Thursday, November 11, 2010

I love you Mommy, But u never Loved Me

I Love You Mommy

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Hi, Mommy. I’m your baby. You don’t know me yet, I’m only a few weeks old. You’re going to find out about me soon, though, I promise. Let me tell you some things about me.  imageI’ve got beautiful brown eyes and black hairs like yours . Well, I don’t have it yet, but I will when I’m born.

I’m going to be your only child, and you’ll call me your one and only. I’m going to grow up without a daddy mostly, but we have each other. We’ll help each other, and love each other. I want to be a doctor when I grow up.

You found out about me today, Mommy! You were so excited, you couldn’t wait to tell everyone. All you could do all day was smile, and life was perfect. You have a beautiful smile, Mommy. It will be the first face I will see in my life, and it will be the best thing I see in my life. I know it already.

Today was the day you told Daddy. You were so excited to tell him about me! …He wasn’t happy, Mommy. He kind of got angry. I don’t think that you noticed, but he did. He started to talk about something called wedlock, and money, and bills, and stuff I don’t think I understand yet. You were still happy, though, so it was okay. Then he did something scary, Mommy. He hit you. I could feel you fall backward, and your hands flying up to protect me. I was okay… but I was very sad for you.
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You were crying then, Mommy. That’s a sound I don’t like. It doesn’t make me feel good. It made me cry, too. He said sorry after, and he hugged you again. You forgave him, Mommy, but I’m not sure if I do. It wasn’t right. You say he loves you… why would he hurt you? I don’t like it, Mommy.

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Finally, you can see me! Your stomach  is a little bit bigger, and you’re so proud of me! You went out with your mommy to buy new clothes, and you were so so so happy. You sing to me, too. You have the most beautiful voice in the whole wide world. When you sing is when I’m happiest. And you talk to me, and I feel safe. So safe. You just wait and see, Mommy. When I am born I will be perfect just for you. I will make you proud, and I will love you with all of my heart.


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I can move my hands and feet now, Mommy. I do it because you put your hands on your belly to feel me, and I giggle. You giggle, too. I love you, Mommy.


Daddy came to see you today, Mommy. I got really scared. He was acting funny and he wasn’t talking right. He said he didn’t want you. I don’t know why, but that’s what he said. And he hit you again. I got angry, Mommy. When I grow up I promise I won’t let you get hurt! I promise to protect you. Daddy is bad. I don’t care if you think that he is a good person, I think he’s bad. But he hit you, and he said he didn’t want us. He doesn’t like me. Why doesn’t he like me, Mommy?

You didn’t talk to me tonight, Mommy. Is everything okay?
It’s been three days since you saw Daddy. You haven’t talked to me or touched me or anything since that. Don’t you still love me, Mommy? I still love you. I think you feel sad. The only time I feel you is when you sleep. You sleep funny, kind of curled up on your side. And you hug me with your arms, and I feel safe and warm again. Why don’t you do that when you’re awake, any more?


I’m 21 weeks old today, Mommy. Aren’t you proud of me? We’re going somewhere today, and it’s somewhere new. I’m excited. It looks like a hospital, too. I want to be a doctor when I grow up, Mommy. Did I tell you that? I hope you’re as excited as I am. I can’t wait.

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…Mommy, I’m getting scared. Your heart is still beating, but I don’t know what you are thinking. The doctor is talking to you. I think something’s going to happen soon. I’m really, really, really scared, Mommy. Please tell me you love me. Then I will feel safe again. I love you!

Mommy, what are they doing to me!? It hurts! Please make them stop! It feels bad! Please, Mommy, please please help me! Make them stop!

Don’t worry Mommy, I’m safe. I’m in heaven with the angels now. They told me what you did, and they said it’s called an abortion.

Why, Mommy? Why did you do it? Don’t you love me any more? Why did you get rid of me? I’m really, really, really sorry if I did something wrong, Mommy. I love you, Mommy! I love you with all of my heart. Why don’t you love me? What did I do to deserve what they did to me? I want to live, Mommy! Please! It really, really hurts to see you not care about me, and not talk to me. Didn’t I love you enough? Please say you’ll keep me, Mommy! I want to live smile and watch the clouds and see your face and grow up and be a doctor. I don’t want to be here, I want you to love me again!

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I’m really really really sorry if I did something wrong. I love you!
I love you, Mommy.

If You are against abortion do share this.

Thursday, November 4, 2010

Mouth Ulcers

Mouth Ulcers 


Mouth ulcers are small oval sores, red in colour, which develop inside the mouth. They are commonly found in the inner part of the cheeks, inside the lips, under the tongue or on the soft palate. This type of ulcer is not contagious unlike cold sores and usually disappears after a couple of weeks.
These are also known as ‘canker sores’ or ‘aphthous ulcers’.
Mouth ulcers affect both men and women although women are more commonly affected. Teenagers are especially prone to developing these which can often be a result of stress, poor diet or a lack of sleep!
You may find that you develop mouth ulcers if you are ‘run down’ or have high stress levels.

What does a mouth ulcer look like?

It is a round or oval type of swelling with a yellow or white coloured centre. It may have a ‘crater-like’ appearance and is often red and painful. Most people experience a single mouth ulcer but it is not uncommon to develop several ulcers at once.
You may experience pain when you eat or drink anything hot or cold. For those suffering with chronic mouth ulcers, they can expect to see as many 15 or 20 at a time.

