understanding

CONSTIPATION

A patient’s guide from your doctor and

Constipation Basics
— The frequency of bowel movements
among healthy people varies from three
movements a day to three a week.

— Individuals must determine what is normal

for them.

— As a rule, constipation should be suspected

if more than three days pass between
bowel movements or if there is difficulty or
pain when passing a hardened stool.

— Most people experience occasional short

bouts of constipation. If a laxative is
necessary for longer than three weeks,
check with a doctor.

— Prevention is the best approach to

constipation. While there is no way to
ensure never experiencing constipation,
the following guidelines should help:
– Know what is normal and do not rely
unnecessarily on laxatives.
– Eat a well-balanced diet that includes
unprocessed bran, whole-wheat
grains, fresh fruits and vegetables.
– Drink plenty of fluids.
– Exercise regularly.
– Set aside time after breakfast or din-
ner for undisturbed visits to the toilet.
– Don’t ignore the urge to have a bowel
movement.
– Whenever there is a significant or
prolonged change in bowel habits,
check with a doctor.
Your Digestive System

C
G

F
E

H I

A. Esophagus F. Large Intestine

B. Liver G. Pancreas
C. Stomach H. Rectum
D. Gallbladder I. Anus
E. Small Intestine
Laxative Types
Adapted from NIH Publication No. 07-2759; July 2007: www.digestive.niddk.nih.gov

Bulk-forming
These need to be taken with water. Generally the safest form of
laxative, but may interfere with absorption of some medicines.
Also known as fiber supplements, these laxatives absorb water
in the intestine and may make stool softer.
Many people who report little to no relief after taking bulk-forming
laxatives may experience more bloating and abdominal pain.

Stimulants
Cause rhythmic muscle contractions in the intestines.
Studies suggest that phenolphthalein, an ingredient in some
stimulant laxatives, might increase a person’s risk for cancer.
The Food and Drug Administration has proposed a ban on
all over-the-counter products containing phenolphthalein.
Most laxative makers have replaced, or plan to replace,
phenolphthalein with a safer ingredient.

Osmotics
Cause fluids to flow in a special way through the colon,
resulting in bowel distention. This class of drugs is useful for
people with idiopathic constipation (constipation with no
known cause). People with diabetes should be monitored for
electrolyte imbalances.
Stool softeners
Moisten the stool and prevent dehydration. These laxatives
are often recommended after childbirth or surgery.
Stool softeners are suggested for people who should avoid
straining in order to pass a bowel movement. The prolonged
use of this class of drugs may result in an electrolyte imbalance.

Lubricants
Grease the stool, enabling it to move through the intestine
more easily. Mineral oil is the most common example.
Lubricants typically stimulate a bowel movement within
eight hours.

Saline laxatives
Act like a sponge to draw water into the colon for easier
passage of stool. Saline laxatives are used to treat acute
constipation if there is no indication of bowel obstruction.
Electrolyte imbalances have been reported with extended use,
especially in small children and people with renal deficiency.

Chloride channel activators

Increase intestinal fluid and motility to help stool pass,
thereby reducing the symptoms of constipation. Thereafter,
a doctor should assess the need for continued use.
To help you understand and manage your
condition, the AGA Institute provides you
with the following information, designed
to give you some basic facts, to help you
better understand your condition and to
serve as a starting point for discussions
with your doctor.

Constipation
Constipation is the infrequent and difficult passage of stool.
The frequency of bowel movements among healthy people varies
greatly, ranging from three movements a day to three a week.
 As a rule, if more than three days pass without a bowel
movement, the intestinal contents may harden and a
person may have difficulty or even pain during elimination.
Stool may harden and be painful to pass, however, even
after shorter intervals between bowel movements. Straining
during bowel movements or the feeling of incomplete
evacuation may also be reported as constipation.

Common Misconceptions About Constipation

Many false beliefs exist concerning proper bowel habits. One of
these is that a bowel movement every day is necessary. Another
common fallacy is that wastes stored in the body are absorbed
and are dangerous to health or shorten the life span.
These misconceptions have led to a marked overuse and abuse
of laxatives. Every year, Americans spend $725 million on
laxatives. Many are not needed and routine use of some stimulant
laxatives can cause dependency.

