New possibilities for drug therapy for chronic constipation

After childbirth, many women experience constipation. Problems with bowel movements during breastfeeding (BF) arise for various reasons. Often difficulties are associated with changes in hormonal levels, weakening of the perineal muscles, decreased muscle tone of the peritoneum, lack of physical activity, as well as an unstable mental state after the birth of a child.

How constipation manifests itself

Constipation is defined as difficult, unsystematic or incomplete bowel movements, as well as the inability to go to the toilet for more than a day and a half in a row. The following signs indicate constipation:

• hard, dry, segmented stool;
• decrease in daily stool volume;
• decreased frequency of bowel movements (less than three times a week);
• a feeling of pressure in the rectum during bowel movements.

Constipation is often accompanied by a feeling of heaviness in the stomach and flatulence. A woman often experiences pain in the intestinal area.

When breastfeeding, spastic and atonic constipation may occur.

• Spastic . They occur against a background of nervous tension, stress, fear, or lack of sleep. Due to the nervous shock a woman experiences, the intestinal muscles contract and impede the passage of feces. Spastic constipation is characterized by frequent false urges to defecate. The stool is dry and scanty. Bowel movements are often painful.
• Atonic . Associated with inhibition of intestinal muscle tone. Insufficient peristalsis slows down the speed of stool movement. Stool with atonic constipation has a different consistency: hard at the very beginning of defecation and liquid at the end.

Problems with bowel movements after childbirth are considered normal. In most cases, constipation goes away on its own within a few days. If constipation becomes chronic, causes severe discomfort and is accompanied by unpleasant sensations, it is necessary to identify the cause of its occurrence.

Symptoms of persistent constipation

Frequent constipation is often accompanied not only by difficulties and rare bowel movements. They can be characterized by the appearance of mucus and blood in the stool, pain in the rectum and perianal area. This is due to mechanical trauma to tissues from dense stools.

The normal frequency of bowel movements is three times a day to three times a week. The shape of the stool also matters—with constipation, it is denser.

Associate professors of the Department of Internal Diseases Babieva A. M., Bogatyrev V. G., Marinchuk A. T., Koumbatiadis D. G. believe that “constipation contributes to the development of various diseases, reduces quality of life by 20% and is one of the early risk factors the occurrence of pancreatic, gallbladder and colorectal cancer" (Babieva, Bogatyrev, Marinchuk, Koumbatiadis, 2012, p. 52).

Constipation symptoms

Constipation during breastfeeding can be accompanied by a number of symptoms. Even daily bowel movement, in which there is insufficient volume and dense consistency of stool, is considered constipation. Especially in cases where the condition is accompanied by abdominal pain, bloating, a feeling of heaviness, and a general deterioration in well-being.

Very often, constipation is combined with proctological diseases, if we talk about the postpartum period. Therefore, blood appears in the stool, associated with an anal fissure or exacerbation of hemorrhoids. This should be alarming. It is important to consult a doctor in a timely manner to receive qualified assistance.

Constipation leads to intoxication of the body, which can be manifested by the following symptoms:

• general malaise, fatigue;
• sleep disorders;
• decreased appetite;
• nausea;
• vomit;
• increased sweating;
• dizziness;
• headache.

In some cases, there is a slight increase in body temperature. Abdominal pain can occur in different parts of the abdomen: in the lower abdomen, in the right or left side, and even in the epigastric region. In cases where there is prolonged constipation, general health deteriorates greatly. Stool retention often leads to a longer recovery after natural childbirth and interferes with the healing of sutures after a cesarean section or episiotomy.

Constipation during breastfeeding in a mother often leads to sleep disturbances, increased irritability and other changes in the psycho-emotional sphere. And the general vulnerability of women in this difficult period obliges us to pay special attention to such a delicate problem.

Causes of constipation

The enlarged uterus during pregnancy displaces the pelvic organs, including the rectum. As a result, the peristalsis of the latter decreases, that is, the intestine begins to contract worse. In addition, during lactation the hormone progesterone is produced, which suppresses intestinal motility and has a relaxing effect. Other causes leading to constipation include:

• lack of plant fiber (fiber) in the diet;
• endocrine disorders, metabolic disorders;
• insufficient fluid intake;
• sedentary lifestyle and stress.

In addition, constipation during breastfeeding is often associated with hemorrhoids that appeared or worsened after childbirth. Problems with stool also appear due to the fact that the young mother’s menu does not have enough products containing coarse fibers and fiber.

Constipation after childbirth during breastfeeding can be psychogenic, that is, associated with conscious inhibition of the natural urge to defecate. Many women who have had an episiotomy or cesarean section are afraid of going to the toilet. If the doctor observing the patient after childbirth does not check whether spontaneous regular bowel movements have appeared, a serious problem with bowel movement appears by the time she is discharged from the maternity hospital.

Why is constipation dangerous during breastfeeding?

Deterioration of intestinal function negatively affects a woman’s physical condition. Bloating and heaviness appear in the abdomen, and appetite decreases. Constipation may cause sleep disturbances, headaches, increased nervousness and decreased performance.

