Rare stool in an adult - causes, symptoms, treatment

Author, editor and medical expert - Klimovich Elina Valerievna.

Editor and medical expert - Harutyunyan Mariam Harutyunovna

Number of views: 380 599

Last updated: 02/16/2022

Average reading time: 16 minutes

Probably, most of us at least once during our lives experience constipation caused by dietary errors and bowel dysfunction. However, for some, long “get-togethers” in the toilet become commonplace. Presumably, chronic constipation affects up to 50% of Russians of all ages: from infants to the elderly1. We will talk about the causes of bowel dysfunction and ways to normalize it in this article.

Symptoms and signs

Chronic constipation (constipation) is understood as constantly slow, difficult and systematically insufficient bowel movement, accompanied by abdominal discomfort and a disturbance in the general condition1,2.

Signs of constipation:

• stool retention for more than 48 hours;
• reduction in stool volume to 35 g per day;
• dense, dry, fragmented feces, traumatic to the anus;
• a feeling of incomplete emptying or “blockage” of the rectum;
• the need for prolonged pushing, taking more than a quarter of the time from the moment the urge to defecate occurs until feces are released.

The presence of two of the six listed signs indicates stool retention1. Chronic constipation is said to occur if difficulties occur with every fourth visit to the toilet for a total of more than 3 months over a six-month period2.

Many are sure that bowel movements should be daily, and their absence is regarded as a problem. However, some people, due to the characteristics of their body, go to the toilet “largely” once every 2 days and do not experience any inconvenience1.

Constipation always causes discomfort. Symptoms that may accompany frequent constipation1::

• bloating and heaviness in the abdomen;
• nausea and belching;
• dullness, pallor and yellowish-brown skin tone;
• decreased skin turgor (flabbiness);
• the appearance of dermatological diseases: eczema, pyoderma, urticaria, acne.

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Can medications cause constipation?

Yes, many medications, including painkillers, antidepressants, tranquilizers and other psychiatric medications, blood pressure medications, diuretics, iron supplements, calcium supplements, and antacids containing aluminum, can cause or worsen constipation.

Moreover, some people who are not constipated in normal life may become dependent on laxatives, which they take to achieve daily bowel movements. For many of them, constant use of laxatives causes significant harm.

Causes of chronic constipation

Systematically difficult defecation can be caused by a variety of reasons that disrupt the normal functioning of the intestines and the process of excretion of feces1.

1. Peristalsis plays a major role in normal intestinal function. To activate it, it is necessary that the intestinal contents be sufficient in volume1: a decrease in the amount of feces leads to a slowdown in motility and constipation.
2. Compaction of feces associated with insufficient intake of water into the body and its active absorption in the intestines.
3. Difficulty moving stool through the intestine may also be due to:

• damage to her muscular system;
• problems of the nervous system involved in the formation of peristaltic waves;
• disruptions in the endocrine regulation of the gastrointestinal tract;
• “damage” to the defecation reflex that occurs when the rectum is filled;
• mismatch in the functioning of the pelvic floor muscles, in particular the anal sphincters, which regulate feces1.

The above-described disorders occur with various types of chronic constipation.

Depending on the causes of constipation, there are 1:

1. Nutritional (simple) problems associated with nutritional errors, non-compliance with the water regime and a sedentary lifestyle.
2. Habitual, arising due to the bad habit of delaying bowel movements or the inability to go to the toilet when the urge occurs.
3. Metabolic and endocrine , which occur against the background of hypothyroidism, diabetes mellitus, pregnancy, pheochromocytoma, as well as disorders of potassium and calcium metabolism and are accompanied by a decrease in the level of these microelements in the blood.
4. Medicinal , developing as a side effect of drugs, for example, antispasmodics, anticonvulsants, antihistamines, non-steroidal anti-inflammatory drugs, antidepressants.
5. Neurogenic, caused by diseases of the central and peripheral nervous system: multiple sclerosis, deterioration of cerebral circulation, Parkinson's and Alzheimer's disease, spinal damage.
6. Psychogenic caused by chronic stress, hypochondria and depression, schizophrenia, anorexia nervosa.
7. Associated with systemic diseases (scleroderma), diseases of internal organs (cholecystitis, pancreatitis), “congestion” in heart, kidney and liver failure.
8. Provoked by diseases of the colon : inflammatory, non-inflammatory, tumor, including cancer.
9. Caused by problems of the rectum and pelvic floor: tumors, weakening of the pelvic floor muscles, prolapse of the pelvic organs, etc.1,4

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What causes constipation?

There are several reasons that explain the development of constipation, including insufficient fiber and fluid intake, a sedentary lifestyle and changes in the usual environment. Travel, pregnancy, or dietary changes can cause constipation. In some people, constipation may occur following repeated volitional refusals to defecate when the urge to defecate appears.

More serious causes of constipation may be tumors or narrowing of the intestinal lumen. Therefore, if you have persistent constipation that cannot be corrected on your own, you should consult a coloproctologist. In rare cases, severe diseases such as scleroderma, lupus, disorders of the nervous and endocrine systems: thyroid diseases, multiple sclerosis, Parkinson's disease, stroke, spinal cord injuries can lead to the development of constipation.

