Constipation – The Sisyphean Myth of Regularity.
Remember Sisyphus, the Greek King of Ephyra? Punished for his hubris, he was made to roll a boulder uphill for eternity. Just before reaching the top of the hill, the boulder would roll down to the bottom of the hill and Sisyphus would have to begin anew. Interminable activities are often referred to as Sisyphean. And so it is with constipation. It seems interminable and unbearable.
Everyone claims to be constipated at sometime. The constipation may be an acute episode or a chronic condition. For some it is an acute episode. Yet, ask the average person to describe constipation and the answers are all different. Does a rock-hard bowel movement or a sense of fullness after evacuation qualify? What about straining to have a bowel movement? Is that constipation? To further complicate matters, when science defines constipation, very few people meet the criteria. Are constipation sufferers doomed to the Sisyphean struggle of pushing rocks? Can the feelings of fullness and “I can’t go” be remedied?
Am I Constipated?
An acute change in bowel habits requires an explanation. Finding none, constipation is diagnosed when a patient reports having less than three bowel movements per week, with severe constipation diagnosed with less than one b.m. per week. Statisticians tell us that ninety five percent of adults have between three and twenty one bowel movements per week. The median is one bowel movement per day. Unfortunately, one bowel movement per day seems to be the “holy grail” of bowel movement frequency and patients are often frustrated in their attempts to achieve this average. In fact, natural irregularity is the true normal.
Most true constipation has an idiopathic etiology and the treatment of the psychological and physical distress associated with idiopathic constipation is usually in the form of symptomatic relief.
What is available for those patients who must “do something” about their bowel habits?
A Kind Word Might Help
The first step in relieving patient anxiety is through education, with an effort to dispel the myth of stool regularity. Verbal reassurance is the best first medicine. “What goes in will come out…relax.” This advice actually helps…occasionally.
Failing this advice, patient education will allow the seeker to choose from panoply of available options. It is important that the patient discuss all of the following options with a physician prior to beginning any treatment programs. Some of these preparations can decrease the absorption of important prescription medications, and alter their effectiveness.
Want the Hulk? Eat the Bulk!
In our westernized diet we fall short of the recommended consumption of 25 grams of fiber per day, but this recommendation varies with age and gender. Fiber binds up to 30 times its own weight in water and allows for a bulkier, softer and easier movement. Fiber is found in fruits and vegetables or in bran, and when ingested in sufficient quantities, often relieves constipation. Some cereals contain fifteen grams of fiber per half cup. Some actually taste good. As patients see dietary changes as “natural”, the psychological burden of having to take a daily “medication” is avoided. Not uncommonly, side effects such as abdominal bloating and flatulence may occur.
Different preparations affect individuals differently; both in stool bulk and flatulence. A trial and error approach is used. Patience is advised as the body begins to adjust. Water must be consumed with each preparation. Excessive flatulence may be removed by rectal transport or by ingesting a different fiber preparation.
Psyllium seeds are derived from plants. When taken as 7 grams per serving with 8 ounces of water three times daily, the seeds absorb water and increase bulk. The seeds and the stool become surrounded by mucilage, a thick glue-like substance, promoting softening. Psyllium preparations are marketed under brand names such as Fiberall, Konsyl, Metamucil, Modane Bulk, or Serutan. Benefiber contains wheat and dextrin, a type of sugar and also a bulking agent.
Cellulose is found in the cell walls of green plants. Methylcellulose is a synthetic compound created from cellulose. Methylcellulose strongly attracts and holds water, bulking and softening the stool. It is marketed under the brand name of Citrucel, and is also available in a generic form. It must be taken with water.
Polycarbophil is a synthetic chemical which also attracts water, increasing stool bulk and softness. It is marketed as Equilactin, Fibercon, or Konsyl Fiber. As always, it should be ingested with at least eight ounces of water.
Mineral oil serves as an excellent facilitator of bowel movements. The oil coats the stool and traps water within the stool, promoting soft bulk. The various commercial preparations are supplied as either the plain oil, or as an emulsion of oil and water.
