Constipation, Irritable Bowel Syndrome, and Colic (Stomach Cramps)
Patients with functional constipation will often come in with the complaint of abdominal pain or bloating. Often, it is not until they are asked that they will describe infrequent bowel movements, straining at stooling, incomplete evacuation, hard or small stools, a blockage in the anal region, or the need for digital manipulation to enable defecation.
Patients with irritable bowel syndrome (IBS) will complain of abdominal pain or discomfort, with a change in the form or frequency of defecation. They will have constipation (fewer than three bowel movements per week), diarrhea (more than three bowel movements per day), or alternating constipation and diarrhea. Their pain is relieved by defecation.
At the age of 6 weeks, infants with colic will begin having episodes of inconsolable crying that last more than 3 hours per day for more than 3 days per week and that continue longer than 3 weeks. These infants are well fed and otherwise healthy.
In all of these cases, the patient’s discomfort is not accompanied by other symptoms, such as nausea, vomiting, fever, anorexia, or weight loss. Rarely are patients awakened with nocturnal symptoms.
The physical examination is benign, with normal vital signs and no jaundice, tenderness, masses, organomegaly, rectal bleeding, or other abnormalities, and the patient does not appear ill between the episodes of abdominal pain.
What To Do:
Take a thorough history and try to determine the time of onset of symptoms and whether their severity is increasing or decreasing. Ask if there was a similar episode in the past. A careful medication history should be obtained, because many commonly used drugs may cause constipation.
Perform a complete physical examination, including rectal and/or pelvic examination, and a repeat abdominal examination after an interval. The patient’s skin is checked for pallor and signs of hypothyroidism (e.g., reduced body hair, skin dryness, fixed edema), and the abdomen is examined for masses, distention, tenderness, and high-pitched bowel sounds. The rectal examination includes careful inspection and palpation for masses, anal fissures, inflammation, and hard stool in the ampulla. Test stool for the presence of occult blood.
For patients with symptomatic constipation, it is appropriate, but not always necessary, to obtain a complete blood count, biochemical profile, serum calcium, glucose levels, and thyroid-stimulating hormone.
If the presentation is not clear or there is any concern about significant underlying disease, consider using diagnostic tests, such as urinalysis (to help rule out renal colic or urinary tract infection), an erythrocyte sedimentation rate (a clue to infection or inflammation), abdominal radiographs (to show free peritoneal air, bowel obstruction, or fecal impaction), and ultrasonography (for pyloric stenosis, malrotation and intussusception in children, or gallbladder and pelvic disorders in adults). CT imaging should be used to rule out any suspected intra-abdominal or retroperitoneal catastrophe. Adult patients with a change in bowel habits or hemoccult positive stool should be referred for colonoscopy to assess for malignancy.
If simple constipation is the problem and there is obstructing stool on rectal examination, disimpact the rectum by pulling out hard stool (scybala), and follow with one oil retention enema. This may be very painful and require parenteral analgesia. For dry, obstipated feces, repeated tap-water enemas or phosphate enemas should be administered once or twice daily until clear.
Disimpaction by the oral route, using medication, is noninvasive and more easily accepted by adolescents, who will often be reluctant to receive enemas. If there is no mechanically obstructing fecal impaction, this can also be done for adults. Magnesium citrate (Citro-Mag), 150 to 300 mL given once or divided doses for those 7 to 12 years old. For pediatric patients younger than 6 years, 2 to 4 mL/kg given once or in divided doses.
Disimpaction by means of a combination of the rectal route and the oral route has been shown to be effective.
Instruct the patient to return if symptoms do not resolve over the next 12 to 24 hours or to return immediately if the pain worsens.
Instruct the patient to drink plenty of fluids.
Instruct the patient that the recommended amount of dietary fiber is 20 to 35 g per day.
