Constipation
By PALS Diane Huberty, CNRN
(reprinted by permission)
That may sound like a foolish question, but many people think of constipation as having infrequent bowel movements. It is actually defined as having dry, hard stools that are hard to pass. Many people have only a couple of bowel movements a week, but if they do so without straining, they are not constipated.
Normally food is liquefied in the stomach by
digestive juices and moves through the small intestine in liquid form. Nutrients are absorbed in the small
intestine. Waves of muscle contraction
called peristalsis moves the remainder along into the large intestine. In the large intestine, water is reabsorbed
from the left over waste product, leaving just fecal material (stool) which is
moved along and passed out of the body in a bowel movement.
Anything that changes the speed with which foods
move through the large intestine interferes with the reabsorbtion of water and
causes problems. Rapid passage causes
diarrhea, slowed passage allows too much water to be reabsorbed, leaving hard,
dry stool that doesn't move easily through the bowel. Many medications affect this but constipation is common for
anyone with poor mobility. Lack of
activity and exercise slow bowel mobility.
Long delays in getting to the bathroom further complicates the problem
by keeping the stool in the large intestine longer where it becomes dryer and
harder. In ALS swallowing problems make
getting a good diet and sufficient fluids difficult and the problem gets
worse. Breathing problems make it
difficult to take a deep breath and bear down, something we don't even realize
is important in having a bowel movement until we cannot do it. Because so many things contribute to
constipation in the ALS patient, the solution may change over time.
Although we joke about constipation, it is a
miserable experience and should never be taken lightly in the ALS patient. Loss of appetite from frequent constipation
leads to weight loss, weakness and dehydration. It can progress to nausea and
vomiting, very dangerous for a person who cannot turn over when lying on his
back. The blockage can become so severe as to require hospitalization to
correct.
The first - and best - way to approach constipation is by improving your diet. Eat lots of high fiber foods. (Check with your doctor if you have other digestive or bowel problems or are on a special diet.) There are many high fiber cereals available and granola bars are convenient and easy to handle when feeding yourself begins to be difficult. Raw fruits and vegetables are also easy to eat sources of fiber if swallowing is not a problem. Drink lots of fluids. If you are using tube feeding, fiber is added to most tube feedings formulas and high-fiber formulas are available. When diet alone isn't quite enough, try the old remedy of prunes or prune juice. It really does work!
Remember that everyone's bowel pattern is different.
Very few people need to have a daily bowel movement. Every other day or
every third day is probably most common. Insisting on a daily bowel
movement and using laxatives to try to attain it is asking for trouble!
There are basically 3 types of laxatives:
·
Bulk or Fiber Laxatives supply the fiber necessary to add bulk which holds
water and makes it easier to move the stool through the bowels.
·
Stool Softeners also keep the water content of the stool higher which keeps it softer
and allow it to move more easily through the bowels.
·
Stimulants increase the muscle contractions (peristalsis) of the bowel which moves
the stool along. These are available as
pills that generally result in a bowel movement in 6-12 hours and as
suppositories that work within an hour.
Generally the first laxative recommended is a high
fiber laxative such as Metamucil or Citracel.
Fiber laxatives are available as a powder, (which is mixed with water or
juice and generally needs to be drunk fairly quickly before it thickens to a
goo) a tablet, or a chewable tablet.
Fiber laxatives are very slow acting are generally taken daily to
prevent constipation rather than for relief once constipation is making you
uncomfortable. For the ALS patient
there are two concerns with this type of laxative. First, it is essential that fluid intake be very good. Taking fiber laxatives without enough fluid
can cause intestinal blockage. Second,
they are not to be used when swallowing problems begin. Failure to drink enough water to wash down
the fiber might allow it to begin to swell in the esophagus and this requires
immediate medical attention. Fiber
laxatives can safely be given through a feeding tube, but the fiber needs to be
promptly followed by flushing the tube with water to prevent clogging.
Stool softeners are often ideal for ALS patients.
Not only do they help when fluid intake is difficult, but they also are very
helpful when breathing problems make it difficult to bear down and push. The longer stool remains in the digestive
tract, the more water is removed from it.
As the stool becomes dryer, it becomes harder and more difficult to move
along. Stool softeners prevent the
drying and allow the stool to move through with normal peristalsis. They do not cause cramping or urgency but
greatly reduce the amount of straining needed to have a bowel movement. Stool softeners are generally taken daily as
a preventative measure. Stool softeners are available in pill or liquid
form. (Note: I don't know about other
brands, but Colace liquid needs to be diluted in juice or it burns all the way
down!) If the stool softener alone
isn't sufficient, they are also available combined with a stimulant laxative.
Stimulant laxatives increase the normal peristalsis
to move the stool quickly and forcefully along. Most are intended to be fairly gentle result in a bowel movement
within 6-12 hours, but even these can cause cramping. If constipation is already making you uncomfortable,
suppositories will provide relief within a hour but are likely to cause
cramping. Stimulant laxatives should be
reserved for occasional use until other methods fail. Frequent use of stimulant laxatives can actually aggravate
constipation because the bowels become dependent on them for the stimulation
for even normal peristalsis. Stool
softeners and stimulants are available in combination and may be needed when
stool softeners alone are not effective.
Enemas are all right for occasional use but are
generally the last resort as a routine method of bowel management. The repeated distension of the bowel can
eventually cause loss of bowel tone which aggravates the problem. This "eventual" problem is not a
concern for the ALS patient who does not plan on going on a vent, but should be
considered when planning a bowel program for long term use.
Daily Routine
Few people need to have a daily bowel movement but
having a routine time when you can spend a longer period of time on the toilet
is helpful. Although choosing a time is probably going to be more a matter of
convenience for your caregiver, if you already have a certain time of day you
are more likely to have a bowel movement, try to arrange for that time. If having a bowel movement at a consistent
time of day is important because you don't always have the necessary help to
get to the toilet the rest of the day, you can encourage that schedule. Begin
by using a suppository or stimulant laxative to promote bowel movements on the
scheduled day at the chosen time.
After a week or so, use the
laxative only if you can't have a bowel movement on your own. Within a week or two, you should be able to
reduce the stimulant laxative use to very infrequently.
An unrushed and private bathroom trip is ideal, but
safety and security need to be assured.
Having some type of buzzer or doorbell type button (available from Radio
Shack) to call for help works well.
Sitting upright and as comfortably as possible is also important. Armrests and a seatbelt might be necessary
for safety. (The correct and safe angle
for a seatbelt is diagonal as they are in cars: The belt is around the hips and anchored lower. A belt anchored behind you at stomach level
will allow you to slide down through it
and end up tight around your chest.)
A padded toilet seat can be a lifesaver! If you have a high-rise toilet, using a footstool and leaning
forward over a pillow can help provide the necessary push. Drinking a cup of coffee or other hot
beverage before or while in the bathroom will often help.
Diane Huberty is a retired RN. She worked
general Med-Surg units, then 5 years in Critical Care where she began
specializing in Neuro and earned Neuro Certification (CNRN). Diane was diagnosed with ALS in 1985 at the
age of 37. When her hospital opened a Neuro Unit, she was selected for the
position of Neuroscience Educator. She
was able to continue working in that
position until 1995, when arm weakness and fatigue made it too difficult to
continue and she retired. Through the
internet, Diane communicates daily with other ALS patients and keeps up
on research, treatments and care issues. In addition to maintaining and posting
a set of ALS Frequently Asked Questions on the ALS newsgroup
(sci.med.diseases.als), she has her own ALS website
which focuses on nursing care rather than research. Diane can be contacted by
email at " liveletdie@att.net ".