Is Constipation Serious?
Although it may be extremely bothersome, constipation itself
usually is not serious. However, it may signal and be the only
noticeable symptom of a serious underlying disorder such as cancer.
Constipation can lead to complications, such as hemorrhoids caused
by extreme straining or fissures caused by the hard stool stretching the
sphincters. Bleeding can occur for either of these reasons and appears
as bright red streaks on the surface of the stool. Fissures may be quite
painful and can aggravate the constipation that originally caused
them. Fecal impactions tend to occur in very young children and in
older adults and may be accompanied by a loss of control of stool,
with liquid stool flowing around the hard impaction.
Occasionally, straining causes a small amount of intestinal lining
to push out from the rectal opening. This condition is known as
rectal prolapse and may lead to secretion of mucus that may stain
underpants. In children, mucus may be a feature of cystic fibrosis.
Causes of Constipation
Constipation is a symptom, not a disease. Like a fever,
constipation can be caused by many different conditions. Most
people have experienced an occasional brief bout of constipation
that has corrected itself with diet and time. The following is a list
of some of the most common causes of constipation:
 Poor Diet. A main cause of constipation may be a diet
high in animal fats (meats, dairy products, eggs) and
refined sugar (rich desserts and other sweets), but low
in fiber (vegetables, fruits, whole grains), especially
insoluble dietary fiber, which helps move bulk through
the intestines and promote bowel movements. Some
studies have suggested that high-fiber diets result in
larger stools, more frequent bowel movements and,
therefore, less constipation.
 Imaginary Constipation. This is very common and
results from misconceptions about what is normal and
what is not. If recognized early enough, this type of
constipation can be cured by informing the sufferer that
the frequency of his or her bowel movements is normal.
 Irritable Bowel Syndrome (IBS). Also known as
spastic colon, IBS is one of the most common causes of
constipation in the U.S. Some people develop spasms of
the colon that delay the speed with which the contents
of the intestine move through the digestive tract, leading
to constipation.
 Poor Bowel Habits. A person can initiate a cycle of
constipation by ignoring the urge to have a bowel
movement. Some people do this to avoid using public
toilets, others because they are too busy. After a period
of time, a person may stop feeling the urge. This leads
to progressive constipation.
 Laxative Abuse. People who habitually take stimulant
laxatives become dependent upon them and may require
increasing dosages until, finally, the intestine becomes
insensitive and fails to work properly.
 Travel. People often experience constipation when
traveling long distances, which may relate to changes in
lifestyle, schedule, diet and drinking water.
 Hormonal Disturbances. Certain hormonal
disturbances, such as an underactive thyroid gland,
can produce constipation.
 Pregnancy. Pregnancy is another common cause of
constipation, which may be partly due to hormonal
changes during pregnancy.
 Fissures and Hemorrhoids. Painful conditions of the
anus can produce a spasm of the anal sphincter muscle,
which can delay a bowel movement.
  Specific Diseases. Many diseases that affect the body tis-
sues, such as scleroderma or lupus, and certain neurological
or muscular diseases, such as multiple sclerosis, Parkinson’s
disease and stroke, can be responsible for constipation.
 Loss of Body Salts. The loss of body salts through the
kidneys or through vomiting or diarrhea is another cause
of constipation.
 Mechanical Compression. Scarring, inflammation around
diverticula, tumors and cancer can produce mechanical
compression of the intestine and result in constipation.
 Nerve Damage. Injuries to the spinal cord and tumors
pressing on the spinal cord can produce constipation by
affecting the nerves that lead to the intestine.
 Medications. Many medications can cause constipation.
These include pain medications (especially narcotics),
antacids that contain aluminum or calcium, antispas-
modic drugs, antidepressant drugs, tranquilizers, iron
supplements, anticonvulsants for epilepsy, antiparkin-
sonism drugs and calcium channel blockers for high
blood pressure and heart conditions.
 Colonic Motility Disorders. The peristaltic activity
of the intestine may be ineffective resulting in colonic
inertia or outlet obstruction.