In addition, with constipation during lactation, fewer digestive enzymes enter breast milk, which also affects the baby’s stool. In some cases, delayed bowel movements can cause a reduction in breast milk production.

To normalize intestinal function, it is necessary to reconsider the daily diet and physical activity regime.

Treatment of constipation in nursing mothers

Not all pharmaceutical products are suitable for nursing mothers. To choose medications, it is best to consult a doctor. The specialist may prescribe microenemas, rectal suppositories or oral medications.

But most medications can only be used for a short time. Other methods will help normalize stool during breastfeeding.

The doctor's first recommendation for treating constipation during breastfeeding is a balanced diet. Laxatives are prescribed when measures to correct the diet are ineffective or there is a high risk of complications, in cases where constipation requires emergency help.

There is one most important principle of treatment: the development of a morning reflex to bowel movement. It is important to try to maintain a daily routine, setting aside enough time to go to the toilet in the morning immediately after waking up and having breakfast. This can be difficult for a new mother, especially on days when the baby is restless. But you should pay attention to your needs even in this case.

Compliance with the drinking regime is of great importance. During lactation, large amounts of fluid are required, so it is important to drink at least 1.5-2 liters of water per day.

Physical activity improves microcirculation, stimulates intestinal motility, strengthens the muscles of the peritoneum and pelvic floor. You should consult a doctor so that he can suggest light exercises based on your health condition.

Herbal medicine should be selected with care by a nursing mother. There are a number of medicinal herbs approved for use. Herbal decoctions and infusions should be taken according to the recommendations of a specialist.

Laxatives should be prescribed by a doctor. There are not many products allowed for nursing mothers. It is important to avoid taking stimulant laxatives, which are addictive. It is allowed to take bulk laxatives, osmotic agents, and topical medications. There are categories of laxatives that are approved for long-term use and have a beneficial effect on the digestive system of a young mother.

Treatment of chronic constipation

Your doctor will tell you what to do if you have persistent constipation; if you have a chronic problem, it is important to see a therapist or gastroenterologist. Many patients self-medicate by uncontrollably taking laxatives or using cleansing enemas on a regular basis. This may cause the condition to worsen.

Thus, Professor Parfenov A.I. writes that “the systematic use of cleansing enemas inevitably leads to the formation of an inert colon due to the loss of visceral sensitivity and defecation reflex” (Parfenov, 2013, p. 100). To cure chronic constipation, it is important to adjust your diet and not uncontrollably take laxatives.

It is worth understanding that long-term constipation requires complex treatment. There are several directions in which you can act to normalize stool.

Consultation with a gastroenterologist

Contacting a specialist is mandatory if constipation does not occur just once due to certain circumstances, but is observed systematically or appears from time to time. The doctor will examine the clinical picture, listen to complaints, collect anamnesis and prescribe diagnostic methods to identify the exact causes of intestinal dysfunction. These include:

• laboratory blood tests;
• stool examinations, including occult blood tests;
• colonoscopy, irrigoscopy according to indications, etc.;
• FGDS;
• Ultrasound of the abdominal organs.

During the initial consultation, the gastroenterologist will talk about possible causes and provide referrals for research. At the second appointment, based on the results of the completed diagnostics, the exact diagnosis will be known.

In the vast majority of cases, chronic constipation is associated with dietary habits. But sometimes the doctor deals with diseases of the gastrointestinal tract accompanied by constipation. These include the following:

• dolichocolon;
• intestinal diverticulosis;
• peptic ulcer;
• cholelithiasis;
• intestinal tumors;
• haemorrhoids.

A number of diseases lead to disruption of the digestive processes and contraction of the intestinal muscles, others represent a mechanical obstacle to the movement of feces.

Diet to get rid of constant constipation

Nutrition for chronic constipation should be revised in the direction of replenishing the diet with fiber. A high amount of dietary fiber is found in bran, fresh vegetables, fruits, and dried fruits.

However, to get your daily fiber intake you will need to eat a lot of fiber-rich foods. This can be difficult, so sometimes it makes sense to find a source of dietary fiber in the form of a supplement.

Regular use of fiber will help speed up the movement of stool through the intestines and ensure regular spontaneous bowel movements.

It is important to pay attention to the drinking regime. Drinking less than 1.5–2 liters of water per day can lead to excessive absorption of water in the intestines and dehydration of stool. Therefore, it is necessary not only to drink enough fluid, but also to avoid losing it - eliminate or reduce the consumption of drinks with a diuretic effect. These include tea and coffee.

It is better to exclude from the diet foods and dishes with an astringent, fixing effect: +

• crackers, confectionery products made from premium flour;
• fatty food;
• confectionery;
• peeled rice;
• jelly.

The menu for chronic constipation must include vegetable oils, vegetables and fruits, wholemeal bread, and dairy products without sugar. It is better to choose low-fat poultry, meat and fish, and prefer cereals as side dishes.

Nutrition for constipation in nursing mothers

Very often, correcting the diet is enough to eliminate constipation in a nursing mother. A nutritious, balanced diet is the key to successful breastfeeding and the well-being of the woman and baby. You should not get carried away with fried, salted, smoked and peppered foods. Carbonated drinks, strong tea and coffee are prohibited. It is important to consume flour, confectionery, and sweets in minimal quantities.

