Constipation

 

Constipation is the term used to describe difficulty going to the toilet or opening the bowels. We probably all suffer from this for short periods during our lives, but for some it becomes a chronic or recurrent problem. To understand constipation, you have to understand how the large intestine creates feces (stool). Food flows through the small intestine as a liquid mixture of digestive juices and the food you eat. By the time it reaches the large intestine, all the nutrients have been absorbed. The large intestine has one main function: to absorb water from the waste liquid, and turn it into a waste solid (stool).

 

General Background

Over recent years it has become apparent that people who eat more fiber are less prone to various bowel diseases and also are likely to be healthier in other ways. Fiber tends to diminish transit time (i.e. the length of time it takes for something that is eaten to pass right through the system) and thus reduce constipation. Funnily enough, if you take more fiber it will tend to normalize bowel habit, and may well cut down the frequency of motions in somebody tending towards diarrhea.

In general it is wise to eat small meals often and plenty of fresh fruit and vegetables, as well as having plenty to drink (one and a half to three liters of fluid daily). Foods containing fiber include brown rice, whole meal pasta. Whole meal/brown bread, potatoes with their jackets, etc.. It is also wise to take regular exercise or, at least remain active. You should not make a habit of putting off the "call of nature", as this can make the body's natural functions more sluggish.

 

What is normal?

Some people would regard it as normal to open their bowels three or four times a day, while for others normality would be once a week. Certainly, the human body can function quite well at either extreme, but most people probably open their bowels every day or every couple of days. It is wise not to get obsessed by the need to open the bowels daily, but if you experience a change of bowel habit that persists then you should seek the advice of your doctor. Because of the serious problems that can occur from constipation in the patient with chronic pain, the goal should be one soft bowel movement every one to two days without cramping or straining.

 

Common Causes

Change of diet or dehydration and a change of daily schedule may lead to constipation. Certain medications, especially some painkillers, may lead to problems. Sometimes the cause is a bowel disorder, but this is the exception, rather than the rule. Sometimes too much water is absorbed by the large intestine, leaving a very hard and dry stool that can't be passed without straining. That's constipation. Constipation itself is unpleasant enough, but when compounded by hemorrhoids created from straining, it can be miserable.

 

Listed below are some common causes of constipation:

…         Not drinking enough fluids. Your colon will absorb more water to prevent dehydration, resulting in dry, hard stools.

…         Not having a bowel movement when you have the urge. This keeps stool in the colon longer, where more water is absorbed and stools get harder.

…         Anything slowing movement of food through your colon increases your risk for constipation. Again, the longer it stays in, the harder it gets.

 

Common factors slowing down the colon:

…         Being inactive

…         Not eating enough fiber

…         Not eating regularly enough to stimulate the intestines to move food along

…         Certain high-protein foods

…         Many drugs

 

Why do patients with chronic pain have problems with constipation?

…         Inactivity and lack of exercise can slow down the bowel. Exercise stimulates bowel contractions. Because of pain, many chronic pain patients are not active.

…         Medications frequently cause constipation. Some of the medications that frequently cause problems in pain patients are:

-        Opioids (narcotic pain medicines) such as codeine, VicodinÆ or LortabÆ, DarvocetÆ, morphine, OxycontinÆ, methadone, DilaudidÆ. (There are the most notorious for causing constipation) Among the drugs that fall within this class - sometimes referred to as narcotics - are morphine, codeine, and related drugs. Morphine is often used before or after surgery to alleviate severe pain. Codeine is used for milder pain. Other examples of opioids that can be prescribed to alleviate pain include oxycodone (OxyContin-an oral, controlled release form of the drug); propoxyphene (Darvon); hydrocodone (Vicodin); hydromorphone (Dilaudid); and meperidine (Demerol), which is used less often because of its side effects. In addition to their effective pain relieving properties, some of these drugs can be used to relieve severe diarrhea (Lomotil, for example, which is diphenoxylate) or severe coughs (codeine).

