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Western-style societies have the highest incidence of constipation as compared to less developed societies. Dietary composition, especially fiber content, may be a leading contributing cause of constipation. Inadequate dietary fiber intake produces stools that are less bulky, lower in water content, lower in volume, and more difficult to eliminate. In societies such as western Africa where the average dietary fiber intake is as much as 35 g of insoluble fiber, individuals have two to three large soft bowel movements per day on average, and reports of constipation are uncommon.2 In the United States, dietary fiber intake averages less than 12g per day, and complaints of constipation may affect 3% to 5% of the population at any given time.2 Insoluble dietary fiber acts by drawing water into the intestinal lumen, resulting in bulky, soft, large stools that have higher water content. Colonic peristaltic movements, in turn, are in part stimulated by colonic distention.

Frenetic Pace of Life

Strange as it may seem, a hectic schedule and lack of time to eliminate is an increasingly frequent cause of constipation, particularly in individuals trying to manage more than one job.

Medications

Numerous medications (anticholinergics, anti-depressants, narcotics) may lead to iatrogenic constipation by impeding neural signaling, resulting in impaired colonic muscular coordination (Table 3.1). Initial treatment of constipation with an identified pharmacologic cause consists of discontinuing the offending drug or replacing the drug with a nonconstipating alternative, if available. Psychiatric disorders such as depression, psychosis, and anorexia nervosa, as well as their pharmacologic treatments, may contribute to or worsen constipation. This has become a real clinical problem with the increasing and almost ubiquitous prescription of

Etiology of acquired constipation

Lifestyle-related causes

Diet

Pace of life Medications Weight loss/anorexia/ laxative abuse

Infectious etiology i

Trypanosomiasis

Anatomic/functional abnormalities

Mechanical causes

> Neoplasms

> Strictures Adhesions Volvulus Rectal prolapse

Full-thickness Internal Rectocele

Physiologic and other abnormalities

Diabetes mellitus

Hypothyroidism

Hypopituitarism

Porphyria

CNS trauma

Parkinson's disease

Brain and CNS tumors

Functional, with or without mechanical component

• Nonrelaxing puborectalis

• Slow-transit colonic constipation

• Megacolon/megarectum

• Descending perineum

Figure 3.1. Algorithm describing etiologies of various acquired constipation.

Table 3.1. Pharmacologic causes of constipation Amiodarone

Antacids (e.g., aluminum)

Anticholinergics

Anticonvulsants

Antidepressants

Antihypertensives

Calcium channel blockers Diuretics

Ganglionic blockers Antiparkinsonians Bismuth Bromocriptine

Bulk laxatives with inadequate hydration

Carboplatin

Cholestyramine

Erythropoietin

Filgrastim [granulocyte colony-stimulating factor (G-CSF)] Iron

Lovastatin

Mesalamine

Narcotics/opiates

Pravachol

Sandostatin

Valproic acid

Vincristine antidepressants and psychotropic drugs by many physicians.

Weight Loss, Eating Disorders, and Laxative Abuse

Lack of oral intake, or bulimia, can be associated with reduced fecal volume. By their mechanism of action, overuse of laxatives may result in constipation due to dehydration, hypokalemia, or hypermagnesemia, altering neural transmission and function. The role of laxatives in damaging enteric neurons is uncertain. Long-term use has been associated with changes in neurons of the myenteric plexus and smooth muscle of the colon.3 Findings such as loss of neurons, morphologic changes of argyrophilic cells, including clubbing and shrinkage, and replacement of ganglia by Schwann cells have been histol-ogically demonstrated.4 Similar morphologic findings have been discovered in patients with inflammatory bowel disease and diabetic neuropathy, and may not be specific for laxative use.5

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