I have decided after many years of dealing with complaints of constipation both in the ER and in correctional facilities that bowel health is the last taboo subject. We all received “The Talk” (about sex and reproductive health) when we were adolescents. But nobody seems to talk about how to have a proper bowel movement. It is a subject that inevitably causes giggling and uncomfortable laughter. It is not spoken of in polite society. As a result many people do not understand how their bowels work. I have found this to be a big problem in the jails I work in. Inmates complain of constipation when they are not really constipated. They are bowel-fixated when there is no reason for them to be. Often, they need education more than they need laxatives. To this end, I want to discuss several essential factors relating to understanding and treating constipation that may help make your correctional medicine practice a little easier.
1. The most common cause of constipation is too little stool, not too much stool.
This is a little counterintuitive, but very true and important to understand. The small intestine absorbs the nutrients from the food we eat and deposits the indigestible bits (mixed with a lot of water) into the colon. The job of the colon is to reabsorb most of the water and thus create feces. The indigestible bits are better known as fiber. The colon moves the mass of fiber and water along by means of peristalsis—the systematic contraction and relaxation of the wall of the colon. If the mass of stool is small, peristalsis has a much harder time moving things along.
You can demonstrate why this is so by playing a game I used to play in grade school—the soap game. To play the soap game, you take a wet piece of soap and squeeze it in your fist, causing it to shoot across the room (extra points if you hit your friend in the head). You will find if you do this that a larger piece of soap works much better than a small sliver of soap. With a larger piece of soap, even a little squeeze will shoot the soap a long way. But if the soap is a small sliver, you have to squeeze very hard and generate a lot of pressure to make the soap move.
It is the same principle with your colon. For peristalsis to work efficiently there has to be enough stool. If there is too little, the colon has to generate high pressures to move it along and it moves inefficiently. This leads to constipation. The essential teaching point here is that in order to relieve constipation, the absolute most important thing we need is more fiber. The other remedies we will discuss are not even close to as important. Just about everyone with complaints of constipation should receive more fiber. Unfortunately, jail and prison diets are all too often deficient in fresh fruits and vegetables and whole grains. But you can supplement dietary fiber with fiber tablets or soluble fiber.
Similarly, another solution to constipation is to drink more water. Remember that the colon reabsorbs water from the stool given it by the small intestine. If you are dehydrated, the colon will absorb a lot of water, leaving the stool small and hard to pass. So, like a reflex, if you are my patient and you say “constipation,” I am going to say “fiber and water.” These are the single most important part of constipation therapy.
Incidentally, the “stool softener” laxatives like mineral oil and colace work by making the surface of the stool more permeable to water thereby attracting water back into the stool. This, of course, makes the final product moister and bigger. However, you can achieve the exact same effect by drinking more water. If you are not dehydrated, the colon will leave more water in the stool to begin with.
2. Bowel movements occur on a circadian rhythm.
By this I mean that we naturally tend to have bowel movements at approximately the same time every day, usually in the morning. And your body tells you when it is time to have a BM by giving you “The Urge.” You can’t just have a bowel movement any time you wish. If you try to have a bowel movement at the wrong time of the day or when you are not feeling the urge, your body may not cooperate.
This is very similar to another natural event that occurs in a circadian fashion—sleep. Our bodies have a signal that tells us it is time to go to sleep (we get tired) and this tends to occur at the same time each day. If you try to go to sleep at the wrong time of day when you are not tired, you will not tend to be very successful.
This fact—the circadian nature of bowel movements—becomes important when prescribing osmotic or stimulant laxatives. (These include Dulcolax, Milk of Magnesia, Magnesium Citrate, Senna and others). These laxatives work by stimulating the colon to contract. They are properly used to re-establish a natural rhythm. I know a doctor who liked to prescribe Dulcolax to be taken three times a day. This makes as much sense as prescribing Ambien to be taken three times a day.
Also, just like sleeping aids, if you take laxatives every day, you can become habituated to them so that it becomes hard to go without them. Laxatives are properly used intermittently to re-establish the body’s natural circadian rhythm of bowel movements.
