Obstipation

What is Obstipation?

Obstipation is a medical condition, which refers to the inability of the patient to pass faecal matter and/or gas. It is chronic and extended constipation. When the complete elimination of waste from the intestines is not carried out, they can become obstructed.

Precise diagnostic tests and exams are not clearly laid out for obstipation.  Identification is through study of the medical history of the patient and by assessment of signs and symptoms present at the time of medical examination.

People with this chronic constipation or obstipation feel bloated almost at all times. Often, the same is accompanied by abdominal discomfort, tenderness and anorexia. If ignored, complications may occur. Hence, seeking medical advice and treatment at the earliest is always wise.

Since intestines clear the body of waste, eliminating solid and semi-solid wastes, the same accumulates because the bowel is not regularly cleared. At the same time, and in a similar manner, even toxins get accumulated.

This further leads to infection, inflammation, bad body odour and bad breath. Prolonged inflammation can also interrupt the supply of blood to the intestines. In this condition, cramps, malaise, peritonitis, tachycardia, fever and collapse of the intestine, may be experienced by the individual.

When there is rise of the intestinal distension, it interrupts or stops the peristaltic movement of the intestines. The normal secretions of the intestine are either absent or severely reduced. The intestines eventually begin to lose the ability of absorption of nutrients and water. Additionally, other symptoms like dehydration, vomiting, and nausea also persist.

Obstipation Symptoms

Abdominal Symptoms of obstipation include:

• Constipation
• Enlargement or feeling of fullness – Bloating
• Increased bowel sounds – Borborygmi
• Persistent pain and cramping
• Abdominal distension

Physical Symptoms of obstipation include :

• Rapid pulse (tachycardia)
• Dehydration and fever
• Nausea and vomiting
• Foul breath and body odour

Eventually, these symptoms can lead to worse situations, which arise from obstipation. These include malfunctioning of bowel leading to dehydration (strangulated bowel), rapid heart rate, vomiting, nausea and low blood pressure. Infection of the inner lining of the intestines, known as peritonitis may also occur.

Obstipation Prevalence

The incidence of constipation ranges from 17% in the general population to 8.2% in middle-aged persons and to a high of 30% in older adults. Using the criterion of two or fewer bowel movements weekly, approximately 5.9% of persons below the age of 40 years and 4%–6% of persons aged 70 and older report having persistent constipation.

The highest reported incidences of constipation in specific populations were 45% of all patients with cancer, 45% of all frail elders and 46% of all hospitalized elders. The incidence of constipation increases with age. Women report being constipated more often than do men Constipation is also a more common problem in pregnancy and after childbirth or surgery.

The incidence of constipation increases in people with diminished functional and cognitive ability and in the frail elderly. Studies also have reported more frequent episodes of constipation in African Americans and persons in lower socioeconomic groups.

Every fourth citizen of the United States have altered bowel function at least 25% of the time, with 17.5% reporting that they have straining with defecation. Chronic idiopathic constipation has both physical and psychological impacts.

Persistent stretching of the pudendal nerves may ultimately result in complications such as rectal prolapse, hemorrhoids, or incontinence. The psychological impact of constipation is often the result of changes in activity levels that often leads to increased isolation

What causes obstipation?

The longest part of the digestive system is constituted by the intestines. The main cause of obstipation – intestinal obstruction, can be caused by blocked colon in the large intestine or a clocked bowel, in the small intestine region. The cause can be an untreated or prolonged constipation caused due to the decreased intake of water, lack of intake of dietary fibre and decreased physical activity.

Structural causes may also exist, like the non development of rectal wall. When the reason is colon obstruction, it can be due to tumours, structural abnormalities, inflammation and hernias in the intestines.