Types of mouth ulcers

There are three types of mouth ulcers which are as follows:
  • Minor ulcers
  • Major ulcers
  • Herpetiform ulcers
Minor ulcers
Around 80% of all mouth ulcers are the minor type. They are oval or round in shape and are no bigger than 10mm in size. They have a pale yellow colour but often look red and swollen although they are not usually painful.
Usually just the one ulcer appears but up to five can appear at the same time.
This type of ulcer lasts for a week to ten days and disappears without any scarring.
Major ulcers
This type of ulcer is bigger and deeper than a minor ulcer and tends to occur in about 1 out of 10 cases. Usually one ulcer develops although two can appear at the same time. This ulcer lasts from ten days to several months but in some cases, they can remain for a year or two. These painful ulcers leave a scar after they have disappeared.
Herpetiform ulcers
Also known as ‘pinpoint’ulcers: these tiny ulcers are no bigger than 3mm in size and appear as clusters. These clusters can contain from four or five ulcers up to 100. In some cases they can combine together to form large, irregular shaped groups of ulcers. 
This type of ulcer appears in 10% of cases.
They usually take a week to ten days to clear and don’t result in any scarring.
Mouth ulcers are more common in people aged between 10 and 40. After that they tend to appear on occasions but this is less likely over time. Basically the older you get the less chance you have of developing mouth ulcers.
At some point you may stop developing mouth ulcers altogether.

Are mouth ulcers contagious?

No. You cannot get mouth ulcers from kissing or sharing a glass which has been used by someone with a mouth ulcer.
But what are contagious are cold sores which are formed from the herpes virus and can be transmitted via personal contact, e.g. kissing.
Some people rarely develop mouth ulcers but there are others who suffer from these on a regular basis. Around 1 in five people experience ‘recurring’mouth ulcers which can be a miserable experience

Diarrhea

Diarrhea


Diarrhea is loose, watery stools occurring more than three times in one day. Diarrhoea is a common problem that usually lasts a day or two and goes away on its own without any special treatment. However, prolonged diarrhoea can be a sign of other problems. People with diarrhoea may pass more than a quart of stool a day.
Diarrhoea can cause dehydration, which means the body lacks enough fluid to function properly. Dehydration is particularly dangerous in children and the elderly, and it must be treated promptly to avoid serious health problems.
People of all ages can get diarrhoea. The average adult has a bout of diarrhoea about four times a year.
What causes diarrhoea?
Diarrhoea may be caused by a temporary problem, like an infection, or a chronic problem, like an intestinal disease. A few of the more common causes of diarrhoea are
  • Bacterial infections. Several types of bacteria, consumed through contaminated food or water, can cause diarrhoea. Common culprits include Campylobacter, Salmonella, Shigella, and Escherichia coli.
  • Viral infections. Many viruses cause diarrhoea, including rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, and viral hepatitis.
  • Food intolerance's. Some people are unable to digest some component of food, such as lactose, the sugar found in milk.
  • Parasites. Parasites can enter the body through food or water and settle in the digestive system. Parasites that cause diarrhoea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.
  • Reaction to medicines, such as antibiotics, blood pressure medications, and antacids containing magnesium.
  • Intestinal diseases, like inflammatory bowel disease or coeliac disease.
  • Functional bowel disorders, such as irritable bowel syndrome, in which the intestines do not work normally.
Some people develop diarrhoea after stomach surgery or removal of the gallbladder. The reason may be a change in how quickly food moves through the digestive system after stomach surgery or an increase in bile in the colon that can occur after gallbladder surgery.
In many cases, the cause of diarrhoea cannot be found. As long as diarrhoea goes away on its own, an extensive search for the cause is not usually necessary.
People who visit foreign countries are at risk for traveller's diarrhoea, which is caused by eating food or drinking water contaminated with bacteria, viruses, or, sometimes, parasites. Traveller's diarrhoea is a particular problem for people visiting developing countries. Visitors to the United States, Canada, most European countries, Japan, Australia, and New Zealand do not face much risk for traveller's diarrhoea. (See "Preventing Traveller's Diarrhoea" below)
What are the symptoms?
Diarrhoea may be accompanied by cramping abdominal pain, bloating, nausea, or an urgent need to use the bathroom. Depending on the cause, a person may have a fever or bloody stools.
Diarrhoea can be either acute (short-term) or chronic (long-term). The acute form, which lasts less than 4 weeks, is usually related to a bacterial, viral, or parasitic infection. Chronic diarrhoea lasts more than 4 weeks and is usually related to functional disorders like irritable bowel syndrome or inflammatory bowel diseases like coeliac disease.
Diarrhoea in Children
Children can have acute or chronic forms of diarrhoea. Causes include bacteria, viruses, parasites, medications, functional disorders, and food sensitivities. Infection with the rotavirus is the most common cause of acute childhood diarrhoea. Rotavirus diarrhoea usually resolves in 3 to 9 days.
Medications to treat diarrhoea in adults can be dangerous to children and should be given only under a doctor's guidance.
Diarrhoea can be dangerous in newborns and infants. In small children, severe diarrhoea lasting just a day or two can lead to dehydration. Because a child can die from dehydration within a few days, the main treatment for diarrhoea in children is rehydration. (See "Preventing Dehydration" below .)

