Intestines after taking antibiotics: warning signs, treatment

• How does spastic constipation occur?
• Signs and features of spastic constipation
• Treatment and prevention of spastic constipation

Most people are familiar with a bowel disorder called constipation.
Developing constipation brings a lot of inconvenience and unpleasant symptoms. Constipation can be accompanied by discomfort, pain, psychological problems and poor health. Constipation is a disorder of the gastrointestinal tract (GIT), in which there is a slow, difficult, incomplete bowel movement. As a rule, a person is diagnosed with constipation if the following symptoms are present: prolonged, most often unsuccessful, straining, stool frequency less than 3 times a week, pain and discomfort when going to the toilet1. More information about the problem of constipation can be found in the article “Why constipation occurs. How to treat?".

There are different types of constipation. In this article we will focus on the problem of spastic constipation.

What is constipation?

Experts diagnose constipation if the baby does “big” things:

• regularly and without problems, but at the same time dry and hard feces are released;
• with difficulty - the child has to push, feces do not come out on the first try;
• less than 5 times a day.

In the first six months of life, constipation is a rather rare occurrence; rather, on the contrary, in the period from 0 to 6 months, 6–10 bowel movements per day is considered the norm. In breastfed children, defecation occurs more often, in bottle-fed children - less often.

How does spastic constipation occur?

Spastic constipation is one of the most common functional bowel disorders1 and is formed due to too high muscle tone, which leads to spasms and creates congestion in certain areas of the intestine. Today, this type of constipation is understood as irritable bowel syndrome with constipation3. Constipation of this type is characterized by convulsive contractions of the intestinal wall (inflammatory and ulcerative processes, reflex response from diseased abdominal organs, fear of pain, etc.)2.

The main causes of spastic constipation are processes distant from the intestines. First of all, it is worth highlighting psychological problems. Most often, spastic constipation occurs against the background of nervous experiences, emotional shocks and stress2.

Constipation is rare before 6 months

Usually, parents of babies in the first months of life are concerned about the opposite of constipation - too frequent bowel movements. But in a baby, regardless of whether he is fed breast milk or formula, the intestines should work exactly like this - in a mode that is considered diarrhea for older children and adults.

There should be no other option, at least until complementary feeding is introduced at 4–6 months. After all, the baby receives mostly liquid food, the waste of which has the same consistency and leaves the intestines without encountering any obstacles on the way - the baby has not yet learned to control the sphincter, which restrains the release of feces.

The baby’s intestines have just begun to “get acquainted” with microorganisms that come from the mother’s milk, from her skin (the baby licks the nipple), and from the environment. Not all new “partners” are accepted: there are some who are rejected, who don’t take root, and so on. Inspection and rejection are accompanied by loose, unstable stools.

Too frequent bowel cleansing does not need correction or treatment if the child is gaining weight and developing correctly. Normal appetite and sleep, gas, absence of fever and other signs of illness indicate that parents have nothing to worry about. If the baby’s mother, tired of changing diapers 10 times in one day, wants to change the situation and asks the doctor to prescribe strengthening medications for the baby, then, without wanting to, she will doom her baby to chronic constipation.

Signs and features of spastic constipation

In addition to the obvious symptom, there are clinical signs that may appear during spastic constipation4:

• increased gas formation (flatulence),
• quite severe cramping pain throughout the abdominal area,
• nausea and in rare cases vomiting,
• heaviness in the stomach and feeling of fullness,
• irritability and stress,
• a sharp decrease in appetite.

With spastic constipation, stool is possible several times a day, but a person may be haunted by a constant feeling of incomplete bowel movement2,3.

Not according to the rules

And yet, in the first 6 months, constipation in infants is not excluded. They can call him:

• microflora transmitted from mother;
• insufficient fluid volume;
• stress.

Let's say a woman has too many bacteria in her stomach and intestines that produce methane, which causes constipation. They grow rather slowly, ferment, releasing carbon dioxide, which promotes flatulence and bloating. The woman lives with this deviation, has adapted and learned to solve the problem with the intestines in one way or another. Noticing the same thing in the child, she decides that the baby has inherited her characteristics and “saves” him using the same means, making a mistake. Babies should not be given laxatives, especially those containing senna. The baby’s body gets used to such drugs too quickly and can no longer cleanse the intestines without them.

