Even though Larry (not his real name) had widespread cancer, no one was prepared for his sudden death.
I certainly didn’t see it coming so abruptly. It shocked the nurses who had spent day and night in his room, trying to do everything they could to give him a moment of comfort. His sister, the only person who ever came into see him during those painful final weeks in the hospital, was stunned when I called to let her know he had died. Most of all though, it was Larry who wasn’t ready. I could see it in his eyes soon after he woke up one morning with crushing pain in his belly.
What surprised us all was not that he died, but how he died. While Larry’s death certificate may have listed his cause of death as a perforated colon, which injected bacteria into his bloodstream, he really died of constipation.
To many people, constipation is little more than an aggravation. To others it is a daily agony. Few realize that it can be a dangerous and even deadly affliction.
Constipation is widespread among Americans. Almost everyone experiences constipation at some point in their lives, with a recent survey showing that 16 percent of Americans and a third of those older than 60 suffer from chronic constipation. It’s the reason for millions of clinic visits each year and more than 700,000 emergency department trips. The number of people admitted to the hospital primarily for constipation has more than doubled since 1997. The cost of that care, along with what we spend on over-the-counter laxatives, runs into the billions of dollars.
What’s blocking the American colon? Seismic changes in our lifestyles are a key culprit. The average American diet includes less fluid and fiber — both essential for regular bowel movements — than it ever has. Marooned at our desks and sprawled out on our couches, we’ve given up the exercise and activity that stimulates the bowels. Constipation also becomes more common with age.
A range of medications can cause constipation. These include iron supplements, some blood pressure medications, and antipsychotic drugs. The biggest culprits, though, are opiate painkillers like OxyContin and morphine. Festering in the shadow of the opiate epidemic is the scourge of constipation. The problem has grown to such an extent that an ad for a medication to treat opiate-induced constipation aired during the 2016 Super Bowl.
People with opiate-induced constipation are some of the most difficult to treat because they usually have chronic pain, are often unable to move around much, and tend to have other health problems, such as cancer. As I witnessed in Larry’s case, the constipation gets worse, so does the pain, which leads to more opiates, resulting in more constipation, essentially trapping the person in an intractable vortex. In fact, almost half of cancer patients receiving palliative care suffer from constipation, making it one of the most common symptoms people experience at the end of their lives.
Constipation sometimes begets more constipation. As feces linger in the colon, water is continuously absorbed from them. While this makes feces smaller, it also makes them harder. During the first week of my internship, I was working in the intensive care unit when a frail elderly woman was admitted after she had a heart attack. As I was trying to figure out what had caused it, I pressed on her belly and felt something hard. We immediately got an X-ray, which revealed that she had a fecalith — a stone-like mass of stool lodged in her colon. Fecaliths, particularly those as large as hers, are removed surgically, but my patient died before that could happen.
The colon and brain are constantly communicating with each other on conscious and subconscious levels, alerting the body about the passage of stool. When the colon senses that a batch of stool is ready for evacuation, it lets you know, though far more gently than the bladder, which is much more powerful in expressing its needs. That’s because the colon is much more flexible. When you tell your burgeoning rectum you aren’t ready for release, it retains the stool until a better opportunity arrives. The colon is not only flexible but trainable. In a remarkable study, researchers were able to have college students train their colons — without any Herculean effort — from defecating once every 28 hours to once every 51 hours.
Constipation can occur when the lines of communication between the brain and the colon are frayed. Patients with such dyssynergic defecation may never have learned how to poop or have somehow forgotten how to. Others, such as survivors of sexual abuse, carry mental scars that often manifest as constipation.
The traditional approach to treating constipation relies on using laxatives and bulking agents such as fiber. The evidence base for most laxatives, though, is poor. Of commonly available over the counter laxatives, polyethylene glycol has shown the best results in clinical trials and was even found to be better than a new prescription drug.
The key to ending chronic constipation is by treating the colon like the highly intelligent organ that it is.
Peace of mind is essential for defecation, with privacy being a big factor. That’s why many people have trouble defecating in a strange bathroom, or become constipated when they travel. Many patients in hospitals and nursing homes lack privacy, which can make defecation difficult.
Instead of drinking more fluids and getting more fiber from food or supplements, a better constipation-fighting strategy is to retrain the colon so it unlearns its bad habits.
One way to do this is to ritualize defecation. Hit the toilet at specified times, preferably half an hour after a big meal twice a day, and sit peacefully for five minutes or so without straining. If nothing happens, go on about your day. Using biofeedback to retrain the mind and the abdominal and rectal muscles, rather than using laxatives, is the first line treatment for people with dyssynergic constipation.
Relieving constipation can have some unexpected effects. One recent study suggested that treating opiate-induced constipation could help cancer patients live longer. I once admitted a patient to the hospital who started having seizures after recently undergoing surgery to remove a brain tumor. He told me that if he could just move his bowels, the seizures would stop. Skeptically, I ramped up his laxatives and asked him to walk laps around the ward. As if by magic, as his bowels came to life later that day, the seizures stopped.
By its very nature, the colon is a flexible and accommodating organ. The average American lifestyle has made it less so. Constipation represents the colon’s revenge for our having ignored and insulted it for so long. It’s time for us to mend this broken relationship.
Haider Warraich, M.D., is a fellow in cardiology at Duke University Medical Center and the Duke Clinical Research Institute, and author of “Modern Death: How Medicine Changed the End of Life” (St. Martin’s Press).