CONSTIPATION IN ADULTS: DIAGNOSIS ACCORDING TO ROME IV, DISEASE FREQUENCY, ECONOMIC BURDEN AND PREVENTIVE MEASURES

Author: Dr. Le Chau Hoang Quoc Chuong 

(Head of Department of Proctology - University of Medicine and Pharmacy Hospital, Ho Chi Minh City)

1. INTRODUCTION TO CONSTIPATION IN ADULTS

The hustle and bustle of daily life draws people into the whirlwind of work, sometimes they unintentionally forget the essential daily needs of food and health, causing the rate of common diseases to increase. One of them is constipation - a common disease of the digestive system.

So is prolonged constipation dangerous? What are the causes and how to completely treat this condition as well as some measures to prevent it?

Constipation is a common digestive disorder that affects the quality of life and intestinal health of many people, especially the elderly and women. It is not only an uncomfortable problem in daily life but can also lead to serious complications such as hemorrhoids, anal fissures, or rectal prolapse if not well controlled.

2. SYMPTOMS OF CONSTIPATION 

Constipation is a condition of having hard, dry stools, wanting to go but not being able to go, having to strain, having to defecate for a long time or having to defecate for many days, under normal eating conditions. This is a fairly common digestive condition. The duration must last for at least 3 months (not necessarily continuously) in the past year.

Diagnostic criteria for constipation according to ROME IV

According to Rome IV Standard, functional constipation is diagnosed when the patient has ≥ 2 of the following criteria for at least 3 months (with symptom onset ≥ 6 months prior):

• Difficulty in defecation ≥25% of bowel movements.
• Solid or hard stools ≥25% of bowel movements.
• Feeling of incomplete bowel movement ≥25% of bowel movements.
• Feeling of anorectal obstruction in ≥25% of bowel movements.
• Manual assistance (e.g., manual support of the perineum, anus) is required during ≥25% of bowel movements.
• Number of bowel movements <3 times/week.
• No symptoms of irritable bowel syndrome (IBS).

Constipation can be divided into functional constipation (not due to organic disease) and secondary constipation (related to disease, medication or diet).

3. FREQUENCY OF CONSTIPATION

Constipation is a common condition worldwide:

• The incidence of constipation in adults ranges from 12-20%, in which women are at twice the risk. 2 times male.
• Older adults (≥60 years) are at higher risk of constipation due to decreased bowel function, reduced physical activity, and use of multiple medications.
• Chronic constipation accounts for approximately 30-50% of cases of constipation, causing many patients to need to visit medical facilities.

4. ECONOMIC BURDEN OF CONSTIPATION

Constipation causes significant economic burden on both the health system and patients:

• Direct treatment costs: 
  • Cost of laxatives, doctor visits, imaging tests (abdominal X-rays, pelvic MRI), and surgery when necessary.
  • In the United States, the total annual cost of treating constipation estimated at over 230 million USD.
• Indirect costs: 
  • Reduced labor productivity, lost workdays due to constipation symptoms and related complications such as hemorrhoids, anal fistula.
• Impact on quality of life: 
  • Negatively affects psychology, causing anxiety, stress and reducing the quality of daily life.

5. CAUSES OF CONSTIPATION

Causes of constipation can be divided into three main groups:

Functional constipation (60%) due to diet, medication, systemic disease; colonic atony (12%), outlet obstruction syndrome (25%) and combined colonic atony + outlet obstruction syndrome (3%).

Functional constipation: When there is no damage to the colon, rectum and anus. This is the most common cause accounting for 60%.

Due to unscientific diet: low fiber diet. Fiber is abundant in vegetables and fruits, some types of fiber are not digested and will help soften stools. Normally, we need 25-30g of fiber in our daily diet. Lack of fiber in the diet is common in people who have the habit of eating fast food, eating a lot of meat, eggs, milk and dairy products; the elderly are afraid to eat foods high in fiber because they cannot chew and swallow easily. In addition, not drinking enough water also contributes to constipation; using stimulants such as coffee and black tea will aggravate constipation.