-        Tricyclic antidepressants such as amitriptyline (ElavilÆ)

-        Non-steroidal anti-inflammatory drugs such as ibuprofen (MotrinÆ)

 

Other medications that can cause constipation include:

…         Iron supplements

…         Calcium supplements

…         Diuretics (water pills)

…         Some anti-cancer drugs

…         Some anti-hypertensives (drugs used to treat high blood pressure)

…         Antacids that contain aluminum

 

What are other causes of constipation?

…         Inappropriate laxative use

…         Drinking too little water

…         Too little fiber in the diet

…         Taking fiber supplements, without enough fluids

…         Diabetes

…         Hypothyroidism (low thyroid function)

…         Bowel problems such as diverticulitis, irritable bowel syndrome, bowel obstruction

…         Neurological problems such as a stroke

…         Depression

 

Why worry about constipation?

Constipation can be painful. In the extreme, it can lead to complete blockage and serious medical problems.

 

Who should be on treatment for constipation?

If you take opioid pain medicines on a regular basis, you should be taking medicines on a regular basis. If you take opioid pain medicines around-the-clock, you should be on bowel medicines around-the-clock. Again, the goal should be one soft bowel movement every one to two days without cramping or requiring straining.

 

What do you recommend for preventing constipation?

If youÖ

TakeÖ

Ö are taking only an occasional pain pill

ÖColaceÆ 100 mg pill by mouth twice a day

Ö are taking pain pills routinely

ÖSenokot-SÆ 2 tablets by mouth at bedtime

Öhave no bowel movements in any 24 hour period

ÖIncrease to Senokot-SÆ 2 to 4 tablets by mouth two to three times a day

Öhave no bowel movements in any 48 hour period

ÖDulcolaxÆ 2 to 3 tablets at nighttime and up to three times during daytime (take this in addition to the Senokot-SÆ)

Öhave no bowel movements in any 72 hour period

You need to be checked by your doctor to make sure you donít have a blockage (impaction). In addition, you will need to take additional laxatives such as:

Magnesium citrate, 8 oz by mouth, or

Lactulose 45-60 ml by mouth, or

FleetÆ phosphasoda enema

Note: For simplicity, we have used trade names for drugs. Generic drugs may be cheaper and work just as well. Your pharmacist can help you.

 

Do you recommend bulk laxatives, such as MetamucilÆ?

No. In patients on large doses of opioid pain medications, bulk laxatives (fiber laxatives) can lead to a high blockage, which can be serious.

 

Prevention

If you do the opposite of everything above, you should be fine. Keep one thing in mind, though: don't become obsessed with how often you have a bowel movement. The norm varies from twice daily to twice weekly. Constipation is defined by the difficulty of getting stools out, not by frequency of BMs.

 

Rules to prevent constipation

…         Eat three meals per day at least 4 hours apart. Frequent feeding keeps your intestines contracting and moving stool along.

…         Drink at least 32 oz. (one quart) of water per day, not including what you drink at mealtime.

…         Avoid caffeine and alcohol, which deplete body water stores. If you can't avoid these, then match your caffeinated or alcoholic beverage intake with an equal amount of water.

…         If your diet is not extremely high in fruits, vegetables, and whole grains, by all means take a bulk fiber supplement.

…         Add as much fruit and vegetables as possible to your diet.

…         Eat high fiber cereals, such as ìGrape-nutsî or ìAll-Branî, among others.

…         If you have to take an anti-acid, use one high in magnesium, which tends to cause diarrhea, as opposed to those containing aluminum, which tend to cause constipation.

 

Treatment

Sometimes people become so constipated that they or their doctor feel that other action is required. There are various medicines/tablets to help constipation (laxatives):

…         Fiber supplements, which come as powder, which makes up a small drink, granules, tablets containing bran, or indeed raw bran.

…         Osmotic laxatives, which act by drawing more fluid into the bowel.

…         Irritative preparations which tend to introduce contractions of the bowel (e.g. Senna).

You may need to use one or more of these together.

 

The fallowing advice is mainly preventative, but it can be helpful in mild cases of existing constipation, too. If you stimulate the colon enough, contractions will help get the hardened stool out. Try prunes or other fruits, or even caffeine to stimulate contractions, as well as moderate exercise. But don't jog too far away from a bathroom!

