidneys will not be well perfused and then constipation may occur. And any addition to this will further make the body system function very well.

Of course, the insensible water loss, particularly because of the high atmospheric temperature at this time, is higher. The insensible water is between 1.5 and 2.5 litres when the atmospheric temperature is not that high. In cold seasons, it may be less than a litre.

 

What are the common medications that contribute to people having constipation?

There are so many medications that can contribute to constipation. Common among these are some medications to treat hypertension, such as amlodipine. Others are antacids that contain calcium or aluminium used to relieve heartburn, calcium and iron supplements, strong pain medicines like codeine and tramadol, cold medicines (antihistamines), nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, and some anti-depression medications.

 

If constipation is a disease, it means that if left untreated, it could lead to some complications. What are these?

Persistent constipation can lead to many complications. As the person is trying to force it out, a tear in the skin around the anus may occur, subsequently causing bleeding. Also, haemorrhoids (the swollen, inflamed blood vessels in the anal part) and prolapse could occur, which is a part of the large intestine that slips out of the anus. Sometimes, it may still go back.

The most dangerous complications are when there is a pile-up of too much faeces in the rectum and anus, what is termed faecal impaction. Both prolapse and faecal impaction can have serious side effects and require intervention from a medical professional.

Sometimes, the difficulty passing stool can cause more serious complications, like bowel incontinence and the leakage of liquid stools, because of the damage to the pelvic floor muscles from straining for too long to pass stool.

Intestinal obstruction from the accumulation of dry and hard faeces can also occur. I remember the case of a university student with intestinal obstruction who was brought to our hospital and was later admitted. The abdomen was obstructed and distending. The student could not pass stool, was vomiting, and was not eating much. We had to pass something into the anus to force the stool out. When anything causes an obstruction in the intestine, it is a kind of emergency.

 

A common remedy for constipation is drinking water and increasing your intake of fruits and vegetables. Are there other things that can be done to relieve constipation naturally?

To talk about natural things that you can do to relieve constipation, I am not aware because constipation is actually a disease. So, there is nothing natural that you will do to relieve it. The best thing is to prevent it from occurring and, if it does, get to see the doctor who will evaluate the case and tell if it is amenable to treatment like increased intake of water and diet modification, like increased intake of fruits, vegetables and other foods with high fibre, provided it is a normal constipation, without any complications. Constipation that arises from an intestinal obstruction, abdominal distension or faecal impaction will require much more than increased intake of water and diet modification. It could have been due to more sinister things, like cancer.