Due to the habit of not defecating on time, forgetting to defecate disrupts the urge to defecate reflex.

Due to drugs: some drugs reduce intestinal motility or dry stools such as: opium, tannin, sedatives, Parkinson's and anticonvulsants, iron-containing drugs, potassium-depleting diuretics. Long-term use of stimulant laxatives.

Systemic diseases that cause metabolic disorders (glucose, protein or lipid): diabetes, hypothyroidism, hyperparathyroidism, scleroderma, post-surgery blood loss, stroke, etc. These causes cause colon motility disorders, water absorption from the colon causes dehydration in the body, resulting in dry and constipated stools.

Due to occupation: jobs that require a lot of sitting and little movement, jobs that expose you to lead, chronic lead poisoning, affecting bowel function.

Due to weakness: the elderly, weak, and those with chronic diseases must lie down for a long time. The above causes reduce intestinal motility and abdominal muscle tone, causing constipation.

Mental disorders: anxiety, depression, inattention to defecation, loss of defecation reflex.

Constipation has physical causes:

It is necessary to rule out tumors of the rectum, colon... in addition to constipation, there may be bloody mucus in the stool, there may be constipation, colonoscopy detects tumors.

Pressure from the outside causes obstruction of defecation: Pregnant women, especially in the last months, the large fetus presses on the rectum. Pelvic tumor (uterine fibroids). Adhesions after surgery, or after inflammation around the colon and rectum cause narrowing of the colon and rectum.

Rectal and anal stenosis

Constipation due to colon atony

Congenital lesions of the colon: Megacolon, megacolon...Lack of Cajal cells in the colon wall

Constipation due to outlet obstruction 

Pelvic floor disorders such as pelvic floor prolapse, uterine and bladder prolapse. Rectal pouch prolapse, recto-anal intussusception, enterocele

Anal sphincter spasm (puborectalis muscle)

6. MEASURES TO PREVENT CONSTIPATION IN ADULTS, ESPECIALLY OLDER WOMEN

Phòng ngừa táo bón rất quan trọng để duy trì sức khỏe tiêu hóa và ngăn ngừa các biến chứng. Một số biện pháp hiệu quả bao gồm:

6.1. Điều chỉnh chế độ ăn uống

• Increase fiber: 
  • Additional 25-30g fiber/day from green vegetables, fruits, whole grains.
  • Some good foods include: flaxseed, oats, ripe bananas, apples, sweet potatoes.
• Drink enough water: 
  • 1.5 – 2 liters of water/day, especially in older adults who tend to drink less water.
• Limit foods that cause constipation: 
  • Processed foods, low fiber, fast food, alcohol, coffee.

6.2. Maintain physical activity

• Exercise at least 30 minutes/day (walking, yoga, swimming) helps stimulate intestinal motility.
• Pelvic floor exercises may help improve bowel function in older women.

6.3. Forming the habit of defecating on time

• Go to the toilet as soon as needed, do not hold in bowel movements for too long.
• Get into the habit of going to the toilet at a fixed time of day (usually in the morning after breakfast).

6.4. Limit laxative abuse

• Use only when clearly needed and as directed by your doctor.
• Laxative abuse can disrupt natural bowel reflexes and cause dependence.

6.5. Stress and sleep management

• Stress disrupts bowel movements, so it is necessary to maintain adequate sleep and apply relaxation methods such as meditation and yoga.

7. CONCLUSION

Constipation is a major health problem, especially in old woman, greatly affecting the quality of life and increasing the economic burden. Early diagnosis according to Rome IV, combined with adjust your diet, lifestyle and physical activity, can help prevent and control the disease effectively.

If constipation persists or seriously affects daily life, the patient should visit a specialized colorectal medical facility to be evaluated and treated promptly.

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