Constipation in Children
Constipation is common in children and may be related to any of
the causes noted in the previous section. In a small number of
children, constipation may be the result of physical problems.
Children with such defects as the absence of normal nerve endings
in portions of the bowel, abnormalities of the spinal cord, thyroid
deficiency, mental retardation, and certain other inherited metabolic
disorders often suffer symptoms of constipation. Constipation in
children, however, is usually due to poor bowel habits.
Studies show that many children who suffer from constipation
when they are older have a history of passing stools that are firmer
than average in their early weeks of life. Because this occurs before
there are significant variations in diet, habits or attitudes, it suggests
that many children who develop constipation have a normal
tendency to have firmer stools. Such children suffer little from the
tendency unless it is aggravated by poor bowel habits or poor diet.
Constipation may result in pain when the child has bowel
movements. Cracks in the skin, called fissures, may develop in
the anus. These fissures can bleed or increase pain, causing a child
to withhold his or her stool.
Children may withhold their stools for other reasons as well. Some
find it inconvenient to use toilets outside the home. Also, severe
emotional stress caused by family crises or difficulties at school may
cause children to withhold their stools. In these instances, the periods
between bowel movements may become quite long, in some cases
lasting longer than one or two weeks. These children may develop
fecal impactions, a situation in which the stool is packed so tightly in
the bowel that the normal pushing action of the bowel is not enough
to expel the stool spontaneously.
Constipation in Older Adults
Older adults are five times more likely than younger adults to
report problems with constipation. Poor diet, insufficient intake
of fluids, lack of exercise, the use of certain drugs to treat other
conditions, and poor bowel habits can result in constipation.
Experts agree, however, that too often older people become
overly concerned with having a bowel movement and that
constipation is frequently an imaginary ailment.
Diet and dietary habits can play a role in developing
constipation. Lack of interest in eating — a problem common to
many single or widowed older people — may lead to heavy use of
convenience foods, which tend to be low in fiber. In addition, loss
of teeth may force older people to choose soft, processed foods,
which also tend to be low in fiber.
Older people sometimes cut back on fluids, especially if they
are not eating regular or balanced meals or to avoid urinating if
they experience stress incontinence. Water and other fluids add
bulk to stools, making bowel movements softer and easier to pass.
Prolonged bedrest, for example, after an accident or during an
illness, and lack of exercise may contribute to constipation. Also,
drugs prescribed for other conditions, such as antidepressants,
antacids containing aluminum or calcium, antihistamines,
diuretics, and antiparkinsonism drugs, can produce constipation
in some people.
The preoccupation with bowel movements sometimes leads
older people to depend heavily on stimulant laxatives, which can
be habit-forming. The bowel begins to rely on laxatives to bring
on bowel movements, and over time, the natural mechanisms fail
to work without the help of drugs. Habitual use of enemas also
can lead to a loss of normal function.

When to Seek Medical Attention

The doctor should be notified when symptoms are severe, last
longer than three weeks, or are disabling; or when any of the
complications listed above occur.
The doctor should be informed
whenever a significant and pro-
longed change of usual bowel
habits occurs.
The historical features are
key to helping the physician
determine a diagnosis and treat-
ment. Is it the infrequency of
bowel movements, straining, pain
or unsatisfied bowel movements
that is most distressing?
In addition, a full record of
prescription and over-the-
counter medications should be
provided to the doctor.
Diagnostic Tests
Constipation may be caused by abnormalities or obstructions of
the digestive system in some people. A doctor can perform tests to
determine if constipation is the symptom of an underlying disorder.
In addition to routine blood, urine and stool tests, a
sigmoidoscopy may help detect problems in the rectum and lower
colon. In this procedure, which can be done in the doctor’s office,
the doctor inserts a flexible, lighted instrument through the anus
to examine the rectum and lower intestine. The doctor may
perform a colonoscopy to inspect the entire colon. In
colonoscopy, an instrument similar to the sigmoidoscope that is
longer and able to follow the twists and turns of the entire large
intestine, is used. To learn more about colonoscopy, read the
AGA Institute brochure on that topic in your gastroenterologist’s
office or visit www.gastro.org/patient.
Other highly specialized techniques are available for measuring
pressures and movements within the colon and its sphincter
muscles.