Constipation in a baby under 6 months is also caused by a lack of fluid and hormonal changes. At 6 months, the baby should receive a lot of moisture - approximately 140 ml per kilogram of weight per day. A breastfed baby gains this amount from mother's milk and does not need additional sources of fluid (but only if there is no predisposition to constipation). Little artificial babies are given extra food from the moment they switch to formula.

If a woman is tense or nervous, her level of the stress hormone cortisol increases. The substance enters the baby's body through breast milk, saliva or sweat and also causes constipation.

Even if the mother does not breastfeed, microorganisms that cause constipation sooner or later reach the baby’s gastrointestinal system and produce negative changes in it.

The effect of antibiotics on intestinal function

When carrying out antibacterial therapy, both pathogenic and beneficial microflora, which are directly involved in the digestive process, are inhibited. As a consequence, due to insufficient selective activity of antimicrobial drugs, a state of microbial imbalance develops, better known as dysbiosis.

Constipation from antibiotics is a negative consequence of the death of beneficial microflora, which includes bacteroids, bifido-, lacto- and propionibacteria. They play a significant role in secretion, absorption of nutrients and normal peristalsis. With the participation of beneficial bacteria, the following occurs:

• maintaining defense mechanisms;
• breakdown and absorption of nutrients;
• evacuation of semi-liquid contents of the stomach and intestines (chyme);
• final protein and fat metabolism and residual digestion of food;
• removal of toxic metabolic products;
• release and absorption of water;
• formation and regulation of fecal excretion.

Beneficial microflora plays an extremely important role in the normal functioning of the body. Therefore, even a slight microbial imbalance can lead to disruption of physiological processes and the appearance of unpleasant symptoms.

Up to contents

Constipation after introducing complementary foods

The baby is growing, improving his skills, and it’s time to introduce him to new foods. These circumstances, on the one hand, help to establish peristalsis, and on the other, increase the risk of constipation.

By six months, the baby is already trying to control bowel movements, because he has realized that unpleasant sensations appear after it - itching, burning and other discomfort in the areas where feces fall. In order not to experience discomfort, the child tries to restrain the urge. At first he fails to do this, because the rectum has already learned to work - to reflexively contract and push out waste. And after a couple of months everything works out, the baby wins and starts on the path leading to chronic constipation. To take the child beyond this vicious circle, the mother must minimize the duration of contact of the baby’s skin with feces and expand his diet by introducing complementary foods.

Proteins, fats and carbohydrates included in foods are absorbed in the small intestine, but do not reach the large intestine, where feces are formed. The same cannot be said about fiber. While the baby drinks breast milk or formula, this component of the dish is unfamiliar to him. Even if a nursing woman herself eats a lot of plant foods, the baby gets nothing. Fiber, as already noted, is not absorbed in the intestines, does not enter the blood, which means it is not in breast milk. For the first time, the baby receives fiber with complementary foods, trying his first 25 grams of pureed zucchini, carrots and other vegetables. Plant fibers literally attract all waste, resulting in the formation of feces, which help the intestines master proper peristalsis. In this section of the gastrointestinal tract, in the intestines, there are many muscles, they must learn to consistently contract - tense and relax - in order to squeeze waste out.

The next new product should be introduced a month after the previous one. The new product will likely cause more frequent and loose stools at first. If it is not green and does not foam, there is no need to run to the doctor and ask to prescribe fixatives. Be patient, after a while the innovation will be mastered and bear fruit. Instead of liquid and shapeless yellow-white feces, you will see formed brown feces.

Introduction

Constipation is one of the common adverse side effects of the use of various drugs, both prescription and over-the-counter [1-3]. Most often, constipation occurs while taking opioid analgesics and anticancer drugs [4-21], any drug with anticholinergic properties [22-38], anticonvulsants, antihistamines, non-dihydropyridine calcium antagonists, diuretics, calcium supplements, antacids containing aluminum [39 -47]. The clinical guidelines of the Russian Gastroenterological Association for the diagnosis and treatment of adult patients with chronic constipation (2017) [48] list anticholinergic drugs, iron supplements, calcium antagonists, and antidepressants as drugs that cause secondary constipation.

Commonly used drugs known to be associated with increased constipation rates (10% or more) are summarized in the table [4-31, 49-68], but this list is constantly expanding.