What is dehydration?
General signs of dehydration include
  • thirst
  • less frequent urination
  • dry skin
  • fatigue
  • light-headedness
  • dark colored urine
Signs of dehydration in children include
  • dry mouth and tongue
  • no tears when crying
  • no wet nappies (diapers) for 3 hours or more
  • sunken abdomen, eyes, or cheeks
  • high fever
  • listlessness or irritability
  • skin that does not flatten when pinched and released
If you suspect that you or your child is dehydrated, call the doctor immediately. Severe dehydration may require hospitalization.
When should a doctor be consulted?
Although usually not harmful, diarrhoea can become dangerous or signal a more serious problem. You should see the doctor if any of the following is true:
  • You have diarrhoea for more than 3 days.
  • You have severe pain in the abdomen or rectum.
  • You have a fever of 102 degrees Fahrenheit or higher.
  • You see blood in your stool or have black, tarry stools.
  • You have signs of dehydration.
If your child has diarrhoea, do not hesitate to call the doctor for advice. Diarrhoea can be dangerous in children if too much fluid is lost and not replaced quickly.
What tests might the doctor do?
Diagnostic tests to find the cause of diarrhoea include the following:
  • Medical history and physical examination. The doctor will need to know about your eating habits and medication use and will examine you for signs of illness.
  • Stool culture. Lab technicians analyze a sample of stool to check for bacteria, parasites, or other signs of disease or infection.
  • Blood tests. Blood tests can be helpful in ruling out certain diseases.
  • Fasting tests. To find out if a food intolerance or allergy is causing the diarrhoea, the doctor may ask you to avoid lactose (found in milk products), carbohydrates, wheat, or other foods to see whether the diarrhoea responds to a change in diet.
  • Sigmoidoscopy. For this test, the doctor uses a special instrument to look at the inside of the rectum and lower part of the colon.
  • Colonoscopy. This test is similar to sigmoidoscopy, but the doctor looks at the entire colon.
What is the treatment?
In most cases, replacing lost fluid to prevent dehydration is the only treatment necessary. (See "Preventing Dehydration" below.) Medicines that stop diarrhoea may be helpful in some cases, but they are not recommended for people whose diarrhoea is caused by a bacterial infection or parasite - stopping the diarrhoea traps the organism in the intestines, prolonging the problem. Instead, doctors usually prescribe antibiotics. Viral causes are either treated with medication or left to run their course, depending on the severity and type of the virus.

Preventing Dehydration

Dehydration occurs when the body has lost too much fluid and electrolytes (the salts potassium and sodium). The fluid and electrolytes lost during diarrhoea need to be replaced promptly - the body cannot function properly without them. Dehydration is particularly dangerous for children, who can die from it within a matter of days.
Although water is extremely important in preventing dehydration, it does not contain electrolytes. To maintain electrolyte levels, you could have broth or soups, which contain sodium, and fruit juices, soft fruits, or vegetables, which contain potassium.
For children, doctors often recommend a special rehydration solution that contains the nutrients they need. You can buy this solution in the grocery store without a prescription. Examples include Pedialyte, Ceralyte, and Infalyte.

Tips About Food

Until diarrhoea subsides, try to avoid milk products and foods that are greasy, high-fiber, or very sweet. These foods tend to aggravate diarrhoea.
As you improve, you can add soft, bland foods to your diet, including bananas, plain rice, boiled potatoes, toast, crackers, cooked carrots, and baked chicken without the skin or fat. For children, the paediatrician may recommend what is called the BRAT diet: bananas, rice, applesauce, and toast.
Preventing Traveller's Diarrhoea
Traveller's diarrhoea happens when you consume food or water contaminated with bacteria, viruses, or parasites. You can take the following precautions to prevent traveller's diarrhoea when you go abroad:
  • Do not drink any tap water, not even when brushing your teeth.
  • Do not drink unpasteurized milk or dairy products.
  • Do not use ice made from tap water.
  • Avoid all raw fruits and vegetables (including lettuce and fruit salad) unless they can be peeled and you peel them yourself.
  • Do not eat raw or rare meat and fish.
  • Do not eat meat or shellfish that is not hot when served to you.
  • Do not eat food from street vendors.
You can safely drink bottled water (if you are the one to break the seal), carbonated soft drinks, and hot drinks like coffee or tea.
Depending on where you are going and how long you are staying, your doctor may recommend that you take antibiotics before leaving to protect you from possible infection.
Points to Remember
  • Diarrhoea is a common problem that usually resolves on its own.
  • Diarrhoea is dangerous if a person becomes dehydrated.
  • Causes include viral, bacterial, or parasitic infections; food intolerance; reactions to medicine; intestinal diseases; and functional bowel disorders.
  • Treatment involves replacing lost fluids and electrolytes. Depending on the cause of the problem, a person might also need medication to stop the diarrhoea or treat an infection. Children may need an oral rehydration solution to replace lost fluids and electrolytes.
  • Call the doctor if a person with diarrhoea has severe pain in the abdomen or rectum, a fever of 102 degrees Fahrenheit or higher, blood in the stool, signs of dehydration, or diarrhoea for more than 3 days.

