Constipation

1. Background/Cultural Points:

   Constipation is common in Cambodia, possibly related to low fiber diet and chronic under-hydration. Whole-grain rice is considered “poor-man’s rice” and inferior in taste. It also does not keep as well in storage. Intermittent diarrhea is also common, usually related to infectious causes or food poisoning. Changes in bowel habits are therefore a “normal” event and may not be reported.

2. Diagnosis & Lab:

   1. Straining, hard stools, feeling of incomplete emptying of rectum, <3 stools per week.
   2. Rectal examination usually indicated.
   3. Consider possibility of constipation with overflow in patients with “diarrhea”. Consider behavioural withholding of stool in toddlers. Fully breast-fed babies never get constipated and have a wide normal range of stool frequency.
   4. Look for medical and drug causes
   5. Investigate only if red flags for serious cause (age >40, general malaise, weight loss, alternating constipation/diarrhea or recent change in bowel habits, rectal bleeding, anemia, jaundice, hepatomegaly, abdominal or rectal mass, poor response to initial management). (We have seen colon Ca in young adults here.)
   6. Consider CBC, U&Es, TSH, Ca2+, colonoscopy (Calmette)

3. Management/Education/Treatment:

   1. Review with patient: 1) most resolve with lifestyle changes which also have other health benefits 2) serious disease considered/excluded 3) minimal use of medications especially stimulants (occasional patients need long-term medications)
   2. Lifestyle Points:
      1. Dietary fiber – whole-grain rice at least 50% of meals (“angkor samroup”), vegetables, fruit (excluding banana which is constipating), nuts
      2. Adequate fluid intake (water source may not be clean – water filter?)
      3. Exercise if sedentary
      4. Minimize constipating medications
   3. Medications (consider if no contraindications and bowel obstruction excluded):
      1. Bran powder 1-2 tsp at least once a day with fluids (bulking agent)
      2. Docusate (Colace) 1-2 tabs at night (softener, mild stimulant) (purchased out of country; check supply)
      3. Bisacodyl +/- Senna 1-2 tabs at night (stimulant) (cheap; easy access)
      4. Lactulose also available

4. Follow-Up:

   Initial follow-up at 1 month, consider investigation if not resolved; Watch for red flags at any follow-up visits