3. You cannot have a bowel movement if there is nothing in your rectum!
Simplified, the large intestine consists of two parts, the colon, which extracts water from the mass delivered to it by the small intestine and creates stool, and the rectum. The rectum is a stool storage place preparatory to evacuating it in a bowel movement. The rectum is analogous to the dumpster in my office complex. During the day, all the medical offices take their garbage out to the dumpster. Then once a day, the city garbage truck comes around and empties it. This is very like our large intestine—during the day, the colon adds finished stool to the rectum and once a day or so, the rectum is emptied.
But what happens if nobody put any garbage into the Dumpster? Let’s say that you generally have a bowel movement every day but recently, well, you just have not been eating very much fiber. It may be that your body has not created enough stool for a bowel movement this day. Or maybe, peristalsis slowed down somewhat for whatever reason and your rectum is empty. On that day, you will not feel the urge to have your normal daily bowel movement. That does NOT mean necessarily that you are constipated. It may mean that there is nothing in the rectum to evacuate right now; there will be tomorrow. Relax! You do not have to take a laxative. Once again, most likely the problem is that you are not eating enough fiber or drinking enough water.
Conversely, if you eat an unusually large amount of fiber, you may need to have two bowel movements a day.
4. You need to be able to identify those “Red Flag” patients who are at high risk to have true constipation problems.
In most patients, constipation is a nuisance rather than a bad medical problem. I mean by this that even if you don’t treat these patients with anything, they will eventually work things out themselves. I have not seen any patients in my jails explode from constipation.
However, there are certain patients who can develop constipation so severe that it becomes a true and urgent medical problem. The most common way for this to happen is to develop a fecal obstruction so large that the patient literally cannot pass it. Think basketball sized.
It is important to identify who these high-risk patients are. It is pretty simple:
- The elderly and infirm.
- Debilitated patients, such as those with cancer or AIDS.
- Patients with an inherited bowel disease, such as cystic fibrosis, that leads to constipation. These patients will tell you who they are.
- Patients taking chronic narcotics (think Elvis).
If you identify a high risk patient, how can you tell if they have a fecal obstruction? Simple—you do a rectal exam. You will not miss the huge stool mass.
5. There are two objective tests to determine if a patient is truly constipated.
One of the problems with diagnosing constipation is that we have to take the patient’s word that they are not having normal bowel movements. Often, especially in corrections, patients may not tell us the truth. When you run into a patient with repeated and incessant complaints of not having bowel movements or in whom nothing works, you can check the validity of the history in two ways.
The first is the rectal exam. Remember that the rectum is the repository for stool preparatory for a BM. If the patient is “set” to have a BM, you should be able to palpate a fecal mass in the rectum. You can also tell if there is a fecal obstruction. If the rectum is empty, the patient is not ready to have a BM. If the patient states she has not had a BM in five days, and the rectum is empty, well, these two things do not jibe.
You can see stool on a plain abdominal x-ray. If you are not sure whether a patient has serious constipation or not, a plain abdominal x-ray can give you the answer. The normal colon will have around 2 or 3 stool boluses visible on x-ray. The seriously constipated patient may have a solid mass of stool extending from the cecum to the rectum. You should not, of course, order an abdominal x-ray frequently, but occasionally an abdominal x-ray is a more efficient and less expensive way to evaluate persistent claims of constipation than is endless prescriptions of laxatives. If the bowel is empty, the most powerful laxative in the world will not produce a bowel movement!
Most patients with complaints of constipation in the correctional environment would benefit more from education than they would from laxatives. Once you have sorted out the rare serious cases of constipation, you can have “The Talk” with the rest of the patients and teach them to manage their bowel health on their own. Give them the tools they need to manage this problem on their own by placing simple constipation remedies like fiber and stool softeners on the commissary.
How have you dealt with constipation complaints at your facility? Please comment!
This article was originally published in CorrectCare Winter 2012
Very interesting article. I especially enjoyed the ‘soap game’ analogy. Makes perfect sense. Thanks!
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