Constipation

Constipation


Constipation means different things to different people. For many people, it simply means infrequent stools. For others, however, constipation means hard stools, difficulty passing stools (straining), or a sense of incomplete emptying after a bowel movement. The cause of each of these "types" of constipation probably is different, and the approach to each should be tailored to the specific type of constipation.
Constipation also can alternate with diarrhea. This pattern commonly occurs as part of the irritable bowel syndrome (IBS). At the extreme end of the constipation spectrum is fecal impaction, a condition in which stool hardens in the rectum and prevents the passage of any stool.
The number of bowel movements generally decreases with age. Ninety-five percent of adults have bowel movements between three and 21 times per week, and this would be considered normal. The most common pattern is one bowel movement a day, but this pattern is seen in less than 50% of people. Moreover, most people are irregular and do not have bowel movements every day or the same number of bowel movements each day.
Medically speaking, constipation usually is defined as fewer than three bowel movements per week. Severe constipation is defined as less than one bowel movement per week. There is no medical reason to have a bowel movement every day. Going without a bowel movement for two or three days does not cause physical discomfort, only mental distress for some people. Contrary to popular belief, there is no evidence that "toxins" accumulate when bowel movements are infrequent or that constipation leads to cancer.
It is important to distinguish acute (recent onset) constipation from chronic (long duration) constipation. Acute constipation requires urgent assessment because a serious medical illness may be the underlying cause (for example, tumors of the colon). Constipation also requires an immediate assessment if it is accompanied by worrisome symptoms such as rectal bleeding, abdominal pain and cramps, nausea and vomiting, and involuntary loss of weight। In contrast, the evaluation of chronic constipation may not be urgent, particularly if simple measures bring relief.

What causes constipation?

Theoretically, constipation can be caused by the slow passage of digesting food through any part of the intestine. More than 95% of the time, however, the slowing occurs in the colon.

Medications
A frequently over-looked cause of constipation is medications. The most common offending medications include:
  • Narcotic pain medications such as codeine (for example, Tylenol #3), oxycodone (for example, Percocet), and hydromorphone (Dilaudid);

  • Antidepressants such as amitriptyline (Elavil) and imipramine (Tofranil)
  • Anticonvulsants such as phenytoin (Dilantin) and carbamazepine (Tegretol)

  • Iron supplements

  • Calcium channel blocking drugs such as diltiazem (Cardizem) and nifedipine (Procardia)
  • Aluminum-containing antacids such as Amphojel and Basaljel
In addition to the medications listed above, there are many others that can cause constipation. Simple measures (for example, increasing dietary fiber) for treating the constipation caused b
y medications often are effective, and discontinuing the medication is not necessary. If simple measures don't work, it may be possible to substitute a less constipating medication. For example, a nonsteroidal antiinflammatory drug (for example, ibuprofen) may be substituted for narcotic pain medications. Additionally, one of the newer and less constipating anti-depressant medications [for example, fluoxetine (Prozac)] may be substituted for amitriptyline and imipramine.
Habit
Bowel movements are under voluntary control. This means that the normal urge people feel when they need to have a bowel movement can be suppressed. Although occasionally it is appropriate to suppress an urge to defecate (for example, when a bathroom is not available), doing this too frequently can lead to a disappearance of urges and result in constipation.
Diet
Fiber is important in maintaining a soft, bulky stool. Diets that are low in fiber can, therefore, cause constipation. The best natural sources of fiber are fruits, vegetables, and whole grains.
Laxatives
One suspected cause of severe constipation is the over-use of stimulant laxatives [for example, senna (Senokot), castor oil, and certain herbs]. An association has been shown between the chronic use of stimulant laxatives and damage to the nerves and muscles of the colon, and it is believed by some that the damage is responsible for the constipation. It is not clear, however, whether the laxatives have caused the damage or whether the damage existed prior to the use of laxatives and, indeed, has caused the laxatives to be used. Nevertheless, because of the possibility that stimulant laxatives can dama
ge the colon, most experts recommend that stimulant laxatives be used as a last resort after non-stimulant treatments have failed.
Hormonal disorders
Hormones can affect bowel movements. For example:
  • Too little thyroid hormone (hypothyroidism) and too much parathy roid hormone (by raising the calcium levels in the blood) can cause constipation.
  • At the time of a woman's menstrual periods, estrogen and progesterone levels are high and may cause constipation. However, this is rarely a prolonged problem.

  • High levels of estrogen and progesterone during pregnancy also can cause constipation.
Central nervous system diseases
A few diseases of the brain and spinal cord may cause constipation, including Parkinson's disease, multiple sclerosis, and spinal cord injuries.
Colonic inertia
Colonic inertia is a condition in which the nerves and/or muscles of the colon do not work
normally. As a result, the contents of the colon are not propelled through the colon normally. The cause of colonic inertia is unclear. In some cases, the muscles or nerves of the colon are diseased. Colonic inertia also may be the result of the chronic use of stimulant laxatives as described above. In most cases, however, there is no clear cause for the constipation.
Pelvic floor dysfunction

How is constipation evaluated?

