A Patient Asks: “How Do You Treat Constipation?”

Constipation is a far more common cause of bloating, gas, and abdominal pain than people realize. Constipation is defined as infrequent and frequently incomplete bowel movements. It has many known causes, including but not limited to drug side effects, diabetes, Parkinson’s disease, hypothyroidism, multiple sclerosis, and autonomic neuropathy. But lest you worry you have one of those conditions, the most common cause of constipation by far is idiopathic, meaning unknown. Idiopathic constipation is benign. The degree of severity varies tremendously. Some people experience only slightly infrequent bowel movements, perhaps only two or three times a week unassociated with any discomfort, while others have rare bowel movements, perhaps only once every one to two weeks, associated with severe abdominal pain and bloating.

There is no required frequency for defecation. That is, if you’re only having one bowel movement every few days but feel fine, there’s nothing you need to treat. On the other hand, if you’re having a bowel movement every day but still feel bloated, gassy, and have abdominal pain, an intervention is required. (Patients often wonder how they can be constipated when they’re having one stool a day. The answer is that the “caboose” can be leaving every day while a large number of “boxcars” remained lined up behind it. That is, your colon can be overflowing with stool that’s causing you symptoms even though a small portion of that stool is excreted daily.)

The management of chronic constipation involves several approaches. Chronic laxative use is to be avoided. Measures that can and should be adopted include:

1. Regular exercise. Moving your body causes movement in your colon.
2. Increased water intake.
3. Increase fiber intake. This can be in the form of food with high fiber content, like fruit (prunes and dates have among the highest fiber content in this category), vegetables (spinach and peas have among the highest fiber content in this category), legumes (baked beans have among the highest fiber content in this category), and wheat bran. The recommended amount of dietary fiber is 20 to 35 g/day. Alternatively, polyethylene glycol (Miralax) is an osmotic agent that can be used regularly by dissolving initially 17 g of powder in a glass of water. It can be titrated up or down according to symptoms. It’s not absorbed into the body so is generally quite safe.

For acute constipation, I recommend the following regimen: Upon awakening, insert a Fleet’s enema. Wait 30 minutes for a result. Then drink half a bottle of magnesium citrate (AKA citrate of magnesia)(you must have normal kidney function to use this medication). By noon, if anything other than clear liquid is the last thing to come out your bottom (that is, if the last thing to come out was formed stool or brown liquid), drink the second half of the bottle of magnesium citrate. Reassess around 4 pm. If you haven’t excreted clear liquid by the end of the day, it’s time to consult your physician.

There are, of course, many other approaches to the problem of constipation, many of which require a doctor’s supervision. And abdominal pain has many other causes besides constipation. But if you’ve been diagnosed with constipation and are reasonably sure that your current symptoms are arising from it, the measures mentioned above are generally effective and safe to try.

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