Suggest adding bulk fiber, 20 to 35 g total fiber intake per day, in the form of bran, psyllium (Metamucil), methylcellulose (Citrucel), or calcium polycarbophil (FiberCon tablets) for prophylaxis. The last two products are made from synthetic fiber and produce less gas. A high-fiber diet, however, does not benefit all patients with constipation. In general, patients with inadequate fiber intake should be advised (with the help of a dietitian) to increase their intake of natural fiber with fruit and vegetable servings.
When possible, medications that may be constipating should be discontinued or replaced. These medications include narcotic analgesics, antacids containing aluminum and calcium, antidepressants, diuretics, nutritional supplements such as iron and calcium, anticonvulsants, antispasmodics, antiparkinson drugs, antihypertensive agents such as calcium channel blockers, and sedatives.
Osmotic agents with laxative effects include sorbitol solution 70% (30 to 150 mL or 1 to 2 mL/kg as single adult dose) or lactulose (Cephulac, Chronulac) (30 to 150 mL daily, may increase to 60 mL daily if necessary). In recent years, the use of over-the-counter polyethylene glycol 3350 without electrolytes (MiraLax), (17 g [1 heaping tablespoonful] of powder dissolved in 8 oz of water, juice, soda, coffee, or tea once daily, titrated to effect with a maximum of 34 g per day) has become increasingly popular. It is relatively expensive but generally has fewer side effects. Because it is virtually tasteless, it has led to better compliance with treatment. Polyethylene glycol (e.g., GoLYTELY) is another option, and is supplied in 14-oz and 26-oz containers as a powder to be administered after dissolution of 1 heaping tablespoon in 4 to 8 oz of water, juice, soda, coffee, or tea qd.
Additionally, bisacodyl (Dulcolax), 5 to 15 mg as single adult dose, or senna (Senokot), 15 mg once daily, are stimulant laxatives that can be given at bedtime and are available over the counter. Both sorbitol and senna are less costly than lactulose and have been shown to be at least as efficacious, if not better.
Functional constipation in infants and toddlers is defined as at least 2 weeks of scybalous, pebble-like, hard stools—or firm stools two or fewer times per week—in the absence of structural, endocrine, or metabolic disease.
Constipation in infants and preschool children is usually treated first with sorbitol-containing juices, such as prune, pear, and apple juice; the addition of pureed fruits and vegetables; formula changes; or treatment with a food product with a high sugar content, such as barley malt extract or corn syrup. If, despite these dietary changes, the stool is still hard and painful to evacuate, osmotic laxatives, such as milk of magnesia, 0.5 to 1 mL/kg body weight/day, or polyethylene glycol 3350 without electrolytes (MiraLax), 1 to 1.5 g/kg body weight/day, are easily administered by parents and well-accepted by children. They have a 92% success rate. Glycerin suppositories can be also be effective. Avoid mineral oil in infants, those with neurologic difficulties, and those with gastoesophageal reflux disease (GERD) because of the risk of aspiration pneumonitis. In addition, avoid enemas and stimulant laxatives, such as senna or bisacodyl, in infants.
If the problem is chronic or recurrent or associated with alternating constipation and diarrhea, consider irritable bowel syndrome (IBS). IBS is characterized by chronic abdominal pain, altered bowel habits, and no organic cause; thus it is a diagnosis of exclusion. The most distinguishing trait of IBS is the presence of discomfort or pain associated with defecation. The Rome III criteria of 2005 to 2006 include the following criteria for IBS: at least 3 months of symptoms, with onset at least 6 months previously of recurrent abdominal pain or discomfort associated with two or more of the following:
Improvement with defecation; and/or
Onset associated with change in frequency of stool; and/or
Onset associated with a change in form (appearance) of stool.
Warning signs of more serious disease include the following: unintentional or unexpected weight loss; nocturnal symptoms (more common in inflammatory bowel disease, celiac sprue, infection, or cancer); fever, weight loss, and bleeding, which suggest ulcerative colitis infection or cancer; abdominal pain with bloat, anorexia, rectal abscess, and constipation, which could signal Crohn’s disease; abdominal pain with iron deficiency and stress fractures, which could be celiac disease or another small-bowel disorder causing malabsorption; and gastrointestinal blood loss (gross or occult), which could be the result of cancer.
