Constipation (Vibandha)

Introduction

Constipation is a disease condition resembling to Vibandha described in Ayurveda. It refers to bowel movements that are infrequent or hard to pass and is a general term used to indicate fewer bowel movements, Solidified hard stools, painful defecation and feeling of bloating, abdominal discomfort or incomplete elimination. Constipation is a common cause of painful defecation. Severe constipation includes obstipation (failure to pass stools or gas, Intestinal obstruction; severe constipation.) and fecal impaction, which can progress to bowel obstruction and become life-threatening. It is a very common gastro-intestinal disorder experienced by most people at some time during their life time. Numerous conditions can lead to constipation by disrupting the normal process of absorption, stool formation and propelling of feces within the large intestine.

Constipation may be just due to a poor diet with insufficient fiber, poor fluid intake or a side effect of certain medication. Sometimes it may be due to any mechanical obstruction or a serious problem such as colon cancer.

Elderly people are more likely to suffer from constipation due to changes in diet, medication and/ or decreased mobility and intestinal motility. The exact figure on the prevalence of constipation is not known. Around 2% of the population suffers recurrent and constant

constipation and is more common in women than in men. The overall prevalence of self reported constipation is 24 to 37%. In the institutionalized elderly, up to 50% self-report constipation and up to 74% use laxatives regularly.

Constipation in Children

Constipation in children usually occurs at three distinct points in time:

1, After starting formula or processed foods (while an infant).

2, During toilet training toddlerhood.

3, Soon after starting school (as in at kindergarten).

After birth, most infants pass 4-5 soft liquid bowel movements a day. Breast-fed infants usually tend to have more bowel movements compared to manufactured food designed and marketed for feeding to babies and infants generally known as formula food. Some breast-fed infants have a bowel movement after each feed, whereas others have only one every 2–3 days. Infants who are breast-fed rarely develop constipation. By the age of two years, a child may usually have 1–2 bowel movements per day and by four years of age, a child may have one bowel movement per day.

Aetiology

Constipation occurs when the large intestine absorbs too much water from the stool with the result dry and hard stools are passed. It may also be due to inadequate contraction of bowel walls to expel the stool and waste product. It occurs due to :-

1,Poor diet(low fiber diet).

2, less immobility and lack of exercise.

3. Ageing, stress and travel.

4. Ignoring the urge to defecate.

5. Inadequate fluid intake

6. Medications (antacids, anti-histamines, anti-psychotic drugs, aspirin, beta blockers,anti-hypertensive drugs, iron and calcium supplements, diuretics, calcium channel blockers etc.)

7. Secondary to Diseases (hypothyroidism, anal fissure, chronic renal failure,colon or rectal cancer, hypercalcaemia e.t.c.)

Risk factors:

1. Older age

2. Female gender

3. Less exercise/ physical activity)

4,Low calorie intake

Clinical features

The following symptoms may be associated with constipation

1. Passage of hard stools

2. Abdominal pain/ discomfort or bloating

3. Straining during passage of stools

4. Headache

5. Malaise

6. Feeling of incomplete evacuation

Complications

Although constipation is rarely serious, but in chronic stage it may lead to

1. Bowel obstruction

2. Hemorrhoids

3. Rectal prolapse

4. Hernia

5. Spastic colitis

6. Laxative abuse - A large number of people use laxatives (self-medication) for constipation. This is not a good practice, especially if these are used regularly for

longer duration. Chronic laxative use can alter the normal physiological functions of the intestines.

7. Excessive straining may have deleterious effects on the cerebral, coronary, and peripheral arterial circulation resulting in syncope, cardiac ischemia, and transient

ischemic attacks.

Diagnosis

Criteria for diagnosing chronic functional constipation

a. Presence of two or more of the following symptoms, for at least 12 weeks in the preceding year

1. Straining with > 25% of bowel movements

2. Sense of incomplete evacuation with > 25% of bowel movements

3. Hard or pellet stools with > 25% of bowel movements

4. Manual evaluation maneuvers with > 25% of bowel movements

5. Feeling of anorectal blockage with > 25% of bowel movements

6. Number of bowel movements two or less per week

b. Absence of loose stools and insufficient criteria for irritable bowel syndrome Investigations

1. Stool examination

2. Barium enema

3. Lower G.I. Endoscopy

4. Ultra-sonography (whole abdomen)

5. Complete haemogram

6. Sigmoidoscopy

Management approaches

a. Prevention

1. Consumption of godhuma (wheat), mudga (green gram), old rice, rasona (garlic), seasonal fruits, high fiber diet, hingu (asafoetida), draksha (grapes), Amalak(Phyllanthus emblica gartn), haritaki (Terminelia chebula Retz.), pippali (long pepper),Shunthi (dry ginger), green leafy vegetables and lukewarm water.