It is better to heat-process vegetables and fruits: stew, bake, boil. Raw fruits complicate the digestion process, take longer to digest and often lead to increased gas formation. In addition, they can negatively affect the baby’s health - cause colic, allergic reactions, and anxiety.

Foods rich in fiber and recommended for consumption by a nursing mother:

• dried fruits;
• boiled carrots or beets;
• freshly squeezed vegetable and fruit juices;
• low-fat fermented milk products;
• porridge from gray and brown cereals.

It is better to introduce new products one at a time, with caution. It is necessary to monitor the child’s reactions and if he develops an allergy, refuse the new dish and consult a doctor.

The issue of getting rid of constipation should be approached comprehensively. First of all, it is necessary to reduce the amount of fatty protein foods consumed and include fresh vegetables and fruits in the diet. For chronic problems with bowel movements, it is important to understand what foods can be eaten for constipation, and what foods a nursing mother should avoid.

Poor nutrition during breastfeeding is usually due to the fact that women are afraid to introduce fruits and vegetables into their diet. Because it is believed that these products may cause allergies or discomfort in the child’s intestines. But doctors believe that eating foods grown in your native region and properly prepared will not harm the baby. During lactation, it is advisable to give up only exotic fruits and legumes.

The daily diet must include first courses in low-fat broth, porridge in water or milk with the addition of butter, baked or stewed main courses of meat, poultry, and fish. You can often eat salads with a dressing based on vegetable oils. Dried fruits, light mousses, and fruit purees are suitable as a snack or dessert.

Berries have a beneficial effect on the mother's intestinal function, but they should be introduced into the diet with caution, observing a possible allergic reaction in the child. Common allergens also include red fish and caviar, honey, citrus fruits - they may be recommended for nutrition for a nursing mother, but provoke allergic reactions in the child.

Keeping a food diary will help not only improve bowel movements, but also find out the possible causes of skin reactions in the baby, and therefore create an appropriate diet.

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Causes of prolonged constipation

There are several reasons for the development of persistent constipation. The most common is poor nutrition, namely a lack of dietary fiber and a predominance of refined foods.

Professor Livkin V.L. believes that “a common cause of the development of chronic disease is a change in the intestinal microflora due to disruption of the production of specific substances by representatives of the normal flora of the colon that promote the formation of stool and support optimal motor activity of the colon” ​​(Livkin, 2013, p. 78).

Constipation can be caused by other factors:

• physical inactivity;
• violation of the water regime;
• intestinal dysbiosis;
• endocrine diseases;
• tumors of the digestive system;
• inflammatory diseases of the gastrointestinal tract;
• proctological diseases;
• neurological diseases.

Also, stool retention may be associated with taking medications. Drugs that can cause constipation as a side effect include drugs to normalize blood pressure and heart rate, antibacterial drugs, hormonal drugs, antiepileptic drugs, diuretics, tranquilizers, iron supplements and others.

By type of reason

Depending on the causes of frequent constipation, they are classified into several types:

• alimentary or nutrition-related;
• neurogenic;
• proctogenic;
• dyskinetic;
• hypodynamic;
• psychogenic;
• medicinal.

The head of the department of gastroenterology of the State Healthcare Institution ROCH Babieva A.M. and other authors believe that “constipation in 80–90% of cases is of a functional nature, the rest is caused by reasons of an organic nature” (Babieva A.M., Bogatyrev V.G., Marinchuk A. T., Koumbatiadis D. G., 2012, p. 53).

By gender and age

Gender and age act as risk factors for the development of constipation. In women, this disorder of intestinal function is more common, developing, among other things, during pregnancy and after childbirth.

According to various sources, up to 60–80% of people over 60 years of age suffer from constipation, which may be due to disturbances in the transmission of nerve impulses, overstretching of the intestinal walls, developed proctological diseases, a sedentary lifestyle and other factors.

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Laxatives

A laxative during breastfeeding is necessary to provide immediate assistance to yourself. However, some remedies help normalize intestinal function in general. To understand the mechanism of their work, consider all groups of laxatives:

• stimulating;
• volumetric;
• osmotic;
• softening.

The first act on intestinal receptors. They are addictive and can cause complications such as lazy bowel syndrome. In addition, taking stimulant laxatives is not allowed during lactation, so the doctor will not recommend using drugs from this group.

Osmotic drugs do not pass into breast milk and are not addictive. They are often prescribed to nursing mothers. However, a significant part of such drugs are used in coloproctology and gastroenterology as a measure of preparation for endoscopic diagnostic methods, surgical interventions, etc. They reliably cleanse the intestines, but have a pronounced effect - they can cause frequent loose stools.

Softening agents are oils, glycerin, etc. They help soften stool and simplify their movement through the intestines. However, such drugs are not approved for continuous use, since they impair the absorption of fat-soluble vitamins. This can be fraught with the development of hypovitaminosis for a young mother.

