Although treatment depends on the cause, severity, and duration of
the constipation, in most cases dietary and lifestyle changes will help
relieve symptoms and help prevent them from recurring.
A diet with enough fiber (20 to 35 grams each day) helps the body form
soft, bulky stool. A doctor or dietitian can help plan an appropriate
diet. High-fiber foods include beans, whole grains and bran cereals,
fresh fruits, and vegetables such as asparagus, Brussels sprouts,
cabbage, and carrots. For people prone to constipation, limiting foods
that have little or no fiber, such as ice cream, cheese, meat, and
Other changes that may help treat and prevent constipation include
drinking enough water and other liquids, such as fruit and vegetable
juices and clear soups, so as not to become dehydrated, engaging in
daily exercise, and reserving enough time to have a bowel movement. In
addition, the urge to have a bowel movement should not be ignored.
Most people who are mildly constipated do not need laxatives. However,
for those who have made diet and lifestyle changes and are still
constipated, a doctor may recommend laxatives or enemas for a limited
time. These treatments can help retrain a chronically sluggish bowel.
For children, short-term treatment with laxatives, along with retraining
to establish regular bowel habits, helps prevent constipation.
A doctor should determine when a patient needs a laxative and which form
is best. Laxatives taken by mouth are available in liquid
tablet, gum powder, and granule forms. They work in various ways:
Generally are considered
the safest, but they can interfere with absorption of some medicines.
These laxatives, also known as fiber supplements, are taken with water.
They absorb water in the intestine and make the stool softer. These
agents must be taken with water or they can cause obstruction. Many
people also report no relief after taking bulking agents and suffer from
a worsening in bloating and abdominal pain.
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. People with
diabetes should be monitored for electrolyte imbalances. e.g.
Moisten the stool and
prevent dehydration. These laxatives are often recommended after
childbirth or surgery. These products 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.
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 8 hours.
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. One such agent is Amitiza, which has been shown to be
safely used for up to 6 to 12 months. Thereafter a doctor should assess
the need for continued use.
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
Help the muscles in your
intestines work correctly when a slow-moving digestive system is caused
by low levels of serotonin. Serotonin is a neurotransmitter found mostly
in the digestive tract. One brand-name agent is Zelnorm, which is
prescribed for the short-term treatment of chronic constipation in
people less than 65 years of age.
People who are dependent on laxatives need to slowly stop using them.
A doctor can assist in this process. For most people, stopping laxatives
restores the colon's natural ability to contract.
Treatment for constipation may be directed at a specific cause. For
example, the doctor may recommend discontinuing medication or performing
surgery to correct an anorectal problem such as rectal prolapse.
People with chronic constipation caused by anorectal dysfunction can use
biofeedback to retrain the muscles that control bowel movements.
Biofeedback involves using a sensor to monitor muscle activity, which is
displayed on a computer screen, allowing for an accurate assessment of
body functions. A health care professional uses this information to help
the patient learn how to retrain these muscles.
Surgical removal of the colon may be an option for people with severe
symptoms caused by colonic inertia. However, the benefits of this
surgery must be weighed against possible complications, which include
abdominal pain and diarrhea.
Symptoms, Signs, and Grading:
Due to the presence of scarring within the liver, cirrhosis leads to
obstruction of the passage of blood through the liver causing portal
This means it is difficult for blood from the intestines to go through
the liver to get back to the heart.Portal-systemic anastamoses
("shunts") develop, and portal blood (from the intestinal veins) will
bypass the liver and return to the heart via another route without
undergoing first-pass detoxification by the liver.
Furthermore, in cirrhosis and other forms of liver disease, the damaged
liver will not be functioning as well as it should be, so even blood
that does travel through the liver may not be as detoxified as it
otherwise would be. In fact, if the degree of liver damage and
malfunction is severe, then, even in the absence of portal hypertension
and the consequent bypassing of the liver by blood coming in from the
intestines, hepatic encephalopathy will still occur.
Such may well be the case, for example, following severe injury due to
acetaminophen poisoning or acute viral infection (e.g. hepatitis A).
The toxic substances which accumulate in the setting of liver failure
and affect the brain are still not well understood. They have been
thought to include ammonia (NH3) and mercaptans. Ammonia is normally
converted to urea by the liver and, as with mercaptans, is produced by
the bacterial breakdown of protein in the intestines.
Ammonia can cross the blood-brain barrier, where it causes the support
cells of the brain (astrocytes) to swell. The swelling of the brain
tissue increases intracranial pressure, and can lead to coma or death
via herniation of the brainstem.
One of the earliest manifestations of hepatic encephalopathy is
'day-night reversal'. In other words, affected individuals tend to sleep
during the day and stay awake at night.
Another early manifestation is impairment in spatial perception. This
can be made apparent by noting the patient's poor ability to copy or
draw various simple images, e.g. cube, star, clock. This deficit can
also be demonstrated by administering a test which, essentially, has the
patient connect a number of randomly placed dots on a sheet of paper
(the "trail test").
In addition to changed level of consciousness, the hallmark of hepatic
encephalopathy on the physical examination is the presence of
Asterixisis an abnormal tremor consisting
of involuntary jerking movements, especially in the hands, frequently occurring with
impending hepatic coma and other forms of metabolic encephalopathy, also called flapping tremor.
It should be noted that asterixis is not specific to hepatic
encephalopathy. It may also be seen in renal failure and carbon dioxide
According to this classification, hepatic encephalopathy is
subdivided in type A, B and C:
In addition, the duration and characteristics of hepatic encephalopathy
were classified into episodic:
Type A (= acute) describes hepatic encephalopathy associated with acute
Type B (= bypass) is caused by portal-systemic shunting without
associated intrinsic liver disease
Type C (= cirrhosis) occurs in patients with cirrhosis.
- Minimal: is defined by patients with cirrhosis who do not demonstrate
clinically overt cognitive dysfunction, but who show a cognitive
impairment on neuropsychological studies.
- Persistent: The evaluation of severity of persistent hepatic
encephalopathy is based on the "West Haven Criteria" for
semi-quantitative grading of mental status, referring to the level of
impairment of autonomy, changes in consciousness, intellectual function,
behavior, and the dependence on therapy.
- Grade 1: Trivial lack of awareness; Euphoria or anxiety;
Shortened attention span; Impaired performance of addition
- Grade 2: Lethargy or apathy; Minimal disorientation for time or
place; Subtle personality change; Inappropriate behavior; Impaired
performance of subtraction
- Grade 3: Somnolence to semistupor, but responsive to verbal
stimuli; Confusion; Gross disorientation .
- Grade 4: Coma (unresponsive to verbal or noxious stimuli)
It is important to prevent and/or remove excess protein from the
inside (lumen) of the gut. This prevents its absorption into the
bloodstream and subsequent conversion to ammonia (and other potentially
toxic substances) which, in the setting of severe liver impairment, will
accumulate and worsen the hepatic encephalopathy. Hence, dietary intake
of protein should be minimized. Likewise, if there has been bleeding
into the lumen of the esophagus or stomach, or small intestine (for
instance, ruptured esophageal varices and bleeding ulcer, respectively)
it should be treated promptly since blood is full of protein
(hemoglobin). In this light, it should be kept in mind that both liver
disease per se and portal hypertension predispose to just such bleeding.