GETTYSBURG MEDICAL NEWS
The Clinical View
By P. E. Hoffsten, M.D.
11 October 2006

THE BOTHER OF THE BOWELS-RECONSIDERED

          Seven years ago this month, I wrote a column called “The Bother of the Bowels.”  I try to avoid topics that have already been covered in these columns, but a repeat every seven years isn’t too bad and there is a new drug available for constipation.  I won’t reiterate what I wrote in the column of October 7, 1999.  (Available online at www.macpierre.com Click on item South Dakota Medical News at the left hand side of the front page.) 

          Constipation provides misery for a large number of people.  It is not medically dangerous, but the discomfort can be disabling.

          The first question to answer is “What is constipation?”  The term is used variously to denote stools that are inordinately hard, infrequent stools, the need to strain excessively to pass a movement, the sense of incomplete evacuation and bloating, or sometimes the complete inability to pass a stool in spite of substantial straining.  That straining can make hemorrhoids much worse. 

          By medical criteria, fewer than three bowel movements per week is defined as constipation.  While some individuals feel that they must have a movement every day, this is not really a necessity for good health and it is certainly not a sign of illness.

          As mentioned in the previous article, there are a number of drugs that make constipation worse.  Most common among these are the pain medications such as narcotics or Darvon.  A blood pressure medication called Verapamil also can cause constipation.  Sometimes when these medications are necessary, an additional medication to help with bowel habit will be required. 

          In the previous article that I wrote on constipation, I noted that there were seven different classes of medications that might be used to help with constipation.  There are two new medications that have come out since then.  The old remedies already known include:

1. Stool softeners.  Basically these are soap that obligate water to stay in the stool thereby preventing it from getting too hard.  Docusate is the most common product. 
2. Lubricants such as mineral oil work for some individuals, but these can be dangerous in people that have gastroesophageal reflux.  Aspiration of the mineral oil into the lungs can cause a very difficult pneumonia. 
3. Fiber products such as Metamucil can be a help by obligating more water into the stool and keeping it easier to pass.
4. Bowel irritants such as Senna, Sagrada, Bisacodyl, Cascara, and Casanthranol can all act as laxatives.  They are not recommended for long-term use. 
5. Milk of Magnesia and Lactulose (Chronulac) are both products that are not absorbed from the bowel when they are taken orally.  They obligate water into the stool and thereby can help with constipation.  These also are not recommended for long-term use. 
6. Castor oil is occasionally used for individuals when they need a complete cleansing of the colon in preparation for surgery or a bowel exam.  This would not be used for any regular type of use. 
7. A product called Metoclopramide (Reglan) can help individuals who have slow gastric emptying.  This product is usually used to treat gastroesophageal reflux, but also increases bowel motility.  The bowel motility increase improves constipation and is a fringe benefit for this medication.

          A 48 -year-old lady recently came to the clinic for her concern about constipation.  She made the challenging statement that “she had tried everything.”  She was using stool softeners and fiber products such as Metamucil, but stated these were simply not enough.  When she tried Chronulac she had difficulty regulating the problem and had diarrhea with constipation alternating.  She found this unacceptable.  She had read on the Internet that Milk of Magnesia and Senokot were not good choices for long-term use and her problem had been present for many years.  She described her constipation as marked irregularity with one to three bowel movements per week, always very difficult to pass, and a constant feeling of bloating as though her abdomen never really emptied.  That was the symptom that bothered her the most.

          Initial work up yielded no abnormality that would suggest a major disease process.  She was concerned that she might have a malignancy blocking her colon, but she had had a colonoscopy done just a year before and it was normal.  She was taking no medications that would predictably cause her constipation.

          A product called Tegaserod (Zelnorm) came on the market several years ago.  Its use has been slow to catch on because it is somewhat expensive.  To random individuals such as this lady, who had a condition called irritable bowel syndrome, this drug was like a miracle.  She was given a trial, initially using six milligrams twice a day.  This turned out to be more than was needed and the dose was dropped to two milligrams twice a day.  This drug works by stimulating receptors in the colon where a natural messenger molecule called Serotonin.  This results in increased bowel motility, moving material through the intestine at an increased rate and thereby solving the constipation problem.  Depending on the person’s insurance policy, the expense is about thirty dollars a month and the drug is approved for long-term use.  The side effect profile is very favorable and really consists only of an overexpression of the drug’s natural effect.  Specifically, some patients develop slight nausea, abdominal cramping, and diarrhea.  Decreasing the dose can solve the problem for most people.  I have now used this medication in multiple individuals and with favorable results when started in the right situation.  The healthcare providers at your local clinic are aware of constitution problems and how to help with them.  This drug provides a new tool to help with this problem.