If constipation is quite severe, or special circumstances (such as hemorrhoids) make it important to control quickly, then consider these laxative groups:

…         Bulk fiber laxatives. Different brands have different ingredients, but they all just add bulk to the stool and prevent too much water from being absorbed. They may take awhile to take effect (12 hours to 3 days).

…         Stool softeners. These can be effective if your stool is too hard or dry to come out, despite normal bowel contractions. They are mainly preventative, but can work very quickly when combined with a stimulant laxative.

…         Stimulant laxatives. These stimulate bowel contractions quickly, but don't soften the stools at all. They are often combined with stool softeners.

…         Glycerin suppositories. Promptly effective, usually within 1/2 hour. They both soften the stool and stimulate contractions. They only work on the stool that is in the rectum and lower colon.

…         Enemas and oral magnesium solutions. Avoid these unless directed by a physician.

 

Recommended Products

…         Citrucel (methycellulose 2 grams/tbs.). Many find this brand of bulk fiber laxative to be less gritty than others, and it comes in both sugared and sugar-free versions.

…         FiberCon (calcium polycarbophil 625 mg/tablet). If you canít stand drinking a bulk fiber laxative, these tablets are an excellent alternative. Just make sure you take them with a full 8-12 oz. of water or other liquid.

…         Senokot, Senokot S, and Senokot Childrenís (Senna concentrate, various concentrations; docusate sodium 50 mg per tablet is the softener in Senokot S). The active ingredient Senna is a bowel contraction stimulant. It is considered safe in children as young as one year. If you need stool softening or lubrication along with the stimulant effect, Senokot S is the recommended combination.

…         Fleet Glycerin Suppositories and Fleet Babylax (glycerin). As stated in îTreatmentî, these are especially useful if you desire very quick results without swallowing a lot of fiber or a drug that may have other side effects. Glycerin works only in the rectum and lower colon, and is one of the few laxative forms that are safe and effective in infants under one year old.

 

Protocol For Prevention of Constipation

 

Each Day (Prevention):

…         Metamucil ñ 1 Rounded tablespoon in water or juice, once a day to three times a day. (Psyllium)

…         Sunsweet” Prune juice (8 oz. Glass). Take twice a day with breakfast and at bedtime. You may increase to three times a day, with meals.

…         Drink eight (8) glasses (8 oz. Glass) of water per day.

 

Plus one of the following:

…         Docusate Sodium (Colace) ñ 250 mg once a day or twice a day.

…         Peri-colace (Docusate + casanthranol) ñ 1-2 capsules or 15-30 ml PO qhs prn.

…         Surfak (Docusate sodium) ñ one 50 mg capsule at bedtime (HS) (May be increased up to a maximum of three 50 mg capsules.) Warning: DO NOT use Mineral Oil while using Surfak.

…         Senokot-S’

Step 1 - Take two Senokot-S’ tablets at bedtime.

Step 2 - If you do not have a bowel movement in the morning, take two Senokot-S’ tablets after breakfast.

Step 3 - If you do not have a bowel movement by evening, take three Senokot-S’ tablets at bedtime.

Step 4 - If you do not have a bowel movement in the morning, take three Senokot-S’ tablets after breakfast.

 

Once you start having bowel movements, use the two steps prior to your last one as your daily laxative protocol.  For example, if you achieved a bowel movement after Step 4, use Steps 2 and 3 (that is, two Senokot-S’ tablets in the morning and three Senokot-S’ at bedtime) s your daily regimen.

 

If No Bowel Movement in any one 48-hour period, add one of the following:

…         Bisacodyl (Dulcolax) ñ 2 to 3 tablets once a day (10-15 mg PO qd or 10 mg PR qd)

…         Milk of Magnesia ñ 30 to 60 ml once a day to twice a day.

…         Lactulose ñ 15 to 60 ml once a day

…         Miralax’ - one pack, 17 gm (one heaping tablespoon) in an 8oz. glass of water, PO once a day for 10 days. Comes in 14 oz. (225gm) bottle, and 28 oz. (527gm) bottle.

