How to treat Advanced Constipation

Transcript of How to treat Advanced Constipation
Martin Carr, MD

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Hello everyone out there this is Dr. Martin Carr and it is November 24th, 2017, the day after Thanksgiving. I’m back here with another broadcast about things GI that’s gastrointestinal and microbiome related. Today I’ll be focusing on the topic of what I refer to as advanced constipation but before we get to that I wanted to mention three books that I have been reading lately that I think would be well worth your looking at. One of them is the Psychobiotic Revolution by Scott Anderson with professors John Cryan and Ted Dinan from Cork, Ireland, another one is the Mind Gut Connection by Emeran Mayer a physician and researcher at UCLA and finally Dirt is Good by Jack Gilbert of University of Chicago and Rob Knight of University of California, San Diego–all excellent books, I recommend them highly.

So onto our topic. This is aimed at patients of mine and other people who are seeking help for constipation that’s not easy to deal with . I’m not talking about basic simple occasional constipation that anyone might have so I’m talking about a group of people who have already tried drinking more water;
they’ve already tried taking a walk everyday;
they have already tried having 6 prunes a day;
having more fruit, having more vegetables;
having some high-fiber cereal;
having some Metamucil;
taking some milk of magnesia with water;
perhaps even buying some stool softener pills.

So I’m talking about a group who have often done all of that and are still having trouble and some of them have even tried, on its own, Miralax. And that hasn’t been enough for them either. So what does someone with Advanced Constipation have to do? First of all, we have to realize that beyond all those basic things that you may have already tried and beyond being well hydrated and having a decent diet there are three variables that we can help someone with Advanced constipation to manipulate. Here are those three variables.

The first one is lubrication.
The second one is controlling the amount of water that stays in the stool.
And the third one is motility or the muscle contraction of the colon.

And the real key is to try some things and if necessary to combine them and then to make adjustments. We’ll talk about lubrication first. For a patient to manipulate lubrication in the colon there are two things that you have to use. The first we mentioned at the beginning. You might have already tried stool softener pills. These are made out of something called docusate sodium as the active ingredient. It causes the surface of the stool to be a little bit softer and to slide easier. It comes in a couple of different strengths. There are store brands of this. The original brand was called Colace. The next thing that is available to change the lubrication of the colon is what I often end up asking people with Advanced constipation to use and that is mineral oil.

Mineral oil is available in any pharmacy and most supermarkets and the larger megastores. Mineral oil is very safe when taken in the small quantities that we’re talking about. It is not absorbed from the intestines into the bloodstream so there’s no toxicity to worry about and taking it in small quantities it is not going to interfere with vitamin absorption or drug absorption. It can be an excellent lubricant for many people just taking 2 tablespoons which is 30 ml or 1 oz a day. After a couple of days it will help the stool to literally slide. So for somebody who’s got slow contractility or having a problem with stools that are harder and without enough water mineral oil alone can sometimes make a significant difference.

There are actually two forms of mineral oil available. There is the plain clear mineral oil which has an oily consistency but really no taste at all and is not very much of a problem for most people to take. There’s also another form of mineral oil called Kondremul. This is mineral oil that’s been emulsified which is specially ultrasound whipped together with a bland vanilla syrup so that it’s not oily at all but it’s still the same dose, for most people 2 tablespoons or 1 oz a day. Most people do the best taking mineral oil in the evening either shortly after dinner or sometime in the evening with a little bit of liquid. It can be tricky to mix it with other things. Just take it and then wash it down with some liquid. It is possible to add to smoothies and take it that way. So mineral oil is safe, it’s easy to find, it’s inexpensive, it does not cause any intestinal cramping If you take too much, and for some people even 2 tablespoons a day might be too much, all that will happen is that the stools will get slightly looser than you want and then you have to stop it and adjust the dose. Some people also might notice a little bit of an oily residue seeping out at times, but again just stop it for a day or two and adjust the dose down a little bit.

