Saturday, 18 September 2021
I MUST apologise in advance for somewhat lowering the tone this week.
My subject is bowel habit or, more specifically, constipation.
According to the National Institute for Health and Care Excellence, the prevalence in the UK of constipation varies between four per cent and 20 per cent, depending on which study you look at. I suspect the reality is closer to the higher end of that range.
We have always been a bit obsessed with our bowels. There are records predating even ancient Egyptian times documenting ailments related to our bowel movements and the various associated treatments.
Enemas of one kind or another have been used since that time, though not always because of constipation.
In fact, in 18th century Europe, enemas of tobacco smoke were trialled as a way to resuscitate drowning victims. I can’t imagine that trial could have gone well, though it got to the stage where kits complete with bellows and tube were placed at strategic spots along the River Thames in case of just such incidents.
Constipation, so named from the Latin verb constipare, meaning to crowd together, has a wide range of severity. For many, it will be a minor inconvenience, soon put right by a trip to the local curry house, but it should be noted that, between 2010 and 2011, it accounted for 57,506 hospital admissions in England alone.
Worse still, in 2011 there were reported to be 57 deaths in England and Wales because of it. It’s worth paying attention to then, I think.
According to the NHS, you might be constipated if you have not opened your bowels at least three times over the last week, if your stool is large, dry, hard or lumpy, or if you are straining when you go to the loo.
Of course, people’s bowel habits vary according to what and how much they eat, but those are the general parameters. Fortunately for us, back in 1997, a team of enterprising doctors from Bristol Royal Infirmary took it upon themselves to develop an aid still used widely today — the Bristol Stool Scale. This gave rise to the widely acclaimed Bristol Stool Chart.
This essentially classifies poo. It uses a scale of 1 to 7 which ranges from watery diarrhoea to hard pellet-like stools.
The ideal type to aim for is either type 3 or 4 and there are reasons to avoid moving outside this range.
Constipation can be pretty miserable. It can affect appetite and cause nausea and pain in the abdomen.
Straining to open one’s bowels increases your risk of hernias as well as piles and anal fissures.
It can also be a factor in the condition known as diverticular disease, which is where the walls of the bowel develop outpouchings that can further add to irritable bowel-type symptoms. These also run the risk of getting infected (diverticulitis).
If constipation continues, things can snowball to the point at which one might develop faecal impaction.
Energy levels, mood, concentration and appetite will suffer as this gets worse and in severe cases the bowel can obstruct, causing vomiting and an inability even to pass wind and warranting an emergency trip to hospital.
Constipation can be a problem for anyone but it tends to be more pronounced in young children, who often hold in their stools until they get home from school or if they are already constipated and it hurts to go.
It is also a big problem in those with dementia as those who suffer from it may not realise what the issue is or may not be able to report it.
In such cases, carers may find the sufferer is more confused or agitated than normal. Often, if there is a build-up of stool, the phenomenon known as “overflow diarrhoea” might occur. In such cases, liquid stool may build up behind the blockage and once a certain threshold is met, it overflows past the obstruction, giving very little warning.
Thus bowel incontinence and sudden urgency is a characteristic feature.
What might cause constipation then? Diet is of vital importance. One must keep an eye on the amount of fibre in the diet. Fibre makes your stools softer but also gives it bulk so that it passes smoothly through the gut and places less pressure on the walls.
Fresh and dried fruits, vegetables, beans, pulses, nuts and cereals are the best sources of fibre but you can also pick up fibre supplements from your pharmacist if you need an extra helping hand.
Not drinking enough fluid through the day (aim for 1.2 to 1.5 litres a day) puts you at greater risk, as does inactivity, ignoring the urge to open your bowels, stress or depression or even just a change in routine.
Being pregnant doesn’t help and a low thyroid level, or being on certain types of medication, may also cause constipation.
The most common medications to cause constipation are opioid pain killers like codeine and morphine. If you are taking these, take extra care in minimising other risk factors.
If you’re struggling, laxatives might be the answer. There are a few different types of laxative, each working in a different way.
1. Bulk-forming laxatives: These increase the bulk of the stool, making it easier to pass as already mentioned. These can take a few days to kick in. One example is fybogel.
2. Osmotic laxatives: These draw water back into the bowel in order to soften things. Again, these may take a couple of days to start working and include things like lactulose or laxido (also known as movicol).
3. Stimulant laxatives: These enhance the natural peristalsis of the gut (the sequential squeezing of the muscles in the gut walls) and start working a bit more quickly, around six to 12 hours. These include senna (Senokot) and bisacodyl (Dulcolax).
4. Softeners: These also draw moisture into the gut and include things like docusate and arachis oil.
In general, it is best to start with plenty of fibre, so something that will bulk up the stools. If they remain hard, you could try an osmotic laxative to soften things.
Once soft, if things still don’t want to work then it’s worth trying a stimulant. Be a bit cautious using these, though, if your stool is still rock solid.
If in doubt. speak to a pharmacist or your doctor, particularly if you have conditions such as inflammatory bowel disease.
Suppositories can be used if there is hard stool in the rectum that is backing things up and these can be purchased over the counter as well.
If all else fails, that is where enemas come into the equation.
As always, prevention is better than cure and that means drinking plenty of fluid, eating enough fibre and moving around once in a while.
07 June 2021
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