If not corrected, the same symptoms as that of chronic constipation can result into obstipation, if left uncorrected. It must be remembered that obstipation is not a disease as such. Yet, there are some important symptoms which must not be ignored. Some factors which may contribute to the same are:

• Side effects of certain medications
• Poor muscle tone
• Insufficient water consumption
• Insufficient exercise
• Certain metabolic conditions including diabetes, celiac disease, etc.
• Anal Fissure
• Gallstone ileus
• Obstruction of intestines
• Hypokalemia
• Impaction of fecal material
• Colorectal cancer
• Low fibre diet
• Fecalith
• Adhesion in peritoneum
• Colonic stricture
• Functional constipation
• Closure or narrowing of intestines – Intestinal atresia
• Folding of intestine into itself, causing obstruction – Intussusceptions
• Twisted Bowels – Volvulus
• Hypothyroidism
• Proctitis
• Pelivic bone dysfunction
• Neurological Hirschsprung’s Disease

Major Causes of Obstipation in children

Children can experience obstipation due to an attempt of withholding stool to avoid pain. They can adapt to increase in pressure on the abdomen, to keep the stool in because of the discomfort caused by bowel movements. Due to this prolonged constipation, obstipation occurs.

On the other hand, the cause can be congenital and neurological as well. During foetal development, there can be failure of migration of certain nerve bodies to the colon. This causes loss of activity regulation of colon and is termed as the Hirschsprung’s disease. A part of the colon is unable to contract, causing obstipation.

Obstipation Complications

Some common complications caused by obstipation include:

• Dehydration
• The normal flow in the intestine may get blocked due to intestinal obstruction
• There can be a lack of blood flow to intestine due to the blockage caused by obstipation, termed as the Ischemic Bowel disease
• Faecal impaction
• Bacterial infection or sepsis of the blood stream
• Infection in abdomen, termed as peritonitis
• Ulceration in rectum
• Cathartic colon
• Volvulus
• Stool soiling around the impaction
• Acquired mega – colon: Poor colon contractions caused along with a functional distension
• Toxic mega – colon
• Depletion in fluid and electrolytes: Secondary result of abuse by laxatives
• Pulmonary aspiration

Obstipation Diagnosis and Tests

Differential diagnosis for Obstipation include:

• Structural Abnormalities – Tumour, volvulus, haemorrhoids, strictures, rectal pro-lapse, IBD related abnormalities, small bowel obstruction, rectocele
• Medication related – NSAIDS, iron supplements, opiates, bile acid resins, laxative abuse, tri-cyclic antidepressants, clonidine, calcium channel blockers, anticholinergics, Anti – Parkinson’s drugs, calcium supplements, antipsychotics, antihistamines, diuretics (HCTZ and furosemide), anticonvulsants, antacids consisting of calcium and aluminium
• Metabolic and endocrine abnormalities – Hypercalcemia, hypocalcemia, renal disease, diabetes mellitus, hypothyroidism, hyperparathyroidism, celiac disease, diabetes mellitus
• Neurologic conditions – Visceral neuropathy, dementia, Hirschsprung’s disease (most common cause, especially in infants), stroke, Parkinson’s disease, spinal cord or nerve compression, anismus
• Myopathic disorders – Amyloidosis, scleroderma
• Environmental factors – Low fibre diet, inaccessible toilet facilities, poor fluid and food intake, body position (it is difficult to defecate in supine position in bed)
• Psychological conditions – Depression, confusion, anxiety
• Functional obstipation – Absence of any secondary causes which can be identified

Criteria for diagnosing each of the diagnosis mentioned above, is as follows:

