CONSTIPATION IN ADULTS: ROME IV DIAGNOSIS, IMPLICATIONS, ECONOMIC BURDEN, AND PREVENTION MEASURES

Author: Dr. Le Chau Hoang Quoc Chuong 

(Head of the Department of Proctology – University Medical Center of Ho Chi Minh City)

1. INTRODUCTION TO CONSTIPATION IN ADULTS

The hustle and bustle of daily life sweeps people into the whirlwind of work, sometimes causing them to unintentionally forget essential daily needs for food and health, leading to an increase in common illnesses. One of these is constipation – a common digestive ailment.

So, is chronic constipation dangerous? What are the causes and how can this condition be treated effectively, as well as some preventive measures?

Constipation is a common digestive disorder that affects the quality of life and gut health of many people, especially the elderly and women. It's not only an unpleasant problem but can also lead to serious complications such as hemorrhoids, anal fissures, or rectal prolapse if left unmanaged.

2. SYMPTOMS OF CONSTIPATION 

Constipation is characterized by the passage of dry, hard stools, difficulty passing stool, straining during bowel movements, prolonged defecation time, or infrequent bowel movements (occurring only every few days), under normal dietary conditions. This is a fairly common digestive condition. It must have lasted for at least 3 months (not necessarily consecutively) in the past year.

Diagnostic criteria for constipation according to ROME IV

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

• Difficulty defecating in ≥25% of bowel movements.
• Stool is solid or hard in ≥25% of bowel movements.
• Feeling of incomplete bowel emptying in ≥25% of bowel movements.
• Feeling of anal-rectal obstruction in ≥25% of bowel movements.
• Manual assistance (e.g., using hands to support the perineum or anus) is needed in ≥25% of bowel movements.
• Number of bowel movements <3 times/week.
• There are no symptoms of irritable bowel syndrome (IBS).

Constipation can be divided into functional constipation (not due to an underlying physical condition) and secondary constipation (related to a medical condition, medication, or diet).

3. FREQUENCY OF CONSTIPATION

Constipation is a common condition worldwide:

• The prevalence of constipation in adults ranges from 12-20%, with women being twice as likely as men.
• Older adults (≥60 years old) are at a higher risk of constipation due to decreased bowel function, reduced physical activity, and the use of various medications.
• Chronic constipation accounts for approximately 30-50% of constipation cases, leading many patients to seek medical attention.

4. THE ECONOMIC BURDEN OF CONSTIPATION

Constipation places a significant economic burden on both the healthcare system and patients:

• Direct treatment costs: 
  • The costs include laxatives, doctor's visits, imaging tests (abdominal X-ray, pelvic MRI), and surgery if necessary.
  • In the United States, the total annual cost of treating constipation is estimated to be over $230 million.
• Indirect costs: 
  • Giảm năng suất lao động, mất ngày công do triệu chứng táo bón và các biến chứng liên quan như trĩ, rò hậu môn.
• Impact on quality of life: 
  • It negatively impacts mental health, causing anxiety, stress, and a decline in daily quality of life.

5. CAUSES OF CONSTIPATION

The causes of constipation can be divided into three main groups:

Functional constipation (60%) is due to diet, medication, or systemic disease; colonic inertia (12%), outlet obstruction syndrome (25%), and a combination of colonic inertia and outlet obstruction syndrome (3%).

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

Unhealthy dietary habits, particularly a low-fiber diet, are a contributing factor. Fiber is abundant in fruits and vegetables, and some types of fiber are indigestible, helping to soften stool. Normally, we need 25-30g of fiber per day. A lack of fiber in the diet is common among people who frequently consume fast food, eat a lot of meat, eggs, milk, and dairy products; and among the elderly who are reluctant to eat high-fiber foods due to difficulty chewing and swallowing. Additionally, insufficient water intake contributes to constipation; and consuming stimulants like coffee and black tea can worsen constipation.

Due to irregular bowel habits or forgetting to defecate, the urge to defecate is disrupted.

Due to medication: some medications reduce bowel motility or dry out the stool, such as opioids, tannins, sedatives, Parkinson's disease medications and anticonvulsants, iron supplements, and potassium-depleting diuretics. Prolonged use of stimulant laxatives.

Systemic diseases that cause metabolic disorders (glucose, protein, or lipid): diabetes mellitus, hypothyroidism, hyperparathyroidism, scleroderma, significant blood loss after surgery, stroke, etc. These causes disrupt colon motility, reduce water absorption from the colon, leading to dehydration and resulting in dry stools and constipation.

Occupational factors: jobs that involve prolonged sitting and little physical activity, jobs involving exposure to lead, chronic lead poisoning, all affect bowel function.

Due to weakness: elderly people, those who are weak, or those with chronic illnesses who have to lie down for extended periods. The above causes reduce bowel motility and abdominal muscle tone, leading to constipation.

Psychiatric disorders: anxiety, depression, neglect of bowel movements, loss of the urge to defecate.

Constipation can have physical causes:

It is necessary to rule out tumors of the rectum, colon, etc. Besides constipation, there may be bloody mucus in the stool, possibly constipation, and a colonoscopy may reveal a tumor.

External pressure obstructing bowel movements: Pregnant women, especially in the later months, with a large fetus pressing on the rectum. Pelvic tumors (uterine fibroids). Adhesions after surgery or inflammation around the colon and rectum causing narrowing of the rectum and colon.

Rectal and anal stenosis

Constipation due to colonic inertia.

Congenital abnormalities of the colon: Megacolon, dilated colon…Deficiency of Cajal cells in the colon wall

Constipation due to bowel obstruction. 

Pelvic floor disorders such as pelvic floor prolapse, uterine prolapse, and bladder prolapse. Rectal prolapse (pouch type), rectal-anal intussusception, small bowel prolapse.

Anal sphincter spasm (pubococcygeal muscle spasm)

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

Preventing constipation is crucial for maintaining digestive health and preventing complications. Some effective measures include:

6.1. Adjusting your diet

• Increase your fiber intake.: 
  • Supplement your diet with 25-30g of fiber per day from green vegetables, fruits, and whole grains.
  • Some good foods include: flax seeds, oats, ripe bananas, apples, and sweet potatoes.
• Drink enough water.: 
  • 1.5 – 2 liters of water/day, especially in older adults who tend to drink less water.
• Hạn chế thực phẩm gây táo bón: 
  • Processed foods, low-fiber foods, fast food, alcohol, and coffee.

6.2. Maintain physical activity

• Exercising for at least 30 minutes a day (walking, yoga, swimming) helps stimulate bowel movements.
• Pelvic floor exercises can help improve colon function in older women.

6.3. Establishing a regular bowel movement routine

• Go to the toilet as soon as you feel the need, don't hold it in for too long.
• Establish a habit of having a bowel movement at a fixed time of day (usually in the morning after breakfast).

6.4. Limit the overuse of laxatives.

• Use only when absolutely necessary and as directed by a doctor.
• Abusing laxatives can disrupt the bowel's natural reflexes and lead to drug dependence.

6.5. Managing stress and sleep

• Stress disrupts bowel movements, so it's important to get enough sleep and practice relaxation techniques like meditation and yoga.

7. CONCLUSION

Constipation is a significant health problem, especially in older women, greatly impacting quality of life and increasing the economic burden. Early diagnosis according to the Rome IV protocol, combined with dietary adjustments, lifestyle changes, and physical activity, can help prevent and effectively manage the condition.

If constipation is prolonged or severely affects daily life, patients should seek examination at a specialized proctology clinic for timely assessment and treatment.

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