There are several potential problems with ingesting mineral oil preparations. The first is that fat soluble vitamins may become dissolved in the oil rather than being absorbed, and patients taking oil on a long-term basis might become deficient of vitamins A, D, E or K. Lipoid pneumonia might occur if patients, especially the elderly, aspirate the oil preparation when taking it prior to bedtime. Both of these complications may be more of a theoretical concern than a true hazard. Taking large doses of mineral oil may lead to an embarrassing rectal leakage of the oil. Finally, there are reports of oil interactions with warfarin and birth control pills, with the effect that both of these medications may exhibit a decreased effectiveness.
Emollients. Gentle but Unpredictable
Emollients are wetting agents or chemical substances that lower the surface tension of liquids such as water and increase their spreading and penetrating properties. As a result, water more easily penetrates the stool and softens it. The most common chemical in this class of softeners is docusate (butanedioic acid, sulfo-,1,4-bis (2-ethylhexyl) ester, sodium salt, Sodium 1,4-bis(2-ethylhexyl) sulfosuccinate, or C20H37NaO7S444.56). It can be found in Colace, Surfak, Dialose, Docusate and other commercially available preparations. These may cause bloating and flatulence. Results are not as predictable as with other medications and dosing my need to be changed to achieve the desired effect. This class of compounds is often used to soften the stool in patients with painful anal fissures and after various anal operations.
Hyperosmolar Laxatives. Hold Your Water.
The best known preparations in this group of laxatives are Miralax and glycolax. They contain polyethylene glycol (PEG) powder which is mixed with liquid. Taken on a regular basis, they promote the retention of stool water. PEG is not digested or absorbed and does not alter electrolyte balances. Lactulose and sorbitol, both sugars, function in a similar manner. Bloating and flatulence are not uncommon side effects, and are dose-related.
Saline Laxatives. Potentially Harmful.
Phosphate, citrate, magnesium and sulfate are ions that cause water to be drawn into the stool resulting in softening and bulking. They are rapid acting and are also used in bowel cleansing prior to colonoscopy or colonic operations. Serious, potentially life-threatening electrolyte disturbances, dehydration, and hypovolemia may occur. The phosphate preparations are also associated with rare nephrocalcinosis and renal failure, especially in those patients taking ACE inhibitors or ARB’s. Preparations include Fleets Phosphosoda, which has been recalled, and the pill form of the compound, Visicol, which has fallen out of favor due to the potential renal side effects. Other saline laxatives are marketed under the names of Milk of Magnesia, Magnesium Citrate and others.
Stimulants. Popular, but Not Advised for Regular Use.
Stimulants stimulate. Stimulants are chemicals. They work by increasing the rate and intensity of intestinal peristalsis and they promote water secretion into the small intestine. They may also increase the amount of water in the stool by decreasing water absorption.
Dulcolax and Correctol contain bisacodyl (triphenylmethane). Cascara, Aloe, Senna, Senokot and Ex-Lax contain the organic hydrocarbon anthraquinone. Castor Oil contains ricinoleic acid. Prunes contain the stimulant phenolphthalein but may also promote peristalsis through the osmolar action of sorbitol.
Prolonged usage of these compounds may lead to a peristaltic dependence and should be avoided. Melanosis coli is seen endoscopically in the colon. It is a brown spotted discoloration of the mucosa, is benign and is an indicator of chronic stimulant use.
Most herbal or “natural” products (including green tea) contain a polyphenol stimulant laxative or an anthranoid stimulant. These can lead to colonic peristaltic dependence. Herbal preparations may promote secretion of water into the small intestine or reduce water absorption in the colon. These are not recommended for regular use as laxatives.
The Bottom Line? Listen to Your Father.
Most people are not truly constipated. For those wishing to avoid the uncomfortable feeling associated with a lack of regularity, numerous preparations are available. Some are innocuous and some must be used with caution. However, the best bowel movement is a natural bowel movement, delivered on nature’s timetable. Remember, “What goes in will come out…relax.”