Constipation is apparently not interesting. Even the large bowel is apparently too boring to have a presence on the internet. On Amazon I found a lovely volume by several experts published in 1992 about the large intestine in health and disease, but it is out of print. I suspect there are researchers even now figuring out amazing things regarding bowel function, especially with increasing belief in the importance of the intestinal microbiome. The neurology of the gut is fascinating. How exactly does food that is chewed and swallowed transit through a flexible tube, get stripped of its water and nutrients and eventually depart the body as perfect little packages of indigestables, fats and bacteria?
Not to say that they completely failed to teach this subject in medical school. I definitely remember stuff about digestive enzymes and acid secretion in the stomach, the presence of bile in the small intestine aiding in fat absorption, semipermeable membranes, the portal vein which transports nutrient rich blood to the liver, bacteria which conveniently limit themselves to the large intestine, keeping the small intestine cleaner though not sterile. The eventual absorption of most of the moisture and peristalsis through 20 feet of combined small and large bowel and the layers of muscle and mucosa that were responsible for this feat. I am absolutely sure the real story is more interesting and that the subject is an active area of research. I just can't find it.
Nevertheless the subject did reach out and find me this past week.
A close family member had a perfectly uncomplicated laparoscopic surgery. This is a same day procedure, no need for a night in the hospital. Complications are rare and it is common enough that surgeons are very good at it. This family member was recovering just fine, needing minimal pain relief, and that provided by over the counter acetaminophen and ibuprofen, only mildly concerned by lack of normal bowel movement. At day 3 this was no longer tolerable. Mild laxatives provided an urge to go, but no action at all. Examination revealed a fecal impaction.
A fecal impaction is a collection of stool in the rectum that can't move any further. The rectum is a very stretchy piece of intestine which precedes the anus, the muscular ring that allows us to poop when we intend to rather than when the poop arrives. The rectum in an impaction can hold blobs of stool measuring several (sometimes many) inches in diameter. This stool may be hard or soft, but the sheer size of it makes it so the rectum cannot adequately contract to eject it. Some of it must be removed for regular bowel movement to resume.
During my training and early years as a doctor I often had to do this procedure. It was particularly hard because it was not only an insult to the patient's dignity but extremely painful. Also it was technically difficult because even when one could hook the goop with a gloved finger, pulling it through the anus was very tricky. Sedating the patient might help but would also cause confusion. If opiates were used to ease the pain of the procedure they might constipate the patient further. After removing what feces we could manually, we would try suppositories and clever enema recipes, hoping to unload the rectum still more. Then we would use oral laxatives to move the higher intestinal contents through, in order to avoid another impaction. The laxatives were ones that brought water into the gut, what were known as osmotic laxatives. Magnesium is a very effective agent for this purpose, since it is mostly not absorbed and so brings in water to dilute itself. Polyethylene glycol (Miralax and others) is gentler and avoids the possibility of raising magnesium levels too high in people with kidney dysfunction. Stool softeners and fiber are of little help in this acute stage though are quite useful to prevent the problem in the future. People who are impacted because of opiate use can use an injection or pill that reverses the effect of opiates on the gut.
Nurses are now primarily responsible for manually disimpacting patients (not sure if this is universal, but it is my more recent experience.) If doctors had to do it themselves I think there would be more money put into research on the subject. Severe cases sometimes require surgery of one kind or another, and in one article looking at a series of patients with the diagnosis of fecal impaction, over 20% of patients admitted to the hospital for this diagnosis died of it. That is likely because they tend to be older, often residents of nursing homes or either addicted to opiates or requiring them for pain. Nevertheless, having a section of intestine stretched beyond its ability to function is dangerous, and the level of pain associated with the condition may lead to levels of sedation that have their own complications.
So let's get on with my story. My family member needed manual disimpaction and I did it. I'm pretty sure that he redlined the pain scale, recalibrating his 10 out of 10 to a much higher level. The process of returning to near normal bowel function took 3 solid days and taught me some things that I would love to share:
1. Why does it hurt so much? Every morning a person has a bowel movement the anus has to stretch open up to an inch in diameter (or more) to allow passage of a BM. That is completely tolerable. When you are healthy, a rectal examination with a gloved finger is disturbing but not painful. But here's the problem. When the rectum is stretched tight with stool, the anus and surrounding tissues, which have exquisite sensation to pain and can even tell the difference between liquid and solid, are swollen. This is because the blood that the heart pumps into these tissues cannot return normally to the circulation via the hemorrhoidal veins that are supposed to drain the area. ("Hemorrhoids" are abnormally dilated hemorrhoidal vessels. Hemorrhoidal vessels are part of normal anatomy.) The extra pressure of a finger pushing on this tissue is agony. When I felt around to make sure there were no tumors in the rectum I could feel each hemorrhoidal vessel full to bursting in the circle where they are usually flat.