Epidemiology

There are no precise data on the incidence of drug-induced constipation [69]. The incidence of opioid-induced constipation (IOI) has been most studied: it occurs in 17–67% of patients [70]. Taking some antibiotics causes the development of constipation in up to 18% of cases [69], and constipation while taking the non-dihydropyridine calcium antagonist verapamil has been described in 4-42% of cases [56, 57].

Pathophysiological mechanisms

Taking into account the assessment of the transit time of contents through the intestines, as well as the state of the pelvic floor muscles, the following preferential mechanisms for the formation of chronic constipation are distinguished [48, 71]: slowing down of transit, disruption of the act of defecation (dyssynergic defecation), constipation with normal transit (irritable bowel syndrome with constipation) , mixed forms. The mechanisms of development of drug-induced constipation vary depending on the class of drugs and specific medications (see table) .

Table. Medicines, the use of which is associated with the development of drug-induced constipation [4-38, 49, 52, 53, 55-68, 94].

Note. Determination of levels of evidence: level A - data from one or more randomized controlled clinical trials; level B - data from non-randomized clinical trials, prospective observational studies, cohort studies, retrospective studies, case-control studies, meta-analyses and/or post-marketing studies; Level C—data from one or more published case reports or case series.

Clinical picture and differential diagnosis

Symptoms of drug-induced constipation include [69]: abdominal pain, including cramping, rectal (anal) or perianal pain, anal prolapse/hemorrhoids, anorexia, bloating, abdominal discomfort, fullness in the abdomen, absence of abdominal sounds, nausea/vomiting, symptoms of decreased bowel movements, infrequent/rare, difficult or delayed bowel movements, lack of urge to defecate, the need to push for a long time and often unsuccessfully, a feeling of incomplete bowel movement after defecation, a feeling of blockage of the contents in the bowel rectum during pushing (anorectal obstruction), pain when passing stool, change in the shape and consistency of stool (small, hard, dry), weight loss.

Symptoms of decreased intestinal motility include: abdominal pain of varying degrees of severity (from mild discomfort to severe cramps), which decreases after bowel movements, the passage of gases and increases with food intake and negative emotions, a feeling of heaviness in the lower abdomen, difficulty defecating, bloating , increased gas formation. However, the onset of drug-induced constipation is very variable [69].

Differential diagnosis between drug-induced constipation and constipation due to other causes is very important to determine treatment tactics and/or methods of prevention [69]. When conducting a differential diagnosis of constipation, it is necessary to take into account the presence of dehydration, diabetes mellitus, impaired intestinal structure and function, diverticulitis, hypercalcemia, hypothyroidism, irritable bowel syndrome, ischemic bowel disease, malignant neoplasms, mechanical obstructions, a number of neurological diseases, pregnancy, mental illness and disorders [69].

A detailed history should be obtained, paying particular attention to constipation due to any cause [69]. You should also get a complete picture of the patient’s dietary habits and create the most complete list of all the drugs he takes, including over-the-counter drugs, as well as biologically active supplements, including food, and herbal preparations. Patients are recommended to fill out a special diary about the amount and shape of stool, the presence of impurities in it (undigested food debris, blood, pus, mucus, various foreign inclusions). The temporal relationship between changes in therapy and the appearance of corresponding symptoms should be especially carefully analyzed. Determining the patient's dehydration and level of physical activity is important to rule out other common causes of constipation. Psychosocial factors, changes in home or work environment, and certain comorbidities may also lead to constipation and should also be assessed. Severe abdominal pain, unintentional weight loss (more than 10 kg), hematochezia (traces of blood in the stool), positive stool occult blood test, unexplained anemia, sudden change in stool (eg, changes in consistency, color, or appearance), familial A history of colorectal cancer or a combination of any of these signs requires special attention from the physician [69]. In such cases, it is advisable to prescribe endoscopic research methods or imaging methods (computed tomography) - primarily to exclude malignant neoplasms. Rectal examination may help identify some anatomical features and disorders (eg, pelvic floor dysfunction) associated with constipation [69].

Risk factors

Risk factors for the development of drug-induced constipation include [69]: the patient has primary or secondary constipation due to other causes, old age, female gender, simultaneous prescription of 2 or more drugs that can cause constipation, duration of therapy with drugs that can cause constipation (for OIZ), dehydration, low physical activity/lack of physical activity, poor/unbalanced nutrition, pregnancy.

