Patrick O’Neil, PA
Constipation is the most common gastrointestinal ailment that I see in the Family Practice and Urgent Care setting. I would also frequently see this in the Emergency Room, but in the vast majority of instances, this is definitely NOT an Emergency Room condition. (See the article on Emergency Room vs Urgent Care). Constipation affects everyone at some point in their life, and for those of us that have had it, is an extremely uncomfortable event. It affects approximately 4.5 million people in the USA, and between 2 and 3 million people use laxatives regularly at an annual expenditure approaching $400 million for over-the-counter laxatives. Without a doubt, a lot of people have problems with defecating regularly.
What Causes Constipation
There are a lot of things that cause constipation! Hang on, because this can get a little lengthy!
1. Low Fiber intake
2. Low fluid intake/slight dehydration
Decreased Physical Activity
1. Narcotics: We have a HUGE constipation problem with narcotic meds
2. Antacids that contain aluminum and calcium
3. Iron supplementation
4. Chronic GI stimulant use to resolve constipation can actually worsen it
5. A lot of other meds! Check with your pharmacist or look at the package insert that comes with the medications.
Irritable Bowel Syndrome (two types: IBS-C is for constipation, IBS-D is for diarrhea)
Psychiatric: Depression can cause Constipation
4. A whole lot more…..
Signs and Symptoms
The patient suffering from Constipation will come in with a complaint of:
Definition of Constipation: Fewer than 3 stools per week
Straining when trying to have a bowel movement
Small, hard stools
Bloating with a general sensation of being very uncomfortable
Nausea with possible vomiting
Hemorrhoids, or possibly an anal fissure
I treat constipation with multiple medications in a step-wise approach. The very first thing you need to do is ensure there isn’t fecal impaction. If you believe you may be impacted, you will need to use an enema. Yeah, I know, nobody wants to do it…..but it is effective and will allow the other products to work more effectively.
Push liquids: You absolutely have to be hydrated well or the constipation is going to continue. You know you are hydrated when your urine is clear to straw-colored.
FIBER. The absolute most important over-the-counter supplement you can take. Take it daily unless it is causing Diarrhea. Examples are Metamucil, Citrucel and my personal favorite…Gummy Fiber!
Stool softeners: The most common stool softener is Colace. The generic name is Docusate. Only take this product if your stools are pretty hard. You should aim for your stool to be just a little firmer than soft-serve ice cream. If you don’t know what soft-serve is, it is what they serve at Dairy Queen or McDonalds. Just a little firmer than that and you will be right where you want to be.
Laxatives: I tell my patients that they should aim for a bowel movement daily, but at the very least, every other day. If they did not have a bowel movement the day prior, they are to take a laxative such as MiraLax. There are plenty of others, but this one seems to work pretty quickly and without a lot of cramping
Magnesium Citrate: This is my last resort. If all the other methods above have not worked, it’s time to pull out the big guns and let fly havoc! I take ½ bottle and wait an hour. If I have not had a bowel movement in that time, I take the other ½ bottle. You can take up to two bottles per day, but I have never had to use two bottles. One bottle is usually sufficient to blow the back of the toilet clean off.
When to seek medical attention
People normally come in to the clinic when the discomfort level has gotten to the point they cannot sleep and just sit on the couch rocking back and forth to ease the pain. They may also have severe nausea because everything is backing up. They will also have weight loss because they are not eating and not drinking enough. Constipation in itself is not life threatening, but it can sure make you miserable.
The key to constipation is through prevention. Eat a high fiber diet, take fiber supplementation daily, push fluids to remain hydrated and that is the answer for the vast majority of patients suffering from constipation.
There is one key illness that I want to talk about that can result from chronic constipation. Diverticulitis is an inflammation of the large bowel caused by small pouches created by constipation. The constipation causes pressure to build up inside the large colon and the pressure is looking for somewhere to go. If you have a small weakness in the colon, it can cause a pouch (diverticuli) to develop and later become infected/inflamed. Pain will be dramatic and it will cause you to want to come to the Emergency Room.