Bulk laxatives are represented by herbal or synthetic-based drugs. They act similarly to natural fiber - they are not digested in the intestines, absorb water and swell, increasing the volume of intestinal contents and softening the stool. In addition, such drugs gently stimulate intestinal motility, causing defecation. The components of such products do not pass into breast milk. They are allowed for nursing mothers and can be taken for a long time.

One such remedy is the British drug Fitomucil Norm. It contains psyllium seed hull and plum fruit extract - natural soluble and insoluble fiber. The drug gently stimulates bowel movements and promotes regular bowel function.

Drinking regime

An important point in the fight against constipation in mothers is maintaining a normal drinking regime. Experts recommend drinking at least 1.5–2 liters of clean drinking water per day. In addition to water, you can drink rosehip decoction, berry compotes, and chicory.

For additional stimulation of the intestines, it is advisable to drink a glass of water on an empty stomach in the morning, and also 20-30 minutes before each meal.

It is best to drink water in small portions throughout the day. For example, it is good to take a few sips of water when you first feel hungry. This technique will help quench thirst, which many people mistake for hunger.

Herbal medicine for constipation

Herbal medicines demonstrate a good effect in the fight against constipation. During breastfeeding, you can take herbal products and herbal decoctions that do not have a negative effect on the quality of breast milk. These include decoctions based on:

• Gooseberry . Pour a tablespoon of berries into a glass of water and boil for 10 minutes. Strain the finished broth. Drink ¼ glass a day.
• Cumin, fennel and anise . The seeds of these plants stimulate milk production, as well as the functioning of the gastrointestinal tract. Two tablespoons of the seeds of each plant need to be mixed and poured with boiling water. Let it brew for half an hour. Take on an empty stomach 30 minutes before meals.
• Figs (with milk). Dried figs (2 tablespoons) need to be poured with a glass of boiled milk or water. You need to let the broth cool and drink a tablespoon 3 times a day.

Unfortunately, diet correction is not always enough to normalize the bowel movement process. As an additional supportive and preventive measure, it is recommended to take special supplements. For example, a ready-made herbal preparation “Fitomucil Norm” can help a nursing mother with constipation. It does not contain senna or synthetic components, so it is approved for use during pregnancy and lactation.

The product acts very delicately, does not provoke cramps and abdominal pain, and does not cause bloating. Soluble and insoluble plant fibers that make up the drug stimulate intestinal function and help cleanse it.

Before you start taking any medications or using traditional methods to relieve constipation, you should consult your doctor.

Modern problems of complex therapy of constipation

Constipation is a decrease in the frequency of stools and difficulty in defecating, usually for two days or more, which can lead to pain, discomfort in the abdomen, subsequent obstruction of the intestinal lumen and, rarely, perforation. The term “constipation” is understood as a persistent or intermittent dysfunction of the colon with a decrease in stool less than three times a week and with forced straining, occupying more than 25% of the time of defecation. Constipation is a common and usually subjective complaint. Predisposing factors include physical inactivity, refined, easily digestible foods, and inadequate timing of bowel movements. According to statistics, 30–50% of the adult population suffers from constipation. They are leading among the reasons for visiting therapists and gastroenterologists.

Working classification of constipation

1. Primary constipation (with intestinal diseases):

A. Functional constipation (“habitual”):

1. rectal constipation (dyschezia) - a sharp weakening of the defecation reflex;
2. cologenic constipation is a slowdown in the intestinal passage of chyme as a manifestation of dyskinetic disorders.

• B. Organic constipation. Develops with structural lesions of the intestine: colitis, dysbiosis, anal fissure, hemorrhoids, cryptitis, papillitis, cicatricial narrowing of the colon, prolapse of the perineum and prolapse of the rectal mucosa, cancer and other intestinal tumors, elongated colon, idiopathic megacolon.

1. Secondary constipation (caused by extraintestinal causes):

• a) reflex (for peptic ulcers, cholecystitis, nephrolithiasis, gynecological diseases);
• b) for diseases of the endocrine (myxedema, diabetes mellitus) and nervous systems (spinal cord diseases, parkinsonism);
• c) metabolic and toxic (porphyria, lead poisoning, anticholinergics, ganglion blockers, iron supplements, diuretics, sedatives);
• d) muscular constipation: damage to the muscles (diaphragm, abdominal wall, anus) involved in the passage of feces and the act of defecation: myopathy, scleroderma, pulmonary emphysema;
• d) psychogenic.

1. Idiopathic constipation.

Constipation is divided into acute, which occurred less than three months ago, and chronic, which lasts longer.

Clinic and diagnostics

The frequency of bowel movements can vary: from once every 2-3 days to once a week or less. Feces are usually compacted, dry, have the appearance of balls or lumps, reminiscent of sheep; can be bean-shaped, ribbon-shaped, cord-shaped. Patients may be bothered by pain and a feeling of fullness in the abdomen; relief comes after defecation or passing of gas. Appetite may decrease, belching of air, and bad taste in the mouth may appear. Often the ability to work decreases, headaches, myalgia, nervousness, depressed mood, and sleep disturbances occur. Persistent constipation may be accompanied by skin changes. It becomes pale, yellowish, flabby, and loses elasticity.

