What Causes Constipation? What are the Causes of Constipation?

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Although the number of defecations per day varies depending on the societies, individuals and nutritional habits, hard and difficult defecation 3 times a week or less can be called constipation.
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Some people may express that they do not complain when they defecate 2 or 3 times a week, but in a normal consistency and without difficulty. The most important characteristic of constipation is hard stool consistency, low stool quantity, strain during defecation and not enough relief after defecation. Absence of defecation, inability to defecate when going to the toilet despite the feeling of defecation, straining to defecate, defecating in small and hard pieces, feeling of not being able to empty completely after defecation are other findings in constipation.

Some patients try to assist defecation with their fingers. In chronic constipation, no underlying organic cause is usually found and this type of constipation is called functional constipation. However, it should not be forgotten that constipation is not a disease, but a symptom that may develop secondary to another disease. Rarely, the cause of constipation may be a tumor, inflammatory bowel disease, or a deformity in the bowel that prevents stool from moving through the bowel.

This type of constipation is called constipation due to organic causes. For this reason, some tests are usually required in patients who apply with the complaint of constipation.

What Causes Constipation?

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The large intestines are 140-180 cm long and their main task is to absorb the water and electrolytes in the watery intestinal contents from the small intestines. The large intestines can absorb up to 4 liters of water per day. Passing water above this amount from the small intestines to the large intestines causes diarrhea.

The intestinal contents, whose water is absorbed, solidify and are stored in the form of feces, especially in the last 30-40 cm of the large intestine. If the stool stays in the large intestine for a long time, it causes the water in it to be absorbed more and harden more.

The large intestines have different movements that allow the contents to move forward. Some of these movements are in the form of segmental contractions, which are movements that increase the back and forth movement of the stool and the absorption of water in it, causing the stool to become small pieces (Segmentary contractions).

These movements do not contribute to the progress of stool in the intestine. Another form of movement in the large intestines is in the form of progressive contractions that follow each other from proximal to distal, allowing the stool in the intestine to move towards the exit (Peristaltic contractions).

When the stool reaches the last 15 cm of the large intestine, which we call the rectum, it is expelled by creating a feeling of defecation.

In general, three basic mechanisms play a role in the formation of functional constipation;
  • Constipation due to excessive contraction of the large intestine (Hyperkinetic constipation): Increased segmental contractions in the large intestine; In this type of contractions in the large intestines, segmental (local) contractions that do not contribute to the progress of stool in the intestine have increased, the stool is hard and in small pieces. It is usually associated with irritable bowel disease (See Irritable bowel disease).
  • Constipation due to the decrease in contractions that allow the forward movement of stool in the large intestines (Hypokinetic constipation- lazy large intestine): In this type, the laziness of the large intestines is in question. Neurological diseases (Parkinson’s disease, stroke, etc.), under-functioning of the thyroid gland (hypothyroidism), long-term diabetes, fasting and fiber-free diet, pregnancy, long-term travels, stress, use of certain drugs (Psychiatric drugs, Long-term and unconscious use of drugs used for constipation treatment, etc.) can lead to this type of constipation.
  • Disruption of the defecation mechanism (Dyschesia, Dyssynergic constipation): In this type of constipation, there is a disruption in the perception of the stool coming to the last part of the large intestine near the exit (Rectum) and in the formation of coordinated movements that allow the stool to be thrown out by opening the anus. It is usually seen in rectal diseases and neurological diseases.
  • Pelvic outlet stenosis: Constipation due to pathologies that cause temporary obstruction during defecation in the rectum and sigmoid colon, which is the last part of the large intestine near the outlet (such as anterior rectocele and invagination).

How Is Constipation Diagnosed?

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A detailed history should be taken from every patient who applies to a physician due to constipation, a physical examination should be performed, and the medications used should be reviewed.

Although the probability of an organic cause is very low in patients with long-standing constipation, biochemical blood tests and stool examination, including thyroid function tests, should be performed.

Double-contrast colon X-ray The method that should be preferred for the examination of the large intestine in a constipated patient is ‘double contrast barium X-ray of the large intestine’.
Colon X-ray, when taken by a radiologist experienced in this field using a good device, is of the same value as a colonoscopy.

In addition, with this method, it is possible to obtain information about the length of the large intestines and, if any, deformities (excessive folds, stenosis, etc.). Another radiological method is defecography. Especially in the elderly population, it is preferred to be performed together with a colon radiography.

