How is constipation treated?

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.

Diet:
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 processed foods.

Lifestyle Changes:
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.

Laxatives:
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
(Sedalac), tablet, gum powder, and granule forms. They work in various ways:

Bulk-forming laxatives

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.

Osmotic

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. Sedalac syrup

Stool softeners

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.

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 8 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. 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.

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.

Serotonin agonists

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.

Other Treatments:
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.

Hepatic encephalopathy
Pathogenesis:
Due to the presence of scarring within the liver, cirrhosis leads to obstruction of the passage of blood through the liver causing portal hypertension.
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.

Symptoms, Signs, and Grading:
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 retention.

According to this classification, hepatic encephalopathy is subdivided in type A, B and C:
Type A (= acute) describes hepatic encephalopathy associated with acute liver failure
Type B (= bypass) is caused by portal-systemic shunting without associated intrinsic liver disease
Type C (= cirrhosis) occurs in patients with cirrhosis.

In addition, the duration and characteristics of hepatic encephalopathy were classified into episodic:
  • 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)

Treatment:
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.

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