Treatment of patients with drug-induced constipation

If drug-induced constipation occurs, the drug should be discontinued, if possible, and replaced with an alternative drug with a lower likelihood of causing constipation [69]. If discontinuation of the drug causing constipation is not possible, consider reducing its dosage. The patient should be advised to make lifestyle modifications, including changes in diet (increasing consumption of fruits, vegetables and other dietary sources of fiber; fiber intake should be at least 25 g/day), increasing fluid intake and increasing physical activity [69].

If non-pharmacological measures do not lead to the disappearance of constipation, it is advisable to consider the possibility of prescribing drug therapy - laxatives [69]. The choice of laxative drugs should be made taking into account the main mechanism of constipation development during the use of a particular drug, and the duration of use of laxative drugs should correspond to the expected duration of therapy with drugs that can cause/have caused drug-induced constipation [72-77].

As a rule, bulk laxatives or bulking agents that increase the volume of intestinal contents, as well as osmotic laxatives, are used as the treatment of choice; if therapy turns out to be ineffective / insufficiently effective, laxative drugs can be used, causing a laxative effect by chemical irritation of the receptor apparatus of the colon and thus stimulating its peristalsis [72, 74, 77].

Management of patients with opioid-induced constipation

The first step in the management of patients with AID should be to ensure that the indications for opioid analgesic therapy are correct, the dose of the drug is the minimum necessary, and that the patient is participating in specific pain management programs (ideally in collaboration with a pain specialist) [69]. Patients receiving opioid analgesic therapy for a long time should be informed about the risks of side effects, which include death as a result of abuse of these drugs [78]. It is very important to pay increased attention from doctors, the patient and his relatives to adherence to the exact regimen for taking opioids, taking into account potential drug interactions, early detection of opioid-induced adverse reactions and prescribing evidence-based methods for their non-drug and drug correction and prevention [79, 80].

Lifestyle modification is the first step for all those suffering from OID and includes increasing fluid intake [81] and regular moderate dynamic exercise [82]. Switching to an equivalent dosage of alternative medications or an alternative route of opioid administration to relieve constipation may also be helpful [83]. For example, oral or parenteral morphine is more likely to cause constipation than transdermal opioids such as fentanyl [84]. Combination opioids (eg, oxycodone/naloxone) have a lower risk of constipation [85].

The American Gastroenterological Association (AGA) recommendations for drug treatment of AID are as follows [86]:

1. It is recommended to use laxatives as first-line drugs in patients with acute respiratory infections (high strength recommendation, moderate level of evidence).

2. In case of refractoriness to laxatives, it is possible to consider the appointment of peripheral antagonists of µ-opiate receptors:

a) naldemedine is recommended for use if other therapy is ineffective (high strength recommendation, high level of evidence);

b) naloxegol is recommended for use if other therapy is ineffective (high strength recommendation, moderate level of evidence);

c) methylnatrexone is acceptable for use if other therapy is ineffective (conditional strength recommendation, low level of evidence).

3. In patients with ARI, the use of a member of the group of secretagogues, lubiprostone, is not recommended (no recommendations, no evidence base).

4. In patients with AID, the use of prucalopride, a representative of the group of 5-hydroxytryptamine receptor agonists (serotonin receptors), is not recommended (no recommendations, no evidence base).

To assess the effectiveness of therapy, experts recommend using special scales [86]. One of them is the Bowel Function Index, which is a visual analogue scale (0 points - easy and without difficulty, 100 points - severe difficulty) and consists of 3 questions (How does the patient rate the ease of defecation during the last 7 days? How does the patient feel the completeness of bowel movements during the last 7 days? How does the patient feel constipation during the last 7 days?) [87, 88]. This scale is used to determine which patients have an inadequate response to first-line laxatives and therefore require intensification of therapy (with a score of 30 or more on this scale) [89]. Also, to assess the severity of constipation, including over time, you can use the constipation questionnaire The Patient Assessment of Constipation Symptoms (PAC-SYM) [90].

Prevention

Prevention of drug-induced constipation includes [69, 72, 91-94]: increased physical activity, a high-fiber diet (25-35 g/day for adults), drinking enough fluids, individual selection of the dose of drugs that can potentially cause drug-related constipation. - induced constipation, taking into account the patient’s age, body weight, liver and kidney function, the use of alternative drug therapy regimens (drugs with a low risk of constipation), slow titration of the drug dose with mandatory consideration of its tolerability. It is also necessary to explain to the patient that he should not, if possible, ignore the urge to defecate. It is important to try to develop in the patient a conditioned reflex to defecate at a certain time of day (for example, in the morning, 15-20 minutes after drinking a glass of cold water on an empty stomach).