Treatment
The first step in treating constipation is to understand that
normal frequency varies widely, from three bowel movements a
day to three a week. Each person must determine what is normal
to avoid becoming dependent on laxatives.
For most people, dietary and lifestyle improvements can lessen
the chances of constipation. A well-balanced diet that includes
fiber-rich foods, such as unprocessed bran, whole-grain bread,
and fresh fruits and vegetables, is recommended. Drinking plenty
of fluids and exercising regularly will help to stimulate intestinal
activity. Special exercises may be necessary to tone up abdominal
muscles after pregnancy or whenever abdominal muscles are lax.
Bowel habits also are important. Sufficient time should be set
aside to allow for undisturbed visits to the bathroom. In addition,
the urge to have a bowel movement should not be ignored.
If an underlying disorder is causing constipation, treatment will
be directed toward the specific cause. For example, if an
underactive thyroid is causing constipation, the doctor may
prescribe thyroid hormone replacement therapy.
In most cases, stimulant laxatives should be the last resort and
taken only under a doctor’s supervision. A doctor is best qualified
to determine when a laxative is needed and which type is best.
There are various types of oral laxatives and they work in different
ways. (See list of laxatives.)
Above all, it is necessary to recognize that a successful
treatment program requires persistent effort and time.
Constipation does not occur overnight and it is not reasonable to
expect that constipation can be relieved overnight.
 Go to www.gastro.org/patient
for more information on digestive
health and tests performed by
gastroenterologists and to find an
AGA member physician in your area.
The American Gastroenterological Association (AGA) is dedicated to
the mission of advancing the science and practice of gastroenterology.
Founded in 1897, the AGA is one of the oldest medical-specialty
societies in the U.S. Our 16,000 members include physicians and
scientists who research, diagnose and treat disorders of the gastro-
intestinal tract and liver. The AGA Institute runs the organization’s
practice, research and educational programs.
The content in the series of AGA Institute patient education
brochures was reviewed by the following gastroenterologists:

John I. Allen, MD, MBA, AGAF Stephen W. Hiltz, MD, MBA, AGAF
Minnesota Gastroenterology TriState Gastroenterology
Chair, AGA Clinical Practice & Quality
Lawrence R.
Management Committee
Kosinski, MD, MBA, AGAF
Harry R. Aslanian, MD Elgin Gastroenterology, S.C.
Yale University School of Medicine
Linda A. Lee, MD, AGAF
Stephen J. Bickston, MD, AGAF Johns Hopkins School of Medicine
University of Virginia Health System
Stephen A. McClave, MD, AGAF
Joel V. Brill, MD, AGAF University of Louisville School of Medicine
Predictive Health LLC
Chair, AGA Practice Management Kimberley Persley, MD
& Economics Committee Texas Digestive Disease Consultants

Marcia I. Canto, MD, MHS John Schaffner, MD

Johns Hopkins University Mayo Clinic, Rochester

Richard Davis, Jr. PA-C Joanne A.P. Wilson, MD, FACP, AGAF
University of Florida College of Medicine Duke University Medical Center

Mark H. DeLegge, MD, AGAF Cynthia M. Yoshida, MD, AGAF

Medical University of South Carolina University of Virginia Health System

Kenneth DeVault, MD Atif Zaman, MD, MPH

Mayo Clinic, Jacksonville Oregon Health and Science University

The Digestive Health Initiative® (DHI) is an AGA Institute initiative that offers educational programs on
digestive disorders for individuals who are affected by a digestive disease, in an effort to educate the larger
health-care community.

This brochure was produced by the AGA Institute and funded by a grant from
TAP Pharmaceutical Products Inc.

For more information about digestive diseases,

please visit the AGA Web site at www.gastro.org.
The AGA Institute offers the information in these brochures for educational purposes to provide
accurate and helpful health information for the general public. This information is not intended as
medical advice and should not be used for diagnosis. The information in these brochures should not be
considered a replacement for consultation with a health-care professional. If you have questions or
concerns about the information found in these brochures, please contact your health-care provider.
We encourage you to use the information and questions in these brochures with your health-care
provider(s) as a way of creating a dialogue and partnership about your condition and your treatment.
CSTP.PB.0408 2007-030-09044