There are 3 questions that I always ask my patients. They are about “E, S, B&M”:
- How well are you eating?
- How well are you sleeping?
- How are your bowel movements?
These are questions that patients are glad I ask. They show that I care about life’s most basic needs. It’s a doctor’s more specific way of asking “how are you doing?”
ESBM are important in childhood, adult life and as people get older. The answers to these questions are “life” vital signs. Just like heart rate or respiratory rate, they give me clues about how a person is doing. “Just right”, not too much and not too little, are good vital signs. They tell me that a person is likely to be physically, mentally, and emotionally stable.
In this post, I will discuss chronic constipation. I have a funny story about constipation:
A very sweet older patient and I were talking about her constipation. We agreed that it is common and troublesome in older people. She joked and told me: “For young people, there is nothing like good sex. At middle age, there is nothing like a good steak. In old age, there is nothing like a good bowel movement.” Then she made me laugh really hard: “Even though there’s nothing like a good bowel movement in old age, having good sex once in a while is great too!!...and I haven’t had any in decades!!”
Is constipation a real problem?
In any drug store, there are many products devoted to treating constipation. People are different. Some people have more than one stool a day while others go for 2 or more days without one. Does that make a difference? It certainly feels better to have a good daily bowel movement. Being regular feels much better than being irregular. There’s nothing like constipation to make a person feel grumpy. But is constipation a serious concern?
Constipation does not usually cause major medical problems. But it is much more common as people get older and frail. It can be very distressing and affect a person’s quality of life. Constipation can also cause medical problems:
- Constipation sometimes causes bloating. Bloating is a sensation of discomfort and/or fullness in the abdomen. Bloating can be due to an upset stomach, gas, or fullness due to constipation. Laxatives themselves can cause bloating.
- Loss of appetite. Constipation seldom causes nausea. However, some people don’t want to because they feel constipated and “full”. In reality, eating less is likely to result in less stool production and more constipation.
- Constipation increases the likelihood of urine infections. Taking antibiotics for a urine infection resolves the immediate problem. However, physicians seldom talk about issues that make urine infection more likely.
- When people are constipated, they push down harder. This increases the likelihood of having uncomfortable and bleeding hemorrhoids.
- Injury/tear to the anus. This is less common but can happen when large, hard stools are passed. A possible injury requires medical examination.
- Lower gastrointestinal bleeding means that there is bleeding in the colon. Obvious blood or clots come out of the rectum. This is frequently painless. The blood pressure can drop rapidly if there is a lot of bleeding. That is a medical emergency.
Lower GI bleeding is more common in seniors. The most common reason is not cancer. It is diverticulosis. Diverticulosis means that there are weakened pockets and blood vessels in the colon. Long-term constipation increases the likelihood of diverticulosis. Diverticulosis is present in more than 50% of seniors. Ongoing constipation increases the likelihood that fragile blood vessels will break and bleed.
- Fecal impaction. This means that stool is stuck inside the rectum. This can result in blockage. Fecal impaction does not always hurt. Caregivers are sometimes surprised to hear that a patient has a fecal impaction.
- Bowel obstruction. This is an uncommon but serious consequence of severe fecal impaction. The colon and intestines become blocked. The abdomen becomes bigger and painful. This needs immediate medical attention.
The Bottom Line
In my opinion, it’s optimal for a person to have a good bowel movement daily. When people say they are constipated it can mean different things. It can mean infrequent bowel movements or stools that are hard to push out. Sometimes there is a sensation of stool still stuck inside after a bowel movement. There are different causes for these distinct problems. I’ll discuss this in my next post.
In the past, there was a common belief that stool inside led to accumulation of toxins in the body and GI tract. Long ago, “cleansing” was popular. Physicians discourage cleansing these days. However, I have had patients who habitually use an enema every day. This is a harmful practice. It can result in total dependency on enema use.
P.S. Chronic constipation is different from acute constipation. Acute constipation means that the problem happens suddenly. It is often associated with severe pain. Acute constipation requires prompt medical attention.
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