Most common constipation

Most often, alimentary simple and habitual variants of constipation occur, as well as irritable bowel syndrome (IBS), the development of which is explained primarily by psychological reasons1,2.

Nutritional

This type of constipation is associated with slow movement of food through the gastrointestinal tract as a result of a number of factors. These include:

• A sharp decrease in the amount of food consumed when following a diet, lack of appetite, the presence of contraindications and obstacles to proper nutrition, for example, after surgery, in the absence of teeth1.
• Insufficient fluid intake, which causes dehydration and a decrease in the volume of intestinal contents1.
• Excessive enthusiasm for products that “fix” stool3 due to their crushed composition, low fiber content, and the presence of astringents and diuretics. This group includes strong broths, pureed soups and porridges, jelly, puddings, pear, blueberry, quince compotes, strong tea and coffee3.

A sedentary lifestyle also contributes to the development of nutritional constipation1. Difficulty in defecation occurs due to decreased motility and is not accompanied by structural changes in the intestine characteristic of diseases. Normalizing nutrition and increasing physical activity, as a rule, helps normalize stool1,2.

Habitual

Constant constipation in adults and children is often the result of the habit of holding back bowel movements.

The best time to visit the toilet “in a big way” is considered to be morning1,3. The beginning of physical activity and eating during breakfast reflexively enhance intestinal motility and facilitate bowel movements. If in the morning rush you postpone going to the toilet over and over again, feces stretch the rectum, and its receptors stop responding to irritation - the reflex to defecation becomes weakly expressed. As a result, habitual constipation arises.

Habitual, constant constipation is experienced by people who deliberately delay going to the toilet when the urge arises. This happens when a person is demanding about the sanitary conditions of public places and cannot go to the toilet while at work or school1.

Often problems with excretion of feces occur in people who do not have the ability to immediately satisfy a natural need when necessary, for example, public transport drivers, teachers, assembly line workers, judges, surgeons1.

Often the cause of unconscious delay in bowel movement is fear of defecation due to regularly occurring pain syndrome in the presence of hemorrhoids, chronic anal fissure, inflammatory diseases and rectal cancer1. Treatment of these diseases helps solve the problem of constipation.

Psychogenic

One variant of this group of disorders is irritable bowel syndrome (IBS)1. It is believed that the basis for the development of the disease is problems in the psycho-emotional sphere1. The imbalance of hormones that occurs against the background of nervous overload and chronic stress leads to changes in intestinal motility, and nutritional problems and a sedentary lifestyle aggravate the situation1. A distinctive feature of constipation in IBS is the appearance of abdominal pain, which goes away immediately after the passage of feces; a combination of bowel movements with migraines, insomnia at night and drowsiness during the day, sudden hot flashes and rapid heartbeat, painful menstruation and other symptoms arising from malfunctions of the nervous system. These manifestations also help distinguish IBS from habitual constipation1.

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Chronic constipation in children

Chronic bowel retention affects not only adults, but also children. True, the concept of normal bowel movement in this case is unclear. In newborns and infants in the first months of life, feces can be excreted after each feeding, that is, up to seven times a day, and with artificial feeding - once a day3. The absence of stool for 36 hours can already be considered constipation3. For children over 3 years old this period is 48 hours3.

Constipation in children is in most cases limited to functional impairments3. Currently, the main reason for irregular rectal emptying in children of the first year of life is considered to be the immaturity of the child’s digestive and nervous system4. A difficult pregnancy for the mother, premature birth, cesarean section - all this sometimes leads to delays in the development of the baby3.

Among the nutritional causes of constipation are refusal to breastfeed, incorrect choice of formula for artificial feeding and complementary feeding, and insufficient fluid intake3.

In older children, habitual constipation is especially common, associated with ignoring breakfast, suppressing the morning natural urge due to haste, deliberate retention of stool caused by shyness and refusal to visit the public toilet in kindergarten and school3.

“Children’s” constipation is predominantly accompanied by increased peristalsis and discoordination of intestinal motor activity, leading to spasms, so treatment should be aimed at relaxing the intestinal muscles3.

For persistent problems with rectal emptying in children, in addition to recommendations for dietary changes, doctors prescribe antispasmodic drugs and procedures, as well as medications that normalize the functioning of the nervous system and prebiotics3. In this case, laxatives that stimulate intestinal motility and inhibit the absorption of water and salts in the gastrointestinal tract are not used3.

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The connection between intestinal microflora and constipation

The consequences of chronic constipation may be disturbances in the balance of intestinal microflora, but there is also an inverse relationship: dysbiosis leads to the development of prolonged constipation. In both cases, the intestinal microbiome should be restored and, at the same time, stool retention should be corrected.

For this purpose, both prebiotics and combination preparations containing them can be used. This is especially true for cases when dysbiosis develops against the background of antibacterial therapy.

Chronic constipation in older people

Elderly people, like children, are a special category of patients who turn to gastroenterologists with chronic constipation. According to statistics, in older people, stool retention occurs 5 times more often than in young people4, and they are associated mainly with reduced intestinal tone and slower peristalsis4.