• Structural Abnormalities – Rectal prolapse as well as haemorrhoids are visible in the rectal exam. The vaginal exam can be used to diagnose rectocele. The medical history of the individual can also help with the diagnosis of the above. Tumour, volvulus, small bowel obstruction, IBD related abnormalities and strictures can also be seen on imaging.
• Obstipation related to medication is a diagnosis of exclusion. The same can be made by chart and history review. Even if other causes are identified, any offending medications can be having a possible contribution. Specifically, the laxative abuse must be monitored.
• Metabolic and endocrine abnormalities, namely hypercalcemia, hypocalcemia, renal disease, diabetes mellitus, hypothyroidism, hyperparathyroidism, and diabetes mellitus are diagnosed on the basis of laboratory testing. Though celiac disease can be suggested by the individual’s medical history, for confirmation purposes, antibody testing is required, EGD with biopsy.
• Any neurological conditions including Parkinson’s disease, MS, dementia, stroke, visceral neuropathy, and Hirschsprung’s disease should be apparent in the medical history of the individual. In case the diagnosis is new, anismus and spinal cord or nerve compression can be identified by physical exam.
• Myopathic disorders – consistent clinical features are required by scleroderma. These include thickening of skin, either diffuse or limited; in the case of a limited disease, the patient will be suffering from Raynaud’s phenomenon, positive ANA, oesophageal disease, telangectiasias, anti – centromere or anti – scl – 70, which depends on the diffuse v/s limited disease. In absence of other features, the obstipation will not be scleroderma. Biopsy is required by amyloidosis for final diagnosis. Along with other manifestations of amyloidosis, the patient is likely to have a known diagnosis.
• Environmental factors like low fibre diet, inaccessible toilet facilities, poor fluid and food intake, body position (it is difficult to defecate in supine position in bed) and inactivity are identified by individual’s history obtained from the patient himself, or any caregiver as these are more likely to affect the ill and elderly.
• It is difficult to assess psychological conditions like anxiety, depression and confusion, which may make it difficult for individuals to leave the bed. Additionally, these patients are often on medications which can be a contributing factor for obstipation. Chart review and history reveal the same.
• Thorough evaluation is required for functional obstipation, as it is a diagnosis of exclusion.

A physical examination as well as palpation of the abdomen helps in diagnosis of obstipation. Presence or absence of stools in the rectum, polyps or haemorrhoids can be revealed by a manual rectal exam. Decrease in levels of urobilinogen is shown in urine tests.

Several other diagnostic tests can also be performed in addition to these. CT scan or x-ray visualization of the patient’s abdomen can help the physician in confirming the condition of obstipation. Upper GI series, colonoscopy, barium enema or sigmoidoscopies are other useful diagnostic tests.

Blood tests can be performed to check and find any signs of infection or for checking the kidney and thyroid function. The location of the cause of obstipation can also be visualized by an ultrasound. The bowel function test may be performed to check nerve sensitivity as well as muscle tone of the anus and the intestines.

Obstipation Treatment

Before initiation of any prescription medications, it is necessary for the individual to ensure that no life threatening conditions or structural abnormalities requiring surgical treatment are present. The same include toxic mega – colon and ischemic colitis.

If hard stool is found on digital rectal exam, the best indication is use of physical measures to remove the stool. It includes manual dis-impaction and use of enemas (tap water based). Medication therapy is safe to begin in the absence of any faecal impaction.

A rise in mobility and fluid intake is usually helpful but is not possible in the case of some patients. A helpful long term measure is addition of fibre to diet for patients with low fibre consumption. For the short term, a soft impaction can be caused by fibre increase in diet, usually worsening the situation. Only after the patient is asymptomatic and the acute crisis is over, increase the fibre in diet.

Miralax (PEG) for obstipation

Miralax (PEG) has been found to be the easiest to tolerate and is the safest of all osmotic laxatives available. It is flavourless. Osmotic laxatives containing magnesium, like Milk of Magnesia, can have an association with imbalance in electrolytes, with derangement of Mg. Adding to this, phosphorus and magnesium salts also have a contraindication in renal failure.

Dehydration can be worsened by hyperosmolar solutions due to drawing of body water in the lumen of the gut. Lactulose and sorbitol are sickly sweet and can cause tolerance difficulty for patients. A significant amount of gas is also produced by lactulose in the lumen of the intestine. Polyethylene glycol and walnuts are other laxative options.