The duration of constipation should be clarified. Acute constipation is often “situational”. For example, constipation in tourists, when consuming refined foods, medications, due to emotional factors. They may be associated with exacerbation of chronic diseases of the upper digestive tract (peptic ulcer) or anorectal area (thrombosis of hemorrhoids, anal fissure).

Taking an anamnesis helps in differentiating constipation from transit and evacuation disorders. The first will be supported by a decrease in bowel movements and flatulence. Disorders of the act of defecation can be assumed when there is a feeling of obstruction or incomplete emptying of the rectum, and the need for manual assistance.

A clinical examination of the patient is carried out; digital examination of the rectum, sigmoidoscopy, and irrigoscopy are desirable. In case of chronic constipation, emphasis should be placed on searching for concomitant neuroendocrine disorders, mental disorders, collagenosis, and metabolic pathologies. It is necessary to clarify whether the patient is taking medications and which ones.

For example, with diabetic autonomic neuropathy, constipation occurs in 60% of patients; with pheochromocytoma, they occur no more often than in 15%. Barium sulfate can cause constipation in susceptible individuals after a single dose, but antidepressants only with long-term use.

If the patient’s condition worsens with increasing constipation, weight loss, anemia, it is necessary to exclude a tumor of the colon or internal organs. The diagnostic program is complemented by colonoscopy with targeted biopsy and ultrasound of the abdominal and pelvic organs.

During the first stage of the diagnostic search, it is necessary to exclude tumor and inflammatory diseases, identify endocrine and mental pathologies, and determine megacolon and megarectum. These diseases require fundamentally different treatment and can be diagnosed during examination, colonoscopy or irrigoscopy.

After excluding them, patients can be offered trial therapy, including dietary fiber, motor correctors, and regulation of the urge to defecate. A positive response to treatment allows the diagnosis to be stopped and maintenance therapy to be carried out. Patients with refractory constipation are subject to in-depth examination. The criterion for treatment failure is the lack of positive dynamics when using dietary fiber. In these cases, an intestinal transit study, sphincterometry, and electromyography will be required.

Treatment

Treating constipation is quite a difficult task. Continuous attempts to develop an effective long-acting treatment regimen have not yet yielded results. Obviously, the mechanism that partly explains this fact, and the factor that is most difficult to influence, is the psychosocial environment.

Patients are advised to increase their consumption of wholemeal products, fresh and dried fruits and vegetables, and take more fluids. Patients should avoid taking herbal laxatives and high cleansing enemas. Microenemas of up to 200 ml in volume daily in the morning are acceptable in order to develop the urge to defecate.

Drug therapy is prescribed taking into account the predominance of certain symptoms. Drugs of different groups can be used constantly or as needed, in the latter case it is recommended for patients with periodically occurring symptoms. In patients refractory to treatment, drugs with different mechanisms of action are combined.

Special treatment includes eliminating intestinal obstruction (fecal stones, tumor), avoiding the use of drugs that inhibit peristalsis (antacids containing aluminum and calcium, opiates).

Fiber (dietary fiber) (20–30 g/day) is good for chronic constipation, but it only works after a few weeks and can cause flatulence. Dietary fiber (DF) is a product of plant origin containing non-fermentable substances of a polysaccharide nature - cellulose, hemicellulose, lignin. They regulate the consistency of stool, increase its mass and speed up the movement of contents. PIs bind fatty acids (natural laxatives), delivering them to the colon. People suffering from constipation have insufficient fiber intake or an increased need for dietary fiber. To make up for the daily need for dietary energy, you need to eat up to 1.5 kg of wholemeal bread, cabbage and apples, which is unrealistic for a modern person.

PF includes wheat bran, microcrystalline cellulose (MCC), agar-agar, laminaride, flaxseed. Wheat bran is added to food, and plantain seed is mixed with water and taken 2-4 times a day. It is usually recommended to start taking bran 3 to 6 tablespoons per day with food, pouring boiling water over it. The amount of fluid is increased to 2–3 liters per day.

Wheat bran does not immediately exert its effect; the latent period can be 5–7 days. This is the time required for the bran taken orally to enter the ampulla of the rectum and be ready for defecation.

If the effect is not achieved, it is possible to use MCC at a dose of 4–9 g per day or the preparation from plantain seeds Mucofalk (10–30 g per day). The latter retains liquid more strongly, does not produce intense gas, and is better tolerated by patients. Dietary fiber can be combined. However, their use is limited if the patient is not able to increase fluid intake, which is fraught with the development of obstruction.

Laxatives are prescribed when fiber is ineffective. Their long-term use is undesirable. For abdominal pain of unknown origin or intestinal obstruction, laxatives are contraindicated.