If the patient meets the Rome III criteria, if routine testing shows no abnormalities, and if the patient has no warning signs of more serious disease, then you can initiate treatment for IBS and provide follow-up in 3 to 6 weeks (sooner if symptoms change dramatically or the patient’s condition deteriorates).
IBS is a chronic condition without known cure. A meticulous dietary history, as it relates to symptoms, can be helpful. Dietary interventions such as a lactose-free diet, restriction of carbohydrates, avoidance of gluten, and avoidance of foods that produce gas may be undertaken.
For constipation-predominant IBS, you can give synthetic bulk fiber as described earlier.
Psychological therapy has been found to have some efficacy in IBS symptom reduction, as noted in the 2009 American College of Gastroenterology Task Force on Irritable Bowel Syndrome, which also provides further guidelines for management of this disorder.
The use of pharmacologic agents may also be considered. Antidepressants, such as SSRIs or low-dose TCAs, may be useful in adults with severe, unrelenting symptoms. Antispasmodic drugs, such as dicyclomine (20 mg PO, 4 times daily prn for nongeriatric adult) and hyoscyamine (0.125 to 0.25 mg PO or sublingual tid prn for adult, maximum 1.5 mg/24 h) may provide short-term relief. 5-Hydroxytryptamine (serotonin)-3 (5-HT3) receptor antagonists such as alosetron (Lotronex), for female patients with diarrhea-predominant IBS, were removed from the market because of problems with ischemic colitis and severe constipation, but are now available with tight restrictions. Tegaserod (Zelnorm), a partial 5-HT4 receptor agonist approved for constipation-variant IBS was removed from the market in 2007. Lubiprostone for patients with IBS with constipation has been approved, but there is a lack of controlled studies and long-term safety concerns exist.
Rifaximin is a nonabsorbable antibiotic that has shown modest benefit in studies with relatively short-term follow-up for those with IBS and bloating.
If there is weight loss, anemia, occult blood in the stool, abdominal distension or mass, or a family history of colon cancer, refer the patient for colonoscopy and gastroenterology consultation.
For infant colic (defined as crying for a minimum of 3 hours daily 3 days per week for the previous 3 weeks, without weight loss, vomiting, or diarrhea), there is no “magic bullet.” Use of whey hydrolysate milk is considered likely to be beneficial. Other therapies are of uncertain effectiveness. You may instruct the parents to administer for infants, 2 mL of 24% solution of sucrose in distilled water and for neonates, 0.2 mL of 24% solution, with each episode for a 1- to 2-day trial. If this is not successful, a higher concentration of sucrose may be more effective. Probiotics (Lactobacillus reuteri) have been shown to be beneficial in two randomized trials, with no ill effects observed. However, these are not regulated by the Food and Drug Administration. Homeopathic remedies, simethicone and lactase have no proven benefits.
A product called “Gripe Water,” which may include any variety of herbs and herbal oils (such as cardamom, chamomile, cinnamon, clove, dill, fennel, ginger, lemon balm, licorice, peppermint, and yarrow), is available online and in health food stores. It is not entirely without risk. Contaminants and alcohol have been found in some preparations. Parents who choose to use this product should avoid versions made with sugar or alcohol and look for products that were manufactured in the United States.
With breast-feeding mothers, there is a possible therapeutic benefit from eliminating milk products, eggs, wheat, and nuts from the mother’s diet.
Some studies suggest that casein hydrolysate formulas (considered hypoallergenic) or replacement of cow’s milk formula with a soy-based formula may be beneficial; a trial period of formula substitution can be recommended.
