Text A

The normal frequency of emptying the bowels varies from three times a day to three times a week, although some people may go a whole week without experiencing discomfort or harmful effects. The accepted international definition of constipation requires the presence of two of the following symptoms for at least 12 months when not taking laxatives:

• straining at least 25% of the time
• feeling of incomplete evacuation at least 25% of the time
• pellet stools at least 25% of the time
• two or fewer bowel movements per week.

A person is likely to be constipated if they have:

• waste matter that is too hard to pass easily
• bowel movements that are so infrequent that pain and discomfort may result
• a sensation of incomplete evacuation
• less frequent bowel movements than are normal for that individual.

Primary constipation has no underlying causative illness and is associated with lifestyle factors such as lack of fibre in the diet, insufficient fluid intake, inadequate exercise, and environmental or psychological reasons. Secondary constipation has an underlying cause: iatrogenic (e.g. opiates, diuretics, anti-depressants); endocrine (e.g. hypothyroidism, diabetes); neurological (e.g. Parkinson’s disease, stroke) or psychiatric (e.g. depression, anxiety, dementia).

Being regularly constipated is more common in women (10%) than men (2%) although regular straining is experienced by 52% of women and 39% of men. Prevalence rapidly increases in those aged over 65.

TEXT B Assessment and Treatment

Once constipation has been identified, advise on how to promote regular opening of the bowels without undue straining or discomfort. While initially medication may be needed to achieve this, for simple constipation a change in dietary habits, increased fluid intake and improved mobility may be all that is needed.

Dietary and lifestyle advice should be the first-line approach to treatment. The majority of patients should be encouraged to increase their dietary fibre and fluid intake, as this will improve the long-term outcome of their constipation. The fluids increased should not include alcohol, tea and coffee, which themselves are diuretics. A high-fibre diet may be a more expensive option and many elderly people consider it unpalatable, especially if their appetite is reduced. A high-fibre diet should not be introduced to patients with megacolon/rectum or hypotonic colon, as faecal bulk will not trigger peristalsis or defecation, and their condition will be made worse.

People with constipation should be encouraged to respond to the urge to defecate and make use of the gastrocolic reflex that occurs after meals. The long-term benefits of the initial treatment will re-educate the patient and the bowel. This lifestyle advice should also be implemented with any pharmacological therapy.

TEXT C Pharmacological Treatment

TEXT D Laxative Overuse

Chronic use of stimulant laxatives can lead to serious medical consequences such as fluid and electrolyte imbalance, steatorrhoea (excess fat in the stools), protein-losing gastroenteropathy, osteomalacia (softening of the bones), and vitamin and mineral deficiencies.

Cathartic colon is the anatomic and physiologic change in the colon that occurs with chronic use of stimulant laxatives (> 3 times per week for at least 1 year). Signs and symptoms of cathartic colon include bloating, a feeling of fullness, abdominal pain, and incomplete faecal evacuation. Radiologic studies show an atonic and redundant colon. When the laxative is discontinued, radiographic and functional changes in the colon may only partially return to normal because of drug-induced neuromuscular damage to the colon.

Anthranoid laxatives (aloe, cascara sagrada, and senna) are derived from naturally occurring plants and are stimulant laxatives. Short-term use of stimulant laxatives is safe, but overuse of these drugs can cause melanosis coli and possibly increases the risk of colonic cancer. Melanosis coli, a benign condition, is characterized by dark pigmentation of the colonic mucosa that usually develops nine months after initiating the use of these drugs, and disappears just as quickly after the drug is discontinued.

Adult constipation

For each of the questions 1–6, decide which text (A, B, C or D) the information comes from. You may use any letter more than once.

In which text can you find information about

Adult constipation

Answer each of the questions 7–11 with a word or short phrase from one of the texts. Each answer may include words, numbers, or both.

Reading A: questions 12–20

Adult constipation

Complete each of the sentences 12–20 with a word or short phrase from one of the texts. Each answer may include words, numbers, or both.

That is the end of Part A. Now go to the next screen to look at Part B.