…         Sorbitol ñ 15 to 60 ml once a day.

 

If No Bowel Movement by 72 hours, add one of the following:

…         Dulcolax ñ 2 to 3 tablets rectally at bedtime.

…         Mineral Oil ñ 30 to 60 ml by mouth

…         Magnesium Citrate ñ 8 ounces by mouth, and can follow with additional 8 ounces if no effect after 4 hours

…         Fleet Enema, Tap Water Enema, or Soap Suds Enema

 

Remember that constipation is a common side effect of many medications.  A daily bowel regimen helps to prevent this potentially troublesome side effect. If you are unsure about what to do, please talk to your physician for advice.

 

PATIENT INSTRUCTIONS

DOCUSATE CALCIUM  ( SURFAK )

TAKE THIS MEDICATION ACCORDING TO THE FOLLOWING INSTRUCTIONS:

Preferably taken at bedtime.

May be taken with milk.

Take tablets and capsules with a full glass of water (8 ounces).

Do NOT take other medications within 2 hours of taking this medication.

Do NOT exceed recommended dosages.

Do NOT crush tablets or open capsules; take this medication intact.

Take this medication at the same times(s) each day.

WHILE TAKING THIS MEDICATION:

Follow your doctor's guidelines regarding diet.

Do NOT take mineral oil.

Take at least 6 to 8 glasses of fluids daily unless advised otherwise.

Maintain adequate dietary fiber intake.

Follow doctor's guidelines regarding exercise.

Do NOT take over-the-counter products, before checking with pharmacist.

OTHER INSTRUCTIONS AND PRECAUTIONS:

Do NOT take if you have abdominal pain, cramping or soreness;  seek advice.

Do NOT take other medications within 2 hours of taking stool softeners.

Long-term use requires guidance by your doctor; keep all appointments.

Do NOT take more than 7 days unless advised otherwise by your doctor.

Read package directions carefully before using this medication.

INFORM YOUR DOCTOR - IMMEDIATELY - AT THE SUDDEN ONSET OF:

Persistent vomiting.

A rash upon any part of your body.

Diarrhea that lasts more than 24 hours.

INFORM YOUR DOCTOR - AS SOON AS CONVENIENT - AT THE ONSET OF:

Severe and persistent constipation.

 

SENNA

( BLACK-DRAUGHT LAX-SENNA, FLETCHER'S CASTORIA, GENTLE NATURE, NYTILAX, SENEXON, SENOKOT, SENOLAX, X-PREP )

TAKE THIS MEDICATION ACCORDING TO THE FOLLOWING INSTRUCTIONS:

Preferably taken at bedtime.

Take tablets and capsules with a full glass of water (8 ounces).

Do NOT take other medications within 2 hours of taking this medication.

Do NOT exceed recommended dosages.

Mix granules/powders with liquid, per instructions, before taking.

Do NOT use more than 10 days unless advised otherwise by your doctor.

WHILE TAKING THIS MEDICATION:

Maintain adequate dietary fiber intake.

Follow your doctor's guidelines regarding diet.

Do NOT take over-the-counter products, before checking with pharmacist.

OTHER INSTRUCTIONS AND PRECAUTIONS:

Read package directions carefully before using this medication.

INFORM YOUR DOCTOR - IMMEDIATELY - AT THE SUDDEN ONSET OF:

Itching and/or hives.

Any breathing difficulty or shortness of breath.

Severe confusion.

Severe abdominal pain.

Persistent vomiting.

A rash upon any part of your body.

Unusual tiredness and/or weakness.

INFORM YOUR DOCTOR, AS SOON AS CONVENIENT, AT THE ONSET OF:

Muscle cramps and/or spasms.

 

BISACODYL

( BISCO-LAX, CARTER'S LITTLE PILLS, DACODYL, DEFICOL, DULCOLAX, FLEET BISACODYL, THERALAX )

TAKE THIS MEDICATION ACCORDING TO THE FOLLOWING INSTRUCTIONS:

Preferably taken at bedtime.