The following factors predispose to regular bowel problems4:

• Dietary features, in particular, reducing the amount of food and rarely consuming coarse foods - due to problems with teeth and stomach, crushed refined foods, low in fiber, begin to predominate in the diet.
• Decreased physical activity due to muscle weakness, diseases of the musculoskeletal system and cardiovascular system.
• Weakening of the muscles of the anterior abdominal wall and pelvic floor due to a general age-related decrease in muscle volume and loss of muscle tone4.
• Reduced intestinal motility due to age.
• Slowing of digestion due to decreased activity of digestive enzymes and changes in the composition of intestinal microflora4.
• Taking a large number of medications, some of which cause problems with stool4.
• Abuse of addictive laxatives4.

The danger of chronic constipation in older patients is the high risk of fecal stone formation. Prolonged presence of feces in the intestines and their pressure on the intestinal wall can cause the formation of fecal ulcers and the development of cancer4. According to statistics, the risk of colorectal cancer in the presence of constipation is 1.48-2 times higher than in people without constipation4.

In old age, the so-called “alarming symptoms” require special attention:

• changes in the thickness and shape of stool,
• progression of bowel problems
• the appearance of diarrhea after prolonged retention of stool,
• the presence of blood in the stool,
• pale skin caused by anemia,
• general weakness and weight loss.

The appearance of the above symptoms over the age of 50 is a reason to immediately contact a doctor.

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Herbal laxatives

There are different types of herbal laxatives - some of them are called bulk laxatives, others are classified as stimulants. Bulk ones act on the principle of dietary fiber: they absorb and retain water in the intestines, increase the volume of feces, soften them and promote gentle excretion.

Functional problems with stool in women in the absence of organic pathologies and other serious causes can be easily corrected with bulk laxatives of plant origin. In some cases, fiber supplementation or laxatives may be sufficient. You can take them for a long time.

For example, doctors Parfenov A.I., Ruchkina I.N., Silvestrova S.Yu. emphasize that “volumetric agents are acceptable for long-term use. They act slowly, gently and are safe for the systematic support of normal stool” (Parfenov A.I., Ruchkina I.N., Silvestrova S.Yu., p. 109).

One of these herbal preparations is the British drug “Fitomucil Norm”. It contains the pulp of plum fruit, the shell of plantain seeds, which is called Psyllium - soluble and insoluble fiber. The former dissolve in the intestines and turn into a mucous gel due to the absorption of water, the latter gently stimulate the intestinal walls and its motility, this leads to the desired effect. The drug acts gently, predictably, and does not provoke spasms and pain, as well as the appearance of the so-called drastic effect - diarrhea.

Stimulating herbal preparations based on senna, buckthorn, and rhubarb act on intestinal receptors. They are very fast and powerful, sometimes work unpredictably and cause diarrhea with severe pain and abdominal cramps. They have a large list of contraindications, so such herbal remedies should be used under the supervision of a doctor. Using them constantly or regularly is prohibited in almost all clinical cases.

What to do if you have constant constipation

First of all, you need to contact a gastroenterologist and undergo an examination that will allow you to determine the causes of the disorders. Taking into account the results, the doctor will prescribe treatment, which in any case will include the following measures.

Nutrition correction.

When constipation is accompanied by weakened intestinal motility, it is useful to include in the diet foods rich in coarse fiber: raw vegetables and fruits (at least 200 g per day), crumbly porridge (oatmeal, buckwheat, pearl barley, millet, bulgur and others) and whole grain bread , flaxseed and bran, prunes and dried apricots, fermented milk products, vegetable fats and meat containing ligaments and tendons1,3,4.

If constipation is accompanied by decreased intestinal motility, doctors advise carefully increasing the fiber content in the diet over 5-7 days1.

To prevent dehydration and hardening of stool, it is recommended to consume at least 1.5-2 liters of fluid per day1,4.

It is important to follow a diet: be sure to have a hearty breakfast and eat at least 3-4 times a day3.

Increased physical activity

In order to stimulate intestinal function, therapeutic exercises, yoga, swimming, long walks, and physical education are recommended.

Abdominal massage2 and special exercises for the abdominal muscles3, which involve alternating tension and relaxation, will help mechanically strengthen motor skills.3.

For infants with difficulty defecating, it is recommended to have a special abdominal massage after eating,3,4.

Development of a conditioned reflex

With the usual variants of constipation, it is important to develop a morning reflex to defecation. To do this, it is recommended to get up a little earlier to avoid the morning rush, have breakfast and then empty the rectum in a calm atmosphere. A traditional morning visit to the toilet helps develop a healthy habit.

In turn, children need to be put out on the potty at the same time of day and always in the morning after breakfast. At the same time, it is important that the potty is warm, comfortable, and that the process itself is not accompanied by requests to “do everything faster.”

Laxatives

For chronic constipation, various laxatives are used to empty the bowel:

• osmotic, retain water in the intestinal lumen, helping to soften stool2;
• stimulating, irritate the receptors of the intestinal mucosa and increase peristalsis;
• local, which soften stool in the rectum2.

However, frequent use of stimulants carries a high risk of side effects, particularly diarrhea and addiction2.