So the next of the three main variables we are going to talk about is adjusting the amount of water in the stool. Now some of you may know that the one of the jobs of the small intestine and the colon or large intestine is to remove a lot of the water from the liquidy content that flows into the small intestine and then out of the small intestine into the large intestine each day. If you have a colon is contracting slowly then there’s even more time for that to take place and the stools can get quite dry and hard. For people in this situation drinking more water won’t necessarily make the stools get any softer. So how do we add some water to the stool to make little bit softer and easier to pass? There are a couple of answers to this. One of the easily available ones is milk of magnesia which contains magnesium hydroxide. This is a form of magnesium that we don’t absorb well into the bloodstream. It stays mixed in water in the intestines and it will carry that into the colon and prevent that water from being absorbed. This is what it means to say that something is an osmotic laxative. Another example of this kind of osmotic laxative that will increase the water content of the stool was originally called Miralax and that brand is still for sale. Almost every store will now have a store brand generic right next to the Miralax on the shelf. Miralax and the store brand equivalent contain a powder made of something called polyethylene glycol. Polyethylene glycol is a large molecule that we cannot absorb from the intestines into the bloodstream. It’s very safe and it’s very rarely anything that people would have allergy or other reaction to. When you take a 17 gram or heaping tablespoon dose using the cap on the container or the scoop that’s that’s inside and you add that to 8 oz of water that is your single dose of this osmotic laxative. It’s tasteless. You drink that glass of water and you can imagine that most of that 8 oz of water is going to stay in the intestines all the way into the colon and mix with the stool to make the stool softer by making it contain more water. Also if you take a glass of water with Miralax everyday or for some people it might be a dose and a half in 12 oz of water and for a few people even 2 doses in 16 oz or one dose in 8 ounces twice a day, and if you took an x-ray first before starting that habit of taking Miralax each day and then took another x-ray a couple of weeks later there be generally a lot less stool in the colon.

So now we finished discussing lubrication and we’ve also discussed agents like milk of magnesia or Miralax to increase the amount of water in the stool. Now for the third major variable that we have to adjust we’re talking about motility or contraction of the colon. There are two very easily available chemicals to use to increase the contraction of the colon one of them is called Senna and this is derived from a plant. It’s been around for many many hundreds of years and has a very good safety record. Years ago there was a myth that using senna would paralyze the colon and make the problem worse but that’s really been shown not to be true. Senna is available from all pharmacies and supermarkets and stores like Walmart and Target and Costco. For most people two or three Senna tablets taken at bedtime will increase the contraction or squeezing or movement of the column and over 6-8 hours help to facilitate a bowel movement. Another agent that works in a similar way is bisacodyl. That was originally sold under the brand name Dulcolax and it’s still available that way. This is also available in all pharmacies and most supermarkets and other stores and it’s quite inexpensive just like senna. Two, sometimes three, pills at bedtime can facilitate a bowel movement if the other variables are acceptably well-controlled, that is, there’s enough lubrication, there’s enough water in the stool. Bisacodyl in my experience tends to cause a little bit more uncomfortable cramping than senna so I have gotten in the habit of recommending senna for people to try for this purpose rather than the bisacodyl.

For many people it could just be adding mineral oil that would help them get control of their Advanced Constipation or adding water with Miralax or polyethylene glycol every day or taking senna pills either every night or 3 or 4 nights a week but there are also people who don’t get results with just one of these agents. I find very often that when I’m seeing patients in my office referred to help with their difficult constipation what I’m teaching the patients is that it’s safe for them to combine these things. In fact I have some patients who have to use mineral oil, water with polyethylene glycol or Miralax and also some senna either everyday or multiple days each week in order to get a good result. This is completely safe. Typically we will have people start with one and then keep adding. For example to a person who has just experimented with Metamucil and high-fiber cereal and eating more prunes and is not having much luck I will suggest starting with water with Miralax or polyethylene glycol. After 4 or 5 days, then add a small amount of mineral oil either 1 or 2 tablespoons at night and finally after a couple more days at some senna pills to that mixture. What I have found is that even for people with very difficult constipation there is a combination of these three things that will give good results. Even if we end up moving on to some of the prescription agents, which we will talk about in another segment of this podcast, it’s good for people to know how can they mix mineral oil and water with polyethylene glycol and some senna to get good results and good control of their Advanced Constipation. Thank you all for listening and you’ll be hearing more about this and other topics in the additional podcasts.