2. Consumption of light and easily digestible high fiber diet.

3. Intake of plenty of fluids and water (minimum 2-3 lt. per day)

4. Drink a glass of warm water, early in the morning (This helps in gastro-colic reflex and results into bowel evacuation)

5. Practice regular exercise

6. Follow a healthy dietetic plan that emphasize fruits, green leafy and other vegetables and fibre rich diet

7. Avoid irregular food habits, heavy, unwholesome, excess oily and spicy food items,bakery and preserved items

8. Avoid suppression of natural urges, excess tea, coffee, smoking

9. Avoid using self medication

b. Medical management

Line of treatment (Ca. Ci. 28/ 90)

1. Nidana parivarjana (avoidance of aetiological factors) Incompatible diet, irregular food habits, low fiber diet, stress, and inadequate fluid intake should be avoided.

2. Samshodhana chikitsa (Bio-cleansing therapies) followed by Shamana chikitsa (Palliative therapy) should be advocated.

i. Snehapana (internal oleation) with Sukumara ghrita 50 ml with 2-3 gm saindhava lavana daily for 3-7 days before panchakarma (bio- cleansing procedure)

ii. Sarvanga sveda for 1 day

iii. Virechana (therapeutic purgation) with Draksha (Vitis vinifera) - 10 gm Aragvadha (Cassia fistula) -10 gm Haritaki (Terminalia chebula) - 10 gm

Kutaki (Picrorhiza curroa) - 5 gm along with 1 teaspoon full Eranda(Ricinus communis) taila or Eranda taila 10 - 20 ml with half glass of milk at night.

iv. Vasti

Anuvasana vasti with Dashamula taila/ Pippalyadi taila 50ml and Niruha vasti with Dashamula kvatha 240 ml, honey 120 ml, Pippalyadi taila 120 ml, saindhava

lavana 5 gm etc. alternately for 8 days (Yoga vasti krama)

v. Phalavarti (medicated suppositories)

Virechana and Vasti should be decided by physician according to the condition of the patient whether Shodhana therapy (bio-cleansing therapies) is beneficial or not.

(Above said formulations and dosage are common in practice but dose should be adjusted by the physician according to patient's condition)

3. Drug therapy

If life style modifications fail to relieve the constipation, then only pharmacological therapy usually with laxatives carminatives and pachana drugs should be started.

Common simple medicinal plants

Medicinal plants	Dosage(Per Dose)	Vehicle	Duration
Ashvagol/Isabgol Husk(Plantago Ovata Forsk)	2-5 Gm.	Warm water/Hot milk at bed time	S.O.S
Sonamukhi/Aragvadha(Cassia aungustifolia vahl) fruit pulp/Churna	1-2Gm	Luke warm water at bed time	S.O.S
Haritaki/Harad(Termilalia Chebula Retz)Powder of seed less fruit	3Gm	Luke warm water at bed time	S.O.S.

Formulations

Name of Formulation	Dosage(Per Dose	Vehicle	Duration
Avipatti Churnam	10-25 Gm. Early in the morning empty stomach	in luke warm water	1-3 days or till the appearance of kapham in stool
Pancha sakar churna	1.5-3 Gm.	At bed time only with water	3 days
Trifala churna	2-3Gm.	Lukewarm water	3 days
Gandharvahastadi kashayam	15ml.	Water	7-10days
Kalyan Guda	12-24Gm.	Lukewarm water	3days
Abhayarishta	15-30ml.	Water	7days
Eranda taila	10-20ml.	Lukewarm water.At bed time only.	S.O.S.
Kumaryasava	15-30ml.	water	7days
Hingutriguna taila	10-20ml.	Lukewarm water	7days
Dashmula taila	For Niruha vasti		5days
Dashmula kwatha	For Niruha vasti		5days
Hingvastaka churna	1.5-3Gm.	Takra(Butter milk)/Water	3 days
Sukumara Ghrita	For Achhapana		3days
Chitrakadi vati	1.5Gm.	water	7days
Kaishore guggulu	1.5Gm.	Milk	7days
NOTE: Out of the drugs mentioned above any one of the drug or in the combination may be prescribed by the physician.The duration of the treatment may vary from patient to patient. Physician should decide the dosage (per dose) and duration of the therapy based on the clinical findings and response to therapy.

c. Yogic Practices- The following yogic practices are beneficial in constipation; however, these should be performed only under the guidance of qualified Yoga therapist.Duration should be decided by the Yoga therapist.

1. Kurmasana, Vakrasana, Katichakrasana, Sarvangasana, shavasana, Pavanamuktasana,Mandukasana, Vajrasana, Merudandasanchalanasana etc.

2. Yogamudra, Shankha prakshlana, Nadishodhana

3. Surya anuloma viloma, deep relaxation technique

Counselling - Advice the patient to

1. Make habit of regular bowel habits

2. Walk for about 30 minutes daily

3. Take of warm water or milk in early morning

4. Eat an adequate breakfast

5. Take plenty of fluids

6. Use of rich fiber diet like beans, brown rice, whole cereals, entire fruits, citrus fruits,legumes in diet

7. Don't supress the urge to defecate

8. Sit on the toilet for 10 minutes at the same time every day to induce regularly bowel movements