2. What helps and what does not? Witch hazel is a topical anesthetic. Lovely stuff. In theory. A bottle of standard witch hazel is in an alcohol solution. So with the unavoidably abraded tissue in the anal area, this burned like fire. Also lidocaine, a topical anesthetic, is available over the counter as a cream. In the tube that I bought intended for rectal pain the main inactive ingredient was alcohol. So also ouch. What are they thinking? There are preparations of lidocaine gel intended for the mucosa that are not alcohol based but I was only able to get this as a prescription. Zinc oxide helps. You can buy this as Desitin ointment or Calmoseptine and generics. Desitin is for babies and Calmoseptine is for adults and includes menthol. There is even Boudreaux's Butt Paste, for those who need a little humor in these trying times. After passing stool, use baby wipes, not toilet paper which is rough. Actually there are large ones which attempt to maintain a touch of dignity by calling themselves "Dude Wipes." Bigger is better. While the impaction is working itself out and the rectum is returning to the size where it works, some leakage of bowel is unavoidable. Get pull-up disposable diapers. This stage may last a few days and can involve passing small amounts of blood due to the swollen traumatized tissue.
3. Enemas--these can help, if they go above where the stool is sitting, but that's tricky and can result in scraping the inside of the rectum or even perforating it. Small volume mineral oil enemas are safe but Fleet's phospho-soda enemas can cause electrolyte problems and dehydration in elderly patients so be careful.
4. Also a warm or hot shower. This makes a person feel more human and can relax the area enough to pass stool without too much pain. This is a mess, but beats dying or going to the hospital (and maybe dying.)
5. When the impaction is out it is time to clear out the rest of the gut. Nobody wants to strain at stool when their bottom is this sore. Because there has been backed up stool for awhile, there is definitely softer and liquid stool above that needs to come out. Until the dam breaks and the person is able to expel copious firm, soft and liquid stool, you are not out of the woods. But how? Some people swear by castor oil. Unpleasant but effective, I hear. Miralax (polyethylene glycol, available as a generic) works in 8-24 hours at usual doses. Magnesium works faster, in 30 minutes to 2 hours. I used to be able to get 10 ounce bottles of magnesium citrate liquid which tasted like bad sprite and worked like a charm. I can still see them on Amazon for $9 a pop, but they weren't at the pharmacy I visited and I seem to recall that there was a nationwide shortage some time ago.
Epsom salts are magnesium sulfate and are quite effective as a laxative. The granules are cheap and widely available. The usual recipe is 2-6 teaspoons (2-3 usually works fine) dissolved in plenty of water. It is very bitter. I am quite proud of my recipe for the "Epsom Salt Gin and Tonic" which my family member said tastes almost like the real thing:
3 teaspoons (1 tablespoon) epsom salts
1 cup water
1/2 tsp lemon or lime juice
sugar or agave syrup to taste (?1 teaspoon) (or sorbitol if you want to be clever since that is also a laxative)
a small dash of gin (to make it taste like the real thing)
Dissolve epsom salts in water. Add lemon or lime juice and sugar to taste. Add ice. Add a little gin. Imagine a tropical setting. Drink the whole thing. Make sure to be near a bathroom.
Do not do this more than a couple of times because this is a lot of magnesium.
6. Full recovery is nowhere near immediate. It will be normal to have some incontinence, pain and mild bleeding for days. Talking to a doctor about this is wise, but it is important to have reasonable expectations. The rectum and anus are really good and surprisingly fast at healing so it is likely that all will be well.
7. Most women who deliver a baby vaginally will have a near fecal impaction experience, usually a few days after the baby is born. It is terribly painful when that first bowel movement happens, but it is rarely a real problem. Evolution has made it so we don't usually die, at least not of this.
8. Prevention--If I had a time machine, I would have made sure this family member had taken enough laxatives before the surgery that there wasn't much left inside to cause this problem. Nobody says you should do this so I'm probably wrong, but golly wow, I never want to have that happen again!
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