Particular attention should be paid to the possibility of drug-induced constipation in patients starting long-term therapy with opioid analgesics. In this case, patients should be advised to take non-drug measures regarding nutrition, fluid intake and physical activity (see section Treatment of patients with drug-induced constipation). Some researchers consider it advisable in this case to start using laxative drugs [72, 91-94].

An important role in the prevention of drug-induced constipation is played by increasing the patient's awareness of the possibility of such a side effect in the drugs he is taking, about non-drug methods of preventing constipation and the need for their use.

How to identify and treat constipation in a child after taking antibiotics

Constipation in a child after antibiotics is quite common. Its prerequisite is dysbiosis of the intestinal tract. Constipation after taking medications is not so difficult to cure.

How to avoid constipation in a child after taking antibiotics

Today, medications can be considered the most effective means in the fight against microbes. With their help, complex medical procedures are carried out to eliminate diseases of the digestive tract in children. Replacement drugs have not yet been found. At the same time, they can cause harm to health, leading to certain problems in the child’s body.

If a child has recovered from an illness and gets sick again, but with constipation, then this is a sign of dysbacteriosis. Under the influence of drugs during the treatment process, the drug acts on pathogenic microorganisms with bacteria, but also those that benefit the body, that is, the intestinal tract. As a result, the child begins to experience abdominal pain due to an upset digestive system, which can lead to diarrhea or constipation.

The use of medications by a child sometimes has a negative effect on the baby’s immunity, causing depression of the digestive system and depriving it of its protective functions. Children often suffer from constipation when they are undergoing medication-based treatment.

When determining whether a child has constipation or not, parents pay attention to the following main points:

1. Formation of feces of hard and dense consistency.
2. Frequency of stool – defecation occurs rarely.
3. Anxiety with difficulty defecating.

During the treatment of constipation, children should not be given various medications without a doctor's prescription, since the child's health condition may worsen. It is necessary to be attentive to the peculiarities of the functioning of the child’s body, especially if he is a newborn. As a sign of constipation in children, only the first point among those listed above can be noted.

If a child has frequent constipation, then this is regarded as a manifestation of the disease, but then the presence of constipation is not the only symptom of this disease. However, if the baby’s condition is characterized by apathy, then you should consult a pediatrician so that he can help identify the symptoms of the existing disease.

Doctors do not advise parents to evaluate the activity of the child’s digestive tract based on their own experience, since this assessment will not be accurate. Moreover, in adults and children, the intestinal tract does not function the same. Eating and the food itself are also significantly different. As children grow older, the mechanisms associated with the functioning of the intestinal tract change. If one food is suitable for a one-year-old child, then a slightly different food is needed for an older child.

Children are not born with an integrated program that allows them to control the intestinal tract. The child’s body independently develops a regime for managing the digestive system and intestinal tract, and light and stressful periods associated with bowel movements may occur repeatedly. If it is necessary to give the child an enema every time or use another method to remove feces, then the child’s body will find it difficult to enter the mode of independent defecation, which will aggravate this problem.

The main reason for rare bowel movements in babies from 2 to 6 months is associated with the virtually complete digestion and absorption of breast milk by the child’s intestinal tract. At this age, the child may have nothing to excrete from the intestines; for this reason, the child may have bowel movements quite rarely.

Since the absorption of milk after feeding a child is complete, defecation occurs once every 2 or 3 days and this will be a normal process. It is important that children's stool remains normal and is soft and not hard. Only then will the child be healthy and his sleep will be relaxed.

Since in certain cases constipation occurs after the introduction of drugs into the child’s body, sometimes you can solve the problem yourself without a doctor. To do this, you should perform a massage, which can help with difficulty passing stool. You should not rush to use an enema or laxative; you need to give the baby time so that he can try to do everything on his own.

Usually, the baby needs a light massage in the abdomen, which makes defecation easier. You should stroke the baby's tummy in a circle (clockwise). At the same time, it is necessary to carry out a number of exercises.

You need to lay the baby on his back and unfasten the diaper, you will need to put a diaper on him. Then you should grab the baby's legs so that you can move them carefully, pretending to ride a bicycle. From time to time, the baby will push, so his legs should be pressed against his tummy without effort. During exercise, feces may be released in minimal quantities, but you should be patient and continue to perform them. This will give the child the opportunity to cope with the problem himself.