MICROLAX® is a combined laxative based on sodium citrate, sodium lauryl sulfoacetate and sorbitol5. Acting at the level of the rectum, the drug components displace bound water from the intestinal contents, attract it into the intestinal lumen, soften stool and promote defecation5.

The drug MICROLAX® is available in the form of a microenema, equipped with a special tip for easy insertion into the rectum5. The effect may occur within 5-15 minutes5. The high safety profile allows the drug to be used for the treatment of constipation in adults and children5.

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The information in this article is for reference only and does not replace professional advice from a doctor. To make a diagnosis and prescribe treatment, consult a qualified specialist.

Constipation in clinical practice

To describe the shape and consistency of stool, it is advisable to use the Bristol scale, according to which constipation is characterized by the shape of stool types 1–2 (Table 1). In healthy people, the weight of feces per day averages 110 g, but fluctuations from 40 to 260 g can be observed [5]. Men and young people have a larger stool mass than women and the elderly. The amount of feces is variable and depends on many reasons: diet, social conditions, changes in normal daily routine, climate, fluid intake, hormonal cycle (menses). All of these characteristics of the act of defecation depend on the transit time of intestinal contents through the gastrointestinal tract. When studying the transit time using contrast markers or radioactive isotopes, it was found that in healthy people it is about 60 hours: in women - 72 hours, in men - 55 hours. In patients with constipation, the average transit time ranges from 67 to 120 hours [5 ]. Normally, the sequential movement of contents through the colon is ensured by various types of its contraction. According to a study of myoelectric activity, colon motility is represented by both segmental contractions (single or organized group phase contractions) and propulsive contractions - special propulsive contractions [2,10]. The colon has circadian and diurnal rhythms in motor function. During sleep, her motor activity is inhibited [3]. During the day, segmental and propulsive activity of the colon increases significantly, especially upon morning awakening and after meals. Excitation of motor activity occurs within 1–3 minutes after eating and lasts up to 3 hours [8]. The motility of the colon depends on the composition of the food eaten. Fats and carbohydrates stimulate, and amino acids and proteins suppress, the motor activity of the colon. In the proximal sections, food chyme mixes, accumulates and comes into close contact with intestinal bacteria. Saccharolytic bacteria (bifidobacteria and lactobacilli, Enterococcus faecalis) ferment cellulose and hemicellulose contained in the peel of vegetables and fruits and the shell of cereals, to the final decomposition products - short-chain fatty acids (lactic, propionic, etc.) and gases (methane, hydrogen, dioxide carbon), which stimulate intestinal peristalsis. In addition, indigestible fiber retains water in the intestinal lumen, increasing the volume of intestinal contents. The laxative effect of dietary fiber is complex and is associated with an increase in the volume of intestinal contents due to the retention of water molecules, an increase in bacterial mass and irritation of colon receptors. Proteolytic bacteria, in particular representatives of the genera Bacteroides, Proteus, Clostridium, as well as Escherichia coll, break down proteins into ammonium, phenols, mercaptopurines and purines. In a normal microbiocenosis, proteo- and saccharolytic bacteria work cooperatively, breaking down proteins and carbohydrates into final breakdown products. Changes in the composition of intestinal microflora can lead to metabolic disturbances (imbalance of vitamins, electrolytes) and transit through the colon. The distal colon moves fecal matter toward the rectum. Electrolytes and water are finally absorbed in these sections (about 2 l/day). The act of defecation begins when the sigmoid colon is sufficiently filled. The results of 24-hour manometry of the colon showed that the act of defecation is preceded by an increase in the frequency of high-amplitude and peristaltic contractions [8]. The defecation reflex occurs with acute distension of the rectum. If the supraspinal centers contribute to this process, then with contraction of the sigmoid colon and rectum, the pressure in the rectal ampulla increases and the rectosigmoid angle is smoothed. As a result of relaxation of the internal and external anal sphincters, feces are evacuated. The nerve centers of the lumbar and sacral spine are involved in the regulation of this function. The urge to defecate can be increased by increasing intra-abdominal pressure using the Valsalva maneuver (straining) or suppressed by contracting the striated muscles of the pelvic diaphragm and external anal sphincter. Frequent suppression of the urge to defecate can lead to chronic distension of the rectum, decreased tone and chronic constipation. An important reason leading to the loss of motor-evacuation properties of the intestine is a violation of the sensitivity of the bioreceptors of the intestinal wall. In constipation, disruption of nerve signal transmission may be caused by neuropathy of the sacral spine after damage to the afferent and efferent parasympathetic nerve fibers in the lower hypogastric plexus. With the loss of the afferent phase of the defecation reflex of various origins, the rectum increases in volume and atony of its wall develops. As a result, the urge occurs only after a large accumulation of feces in it (megarectum, or inert rectum). In patients with chronic constipation, colon manometry shows a significantly reduced number and duration of high-amplitude peristaltic contractions, as well as a suppressed or absent “gastrocolytic” response to food intake in all segments of the colon [4]. Thus, with