A careful history and physical examination is important in all patients with constipation. There are many tests that can be used to evaluate constipation. Most patients need only a few basic tests. The other tests are reserved for individuals who have severe constipation or whose constipation does not respond easily to treatment.
Medical History
A careful medical history from a patient with constipation is critical for many reasons, but particularly because it allows the physician to define the type of constipation. This, in turn, directs the diagnosis and treatment. For example, if defecation is painful, the physician knows to look for anal problems such as a narrowed anal sphincter or an anal fissure. If small stools are the problem, there is likely to be a lack of fiber in the diet. If the patient is experiencing significant straining, then pelvic floor dysfunction is likely.
The history also uncovers medications and diseases that can cause constipation. In these cases, the medications can be changed and the diseases can be treated.
A careful dietary history-which may require keeping a food diary for a week or two-can reveal a diet that is low in fiber and may direct the physician to recommend a high-fiber diet. A food diary also allows the physician to evaluate how well a patient increases his dietary fiber during treatment.
Physical examination
A physical examination may identify diseases (for example, scleroderma) that can cause constipation. A rectal examination with the finger may uncover a tight anal sphincter that may be making defecation difficult. If a stool-filled colon can be felt through the abdominal wall, it suggests that constipation is severe. Stool in the rectum suggests a problem with the anal, rectal, or pelvic floor muscles.
Blood tests
Blood tests may be appropriate in evaluating patients with constipation. More specifically, blood tests for thyroid hormone (to detect hypothyroidism) and for calcium (to uncover excess parathyroid hormone) may be helpful.
Abdominal X-ray
Large amounts of stool in the colon usually can be visualized on simple X-ray films of the abdomen; the more stool that is visualized, the more severe the constipation.
Barium enema
barium enema (lower GI series) is an x-ray study in which liquid barium is inserted through the anus to fill the rectum and colon. The barium outlines the colon on the X-rays and defines the normal or abnormal anatomy of the colon and rectum. Tumors and narrowings (strictures) are among the abnormalities that can be detected with this test.
Colonic transit (marker) studies
Colonic transit studies are simple X-ray studies that determine how long it takes for food to travel through the intestines. For transit studies, individuals swallow capsules for one or more days. Inside the capsules are many small pieces of plastic that can be seen on X-rays. The gelatin capsules dissolve and release the plastic pieces into the small intestine. The pieces of plastic then travel (as would digesting food) through the small intestine and into the colon. After 5 or 7 days, an X-ray of the abdomen is taken and the pieces of plastic in the different parts of the colon are counted. From this count, it is possible to determine if and where there is a delay in the colon.
In non-constipated individuals, all of the plastic pieces are eliminated in the stool and none remain in the colon. When pieces are spread throughout the colon, it suggests that the muscles and/or nerves throughout the colon are not working, which is typical of colonic inertia. When pieces accumulate in the rectum, it suggests pelvic floor dysfunction.
Defecography
Defecography is a modification of the barium enema examination. For this procedure, a thick paste of barium is inserted into the rectum of a patient through the anus. X-rays then are taken while the patient defecates the barium. The barium clearly outlines the rectum and anus and demonstrates the changes taking place in the muscles of the pelvic floor during defecation. Thus, defecography examines the process of defecation and provides information about anatomical abnormalities of the rectum and pelvic floor muscles during defecation.
Ano-rectal motility studies
Ano-rectal motility studies, which complement defecography tests, provide an assessment of the function of the muscles and nerves of the anus and rectum. For ano-rectal motility studies, a flexible tube, approximately an eighth of an inch in diameter, is inserted through the anus and into the rectum. Sensors within the tube measure the pressures that are generated by the muscles of the anus and rectum. With the tube in place, the patient performs several simple maneuvers such as voluntarily tightening the anal muscles. Ano-rectal motility studies can help determine if the muscles of the anus and rectum are working normally. When the function of these muscles is impaired, the flow of stool is obstructed, thereby causing a condition similar to pelvic floor dysfunction.
Colonic motility studies
Colonic motility studies are similar to ano-rectal motility studies in many aspects. A very long, narrow (one-eighth inch in diameter), flexible tube is inserted through the anus and passed through part or all of the colon during a procedure called colonoscopy. Sensors within the tube measure the pressures that are generated by the contractions of the colonic muscles। These contractions are the result of coordinated activity of the colonic nerves and muscles. If the activity of the nerves or muscles is abnormal, the pattern of colonic pressures will be abnormal. Colonic motility studies are most useful in defining colonic inertia. These studies are considered research tools, but they can be helpful in making decisions regarding treatment in patients with severe constipation.

What treatments are available for constipation?

There are many treatments for constipation, and the best approach relies on a clear understanding of the underlying cause.