Docusate for obstipation

For patients with painful defecation from haemorrhoids and renal fissure, the best treatment is use of Docusate (Colace) or other stool softeners. The same are not nearly as effective for acute or chronic obstipation. In opioid – induced obstipation, usually Senna is used in combination with colace.

Generally, as a sole agent, it is inadequate. Enema based with mineral oil can be used but should not be given PO, due to the fact that if aspirated, it can result in pneumonitis. Suppositories of glycerine can provide required lubrication and also extract water due to the particles which are osmotically active.

Bisacodyl and Senna for obstipation

Bisacodyl and senna are stimulant laxatives, which may be prescribed to patients with decreased motility or in cased of medication induced obstipation. Before an increase in motility is made, existing constipated stool must be evacuated with enema, or it may result in cramping. Doses must be intiated as one tablet before bed and if needed, uptirate to a 4 tablet BID.

Hardened faecal matter can easily be broken by enemas and then washed out in the faecal impaction setting. Yet, on a routine basis, the same must be avoided as it can also cause the wash out of normal mucous and cause damage to the intestinal mucosa. Initially, tap water enemas must be done. Soap suds or milk and molasses are other liquids, which can unnecessarily irritate the lining of the colon.

If the obstipation is related to opioid abuse, and the enema plus laxative administration has been unsuccessful, another option to be considered is of methylnaltrexone. This chemical does not cross the blood brain barrier. For the peripheral mu – opioid receptors, it serves as a selective antagonist and results in the inhibition of gastrointestinal hypomotility without CNS effect or analgesia reversal.

The medication is approved by FDA to be administered to patients who have failed other therapies, with advanced illness receiving palliative care. The chemical is well tolerated and the most commonly observed side effect is mild abdominal pain.

It is efficacious and has been looked at in cases of critically ill patients. The cost of methylnaltrexone is substantially higher in comparison to other therapies. Additionally, it needs to be given as a subcutaneous injection.

The best cure is always prevention. Patients who are on narcotics or have a high risk for the development of obstipation consider being placed on a bowel regimen. The patient bowel movements must be constantly evaluated by asking the patient as well as nurse or any caregiver, about the BM occurrences. Emphasis and promotion of healthy bowel habits is also important.

These include attempting movement on awakening and 30 minutes after meals for reaping the benefits of gastrocolic reflex. Increase in fluid and fibre intake as well as regular exercising helps to a great extent. Exercise helps is improving the peristalsis by causing an increase in the intestinal circulation.

Though enemas have been used since time immemorial, their productivity is low because only evacuation of the lower part of the colon is done by them. Avoiding coffee, tea, fruit juices and milk can be helpful. Scheduled toilet breaks can be imposed on children.

In cases of patients suffering severe dehydration, administration of intravenous fluids may be required to correct the balance of electrolytes and restoration of body fluids. In absence of severe pain, analgesic or antispasmodic medications might be needed for short time durations. A colonoscopy or laparoscopic surgery may become necessary if there is failure in relieving the obstruction or impaction.

For small and large bowel obstruction, nasogastric suctioning can be used. It is a process in which, insertion of a tube is done through the nose. It suctions out any obstruction causing materials.

For cases with severe episodes of pain, narcotic pain medication can be prescribed for relieving the pain being experienced by the person. These types of drugs can solely be administered by physicians because these narcotic agents are strong and have a potential of becoming addictive.

Obstipation Therapy Guideline

Acute Treatment of Obstipation

Phase I: Emptying of colon and rectum or ‘Cleaning out’

Firstly, before administration of any laxatives, the colon and rectum must be evacuated. Enemas (for emptying distal colon) of GoLytely (solution of polyethylene glycol) or suppositories can be performed. Manual dis-impaction by a physician may be required in this condition; irrigation may be used for cleansing of the colon.

In cases of presence of large mass of hard stool in rectum resulting from severe obstipation, termed as faecal impaction, there may be requirement of inpatient treatment. This is required particularly when the colon is blocked up to the cecum.