1. Softening laxatives: docusate sodium, 50–200 mg orally once daily. Vaseline oil when taken orally and oil enemas, Norgalax, Enimax also have fecal softening properties. For obstruction, the use of petroleum jelly for several days is quite justified. Longer treatment may lead to impaired absorption and granulomatous reactions. Drugs in this group have limited use.
2. Agents that stimulate intestinal motility. Long-term use of these drugs is not recommended. Castor oil (15 ml orally) causes rapid emptying of the colon. Bisacodyl is taken in the evening - orally (10–15 mg) or rectally (10 mg suppositories); defecation occurs within 15–60 minutes. Buckthorn and senna extracts induce bowel movements 10–16 hours after ingestion; with long-term use, atony of the colon is possible. The usual dose of buckthorn extract is 5 ml orally once a day; Senna extract is taken 1 tablet orally 1-2 times a day. Sodium picosulfate (Guttalax, Laxigal, Slabilen) is taken starting with 12 drops at night.

The plant origin of laxatives in this group often determines their choice by patients for self-medication. They are also included in many herbal teas. However, their use should be a necessary measure when other methods of normalizing intestinal function have been exhausted. As the duration of their use increases, the effectiveness of treatment decreases, and the chances of normalizing bowel function decrease.

Most patients taking stimulant laxatives report increased abdominal pain. Thus, senna anthraquinones exert their effect through damage to epithelial cells, which leads to impaired absorption, secretion and motility. Melanosis of the mucous membrane is observed, and in a third of patients an “inert” colon is formed. Patients with melanosis have an increased risk of developing carcinoma. However, short-term use may be considered safe. By “strength”, herbal preparations can be arranged as follows: aloe ® senna ® buckthorn ® rhubarb. To a certain extent, the above applies to both bisacodyl and sodium picosulfate. However, the effect of sodium picosulfate is milder. These drugs should be used once every 3-4 days in the minimum effective dose, which will allow you to maintain sensitivity to them for a longer time and avoid negative consequences.

1. Osmotic laxatives are non-absorbable salts and carbohydrates that retain fluid in the lumen of the colon. Their immediate effect is higher than the effect of dietary fiber. A number of drugs in this group, like magnesia, are used for a short time when it is necessary to induce rapid bowel movement, for example, to prepare a patient for irrigoscopy, others are intended for prolonged use - lactulose, Forlax. Lactulose is a synthetic, non-absorbable polysaccharide that reaches the ileum, where it is broken down to form lactic and other acids. This leads to a decrease in pH, an increase in osmotic pressure and stimulation of peristalsis. Lactulose (Lactulose, Duphalac, Portalac) at a dose of 30–45 ml per day has an effect after 48 hours, but it is often accompanied by a feeling of bloating and distension in the abdomen. Forlax, a polyethylene glycol with a molecular weight of 4000, has the best tolerability. The drug has no side effects, does not affect microflora, and gives a quick effect. Its use is possible for a number of months and even years. Habituation does not develop. The dose of Forlax ranges from 30 to 60 g per day, and in high doses it is also effective for refractory constipation. Dietary fiber and osmotic laxatives are combined with each other, and the dosage of both can be reduced in combination treatment.

A solution of polyethylene glycol with sulfates and other salts is used to quickly cleanse the colon in preparation for endoscopy or surgery. The solution is taken orally, 4–6 liters over 3–4 hours.

When complaints of bloating and flatulence predominate in the clinic, the prescription of drugs is indicated, the mechanism of action of which is based on reducing the surface tension of gas bubbles, which ensures resorption and free release of gases. One of these drugs is Espumisan (the active ingredient is simethicone). It is not absorbed in the digestive tract and is excreted unchanged from the body. By reducing the surface tension at the interface, simethicone impedes the formation and promotes the destruction of gas bubbles in the nutrient suspension and mucus of the gastrointestinal tract (GIT). The gases released during this process can be absorbed by the intestinal walls or excreted through peristalsis. For flatulence, 2 capsules of simethicone are prescribed 3-5 times a day.

There are 4 generations of PB. The first generation includes monocomponent preparations (Colibacterin, Bifidumbacterin, Lactobacterin) containing one strain of bacteria. Second generation drugs (Baktisubtil, Biosporin and Sporobacterin) are based on microorganisms that are non-specific for humans and are self-eliminating antagonists. They can be used to treat severe forms of dysbiosis, but must be combined with bifido- and lactose-containing PBs, which are necessary to normalize the intestinal microbiocenosis. III generation drugs include multicomponent PBs containing several symbiotic strains of bacteria of the same species (Acilact, Acipol) or different species (Linex, Bifiform) that enhance each other's effects. The benefits of third generation drugs are especially evident in patients with decompensated intestinal dysbiosis. The fourth generation includes preparations of bifid-containing PBs immobilized on a sorbent (Bifidumbacterin forte, Probifor). Sorbed bifidobacteria effectively colonize the intestinal mucosa, providing a more pronounced protective effect than unsorbed analogues.

One of the most frequently prescribed probiotics in Russia is Linex. This is a combined drug containing components of natural microflora from different parts of the intestine. It is used for the prevention and treatment of intestinal dysbiosis, including dysbiosis as a result of treatment with antibiotics, diarrhea, constipation, flatulence, nausea, vomiting, regurgitation, abdominal pain.

Linex Bio is a dietary supplement, a source of probiotic microorganisms, inulin and oligofructose. Combines the properties of pro- and prebiotic agents. Used to prevent the development of intestinal dysbiosis in healthy people.