Dietary fiber (bulk-forming laxatives)
The best way of adding fiber to the diet is increasing the quantity of fruits and vegetables that are eaten. This means a minimum of five servings of fruits or vegetables every day. For many people, however, the amount of fruits and vegetables that are necessary may be inconveniently large or may not provide adequate relief from constipation. In this case, fiber supplements can be useful.
Fiber is defined as material made by plants that is not digested by the human gastrointestinal tract. Fiber is one of the mainstays in the treatment of constipation. Many types of fiber within the intestine bind to water and keep the water within the intestine. The fiber adds bulk (volume) to the stool and the water softens the stool.
There are different sources of fiber and the type of fiber varies from source to source. Types of fiber can be categorized in several ways, for example, by their source.
The most common sources of fiber include:
  • fruits and vegetables,
  • wheat or oat bran,
  • psyllium seed (for example, Metamucil, Konsyl),
  • synthetic methyl cellulose (for example, Citrucel), and
  • polycarbophil (for example, Equilactin, Konsyl Fiber).
Polycarbophil often is combined with calcium (for example, Fibercon). However, in some studies, the calcium-containing polycarbophil was not as effective as the polycarbophil without calcium.
A lesser known source of fiber is an extract of malt (for example, Maltsupex); however, this extract may soften stools in ways other than increasing fiber.
Increased gas (flatulence) is a common side effect of high-fiber diets. The gas occurs because the bacteria normally present within the colon are capable of digesting fiber to a small extent. The bacteria produce gas as a byproduct of their digestion of fiber. All fibers, no matter what their source, can cause flatulence. However, since bacteria vary in their ability to digest the various types of fiber, the different sources of fiber may produce different amounts of gas. To complicate the situation, the ability of bacteria to digest one type of fiber can vary from individual to individual. This variability makes the selection of the best type of fiber for each person (for example, a fiber that improves the quality of the stool without causing flatulence) more difficult. Thus, finding the proper fiber for an individual becomes a matter of trial and error.
The different sources of fiber should be tried one by one. The fiber should be started at a low dose and increased every one to two weeks until either the desired effect on the stool is achieved or troublesome flatulence interferes. (Fiber does not work overnight.) If flatulence occurs, the dose of fiber can be reduced for a few weeks and the higher dose can then be tried again. (It generally is said that the amount of gas that is produced by fiber decreases when the fiber is ingested for a prolonged period of time; however, this has never been studied.) If flatulence remains a problem and prevents the dose of fiber from being raised to a level that affects the stool satisfactorily, it is time to move on to a different source of fiber.
When increasing amounts of fiber are used, it is recommended that greater amounts of water be consumed (for example, a full glass with each dose). Presumably, the water prevents "hardening" of the fiber and blockage (obstruction) of the intestine. This seems like simple and reasonable advice. However, ingesting larger amounts of water has never been shown to have any beneficial effect on constipation, with or without the addition of fiber. (There is already a lot of water in the intestine and extra water is absorbed and excreted in the urine.) It is reasonable to drink enough fluids to prevent dehydration because with dehydration there may be reduced intestinal water.
Because of concern about obstruction, persons with narrowings (strictures) or adhesions (scar tissue from previous surgery) of their intestines should not use fiber unless it has been discussed with their physician. Some fiber laxatives contain sugar, and patients with diabetes may need to select sugar-free products.
Lubricant laxatives
Lubricant laxatives contain mineral oil as either the plain oil or an emulsion (combination with water) of the oil. The oil stays within the intestine, coats the particles of stool, and presumably prevents the removal of water from the stool. This retention of water in the stool results in softer stool. Mineral oil generally is used only for the short-term treatment of constipation since its long-term use has several potential disadvantages.
The oil can absorb fat-soluble vitamins from the intestine and, if used for prolonged periods, may lead to deficiencies of these vitamins. This is of particular concern in pregnancy during which an adequate supply of vitamins is important for the fetus. In the very young or very elderly in whom the swallowing mechanism is not strong or is impaired by strokes, small amounts of the swallowed oil may enter the lungs and cause a type of pneumonia called lipid pneumonia. Mineral oil also may decrease the absorption of some drugs such as warfarin oral contraceptives, thereby decreasing their effectiveness. Despite these potential disadvantages, mineral oil can be effective when short-term treatment is necessary. (Coumadin) and
Emollient laxatives (stool softeners)
Emollient laxatives are generally known as stool softeners. They contain a compound called docusate (for example, Colace). Docusate is a wetting agent that improves the ability of water within the colon to penetrate and mix with stool. This increased water in the stool softens the stool. Studies, however, have not shown docusate to be consistently effective in relieving constipation. Nevertheless, stool softeners often are used in the long-term treatment of constipation. It may take a week or more for docusate to be effective. The dose should be increased after one to two weeks if no effect is seen.
Although docusate generally is safe, it may allow the absorption of mineral oil and some medications from the intestine. Absorbed mineral oil collects in tissues of the body, for example, the lymph nodes and the liver, where it causes inflammation. It is not clear if this inflammation has any important consequences, but it generally is felt that prolonged absorption of mineral oil should not be allowed. The use of emollient laxatives is not recommended together with mineral oil or with certain prescription medications. Emollient laxatives are commonly used when there is a need to soften the stool temporarily and make defecation easier (for example, after surgery, childbirth, or heart attacks). They are also used for individuals with hemorrhoids or anal fissures.
Hyperosmolar laxatives
Hyperosmolar laxatives are undigestible, unabsorbable compounds that remain within the colon and retain the water that already is in the colon. The result is softening of the stool. The most common hyperosmolar laxatives are lactulose (for example, Kristalose), sorbitol, and polyethylene glycol (for example, MiraLax). and are available by prescription only. These laxatives are safe for long-term use and are associated with few side effects.
Hyperosmolar laxatives may be digested by colonic bacteria and turned into gas, which may result in unwanted abdominal bloating and flatulence. This effect is dose-related and less with polyethylene glycol. Therefore, gas can be reduced by reducing the dose of the laxative. In some cases, the gas will decrease over time.
Saline laxatives
Saline laxatives contain non-absorbable ions such as magnesium, sulfate, phosphate, and citrate [for example, magnesium citrate (Citroma), magnesium hydroxide, sodium phosphate). These ions remain in the colon and cause water to be drawn into the colon. Again, the effect is softening of the stool.
Magnesium also may have mild stimulatory effects on the colonic muscles. The magnesium in magnesium-containing laxatives is partially absorbed from the intestine and into the body. Magnesium is eliminated from the body by the kidneys. Therefore, individuals with impaired kidney function may develop toxic levels of magnesium from chronic (long duration) use of magnesium-containing laxatives.
Saline laxatives act within a few hours. In general, potent saline laxatives should not be used on a regular basis. If major diarrhea develops with the use of saline laxatives and the lost fluid is not replaced by the consumption of liquids, dehydration may result. For constipation, the most frequently-used and mildest of the saline laxatives is milk of magnesia. Epsom Salt is a more potent saline laxative that containsmagnesium sulfate.
Stimulant laxatives
Stimulant laxatives cause the muscles of the small intestine and colon to propel their contents more rapidly. They also increase the amount of water in the stool, either by reducing the absorption of the water in the colon or by causing active secretion of water in the small intestine.
The most commonly-used stimulant laxatives contain cascara (castor oil), senna (for example, Ex-Lax, Senokot), and aloe. Stimulant laxatives are very effective, but they can cause severe diarrhea with resulting dehydration and loss of electrolytes (especially potassium). They also are more likely than other types of laxatives to cause intestinal cramping. There is concern that chronic use of stimulant laxatives may damage the colon and worsen constipation, as previously discussed. Bisacodyl (for example, Dulcolax, Correctol) is a stimulant laxative that affects the nerves of the colon which, in turn, stimulate the muscles of the colon to propel its contents. Prunes also contain a mild colonic stimulant.
Lubiprostone (Amitiza)
Lubiprostone (Amitiza) is a selective chloride channel activator that increases secretion of chloride ions from the cells of the intestinal lining into the intestinal lumen. Sodium ions and water then follow the chloride ions into the lumen, and the water softens the stool. The FDA approved lubiprostone for the treatment of chronic constipation in both men and women in February 2006. At a dose of 24 micrograms twice a day, lubiprostone significantly and promptly increased bowel movements, improved stool consistency, and decreased straining. The most common side effect of initial clinical studies was mild to moderate nausea in 32% of patients treated with lubiprostone, compared to 3% of the controls. More long term studies of efficacy and side effects are needed to determine the place of lubiprostone in the treatment of constipation.
Enemas
There are many different types of enemas. By distending the rectum, all enemas (even the simplest type, the tap water enema) stimulate the colon to contract and eliminate stool. Other types of enemas have additional mechanisms of action. For example, saline enemas cause water to be drawn into the colon. Phosphate enemas (for example, Fleet phosphosoda) stimulate the muscles of the colon. Mineral oil enemas lubricate and soften hard stool. Emollient enemas (for example, Colace Microenema) contain agents that soften the stool.
Enemas are particularly useful when there is impaction, which is hardening of stool in the rectum. In order to be effective, the instructions that come with the enema must be followed. This requires full application of the enema, appropriate positioning after the enema is instilled, and retention of the enema until cramps are felt. Defecation usually occurs between a few minutes and one hour after the enema is inserted.
Enemas are meant for occasional rather than regular use. The frequent use of enemas can cause disturbances of the fluids and electrolytes in the body. This is especially true of tap water enemas. Soapsuds enemas are not recommended because they can seriously damage the rectum.
Suppositories
As is the case with enemas, different types of suppositories have different mechanisms of action. There are stimulant suppositories containing bisacodyl (for example, Dulcolax). Glycerin suppositories are believed to have their effect by irritating the rectum. The insertion of the finger into the rectum when the suppository is placed may itself stimulate a bowel movement.
Combination products
There are many products that combine different laxatives. For example, there are oral products that combine senna and psyllium (Perdiem), senna and docusate (Senokot-S), and senna and glycerin (Fletcher's Castoria). One product even combines three laxatives, senna-like casanthranol, docusate, and glycerin (Sof-lax Overnight). These products may be convenient and effective, but they also contain stimulant laxatives. Therefore, there is concern about permanent colonic damage with the use of these products, and they probably should not be used for long-term treatment unless non-stimulant treatment fails.