constipation, the transit of chyme primarily through the colon or in the anorectal zone may be impaired, or there may be a combination of these disorders. Constipation can be organic or functional in nature. According to the Rome II criteria (1999), a diagnosis of functional constipation can be made if 2 or more of the following symptoms persist for at least 12, not necessarily consecutive, weeks over a 12-month period: – frequency of bowel movements less than 3 per week; – straining during defecation, occupying at least 25% of the time; – fragmented and (or) hard feces in at least 1 out of 4 bowel movements; – a feeling of incomplete evacuation of intestinal contents at least during 1 out of 4 bowel movements; – a feeling of obstruction during the passage of feces at least during 1 out of 4 acts of defecation; – the need for digital manipulations that facilitate the act of defecation in more than 1 out of 4 acts of defecation. The formation of constipation is based on hypotonic, or spastic dyskinesia of the intestine. The pathophysical mechanisms causing primary disorders of the colon are not well understood. The role of imbalance in the system of gastrointestinal hormones that stimulate (gastrin, cholecystokinin, substance P, enkephalins, motilin) ​​or slow down intestinal motility, in particular glucagon, vasoactive intestinal polypeptide (VIP), serotonin, changes in the sensitivity of the receptor apparatus of the colon to various stimuli is assumed. Importance is also given to dysfunction of the neuroreceptor apparatus of the intestinal wall, which is responsible for its motor activity. In a doctor's practice, constipation caused by secondary intestinal motor disorders is more common. The etiological factors of chronic constipation are diverse [1]. Traditionally, the most common cause of intestinal transit disorders is considered to be poor nutrition (irregular meals, low fluid and dietary fiber intake). However, a comparative analysis of the nutritional pattern of people with constipation and those with normal stools indicates that there are no differences in the use of ballast substances. At the same time, in patients with constipation, the mass of feces was less, and the intestinal transit time was significantly longer than in people with normal stool, regardless of whether they consumed food with fiber or not [6]. Often, constipation occurs as a result of the habitual suppression of the urge to defecate, due to lifestyle (morning rush, peculiarities of work hours, lack of conditions in the toilet). Constipation accompanies many endocrine diseases (diabetes mellitus, hypothyroidism, obesity). Parkinson's disease, paralytic syndrome, multiple sclerosis and mental disorders (depression, stress, dementia) can also be accompanied by constipation. Many medications can inhibit the motor activity of the colon, and the simultaneous use of several drugs can increase and maintain constipation: - antacids containing aluminum hydroxide or calcium carbonate; – anticholinergic drugs (antispasmodics); – antidepressants; – non-steroidal anti-inflammatory drugs; – narcotic analgesics; – antiepileptic drugs; – antihypertensive drugs (b-blockers, calcium antagonists, centrally acting antiadrenergic drugs, angiotensin II receptor blockers, angiotensin-converting enzyme inhibitors); – anti-tuberculosis drugs; – antibiotics (gyrase inhibitors, cephalosporins); – systemic antifungicides (ketoconazole); – iron preparations (its salts); – gestagens; – diuretics; – lipid-lowering drugs (ion exchange); – neuroleptics (phenothiazines); – tranquilizers; – muscle relaxants; – urological drugs (for the treatment of prostate diseases); – drugs used for glaucoma. Constipation associated with impaired anorectal transit is caused either by primary disorders of rectal motility and pelvic floor muscles, or by their structural changes. It should be borne in mind that the identified anatomical disorders are not always the cause of constipation, but may be their consequence or caused by concomitant diseases. Impaired motility of the anorectal area is indicated by constipation with incomplete emptying of the rectum even after strong straining, with the presence of pain in the lower abdomen, in the anal and perianal areas and fecal incontinence. Although constipation and fecal incontinence seem to be mutually exclusive, the underlying mechanisms are often the same. Thus, repeated and prolonged straining during constipation damages the mucous membrane of the rectum, sacral nerves and pelvic floor muscles. Ultimately, these circumstances cause dysfunction of the anal sphincters and fecal incontinence. In addition, with the formation of fecal plugs during constipation, fecal liquefaction occurs in the overlying parts of the intestine, which flow around dense feces and are abundantly discharged from the anus - the so-called paradoxical diarrhea. Constipation can be a symptom of diseases of the upper gastrointestinal tract, colon and rectum. Therefore, when constipation occurs, a thorough examination is required to determine the causes of its development. A detailed analysis of the clinical manifestations of constipation allows us to suggest the main mechanisms of their development (Table 2). The examination of patients with constipation includes two stages. At the first stage, the diagnostic search is aimed at excluding organic pathology. Patients undergo: general clinical examinations; digital examination of the rectum; sigmoidoscopy; irrigoscopy, if necessary - colonoscopy; examination by a gynecologist (for women) and a urologist (for men). Identified organic changes require appropriate treatment, often surgical. Particularly careful examination requires patients with constipation and symptoms of “anxiety”: unmotivated weight loss, nighttime symptoms (pain), constant and intense abdominal pain, onset of the “disease” in old age, colon cancer in relatives, fever, blood in the stool , leukocytosis, anemia, increased ESR, changes in biochemical status, hepato- and splenomegaly. After excluding organic