The balanced composition of Linex is primarily confirmed by the fact that its components allow for the normalization of the functions of all parts of the intestine - from the small intestine to the rectum (enterococci predominantly populate the small intestine, lactobacilli - its lower sections and the large intestine, bifidobacteria - the large intestine).

Bifidobacteria, lactobacilli and non-toxigenic lactic acid enterococcus included in Linex maintain and regulate the physiological balance of intestinal microflora and provide intestinal functions, including motor function, mainly through the production of organic acids and lowering the pH of intestinal contents. Enterococci, in particular, carry out fermentative metabolism, ferment carbohydrates with the formation of lactic acid and also reduce the pH in the intestines to 4.2–4.6. Linex components are also involved in the metabolism of bile acids (in the formation of stercobilin, coprosterol, deoxycholic and lithocholic acids, reabsorption of bile acids). As has long been known, the normal amount and properties of bile have a clear anti-obstipation effect.

The effectiveness of probiotics containing lactobacilli and bifidobacteria, such as Linex, has been demonstrated for irritable bowel syndrome (IBS) with constipation. Treatment led to a decrease in pain and flatulence, and an improvement in the quality of life of patients [Belmer S.V., 2004]. In a clinical study, 4-week therapy with a combination of probiotics similar in composition to Linex (Bifidobacterium, Lactobacillus and Enterococcus) caused a significant improvement in symptoms, especially abdominal pain and stool character, in 74.3% of patients; after cessation of treatment, a stable effect persisted for 2 weeks of observation. In another randomized study, the use of a similar combination made it possible to prolong remission in patients with IBS associated with constipation: exacerbation was observed in only 15% of those receiving probiotics, while in the placebo group - in 100% of cases [Ivashkin V.T., Lapina T.L. ., 2003].

The mechanism of action of Linex for constipation due to IBS remains unclear. It is believed that it may also be associated with its beneficial effect on gas formation in the intestines due to inhibition of the growth of gas-producing microflora.

The duration of Linex therapy depends on the cause of constipation. When using the drug in recommended doses, no side effects were noted. Contraindications: hypersensitivity to the components of the drug or dairy products. The use of Linex is not contraindicated during pregnancy and lactation.

To preserve the viability of the drug components, it is not recommended to take Linex with hot drinks. During the period of using Linex, you should refrain from drinking alcohol.

Colon motility correctors

This group of drugs includes selective antispasmodics and prokinetics. Patients with spastic constipation syndrome have reason to expect success from treatment with antispasmodic drugs (Meteospasmil, Dicetel, Spasmomen, Duspatalin, Buscopan), while prokinetics (cisapride, domperidone) should be used in patients with atonic constipation.

Abdominal pain is eliminated by antispasmodics that regulate, rather than paralyze, intestinal motility. One of them is mebeverine (Duspatalin). The drug acts by reducing the permeability of intestinal smooth muscle cells to Na+. Prescribed 2 tablets or 1 capsule (200 mg) 2 times a day or 1 tablet (135 mg) 3 times a day 20 minutes before meals.

Pinaveria bromide (Dicetel) has an antispasmodic effect by blocking the entry of Ca2+ through calcium channels into intestinal smooth muscle cells. Prescribed 1 tablet (50 mg) 3-4 times a day with meals.

Otilonium bromide (Spazmomen) has an antispasmodic effect as a result of disruption of the mobilization of Ca2+ from the intracellular and extracellular space of intestinal smooth muscle cells without affecting the cell membrane receptors. Prescribed 1-2 tablets (20-40 mg) 2-3 times a day before meals.

Cisapride (Coordinax) , a 5-HT4 serotonin receptor agonist, promotes the release of acetylcholine in the intestinal nerve ganglia. The drug accelerates transit through the colon, stimulates colonic motility, and reduces the sensitivity threshold of the rectum to defecation. However, doses less than 30 mg per day do not have a noticeable effect. Due to the risk of cardiac arrhythmias, it should not be used in elderly patients.

In recent years, new drugs have appeared that selectively act on 5-HT4 receptors, in particular, prucalopride.

In general, serotonergic drugs are considered a promising group of drugs for relieving symptoms of constipation. Serotonin has a pronounced effect on intestinal motility through activation of receptors located on effector cells and in nerve endings. 5-HT3 and 5-HT4 receptors play a leading role in nociception by modulating the afferent side of visceral reflexes. Stimulation of these receptors leads to the release of acetylcholine and substance P, which are transmitters of gastrointestinal sensitivity. 5-HT3 receptor antagonists include motility inhibitors (used for irritable bowel syndrome), while drugs that activate 5-HT4 receptors have a stimulating effect on peristalsis. Currently, the partial 5-HT4 receptor agonist tegaserod is available from this group of drugs.