Chronic Treatment of Obstipation

The long term prognosis depends on the underlying causes and is variable among individuals. Fibre therapies and laxatives are effective for the improvement of frequency of bowel movement, unless, the reason is an underlying disorder or obstipation is caused by slow GI transit.

Phase I: Modification in Lifestyle and Diet

• Ensure that your fibre intake is adequate as per daily requirement of human body – 15 mg/day, sourced from raw vegetables and fruits, bran, whole grain cereals
• Ensure that your daily fluid intake is adequate – non-caffeinated, 6-8 glasses of fluid (preferably water) per day
• Regular exercise and movement is recommended
• Treatment of any somatomoter disorders
• Establishment of a regular bowel elimination program
• Decreaing or avoiding opiates, antipileptics, antacids and antocholinergics, as far as possible
• Advised to drink warm fluids before eating
• Maintaining record o fluid and food intake
• Demonstrating proper bowel movement, which is thighs flexed towards the abdomen
• Maintaining a thorough record of characteristics and frequency of stool
• Considering the recommendation of natural, mild laxatives like apricot, prunes or papaya juice

Phase II: Medication

In cases where diet and lifestyle modifications are alone unsatisfactory or not effective, prescription medications can be taken.

Drugs of Choice

• Docusate Sodium – Stool softeners or emollient laxatives
• GoLytely, MiraLax, Sorbitol, Lactulose, Alumina-magnesia, Magnesium citrate, Milk of Magnesia, Phospho-soda – Osmotic laxatives for a shot term use
• Psyllium, polycarbophil, methylcellulose – Hydrophilic colloids

Alternative Drugs

• Lubricants
• Prokinetic agents (in refractory cases only)
• Polyethylene glycol (MiraLax) – Hyperosmotic laxatives
• Phospho-soda – enemas
• Anthraquinones like Senna (Senokot), Bisacodyl, Castor oil, Phenolphthalein – Stimulant laxatives
• Zelnorm – Tegaserod maleate (usually, a short term administration for women with obstipation predominant irritable bowel syndrome)
• Sodium phosphate, Bisacodyl (Ducolax), glycerine – Suppositories

Contraindications

• Any acute inflammatory condition within the abdomen
• Relative contraindications – renal and heart failure
• Any impediment to bowel transit (for example, ileus or obstructing lesion) – Osmotic laxatives can rather result in bowel perforation or over distension

Surgical Treatment of Chronic Obstipation

Phase II: Surgery

If even the medications are ineffective, apart from the lifestyle and diet modification treatment, surgery is recommended.

• Colostomy
• Ileorectostomy
• Abdominal colectomy
• Appendicostomy (Malone procedure) along with ACE (antegrade continence enema)

Effective Natural Treatment and Home Remedies for Obstipation

Obstipation is usually considered a severe form of constipation, wherein, a tendency to vomit and extreme difficulty in passing stool is experienced by the patient. The abdominal region usually becomes tender and bowel movements highly infrequent. This completely kills the appetite, at times.

Sometimes, eating the wrong foods on a regular basis can be the cause of obstipation and constipation. Processed food, potato chips, milk products, pizzas, chocolates and other fast foods have low dietary fibre and are not recommended as replacements of regular meals. You must steer towards oatmeal, green salads, whole grain breads, raw fruits and vegetables, and lots of water.

An effective method for treating obstipation can be brief apple fasting. First of all, you need to prepare your bowel for the same by switching to light meals for an entire day. From the next day, all your meals must consist of apples, water, or apple juice for a period of three consecutive days. At least one litre of apple juice and a minimum of five apples per day must be consumed. From the fourth day, your regular food habits may be resumed.

Doing yoga on a regular basis is also beneficial. Some yoga postures like ‘Pawanmuktasana’, ‘Vajrasana’ and ‘Vipatikarani’ help bowel movements. You can even consume herbs like triphala and haritaki in the form of dietary supplements for the purpose of treating obstipation.

