Dedicated to Change in the Delivery of Health Care

Constipation

In my work as a hospitalist I am seeing more and more patients who go to the emergency department because of stomach pain and sometimes vomiting. The cause is eventually proven to be due to severe constipation. (A hospitalist is a doctor who only cares for sick patients admitted to the hospital.)

The initial test performed is a CAT scan of the abdomen and the x-ray shows an obstruction of the intestine Rarely mentioned by the radiologist who interprets the CAT scan is the amount of stool present in the colon. A treatment plan is formulated. Along with watching and waiting to see what happens as time passes, pain and nausea medication is given to keep the patient comfortable. The pain is usually severe enough to require a narcotic for relief. Narcotic pain medication slows intestinal activity and can worsen constipation. Some medications used to combat nausea and vomiting do the same. As time goes by the patient does not get better nor worse and a laxative is given to promote intestinal action. Once the patient passes a large amount of stool the symptoms resolve.

Why could constipation become more of a problem than has been the case in the past? More medications that slow intestinal function are being prescribed. Medications to treat urine incontinence, over-active bladder, chronic pain and depression can slow intestinal function and lead to constipation. Taking strong diuretics for heart failure or swelling of other causes may produce dehydration and less water in the intestine to promote normal function.

The large intestine or colon is simply a muscular tube with a very large storage capacity. All muscles in our bodies work best when fully stretched, as does the colon.

Our intestinal ills have been well-advertised and the treatment offered is fiber in a tablet, wafer, or powder to be dissolved in liquid and drank. Without enough extra liquid to be absorbed by the fiber to increase its volume to stretch the intestine and promote propulsion of its contents, stool, a hardened mass forms that moves reluctantly. Repeating the same scenario daily, more fiber tablets/wafers/ powders with not enough extra liquid leads to the accumulation of, well, cement. Eventually the colon's effort to move the cement along is inadequate. The extreme pressure that develops inside the colon from its contracting muscles eventually causes pain.

The most common laxatives recommended are generally known as bulk laxatives because they increase stool bulk. Bulk laxatives draw extra fluid into the intestine to increase the volume of stool which increases the stretch of the muscles to propel the contents forward. The generic names of the drugs are: sennosides or senna, lactulose and polyethylene glycol. All of these work well with normal intestinal function. If intestinal function is impaired by medication or advanced age then increasing stool volume will not help. (Aging is characterized by the gradual loss of muscle mass including that of the colon.)

The average person passes stool daily or every other day. If you are taking any of the above laxatives on a daily basis and not having at least three large bowel movements weekly then you should take a stimulant. The stimulant that works best is milk of magnesia in a dose of two to four tablespoons. If you are taking medication that slows intestinal function I recommend taking two teaspoons of milk of magnesia nightly to prevent constipation that sends you to the hospital. (Do NOT do this if you have advanced kidney disease or are on dialysis.)

Avoid taking medical fiber by eating lots of vegetables, salads and whole grains which contain plenty of fiber. Be sure to drink the liquid necessary to make proper use of the fiber and avoid processing cement.

Back to Lessons

patient centered care

Only patient centered care will lead to quality and cost effective care.