Biofeedback technique

The main method of treating patients with “exit obstruction” is biofeedback (BFB). Two types of training are described: 1) biofeedback training, in which sensory sensors are placed in the anal canal and monitor the activity of the transverse muscles or pressure in the anal canal, and thus provide feedback to the patient; 2) simulated defecation, in which the patient practices defecation with a simulated stool. Both types of training give up to 85% positive effect. The method is effective not only in patients with defecation disorders, but also in slowing down transit, which is explained by additional psychotherapeutic effects.

Differentiated therapy

For nutritional constipation, it is necessary to increase physical activity and achieve a balanced diet; in more complex cases, use dietary fiber and bacterial preparations (Linex). In patients with gallbladder dysfunction, prescribing a herbal mixture of peppermint, chamomile, immortelle, and tansy will increase the effectiveness of treatment.

For severe constipation while taking opiates, osmotically active agents (lactulose, polyethylene glycol solutions) and emollient laxatives administered orally or rectally (sodium docusate), or mineral oil are effective.

Constipation after cholecystectomy is more difficult to treat. These patients, and equally patients with diabetes, respond better to Forlax. For atonic or slow-transit constipation, cisapride (Coordinax) is used along with dietary fiber or osmotic laxatives. In case of “exit obstruction,” the patient needs additional examination in a hospital setting, as well as trial treatment with biofeedback.

With long-term and long-term use of laxatives containing anthraquinones, their abolition and transfer of patients to dietary fiber and osmotic laxatives is often impossible. In such cases, sodium picosulfate is used once every 2-3 days with increasing intervals between doses and withdrawal. The restructuring of intestinal activity may take 3–6 months. If the abolition of stimulant laxatives is impossible, they take the path of reducing the dose and alternating them. In this case, it is advisable to continue taking dietary fiber.

Patients with abnormally prolonged transit and normal pelvic floor parameters, refractory to drug therapy, are considered candidates for surgical treatment.

Forecast

The prognosis for life is favorable. The course of the disease is chronic, relapsing, slowly progressive. Constipation is rarely complicated by bleeding, perforation, strictures, fistulas, or intestinal obstruction. This determines the tactics for monitoring patients and the lack of need for frequent colonoscopies. The doctor should familiarize patients with the features of the prognosis of the disease, which will improve their psychosocial adaptation.

At the same time, the patients’ ability to work is impaired. As a cause of temporary disability, the diagnosis of constipation syndrome in the world comes in second or third place after acute respiratory infections/ARVI. The quality of life of patients with constipation syndrome in terms of nutrition, sleep, rest, sexual activity, family and social status is reduced.

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V. V. Skvortsov, Doctor of Medical Sciences, Associate Professor A. V. Tumarenko, Candidate of Medical Sciences E. M. Skvortsova O. V. Orlov V. V. Odintsov A. M. Yusupova VolSMU, Volgograd

Physical exercise

One of the effective and affordable methods for preventing constipation in a nursing mother is light physical activity. Regular exercise will help strengthen the abdominal and perineal muscles. As a result, muscle tone increases, which helps to activate intestinal motility. Yoga, walking, swimming, and Pilates are suitable exercises for nursing mothers.

Also, don't ignore your daily warm-up. It is best to do exercises on an empty stomach. You should start with simple exercises, gradually increasing complexity. There are also specific exercises that increase intestinal contractility and help cope with constipation, for example:

1. Stand straight with your feet shoulder-width apart.
2. Take a deep breath, then strongly draw in and then sharply push out your stomach.
3. Repeat the action 10 times and take a break.

Exercises must be performed at a slow pace, without sudden jerks. The main thing is regularity. As you get stronger, you can increase the number of repetitions. Gymnastics will help normalize bowel movements and improve your well-being.

Exercises while lying on your back

• Take a breath, stick out your stomach. As you exhale, draw in your stomach and lightly press your hands on the abdominal wall.
• Place your hands behind your head and stretch. At the same time, pull in your stomach. As you exhale, lower your arms and place them along your body.
• Lying on your back, bend your knees without lifting your heels off the floor.
• Pull your right knee towards your stomach as you exhale. Lower your leg while inhaling. Repeat the same with your left leg.

The “bicycle” and “scissors” exercises are good for constipation.

Exercises while lying on your stomach

• Place your hands under your shoulders. Get on all fours, without taking your hands off the floor, and then roll onto your feet. Take the starting position.
• Perform alternating leg swings with simultaneous retraction of the abdomen as you exhale and retraction as you inhale.

Physical activity for frequent constipation

One of the key values ​​in the prevention and treatment of chronic constipation is physical activity. Loads commensurate with age and health status stimulate improvement of intestinal peristaltic activity.

For example, taking a deep breath stimulates improvement of trophism. Trained muscles of the anterior abdominal wall create optimal pressure for the normal functioning of the lower gastrointestinal tract.

Exercise helps improve a person’s quality of life and relieve chronic constipation. Sometimes regular walking for up to one hour is enough to improve bowel function.

Particularly useful in this regard are gymnastics, water aerobics, swimming, and cycling. Therapeutic exercises are the main method of treating spastic and atonic constipation; it improves the tone of the intestinal muscles. Light fitness, yoga, jogging can also be an option to keep fit.

If there are contraindications to exercise, you should consult your doctor and jointly choose the appropriate types of exercise.