In this method, it is applied like a barium enema radiography, but more detailed imaging is performed during the discharge of barium from the intestine to obtain information about the physiology of defecation. When an additional pathology is seen in the large bowel X-ray, colonoscopy can also be performed if necessary.

Endoscopy (colonoscopy) is not the first method to be applied in patients presenting with constipation. Defecography should be performed in patients with suspected pelvic outlet stenosis.

However, in patients with additional findings other than constipation (bleeding, anemia, rapid weight loss, thinning of stool thickness, new onset constipation and change in defecation habits, etc.), colonoscopy should be the first method of choice.

Another examination that can be done in patients who have double contrast colon radiography and no organic pathology is detected is the ‘radiopaque marker study’. In this method, after a certain number of radiopaque marker particles are swallowed by the patient, direct abdominal films are taken to examine the progression of these particles in the intestine and to obtain information about the movements of the large intestines.

If you feel some changes in your defecation habit in the last 6 months compared to the past, if you have started to have difficulty defecating and/or if you see a decrease in stool thickness compared to before, and if you are over 45 years old, this may be a sign of a serious illness. You should immediately consult a gastroenterologist.
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How To Solve Constipation Problem?

Since constipation can have many causes, treatment is shaped according to examination and laboratory findings. Regular and fiber-rich foods, adequate fluid intake (drinking at least 8-10 glasses of water a day), regular exercise (walking, aerobics, etc.) are the general measures that can be applied to alleviate functional constipation.

When the feeling of defecation comes, it is necessary to go to the toilet without wasting time and wait for sufficient time (about 15 minutes). Postponing going to the toilet when the feeling of defecation occurs causes constipation to worsen.


Fiber (fiber) diet is one of the most important steps in preventing and relieving constipation. Fiber is the indigestible part of plant foods. There are two types of fiber, water-soluble and insoluble. Water-soluble fibers are digested by bacteria in the large intestine. Oat bran is an example of water-soluble fiber. Water-insoluble fibers are more beneficial in reducing constipation.

Examples include wheat bran, cereal grains, green vegetables and the skins of various fruits such as apples and pears. Fibers increase the amount and water content of stool by holding water, and in this way, they help reduce constipation by increasing the movement of stool in the large intestine through the intestine.

While the amount of fiber in a Western diet is about 10-20g a day, it is recommended to take 30-35g of fiber a day for a good bowel movement. There are many foods rich in fiber. Fruits, vegetables, bread made from wholemeal flour and bran are examples of fibrous foods. Brown rice can be preferred instead of white rice.

Can Defecation Facilitators Be Helpful?

It is possible to divide the stool softener and stool facilitator drugs into two main groups; Stimulants of bowel movements (such as Tegaserod, itopride, domperidone) and those that stimulate the secretion of fluid into the intestine and thus soften the stool (such as Ca, Mg salts, lactulose, some herbal medicines).

Although drugs that stimulate bowel movements provide some benefit when they are first used, their effects decrease over time when the drug is continued to be used. Herbal medicines and Mg salts generally continue to work as long as they are used.

When used continuously, they can cause electrolyte disorders, osteoporosis, protein loss and addiction. Some (Laxophenol) may cause pigment accumulation in the intestinal mucosa when used for a long time, causing the mucosa to appear brown in color (melanosis coli). Especially when drugs that act by increasing bowel movements are discontinued after long-term use, severe constipation that does not easily improve may occur.

If constipation is a symptom of irritable bowel disease, then drug therapy for irritable bowel disease is administered. If the stool hardens in the last part of the intestine (rectum) near the exit and cannot be removed, it can be helped by making an enema. Attempting to forcefully remove pieces of excessively hard stool can lead to hemorrhoids and very painful tears (anal fissures) in the anus over time.

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  • ​In terms of helping to gain regular defecation habit, the following application can be recommended;
  • Do not use stool softeners whenever possible
  • Increase the amount of fiber in your diet
  • Drink a glass of plum or peach juice in the morning
  • Try to consume at least two meals a day of low-sugar fruit compote
  • Use a preparation containing up to one tablespoon of psyllium once or twice a day. This is a plant species that grows in the Mediterranean basin and increases in volume by swelling the seeds in a wet environment and gains a gelatinous structure.
  • Don’t skip breakfast
  • In the morning, after drinking two glasses of water on one dried apricot, dried fig or prune on an empty stomach, after breakfast, go to the toilet with or without the need for the toilet and sit on the toilet for 15 minutes, but do not force yourself to defecate excessively. Taking time for this defecation attempt each morning can provide long-term relief in bowel habit.

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