Colchicine
Colchicine is a drug that has been used for decades to treat gout. Most patients who take colchicine note a loosening of their stools. Colchicine has also been demonstrated to relieve constipation effectively in patients without gout.

Misoprostol (Cytotec)
Misoprostol (Cytotec) is a drug used primarily for preventing stomach ulcers caused by nonsteroidal antiinflammatory drugs such as ibuprofen. Diarrhea is one of its consistent side-effects. Several studies have shown that misoprostol is effective in the short term treatment of constipation. Misoprostol is expensive, and it is not clear if it will remain effective and safe with long-term use. Therefore, its role in the treatment of constipation remains to be determined.
Exercise
People who lead sedentary lives are more frequently constipated than people who are active. Nevertheless, limited studies of exercise on bowel habit have shown that exercise has minimal or no effect on the frequency of bowel movements. Thus, exercise can be recommended for its many other health benefits, but not for its effect on constipation.
Biofeedback
Most of the muscles of the pelvis surrounding the anus and rectum are under some degree of voluntary control. Thus, biofeedback training can teach patients with pelvic floor dysfunction how to make their muscles work more normally and improve their ability to defecate. During ano-rectal biofeedback training, a pressure-sensing catheter is placed through the anus and into the rectum. Each time a patient contracts the muscles, the muscles generate a pressure that is sensed by the catheter and recorded on a screen. By watching the pressures on the screen and attempting to modify them, patients learn how to relax and contract the muscles more normally.
Surgery
For individuals with problematic constipation that is due to diseases of the colon or laxative abuse, surgery is the ultimate treatment. During surgery, most of the colon, except for the rectum (or the rectum and part of the sigmoid colon), is removed. The cut end of the small intestine is attached to the remaining rectum or sigmoid colon. In patients with colonic inertia, surgery is reserved for those who do not respond to all other therapies. If the surgery is to be done, there must be no disease of the small intestinal muscles. Normal small intestinal muscles are evidenced by normal motility studies of the small intestine itself.

What is the approach to the evaluation and treatment of constipation?

