High Fiber Therapy
The first line of treatment
Patient history and digital rectal exams are easy diagnostics that can reveal a lot of information, whereas sigmoidoscopies, proctograms and colonoscopies are physically demanding procedures with some risk of injury. Moreover, advanced visual diagnostics like sigmoidoscopies are useful when the suspected cause of chronic constipation is an organ-related condition.
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A third, general diagnostic tool that is also easy for both patient and physician is the use of high-dose trial fiber therapy. This should not be considered a cure, but rather as a probe into testing whether dietary modifications can change the severity of the chronic constipation.
Some misconceptions about fiber
Some people are under the impression that a diet high in fresh fruits and vegetables is sufficient as a constipation treatments for staving off constipation. It is true that diet can provide a natural reemdy for constipation. However, in the case of produce, fruit and vegetable fiber can be degraded by intestinal bacteria. This is the reason for the trial therapy: a dose of bacterially non-degradable fiber for two weeks. Positive changes in bowel movement frequency and straining would suggest that proper, nondegradable fiber intake can serve as treatment.
Nondegradable fibers
Nondegradable fibers most commonly used are wheat bran and psyllium. The former, wheat bran is more widely known as a natural remedy for constipation and less expensive. Supplements for constipation treatments often come in powdered form to be mixed with water and drunk as a dose. Psyllium is another source of fiber from the Plantago genus plant. It is derived from the husks of the seeds from the plant. Recently, psyllium has enjoyed a surge in popularity, in no small part to its reputation as the most concentrated form of dietary fiber. It forms the main ingredient of several commercial products used as bulk laxatives, such as Metamucil and Serutan. Preparation of nondegradable fiber supplements should be carefully done, as insufficient water leads to obstruction in the gastrointestinal tract. There is also a small chance of an allergic reaction, especially in those who have been involved in industrial preparation of psyllium products.
Side effects
Trial therapy supplements are generally well tolerated, but thorough research data is not available regarding interactions with drugs, herbal supplements and other constipation medication or constipation treatments. In addition, natural remedies for constipation such as fiber supplements may delay gastric emptying and diminish absorption of certain medical compounds. Although there is a plus side - some evidence exists that show a secondary effect of psyllium is the reduction of blood cholesterol levels.
Assessing success
After two weeks, the physician will assess whether trial constipation treatments were successful by noting whether there was a positive change in frequency of bowel movement, decrease in difficulty of passing stool, and changes in chronic constipation. The changes can also be quantified by measuring transit time, since patients' own reporting has been found to be quite inaccurate. Oftentimes, transit time measurement can contradict a patient's claim that there was "no bowel movement at all" within some time frame. Success of trial therapy implies that diagnostic assessment is no longer needed. The patient will be able to embark on a high fiber diet, perhaps using the same fiber products as those used in the high dose trial therapy, to prevent chronic constipation.
Sources
Muller-Lissner, The Pathophysiology, Diagnosis, and Treatment of Constipation, Deutsches Arzteblatt International, 2009; 106(25):424-32
Fox-Orenstein et al, Update on constipation: One treatment does not fit all, Cleveland Clinic Journal of Medicine, 2008; 75(11):813-824
Eoff and Lembo, Optimal Treatment of Chronic Constipation in Managed Care, Journal of Managed Care Pharmacy, 2008; 14(9a):Supplement