Above all, parents need reassurance that their baby is healthy and that colic is self limited (80% to 90% of infants have symptom resolution by 4 months of age). There are no long-term adverse effects. The potential for child abuse is a real one; parents with crying infants have been known to hurt their babies. Parents should be given reassurance and empathy and have their coping mechanisms addressed; they should be counseled to take breaks from the colicky infant and employ actions to relieve stress. One study concluded that a home-based nursing intervention program reduced both parental stress and overall infant crying time.
What Not To Do:
Do not discharge the patient with significant abdominal pain without 1 to 2 hours of observation and two abdominal examinations. Many abdominal catastrophes may appear improved for short periods, only to worsen in an hour or two.
Do not add fiber supplements without an adequate intake of fluids. Otherwise, they may actually exacerbate symptoms.
The colon performs several complex functions, which include mixing the ileal effluent, fermenting and salvaging the unabsorbed carbohydrate residues, and desiccating the intraluminal contents to form stool. These functions are regulated by neurotransmitters, intrinsic colonic reflexes, and a plethora of learned and reflex mechanisms that govern stool transport and evacuation, most of which are incompletely understood. Constipation may result from structural, mechanical, metabolic, or functional disorders that affect the colon or anorectum, either directly or indirectly. Because there is a significant interaction between the brain and the gut, it is worth emphasizing that neurologic dysfunction may have profound effects on colon function.
Patients who have had two of the following symptoms for at least 12 months fit the criteria for functional constipation: straining, lumpy or hard stools, incomplete bowel evacuation or sensation of anorectal blockage at least a quarter of the time, or less than three bowel movements in a week.
For infants to children 16 years of age, the following constitute functional fecal retention: at least 12 weeks of passage of large-diameter stools at intervals of two per week or fewer and/or retentive posturing, avoidance of defecation, and use of both pelvic floor and gluteal muscles. Functional constipation is most common in women. Colonic inertia and delayed transit are types of functional constipation caused by decreased muscle activity in the colon. Abnormalities that result in an inability to relax the rectal and anal muscles that allow stool to exit are known as anorectal dysfunction or anismus.
When constipation becomes chronic and unresponsive to conventional medical and behavioral treatment, it is necessary to rule out organic diseases that can present with constipation. Some of the more common diseases include irritable bowel syndrome, diverticulitis, intestinal obstruction, anal fissure and abdominal tumors. Metabolic causes include uremia, hypokalemia, hyponatremia, hypomagnesemia, hypophosphatemia, and hypercalcemia. Endocrine causes include diabetes mellitus and hypothyroidism. Neuromuscular disorders that lead to constipation include brain tumors, spinal cord compression, multiple sclerosis, Parkinson disease, cerebral palsy, and stroke or other disorders that cause muscle weakness. Acute constipation is more often associated with organic disease than is long-standing constipation. When a particular disorder is suspected, appropriate laboratory studies and colorectal imaging are required.
Flexible sigmoidoscopy and colonoscopy are excellent for identifying lesions that narrow or occlude the bowel. Colonoscopy is the examination of choice in adult patients with constipation who have iron deficiency anemia, a positive guaiac stool test, or a first-degree relative with colon cancer.
In childhood constipation, most difficulties related to defecation are the consequence of painful or psychologically traumatic defecation experiences. In children younger than 1 year of age, the possibility of Hirschsprung disease or cystic fibrosis must be considered. However, in adolescents, constipation is most commonly a consequence of a learned behavior to suppress the urge to defecate. When specifically asked, adolescents readily admit that they do not use the toilet facilities at school. Repeated suppression of the urge to defecate and stool withholding may be contributing factors to the two colorectal disorders associated with constipation: pelvic floor dysfunction and slow-transit constipation.
A reduction in dietary fiber has been associated with a higher prevalence of constipation in children. Illicit substances, particularly opiates such as heroin, OxyContin, and hydrocodone-containing products, are used by approximately 10% of high school seniors nationwide. These substances may cause or exacerbate constipation. Therefore abuse of these substances should be included in the differential diagnosis of the constipated adolescent patient. In addition, constipation is among the most frequently identified concerns in patients who have anorexia nervosa and bulimia. Many patients with eating disorders are distressed by and preoccupied with their infrequent bowel movements.
