Constipation (Part 3)

Hello Dazzle! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I am going to talk some more about poop. Specifically, I am going to be talking more about constipation. In the first part, I talked about what constipation is and why it is important to prevent it or to treat it when prevention is unsuccessful. In the second part, I talked about chronic constipation. And in this last part I want to talk about treating constipation.

The first thing to consider for the treatment is what is causing the constipation. Addressing the cause is going to lead to greater success rather then focusing on treating the constipation itself. There are times, however, that the cause cannot be removed such as when the cause is a medication side effect that cannot be removed from the care plan. There are also occasions that the cause isn’t known or there are numerous causes that are contributing to the constipation. In all of those cases, it likely be necessary to treat the constipation itself rather then the cause or in addition to the cause. It is also important to note that in many cases it is impossible to determine the cause of the constipation.

One cause of constipation that is often overlooked is the removal of the gallbladder. This small organ was once under valued and frequently removed when a person developed gall stones. Now surgeons try to avoid the removal of the gall bladder because we have a greater understanding of its importance. When the liver makes bile, about half of it goes directly into the duodenum while the other half is stored in the gall bladder for future use. When the gall bladder is removed it makes it so the body can no longer control the release of the bile into the duodenum. This means that our bodies can no longer release the bile from the gall bladder in response to the substances that are present in the duodenum. How does that relate to constipation? The bile salts that are the main component of bile have a significant impact on the motility of the gut. Thus, if you have had your gall bladder removed you might want to consider talking to your doctor about adding bile salts to your treatment plan.

While bile salts are available as an over the counter supplement, I would still recommend that you discuss the specifics of your case with your gastroenterologist before starting them. This is partly because there are conditions in which bile salts are not recommended to be taken such as with liver disease. It is also because there are multiple types of bile salts on the market that the FDA has approved for various different uses. Those being sold over the counter are not the types of bile salts that have been studied and approved by the FDA. The kinds of bile salts that have been approved by the FDA are those that require a prescription.

Occasional constipation can usually be treated with self care. Generally, if you are having hard stools or have not had a bowel movement in 3 days you can start by trying dietary modifications. Drink additional water and eat high fiber foods. If this doesn’t work for you, consider trying an over the counter fiber supplement, stool softener or laxative. If you are not sure which to try, consult with your pharmacist or doctor. If you have any bleeding with your stool you should talk to your doctor. You should also talk to your doctor if you go more then 7 days without having a bowel movement.

If you have recurrent constipation, you should see your doctor for recommendations on how best to prevent the constipation and how to treat it during the episodes. Recurrent constipation is generally treated with diet changes that include increased water intake and a high fiber diet. It also usually includes a fiber supplement. Sometimes, you will need to see a dietician or nutritionist to help you find your best dietary approach. This is more likely to be the case if you have other medical problems. A medical journal can be an excellent tool in helping you establish an effective diet plan.

Functional constipation requires medical management for successful treatment outcomes. Each type of constipation has different treatment approaches that are more likely to be effective. IBS-C will also have a distinct treatment approach. However, there are some things that have been shown to be helpful in all types. In general, dietary changes are helpful in all types of constipation. Increasing water and fiber intake being the dietary changes given primary focus. Using a medical journal can reveal foods that are constipating to the individual rather then eliminating foods based on averages or generalizations.

Fiber supplements are generally considered helpful in all types of constipation. However, it is important to consider the possibility of gastroparesis for those patients with slow transit constipation as this common comorbidity would preclude fiber supplements as well as a high fiber diet as they would exacerbate the gastroparesis. If the person has been diagnosed with slow transit constipation they should be screened for gastroparesis as well, especially if they have historically not noted an improvement in symptoms with increased fiber.

There is a lack of research to support that stool softeners improve any kind of constipation despite them frequently being used to treat all forms of constipation. This is in part due to stool softeners having a low risk profile. If a stool softener is tried and not found to be effective it is important that it isn’t continued simply as a matter of course which is a common practice. While the risk profile is low, it is not fully without risk and those risks can never be justified when there is no benefit being gained.

When considering osmotic laxatives, miralax and lactulose where shown to have an equal efficacy. However, miralax is now over the counter while lactulose still requires a prescription. Additionally, miralax was associated with less gas as a side effect then lactulose. Insurance coverage may play a factor in which medication would be ideal as most health insurance does not cover over the counter medications. However, it being covered by the insurance does not mean that it will cost the patient less than the over the cover option.

Slow transit constipation generally responds better to stimulant laxatives such as dulcolax or senna which are both available over the counter. It also responds better to prokinetic medications which increase bowel motility such as metoclopramide or erythromycin. The prokinetic medications are good choices in the cases where gastroparesis is a comorbidity as these medications are also used to treat the decreased motility of the stomach.

Normal transit constipation does not show any difference in efficacy between the stimulant or osmotic laxative. If the person has problems with electrolyte imbalance an osmotic laxative should be avoided if possible. An osmotic laxative works by drawing water into the bowel which can also lead to electrolytes being drawn into the bowel along with the water. Additionally, osmotic laxatives should be avoided for those who have issues with dehydration or a diagnosis of postural orthostatic tachycardia syndrome.

Probiotics, specifically in the genera Bifidobacterium and Lactobacillus, have been used to treat all types of constipation. The research results on probiotics is unclear due to there being a lack of good data available to fully evaluate the effect they have on the gut in context to constipation. It is unclear whether any one particular strain of probiotic is more effective than another. Due to the paucity and quality of the existing data, and until further evidence becomes available, the use of probiotics in the management of chronic constipation remains experimental. Because microbes used as probiotics already exist naturally in your body, probiotic foods and supplements are generally considered safe. They may trigger allergic reactions and can present an infection risk to immune compromised individuals.

When treating defecation disorders, surgery is often needed when the cause is an anatomical problem such as a prolapse. However, having surgery to correct the anatomical problem does not guarantee the resolution of the defecation disorder but the reason for this is unclear. Subtotal colectomy (removal of part of the colon) can be considered for slow transit constipation, but this procedure does not have good long term outcomes. Generally speaking, surgery is not a recommended treatment for constipation.

When treating defecation disorders it is often necessary to use suppositories and enemas to cleanse the rectum of stool. However, there are other treatments available such as bio feed back, pelvic floor exercises (Kegels), pelvic floor physical therapy or botox.

In conclusion to all of this, I just want to make note that constipation is a complex medical problem that requires complex and dynamic treatment to reach optimal outcomes. However, it is a diagnosis that is all too often not taken seriously resulting in inadequate evaluation and treatment which leaves many suffering when numerous treatment options have never been explored. So, if you are one of the many people who suffer with chronic constipation, know that it is important to advocate for yourself and to seek care from a gastroenterologist rather then a primary doctor.

Well, that’s about it for my rambling today. Thanks for coming and spending some time with me. If you like what you read, click on that like button. It really does help! Until we talk again, you take care of yourselves!

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