pathology, at the second stage of the examination, the level of stasis of intestinal contents is clarified, the type of motor disorders is established (hyper- or hypokinetic), and concomitant pathology of the gastrointestinal tract, endocrine and nervous systems is identified. Transit time can be measured by barium x-ray or radioisotope markers in the colon. In this case, not only the level of stasis in the intestine can be detected, but also the type of motor disorders in a particular segment of the intestine. The examination results should also answer the question: is constipation a primary or secondary functional disorder of the intestine. Therefore, the research protocol should include: ultrasound examination of the abdominal organs, laboratory tests to exclude hypothyroidism, diabetes mellitus, dehydration, hypokalemia and hypercalcemia; study of stool microflora; psychoneurological examination. In case of stasis of contents in the rectum, special studies can be used in specialized medical centers (anometry, defecography, electromyography of the pelvic floor muscles, etc.). Treatment of constipation aims to achieve regular bowel movements and normalize stool consistency. If constipation is a symptom of any disease, then its treatment significantly increases the effectiveness of measures taken to eliminate constipation [1]. At the first stage of treatment, an educational conversation is held with the patient about the causes of constipation and recommendations are given on changes in lifestyle and nutrition. First, it is necessary to explain to the patient that daily bowel movements are not a physiological necessity. If bowel movements are complete, then stool may occur once every 2-3 days. Diet plays an important role in the treatment of constipation. Meals should be four times a day. If there are no contraindications, the diet for constipation includes more foods and dishes that speed up bowel movements: carrots, beets, zucchini, pumpkin, rich in plant fiber, bread made from wholemeal rye and wheat flour, dietary varieties of bread with the addition of wheat bran, wheat porridge, buckwheat, pearl barley and oatmeal. Organic acids and sugars contained in vegetables, fruits and berries also stimulate intestinal function. Therefore, for constipation, fruit and vegetable juices, figs, dates, prunes, dried apricots, bananas, and sour apples are prescribed. You should definitely consume lactic acid products: fresh kefir, yogurt, acidophilus. The total amount of fluid entering the body is at least 2 l/day. Patients should exclude from their diet bread made from premium flour, butter dough, fatty meats, smoked meats, canned food, spicy foods, chocolate, strong coffee and tea, limit the consumption of semolina and rice porridge, vermicelli, potatoes; Products that cause increased gas formation are not recommended (legumes, cabbage, sorrel, spinach, apple and grape juices), and for spastic dyspesia - also products containing essential oils: turnips, radishes, onions, garlic, radishes. For constipation with spastic dyskinesia, to prevent increased spasms under the influence of dietary fiber, treatment begins with a slag-free diet mixed with fat, gradually adding boiled and then raw vegetables to it. Wheat bran can be used as a stimulant of intestinal motility: start with 3 teaspoons per day and gradually increase the dose to 3~6 tablespoons. For patients with constipation, mineral waters “Essentuki”, “Batalinskaya”, “Slavyanovskaya”, “Jermuk” are recommended. More mineralized water, in particular “Essentuki No. 17”, is prescribed for constipation with hypomotor dyskinesia, 150-200 ml cold 2-3 times a day; less mineralized - in the same doses in a warm form, for example, "Essentuki No. 4" - for hypermotor dyskinesia. Patients with constipation are recommended to increase physical activity (walking, swimming, exercise, including strengthening the pelvic floor and abdominal muscles). In the morning, the patient should allow time (15–30 minutes) for bowel movements after a large breakfast. A glass of room temperature water or juice may also be sufficient to stimulate the gastrointestinal reflex. If there is no bowel movement in the first days, laxative suppositories can be used. Diet and exercise can be enhanced with physiotherapy. For electrical stimulation therapy, threshold and exponential electrical pulses are used. This method, in combination with diet, has a positive effect in many patients with hypokinetic constipation [7]. Drug therapy is prescribed taking into account the nature of motor disorders of the colon. For hypomotor dyskinesia of the colon, prokinetics are used, for spastic dyskinesia, antispasmodics of myotropic action are used. In recent years, significant progress has been made in clarifying the mechanisms that control the motor function of the digestive tract and creating new drugs for the correction of motor disorders. The motility of the gastrointestinal tract is regulated by the activity of the central and autonomic nervous systems [9]. In the intestine, the leading role belongs to the autonomic innervation, represented by intramural (autonomous) and intercalary neurons, united in the submucosal and muscular plexuses. Intramural neurotransmitters include: acetylcholine - for cholinergic neurons; serotonin – for serotonergic neurons; ATP – for purinergic neurons (the purinergic system inhibits the tone of smooth muscle fibers). Intramural mediators also include neuropeptides: VIP, which can activate and inhibit the function of muscle neurons; somatostatin, inhibiting and stimulating intramural neurons; substance p, exciting intramural neurons; Enkefalins modulating the activity of intramural neurons. Strengthening of motor skills is observed with stimulation of cholinoreceptors (through acetylcholine), a number of opiate (OR1 and OR3) and serotonin receptors, weakening - with stimulation of adrenergic receptors, dopamine, purin and other opiate (OR2) receptors [1.8]. Prokinetics include the following groups of drugs: agonists 5 - hydroxitriptamine (5NT4) - recipients (cizapride, tagaserod, proucalopride, mosapride); 5NT receptor agonists (collaboration); Antagonists of dopamine D2 - receptors (metoclopramide, domperidone). Of these groups, only 5NT4 -recipient agonists have an effective bleach on the colon. Tsizapride, as established, accelerates transit through the colon, stimulates its motor activity and reduces the threshold of sensitivity of the rectum to defecation. An effective dose of cizapride is at least 30 mg/day. However, the use of this drug is associated with the development of side effects. Cases of heart arrhythmias and sudden death of patients who received cizapride (elongated Q -T interval syndrome) are described. In this regard, in a number of countries its use is limited. Before starting treatment, the “benefit -risk” should be assessed, especially in elderly patients with the initial extension of the Q ~ T interval, hypokalemia and hypomagentia. However, other derivatives of benzamide, such as Mosapride, do not have such a side effect on the function of the heart. Tegaserod is one of the new prokinetics, which is a highly sequential agonist 5NT4 - receptors. It is shown that it can reduce the time of transit with the syndrome of the incapacitated intestine with a predominance of constipation [9]. Clinical studies of this drug continue. Due to the lack of effective and safe prokinetics in the treatment of constipation caused by hypo- or atonia of the colon, laxatives are used. Often, patients themselves choose a laxative drug by trial or on the advice of friends and acquaintances. There are a large number of laxatives and their various division into groups. According to the mechanism of action, laxatives are conditionally divided into four groups: 1) causing chemical irritation of the intestinal mucosa mucosa: anthrakhinones (derivatives of senns, circles, rhubarb, aloe), diphenols (bisacoli, sodium picosulfate), castor oil; 2) possessing osmotic properties: saline (sodium or magnesium sulfate, Karlvar salt), disaccharides (lactulose), multi -tower alcohols (mannitol, sorbitol), macrogol; 3) increasing the volume of the contents of the intestine - ballast substances (agar -agar, methyl cellulose, bran, flax seed); 4) contributing to the softening of feces (liquid paraffin, petroleum jelly, macrogol). The active substance of plant extracts is di- or trihydroxyntrachinones in the form of anthrachinon glycosides. From the extracts of Aloe, Senna, Krushins and Rhubates in the colon, the active derivatives of anthrakhinones are released, which stimulate the motility of the colon, inhibit the absorption of water and electrolytes. The action of the drugs of this group depends on the time of emptying the stomach, passage in the colon and occurs after 6 hours when taking them before meals. According to the severity of the laxative effect, the drugs are located in the following sequence: Senna's leaves> Senna's fruits> crush bark> Rhubarine root. With prolonged use, they cause melanosis of the intestinal mucosa. Often there is an addiction to these drugs, so with prolonged use, an increase in their dose is required. So, after 5 years of admission to the same laxative, every 2 patient responds, and after 10 years, every 10th [3]. The derivative of Diphenylmetana - Bisacodil - in terms of frequency of use takes 1st place among the drugs of this group. It is produced in two dosage forms: in dragees and candles. Unlike drugs containing anthrachinons, Bisacodil when administration is in an active form already in the stomach. Therefore, its reception, especially with an increase in the dose, is often accompanied by spastic pains in the upper abdomen. When used in candles, Bisacodil increases the propulsive activity of the colon, and the laxative effect occurs after 1 hour. This form of the drug is used to quickly clean the intestines when preparing the patient for an urgent operation or instrumental examination. In the small intestine, the bisacodel is partially absorbed and, entering into systemic bloodstream, increases the possibility of toxic effects and the development of allergic reactions. Of the drugs with osmotic properties, lactulose and macrogol are most widespread. Salt laxatives (sodium sulfate, magnesium sulfate) for the treatment of chronic constipation are practically not used due to abdominal pain and the formation of liquid feces, which with frequent use leads to water -electrolyte disorders. Lactulose is a synthetic non -adsorbal disaccharide consisting of lactose and fructose. In a constant form, she enters the colon. In the iliac intestine, lactulose is broken down with the formation of milk and other acids. As a result of this, the pH in the lumen of the intestine decreases, which causes irritation of its receptors and stimulates motor skills. The positive effect of lactulose is its prebiotic effect that promotes the growth of normal sugarlytic bacteria. However, the treatment of constipation requires higher doses of the drug to be accompanied by swelling and bursting of the abdomen. This circumstance forces patients to abandon a long -term intake of lactulose. Macrogol - a drug with a molecular weight of 4000 is a hydrophilic polymer that does not penetrate through biological membranes of the intestinal wall; It is able to form stable connections with water molecules and hold it in the lumen of the intestine. An increase in the volume of the contents throughout the colon contributes to its peristaltic activity. The drug does not interact with drugs, does not change water -electrolyte metabolism. The macrogol is not metabolized, not absorbed, does not change the pH of the intestinal chimus and acts regardless of the composition of the intestinal bacteria. It can be used even in pregnant women. A laxative action occurs 24–48 hours after admission. The persistent effect is observed after 2 weeks of regular intake. The drug does not cause side effects, addiction does not develop to it. The laxatives that increase the volume of the contents of the intestine include dietary fibers of