Constipation

What is constipation?

Constipation (or obstipation) is the medical term for obstruction. There are not enough stools, or they may be over-hard or difficult to eject. The colon pushes stools into the rectum by contracting the intestinal wall. Water and nutrients are extracted as faeces pass through the colon.

If the faeces move too slowly through the intestines, the colon removes too much water and the faeces become dry and hard, causing problems with defecation. Slow movement through the intestines can be caused by the inadequate contraction of the intestines or not enough waste material, with the latter possibly being due to inadequate fibre or fluids in food.

Inadequate contraction of the intestines can be attributed to stress, a sedentary lifestyle, pregnancy or old age. Changes in daily habits, such as a holiday or a sudden change of diet, can also cause constipation, as can an excessive use of laxatives, which can disrupt the normal working of the intestines, or a failure to go to the lavatory in response to an urge.

Medical causes of constipation include scar tissue or tumours in the lower part of the intestines. In addition, constipation may be caused by neurological conditions, such as multiple sclerosis, stroke or spinal cord injury. Metabolic conditions such as a slow-acting thyroid gland can also lead to constipation. Constipation may also occur in depression.

A range of medication can cause constipation. Research has shown that, in people with moderate to severe intellectual disabilities, the Colon Transit Time (CTT, or the time it takes for a substance to pass through the large intestine) increases significantly and this confirms that the intestines work slowly. ²⁸⁹

What are the complaints associated with constipation?

There is irregular, laborious and sometimes painful defecation with hard and dry stools. This can sometimes be associated with a bloated feeling or abdominal cramps. Because defecation frequency varies from person to person, constipation will vary in individual cases. A diagnosis of constipation requires the presence of at least two of the following:

defecation frequency ≤ 2 per week; straining during defecation, hard and/or lumpy stools; sensation of incomplete evacuation; sensation of anorectal obstruction/blockage, digital evacuation (in other words, with the fingers) to expel stools. In children, at least two of the following criteria must be met for a diagnosis of constipation: defecation frequency ≤ 2 per week; retention of faeces; painful, hard or lumpy stools; large amounts in nappies or lavatory; large mass of stools can be felt in the stomach or the last part of the colon; faecal incontinence ≥ 1 episode per week (if the child is continent). ⁵⁵⁶

The complaints are: an inability to go to the lavatory as often as usual, difficulty with defecation, hard, painful stools, sometimes thin stools (owing to 'false diarrhoea' in which the accumulated stools will rot behind the obstruction and exit past the obstruction in liquid form), a bloated abdomen and abdominal pain. In people who are particularly susceptible, such as elderly people, people with dementia, sensory disorders or polypharmacy, severe constipation is associated with an increased risk of delirium: impaired consciousness involving disorientation, delusions and hallucinations, usually with, but sometimes without, agitation. ⁵⁵⁷

People with intellectual disabilities sometimes find it impossible to communicate these symptoms. The people around them may then notice only a change in behaviour or delirium.

How common is constipation in the general population? ²⁹¹

Approximately ten to thirty percent of the general population become constipated at some time and there are indications that women are constipated twice as often as men. Older people are constipated most frequently. ⁵⁵⁶

How common is constipation in people with intellectual disabilities?

The prevalence of constipation in people with intellectual disabilities varies between approximately 10-70% depending on the sub-population. The European POMONA questionnaire survey of a random sample of 1269 adults with intellectual disabilities found a lifetime prevalence rate for constipation of 26.5%. ²⁹²

A Dutch study of 215 people with moderate to severe intellectual disabilities in an institution found constipation in the previous three months in 70%. ²⁹³

A study of 2283 people with intellectual disabilities in an institution in Israel found a two-year prevalence for constipation of 8%. ²⁹⁴

Dutch research looking at older people with intellectual disabilities found that 43% of the sample had a history of chronic constipation. ⁵⁵⁸

A 69% prevalence rate for constipation was found in people with intellectual disabilities who were admitted for psychiatric treatment. ⁵⁵⁹

In a study sample of 884 people with intellectual disabilities living in three institutions, 5% had been admitted once or more for a partial or complete ileus (obstruction of the intestine). ²⁹⁵

Factors that are more often associated with constipation include neurological diseases, immobility, physical inactivity, spasticity, refusal to eat, an IQ <35, anti-epileptic use, benzodiazepines, H2 receptor antagonists and/or proton pump inhibitors. ²⁹³

The prevalence of constipation in children with severe multiple disabilities was found to be 57% in a study conducted in Rotterdam and a large proportion of these children have persistent complaints despite treatment with laxatives. ²⁹⁶

10% to 30% General population 10% to 70% People with intellectual disabilities 57% Children with severe multiple disabilities