May be taken with or following food to reduce stomach upset.

Take at bedtime to produce results in the morning.

Take tablets and capsules with a full glass of water (8 ounces).

Do NOT take other medications within 2 hours of taking this medication.

Enteric coated tablets should be taken intact, DO NOT crush.

Do NOT exceed recommended dosages.

Mix granules/powders with liquid, per instructions, before taking.

Do NOT use more than 10 days unless advised otherwise by your doctor.

Do NOT take antacids within 2 hrs before or after taking this medication.

Do NOT take this medication with milk or other dairy products.

Do NOT crush tablets or open capsules; take this medication intact.

WHILE TAKING THIS MEDICATION:

Increase daily intake of fluids, unless advised otherwise by your doctor.

Maintain adequate dietary fiber intake.

Do NOT take mineral oil.

OTHER INSTRUCTIONS AND PRECAUTIONS:

Digital rectal examinations should be performed regularly during therapy.

INFORM YOUR DOCTOR - IMMEDIATELY - AT THE SUDDEN ONSET OF:

Persistent vomiting.

A rash upon any part of your body.

Unusual tiredness and/or weakness.

Diarrhea that lasts more than 24 hours.

Any breathing difficulty or shortness of breath.

A rapid and/or irregular heartbeat over 120 beats/min.

Severe confusion.

INFORM YOUR DOCTOR, AS SOON AS CONVENIENT, AT THE ONSET OF:

Problems in urinating (hesitancy, pain, etc.).

 

MAGNESIUM CITRATE - LAXATIVE

(CITRATE OF MAGNESIA)

TAKE THIS MEDICATION ACCORDING TO THE FOLLOWING INSTRUCTIONS:

Preferably taken at bedtime.

Do NOT exceed recommended dosages.

Do NOT use more than 10 days unless advised otherwise by your doctor.

Preferably taken on an empty stomach.

Shake oral suspensions or liquids well before using.

WHILE TAKING THIS MEDICATION:

Take at least 6 to 8 glasses of fluids daily unless advised otherwise.

Maintain adequate dietary fiber intake.

Follow your doctor's guidelines regarding diet.

OTHER INSTRUCTIONS AND PRECAUTIONS:

Read package directions carefully before using this medication.

INFORM YOUR DOCTOR - IMMEDIATELY - AT THE SUDDEN ONSET OF:

Diarrhea that lasts more than 24 hours.

Persistent vomiting.

Unusual tiredness and/or weakness.

INFORM YOUR DOCTOR, AS SOON AS CONVENIENT, AT THE ONSET OF:

Changes in mood or mental state.

Muscle cramps and/or spasms.

 

NOTES FROM MIRALAXÆ PACKAGE LABELING

…         MiraLaxÆ (polyethylene glycol 3350, NF powder) is a prescription-only laxative composed of a synthetic polyglycol with an average molecular weight of 3350.

…         It is an osmotic agent. The package labeling indicates that it is unabsorbed and does not have an effect on active absorption or secretion of glucose or electrolytes.

…         The package labeling describes a placebo-controlled clinical trial in patients with less than 3 bowel movements per week. The patients were randomized to receive 17 Grams of MiraLax or placebo for 14 days. In the first week bowel movement frequency increased in both treatment groups. In the second week, MiraLax showed statistically superior results (unspecified).

…         The package labeling reports another study in similar patients randomized to 2 dose levels of MiraLax or placebo for 10 days each. "Superiority" of the 17 Gm dose is stated for both frequency and daily stool weight. No other details are given.

…         Adverse reactions are stated to include nausea, abdominal bloating, cramping, and flatulence. Diarrhea and excessive stool frequency can occur in high doses or in "elderly nursing home patients."

…         The dosage of MiraLax is stated as 17 Gms ("about 1 heaping tablespoon") per day in 8 ounces of water. It is stated that 2 to 4 days may be required to produce a bowel movement.
Miralax comes in a 14 oz. or 28 oz. container with a measuring cap on each bottle. It is stored at controlled room temperature.