Occult constipation should be considered in children with recurrent abdominal pain. Because reporting of stool patterns by children is unreliable, rectal examination should be considered in those with recurrent abdominal pain.
IBS is a common condition in adults and adolescents. There is a significant female predominance in those patients who present to physicians with this condition. Patients with IBS view minor illnesses, such as colds and the flu, more seriously and consult physicians more frequently than do patients who do not have IBS.
IBS is a heterogeneous disorder with diverse clinical presentations and multiple pathogenic mechanisms. Its exact pathophysiology remains undefined. The three most important contributing factors seem to be hypersensitivity of the gut, altered motility, and psychosocial dysfunction. Changes in intestinal microflora, including small intestinal bacterial overgrowth, carbohydrate malabsorption, and the development of gluten sensitivity or food specific antibodies are currently being investigated as potential causes. Gastrointestinal infections may act as a triggering factor in a subgroup of patients. Patients with IBS may present with diarrhea, constipation, or a combination of urgency, pain, gas, and bloating. Symptoms are not constant over time. There is temporal fluctuation, with “flare-ups” alternating with periods of relative well-being in most patients. The type of bowel complaint and predominance of specific symptoms may also vary over time.
Patients who are allergic to gliadin (a constituent of rye, barley, and wheat) may present with symptoms that are indistinguishable from IBS. This condition, known as celiac disease, or sprue, can cause a variety of symptoms, including rancid gas, oily or floating stools, bloating, and constipation or diarrhea. Consultation with a gastroenterologist should be obtained prior to starting the patient on a gluten-free diet.
Infant colic can be distressing to parents whose infant is inconsolable during crying episodes. Colic is a diagnosis of exclusion that is made after performing a careful history and physical examination to rule out less common organic causes. Treatment is limited. Feeding changes are sometimes advised. Medications available in the United States have not been proved effective in the treatment of colic, and most behavior interventions have not been proved to be clearly more effective than placebo. The cause of infantile colic remains unclear.
Colic attacks usually start when an infant is 7 to 10 days old and increase in frequency for the next 1 to 2 months. They tend to be worse in the late afternoon and evening and subside by the age of 3 months. Colicky infants have attacks of screaming in the evening with associated motor behaviors, such as a flushed face, furrowed brow, and clenched fists. The legs are pulled up to the abdomen, and the infants emit a piercing, high-pitched scream. Crying occurs in prolonged bouts and is unpredictable and spontaneous. It appears to be unrelated to environmental events. The child cannot be soothed, even by feeding. These episodes do not just happen suddenly one night when the infant is 6 to 8 weeks old. In that situation, look for some other acute problem, such as intussusception, corneal abrasion, incarcerated hernia, clothing that may be pinching or pricking, or a digital hair tourniquet. A history of apnea, cyanosis, or struggling to breathe may suggest previously undiagnosed pulmonary or cardiac conditions. Lethargy, poor skin perfusion, and tachypnea suggest a serious underlying problem. A rectal temperature greater than 100.4° F (38° C) or poor weight gain suggests infection, a gastrointestinal disorder, or nervous system disorder and requires further workup. During the examination, the infant’s clothing should be removed to facilitate inspection of the skin, to eliminate any irritation to the skin, and to check for any evidence of trauma or abuse. The examination itself may reassure the parents. Organic causes are found in less than 5% of infants presenting with excessive crying. If the child is not awake and calm for a reasonable period, however, consider hospital admission with a complete diagnostic workup.
Laboratory tests and radiographic examinations usually are unnecessary if the child is gaining weight and has a normal physical examination without worrisome symptoms.
At 1-year follow-up, a group of colicky infants compared with noncolicky infants showed no differences in behavior in nine dimensions assessed by means of the Toddler Temperament Scale.