There are several principles in approaching the evaluation and treatment of constipation.
  • The first principle is to differentiate between acute (recent onset) and chronic (long duration) constipation. Thus, with acute constipation or constipation that is worsening, it is necessary to assess for the cause early so as not to overlook a serious illness that should be treated urgently.
  • The second principle is to start treatment early and use the treatments that have the least potential for harm. This will prevent constipation from worsening, and it also will prevent potential damage to the colon that can be caused by the frequent use of stimulant laxatives.
  • The third principle is to know when it is time to evaluate the cause of chronic constipation. Evaluation for the cause of chronic constipation needs to be done if there is no response to the simple treatments.
The goal of treatment in constipation should not be a bowel movement every day, but a bowel movement every two to three days without difficulty (without straining).
Start with the simple things.
  • Don't suppress urges to defecate. When the urge comes, find a toilet.
  • With the assistance of your physician and pharmacist, determine if there are drugs that you are taking that could be contributing to the constipation. See if the drugs can be discontinued or changed.
  • Increase the fiber in your diet by consuming more fruits, vegetables, and whole grains. (There are other health benefits from this recommendation as well.)
  • It may be difficult to get enough fiber in the diet to effectively treat constipation, so don't hesitate to take fiber supplements if necessary (wheat bran, psyllium, etc.).
  • Use increasing amounts of fiber and/or change the type of fiber consumed until there is a satisfactory result.
  • Don't expect fiber to work overnight. Allow weeks for adequate trials.
What if constipation does not respond to these simple, safe measures? These efforts should not be discontinued but other measures should be added. If the constipation is infrequent, that is, every few weeks (as it can be when due to the menstrual cycle), it probably doesn't matter what other measures are added-emollient, saline, or hyper-osmolar laxatives, enemas, and suppositories. Even stimulant laxatives every four to isx weeks are unlikely to damage the colon. Unfortunately, the tendency when using stimulant laxatives is to unconsciously increase the frequency of their use. Before you know it, you're taking them every week, or more often, and permanent damage might result.
If constipation is a continuous rather than an intermittent problem, probably the safest laxatives to take on a regular basis are the hyper-osmolar laxatives. They require a prescription and, therefore, necessitate a call to a physician. As with fiber, increasing doses of different hyper-osmolar laxatives should be tried over several weeks until a satisfactory type and dose of laxative is found. Hyper-osmolar laxatives, however, can be expensive. Milk of magnesia is the mildest of the saline laxatives, is inexpensive, and provides a good alternative. Most patients can adjust the dose of milk of magnesia to soften the stool adequately without developing diarrhea or leakage of stool.
Stronger stimulant laxatives usually are recommended only as a last resort after non-stimulant treatments have failed.
Many people take herbs to treat their constipation because they feel more comfortable using a "natural" product। Unfortunately, most of these herbal preparations contain stimulant laxatives and their long term use raises the possibility that they also may damage the colon.

When should I seek medical care for chronic constipation?

If the main problem is straining to push the stool out, chronic constipation should probably be evaluated early. This difficulty might be due to pelvic floor dysfunction, and the treatment of choice is biofeedback training, not laxatives. If the constipation is not responding to the simple measures discussed previously with the addition of hyper-osmolar laxatives or milk of magnesia, it is time to consult a physician for an evaluation. If a primary doctor is not comfortable performing the evaluation or does not have confidence in doing an evaluation, he or she should refer the patient to a gastroenterologist. Gastroenterologists evaluate constipation frequently and are very familiar with the diagnostic testing described previously.

What's new in the treatment of constipation?

Each part of the intestine (stomach, small intestine, and colon) has a network of nerves that controls its muscles. A great deal of research is being done in order to gain an understanding of how these nerves control each other and ultimately the muscles. Much of this research involves the study of neurotransmitters. (Neurotransmitters are chemicals that nerves use to communicate with each other.) This research is allowing scientists to develop drugs that stimulate (and inhibit) the various nerves of the colon which, in turn, cause the muscles of the colon to contract and propel the colonic contents. Such drugs have great potential for the treatment of constipation that is due to colonic inertia. The first of these drugs is in clinical trials and is likely to be available soon. These drugs are an exciting development because they offer a new treatment for a difficult-to-treat form of constipation.
Constipation At A Glance
  • Constipation is defined medically as fewer than three stools per week and severe constipation as less than one stool per week.
  • Constipation usually is caused by the slow movement of stool through the colon.
  • There are many causes of constipation including medications, poor bowel habits, low fiber diets, abuse of laxatives, hormonal disorders, and diseases primarily of other parts of the body that also affect the colon.
  • The two disorders limited to the colon that cause constipation are colonic inertia and pelvic floor dysfunction.
  • Medical evaluation for the cause of constipation should be done when constipation is of sudden onset, severe, worsening, associated with other worrisome symptoms such as loss of weight, or is not responding to simple, safe treatments.
  • Medical evaluation of constipation may include a history, physical examination, blood tests, abdominal X-rays, barium enema, colonic transit studies, defecography, ano-rectal motility studies, and colonic motility studies.
  • The goal of therapy for constipation is one bowel movement every two to three days without straining.
  • Treatment of constipation may include dietary fiber, non-stimulant laxatives, stimulant laxatives, enemas, suppositories, biofeedback training, and surgery.
  • Stimulant laxatives should be used as a last resort because of the possibility that they may permanently damage the colon and worsen constipation.
  • Most herbal laxatives contain stimulant-type laxatives and should be used, if at all, as a last resort.