They are scientifically proven to have mild laxative qualities and also are known for antioxidant properties which help in tackling the base causes of obstipation.

There are other herbal medicines which can be used in case diet and lifestyle changes fail to give desired results.

• Licorice serves as a gentle laxative and is a common home remedy
• Elderflower can be brought to use irregularly or when a person is unable to defecate
• Aloe Vera is one of the most powerful herbal medicines, which involves the use of the outer part of the leaf. It has a strong effect and must be used with caution.
• Orange, guava and papaya are good remedies and also more easily available, compared to the other herbal or home remedies for obstipation.

Obstipation Prevention

Avoiding chances of constipation is the best method to prevent obstipation. Besides following diet and lifestyle modifications mentioned above in the article, you must also observe the following.

• The best fluids include clear liquids like herbal tea, water and broth. Fruit juices are not as helpful, due to the requirement of metabolic activity.
• Natural fibres can be obtained from bran, psyllium, etc.
• Daily prune and walnut consumption serves as natural laxative or stool softener source
• To activate gall bladder and liver for stimulating the peristalsis and improving the ability to defecate, bitters including radicchio, chicory and artichoke must be consumed

When should the healthcare provider be contacted by Obstipation patients?

• You have an observed change in amount, colour, size or consistency of bowel movement
• You have fever
• You are constantly losing weight, without much efforts
• You have any queries or concerns about your care or condition

When to seek immediate care?

• You are experiencing severe abdominal pain
• You have vomited more than once
• You have observed a black or bloody bowel movement
• You are experiencing stomach, fever, joint or muscle pain, along with fever

Obstipation vs Constipation – What is the difference?

The basic point of difference between obstipation and constipation is related to the duration for which, the retention of stool is observed, as well as the seriousness of loss in bowel movement. Obstipation is a form of constipation, which is rather persistent and can develop or progress over a time period of about one year or even more.

People suffering from constipation usually face slight difficulty in eliminating faeces, and the same may experience bowel movements about 3 times per week or less. Contrarily, patients suffering from obstipation face complete loss of bowel movements which leads to a loss in the ability of defecation.

Management as well as treatment of almost all constipation cases is easy. On the other hand, reasons and causes of constipation can vary. Also, it can have an association with other disorders, making its treatment more problematic.

Obstipation after Surgery

Pain medications are the major causative agent of post operation obstipation. Exposure to narcotics, anaesthetics, lack of exercise and motility as well as alterations caused in fluid and diet intake all add up as causative agents of the condition. A prescription of Colace and Enulose can help deal with the situation, effectively.

Colace (stool softener) consumption is usually prescribed at 100mg twice a day, to a maximum amount of 200mg twice a day, as per requirement. Enulose is a laxative, which is gentler than MiraLax as well as Milk of Magnesia. You must remember to drink water right after the dose of Enulose. Taking other approaches may be required and recommended in cases when this combination of laxative + stool softener turns out to be ineffective.

Obstipation during Pregnancy

Obstipation is a common problem during pregnancy, for women. More than half of the women suffer from constipation, which can become complex and turn into obstipation. One of the major reasons is the spurt in the progesterone hormone. This causes the relaxation of the smooth muscles all over the body, including the digestive tract.

Furthermore, this results in slower passing of the food through the intestines. In case the intestine gets obstructed, obstipation may result. Though taking laxatives can be effective, Senna and other stimulant laxatives need to be avoided as they can potentially cause discomfort and pain. Fibre supplements such as Metamucil are considered safe during pregnancy.

Yet, to – go – to solution must be increase in dietary fibres by focussing on natural sources.  Stool softeners like DulcoLax and DulcoEase Pink can also be recommended by physicians, for pregnant women. Other stool softeners like Ducosate sodium are also considered safe during pregnancy.

But, while you are pregnant as well as breastfeeding, you must consult a healthcare expert before consuming stool softeners. Some home remedies useful for pregnant women include triphala, raspberries, Brussels sprouts, roasted sweet corn and licorice.

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