Clinical Pearl Wednesday #158

Portrait of cute dog wrapped in toilet paper on toilet seat

One of the most common causes for ER visits is abdominal pain; the job of the emergency provider is to ensure the patient is not in immediate danger by ruling out things like a “hot belly” or appendicitis.  After these have been properly evaluated and managed, the patient is most often discharged with instructions to follow up with his/her regular provider in a few days.  At this visit, many providers discover that the abdominal pain is from constipation.  Sometimes, imaging results may even indicate stool or gas in the colon.

To decide if your patient has chronic constipation, ask these questions; 

do you:

have more than 1 day a week that you do NOT poop?

have watery stools?

have hard balls for poop?

ever have explosive diarrhea?

ever have tiny smears of blood on tissue with a BM?

ever strain or wait for long periods of time to poop?

ever feel like there should be more poop in the toilet?

ever feel like there’s more poop inside that should be emptying?

have lower abdominal pains/cramping?

feel bloated and overly full, even short of breath at times?

suffer with reflux, indigestion or heartburn?

have reported diverticulosis on imaging or colonoscopy?

If the patient answers yes to 2 or more of these questions, the problem is most likely chronic constipation. It can be VERY subtle but it’s there. 

Also ask, is your patient having heartburn, indigestion, or reflux? A study from a couple years ago suggested that 85% of people with reflux/severe indigestion actually suffered from constipation and theorized that the constipation is the most likely cause or contributing factor for their reflux symptoms – because if wastes aren’t coming out normally from the bottom, they have nowhere else to go but up. And that makes logical, functional sense. So, how do we fix it?

Many people will occasionally use a laxative or colon cleanser to completely empty the gut. While not safe to use daily, it might help to try one and see if symptoms are relieved.  If kidneys are healthy, a magnesium product is simple and not very pricey.  Milk of magnesia or liquid mag citrate can be recommended for a dose or two, stimulating peristalsis.  Following the colon emptying, encourage the patient to make a few lifestyle changes to prevent the recurrence of the constipation.  

Some experts recommend a bowel movement after every meal, while other recommend once daily as healthy bowel habits.  Identifying your patient’s normal pattern can be a challenge because many of them have unhealthy bowel patterns over many years.  

Steps to take to minimize slow gut motility include:

  1.  Drink plenty of water daily; keep in mind that coffee, soda, and tea are mildly diuretic.  Drinking quantities of caffeine regularly will not hydrate cells or contribute to healthy and daily bowel movements.  
  2. Increase healthy fat intake, especially butter.  Butter gets its name from hydroxybutyrate, a ketone body that is the main nutrition source for many of the healthy gut bacteria. Consuming real butter daily helps support a healthy microbiome for proper digestion and nutrient absorption.
  3. Get adequate healthy salt intake.  Salt is sodium chloride, and both elements are essential nutrients for optimal health.  Sodium and potassium must work together via the Na-K pump to create muscle contractions, including those of peristalsis.  In addition, chloride is vital to production of hydrochloric acid, required for breakdown of foods for proper absorption.  
  4. Consider regular use of some type of magnesium.  Occasional use of citrate, chloride, or oxide forms may be helpful, but they are not advised on a daily basis.  
  5. Reduce processed food intake, as many of these packaged foods contain various ingredients that are constipating, or at best, just not nutritious.  Teaching patients about the risks of processed and packaged food is important to help them take charge of their own health.  

Some natural laxatives you can recommend:  blueberries, prunes, raisins, watermelon, coconut oil, salt, coffee with butter or coconut oil, jalapeno peppers, turnip greens, high dose vitamin C and senna.  

Probiotics can also help with overall gut health, but often make no impact on peristalsis. 

Final Tip: The Bristol Stool Form Scale is a great resource for many patients, especially for children.  The “poop journal” can be really helpful in educating parents and kids what healthy bowel movements look like.  Easily searchable on Google, the Scale is handy in the office too, when trying to assess for slow gut motility and constipation.  Typically, 4 is optimal.  Types 3 & 5 can be within normal limits, if combined with Type 4.  Types 1, 2, 6, & 7 are considered abnormal and the most likely to be indicative of chronic constipation. 

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