Using antibiotics to treat a child can actually cause constipation. Among the probable circumstances of constipation after the use of medications, food dysbiosis may develop, so probiotics are used for treatment. For example, it could be lactulose. In general, probiotics have not only a laxative effect, but also the ability to restore the microflora of the intestinal tract.

>One-time and short-term constipation can be observed in many healthy children, which does not require mandatory treatment, except for first aid. If a large amount of feces accumulates in the rectum and bowel movements do not occur, then this is the cause of constipation. The child needs urgent help to remove feces.

If you use the treatment method with an enema, then the best way to help is by introducing a salt solution into the intestine, prepared at the rate of 1.5 tbsp. l. table salt per 500 ml of water.

Determine how much volume is required based on the age of the baby. If this is a newborn six-month-old child, then 120 to 150 ml of saline solution will be required. If the child is more than 6 months old, the solution is taken in a volume of 150 to 200 ml. To introduce the solution, it should be collected in a special rubber bulb. Then lubricate the tip of the bulb with regular hand cream or Vaseline. The enema must be administered carefully and carefully, placing the child on his side.

If you do not have the ability to give an enema or are not confident in the correctness of this type of procedure, then it is best to use glycerin suppositories, which can be purchased at any pharmacy.

Using glycerin suppositories can perfectly soften stool and stimulate intestinal motility, so this can help cure a child from constipation.

When starting to administer the suppository, you need to put the baby on his side, and then inject the drug into the rectum, squeezing his buttocks slightly so that the glycerin suppository cannot come out. Typically, stool should begin to come out 15 to 45 minutes after the procedure. For children, you should not use more than one suppository per day.

If an hour has already passed since the suppository was inserted into the child’s rectum, and there is still no stool, then you should immediately notify the doctor. Children with constipation are prohibited from administering glycerin suppositories, which are intended for adults, as a whole, that is, the suppository must be divided into 4 parts. Only 1/4 of the candle is given to the child.

If the problem causing constipation has not been resolved after using one or two suppositories, then it is necessary to visit the treating specialist with the child so that he can give recommendations regarding this disease associated with the use of antibiotics. If stool does appear, it can be both copious and watery, which should soon return to normal.

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What to do if your child is constipated

To relieve constipation in a child of any age, you can try using a laxative, such as Duphalac®. It has a dual effect: it gently cleanses the intestines and normalizes its microflora6. Duphalac® does not just cleanse the rectum for a short time, but improves the proper functioning of the intestines, restoring regular and physiological bowel movements13.

Duphalac® can be used for as long as required13,14 and is not addictive*. Duphalac® can be used from birth, has a high safety profile and contains only lactulose and purified water13. For convenience, Duphalac® can be diluted in yogurt, porridge or baby food and used only once a day13.

Co-author of articles, editor - Shimbaretsky Georgy Alekseevich.

Causes of constipation in children

In young years

In a child under one year of age, the causes of constipation may lie in:

• genetic predisposition;
• poor nutrition of a nursing woman;
• insufficient drinking regime;
• muscle hypotension;
• rickets;
• perinatal encephalopathy;
• intestinal dysbiosis;
• intolerance to cow's milk protein;
• iron deficiency;
• sudden transition to artificial feeding;
• feeding children with high-iron formula;
• sudden transition from one mixture to another;
• hypothyroidism. Source: O.N. Komarova, A.I. Khavkin Constipation in young children: causes and features of dietary correction // Issues of modern pediatrics, 2014, No. 13 (1), p. 114-118

In older age

In children older than one year, the cause of constipation may be:

• uncomfortable and unsanitary conditions of toilets in a kindergarten or school (psychogenic constipation); Source: M.I. Dubrovskaya, P.V. Parshina Current issues in the development of constipation in children, approaches to therapy // Issues of modern pediatrics, 2012, v. 11, no. 11, pp. 76-82
• anusitis (inflammation of the skin and mucous membrane of the anal canal from the proximal areas of the skin folds around the anus to the dentate line and the blinker valves, i.e., the sphincter zone);

• improper diet, unbalanced diet;
• taking medications that cause fecal retention as a side effect;
• dehydration – dry food, excess dietary fiber in the diet, condition after diarrhea, vomiting, excessive sweating;
• deliberate delay in defecation for mixed reasons, which leads to compaction and drying of stool in the intestine.