vegetables, fruits and grain, cellulose -containing drugs and mucophal. An increase in the diet of foods rich in fiber often causes dyspeptic disorders (flatulence, abdominal pain). In these cases, cellulose -containing drugs are used. They are not absorbed, absorb water, swell and, causing teething, enhance its peristalsis [2]. However, with constipation caused by the colon atonia, drugs of this group are effective only in 25% of patients, and in case of defecation disorders - in 30%. Drugs softening feces (liquid paraffin and petroleum jelly) have limited use. They do not enhance peristalsis, but reduce the stress during defecation. Oil microclisms have the same properties. With repeated use of vaseline oil, it reduces the absorption of fat -soluble vitamins and can determine their deficiency in the body. The intake of laxatives of various groups leads to the development of a number of side effects: 1. Violation of absorption: - suppression of absorption of vitamins, salts, nutrients; - Stimulating secretion against the background of water loss and salts. 2. Pathological effects and systemic lesions: - pseudo -District, sigmoid colon and colon; - toxic hepatitis; - paraffinoma; - syndrome of potassium and sodium failure; - secondary or tertiary aldosteronism; - intoxication caused by hypermagnium. 3. Functional disorders of the gastrointestinal tract: - intolence in the stomach (nausea, vomiting); - abdominal pain; - Bodder, flatulence, a feeling of overflow; - intestinal obstruction caused by "laxatives that increase volume"; - Violation of the composition of intestinal microflora. 4. The influence of laxatives on metabolic processes: - slowing or decreasing the absorption of nutrients; - an increase in the allocation of urine na+ and k+; - tachyphylaxia. Electrolyte disorders occur in 25–35% of patients who regularly take laxatives. To a greater extent, they are noted when taking the drugs of Senna, Aloe, Bisacodil and sodium picosulfate, which are more often used by patients and prescribed by doctors. The main violation of the electrolyte balance is a shortage of potassium, which contributes to the strengthening of constipation [7]. Hypokalemia can lead to damage to the renal tubules. As a result, the loss of potassium through the renal barrier increases. The deficiency of potassium causes a violation of the contraction of the muscles of the intestine (the formation of the inert intestine) and to an increase in the dose of laxatives. For this reason, a long -term reception of laxatives of these groups should be avoided, especially in high doses. When choosing a laxative, you should adhere to a certain tactic (Fig. 1). Treatment should begin with drugs that increase the volume of the contents of the intestine (fillers and osmotic laxatives). Among these laxatives, the macrogol has an advantage, which, when assessing the effectiveness on a scale of 0–100 mm (0 - lack of effect, 100 - high efficiency), received 89.5 mm, according to doctors, and 78.3 mm - when patients evaluate. On average, a positive index was 77.3 mm. Even with prolonged use, macrogol did not cause side effects. With severe hypotension or atony of the intestine, drugs should be combined that increase the volume of the contents in the intestine: macrogol with prokinetics or laxatives that cause chemical irritation of the intestine. In this case, individual dosing (as few as possible, but as much as necessary; avoid diarrhea). Daily reception of motility stimulants is not required. For example, 2 packets of macrogol should be taken in the morning with an interval of 1 hour (in 8 or 9 hours) daily and additional 2 times a week in the 2nd bag add 15 drops of sodium pycosulfate. It is advisable to take breaks in the reception of laxatives to determine if the constipation has passed. Thanks to the combination of motility stimulants with drugs that provide intestinal contents, it is possible to reliably normalize the activity of the intestines (Fig. 2). For the treatment of constipation caused by spastic dyskinesia and accompanied by abdominal pain, antispasmodics should be used. Preparations should have high selectivity of action on spasmodic areas of the intestine, not violate its peristaltic activity, effectively stop the pain syndrome, and not influence the function of other organs. Of the myotropic antispasmodics, the pain syndrome in the intestine of Pinaveria Bromide, furnitureurin hydrochloride, otilonia bromide and drugs that have a direct effect on intracellular processes in myocyte are most effectively stopped. However, according to the meta -analysis of 26 clinical studies, myotropic antispasmodics in the form of monotherapy did not significantly affect the relief of constipation [3]. Therefore, to obtain regular stools, they should be taken with laxatives that increase the volume of feces and soften its consistency (Fig. 3). The treatment scheme of constipation due to functional anorectal obstruction is presented in table (Fig. 4). With reduced sensitivity of the rectum mucosa, candles are prescribed, freed carbon dioxide, inducing the defecation reflex (lecicarbon). For the production of calls for defecation, microclisms can be prescribed up to 200 ml daily in the morning. In specialized treatment centers of this type of constipation, the biological feedback method is successfully applied - BioFeedBack. BiofedBack - training turned out to be effective in 85% of patients with functional obstruction of the anorectal zone [5]. With all types of constipation, drugs that restore intestinal biocenosis should include in complex treatment. And although the effect of probiotics with constipation from a scientific point of view is not convincing enough, their use allows reducing gas formation in the intestines and often reducing the dose of laxatives. So, effective treatment of constipation is achieved due to the joint interaction of the doctor and the patient when choosing the optimal scheme of therapy that improves the quality of the patient.

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