Potty Talk: Constipation and Diarrhea

I remember when I was a child, “potty talk”—including the forbidden words “poo-poo” and “pee-pee” — was treated with soap suds. Now soap suds and potty talk have a whole new sophisticated meaning for me as an endonurse.

Constipation, diarrhea, and the maladies that cause them are now part of my everyday vocabulary. In this article, I will explore how these conditions differ from what is “normal,” what can cause them, and how they are treated.

What is “Normal?”

Defining terms such as constipation or diarrhea requires a look at “normal” stools. Even normal comes in many sizes and shapes. In the seventh edition of Sleisenger’s and Fordtran’s Gastrointestinal and Liver Disease Volume 7, there is a chart to explain the differences in stool formations. Anmol S. Mahal, MD, a gastroenterologist at Washington Hospital in Fremont, Calif., summed up “normal” quite well: “The spectrum of normal is formed stool two to three times a day to three times a week, depending on fiber, fluid and dietary intake. Stool can be pellet- to banana- or snake-like in size and mushy to hard in consistency.”

Constipation

Constipation can be categorized when observing different causations, such as irritable bowel syndrome (IBS), slow transit or motility, outlet delay or dyssynergia, fecal impaction or pseudo-obstruction. Constipation is found most commonly in children and the elderly. Children may have psychological issues causing impending bowel movement pauses. The elderly have an issue with decrease in muscle turgor and elongated or “saggy” colons that slow the process of defecation.

Pharmaceutically, drugs that can aggravate or cause constipation include: analgesics, opiates, anticholinergics, antispasmodics, tricyclic antidepressants, phenothiazines, serotonin receptor antagonists, and calcium-aluminum-containing antacids, to name a few. Inactivity, muscle disorders, structural abnormalities, bowel diseases, neurogenic disorder, poor diet, heavy junk food consumption and pregnancy are also contributors to constipation.

To treat constipation, the rationale behind high fiber diets is to increase the stool weight, aiding movement, softness and size. Twenty grams of bran/day was the most effective nutrient in improving bowel frequency and transit time oral to anal according to a study from Hamilton, Wagner, and Burdick in the seventh edition of Gastrointestinal and Liver Disease. “Eat your Bran” was the conclusion. Increasing dietary fiber is the simplest, most physiologic and cheapest form of treating constipation. Bulk laxatives are based on wheat plant seed mucilage, psyllium, plant gums or synthetic methylcellulose derivatives usually given twice a day with plenty of water assisting in softening stool.

Bulk laxatives have a limited role in the management of chronic constipation and should not be regarded as long-term treatment. In severe constipation, speed of action for relief is 24 hours. Determining treatment depends strongly on the speed of action. For effects within 24 hours, stimulant laxatives include Senna, bisacodyl, Cascara and aloe. For effects within two to three days, continuous treatment may include osmotic laxatives such as magnesium hydroxide, for adults, lactulose 15 mL two times per day, or lacitol which can be given to diabetics. For effects within one week, continuous bulk laxatives such as ispaghula, psyllium and methylcellulose are in order. Caution should be used with lactulose, which is an osmotic laxative; it causes hydrogen to be present in the colon and there is a danger in performing endoscopy with electrocautery, after ingestion.

Anthranoid laxatives — i.e., Senna, aloe, and Cascara — given over the long term can cause structural and functional changes in the intestine. The proximal colon is affected more than the distal, and upon colonoscopy, one can visualize pseudo melanosis, a pigmentation with snakeskin-like appearance. Bisacodyl tabs, 5-10 milligram tablets at night, are commonly used to prep patients prior to colonoscopies due to the 12-24 hour result. Bisacodyl is hydrolyzed by intestinal enzymes and can act on both the small and large intestine. Detergent type of laxatives include dioctyl sodium sulfosuccinate or docusate sodium in 100 mg to 500 mg capsules.

One of the hazards of laxatives is the abuse of them, especially in the elderly and in women and men with weight concerns. Abuse of laxatives leads to liquid stools and the potential for hypokalemia and other electrolyte imbalances. Haustral folds in the colon are often lacking in people abusing laxatives; these folds are important in peristalsis.

Alternative treatments for constipation include probiotics, which are found in yogurt, cheese and capsules, tablets, suppositories and powder beverage forms. Holistic or nutritional approaches to constipation involve nutrients such as garlic (two capsules/day) to destroy harmful bacteria; vitamin C, 5,000-20,000 mg/day in divided doses as a cleansing and healing effect; acidophilus (1 tsp. twice a day) allows survival and rapid passage of “friendly” bacteria. Apple pectin (500 mg/day) is a source of fiber as well as carrots, beets, bananas, cabbage, okra and citrus fruit. Chlorophyll liquid or alfalfa (one tsp. three times/day), eliminates toxins and bad breath. Freshly ground flax seeds (one tbsp. three times/day), provide B vitamins, fiber and essential fatty acids needed for proper digestion. Other herbs include Cascara Sagrada, rhubarb root, senna leaves, yerba mate, psyllium and kombucha tea. Figs and prunes are some of the best natural laxatives.

Diarrhea

Diarrhea happens when the food and fluids we ingest pass too quickly or in too large of an amount — or both — through the colon. Fluids aren’t sufficiently absorbed, and the result is a watery bowel movement. In addition, the lining of the colon may be inflamed or diseased, making it less able to absorb fluids. The most common causes of diarrhea are the Norwalk virus, cytomegalovirus, viral hepatitis, herpes simplex virus, and the rotavirus common in childhood diarrhea, which is spread easily. Bacteria and parasites in contaminated food or water can transmit infection to the body, causing diarrhea. Giardia lamblia and cryptosporidium are parasites. Causative bacteria commonly found include Salmonella, Shigella and Escherichia coli, which is also commonly found in people who travel. Clostridium difficile is the leading cause of bacterial diarrhea after antibiotic therapy, and is especially found in hospitals and chronic conditions.

Other causes of diarrhea include lactose intolerance and artificial sweeteners in abundance such as sorbitol and mannitol, and surgery of the abdomen or gallbladder. Crohn’s disease, celiac disease and irritable bowel syndrome are other common causes of diarrhea.

Often, a combination of factors can cause diarrhea, including an increase in transit time and osmotic stimulation of water secretion by unabsorbed contents. Therapy involves limiting secretions, slowing motility and improving solute absorption. The stomach produces 2.⁵ liters of fluid/day, which is absorbed in the small bowel. Drugs that decrease small intestine secretions are Sandostatin or octreotide acetate. Therapy with octreotides decreases stool from ostomies by a volume of 500-4,000 grams/day. Octreotide is expensive, although worth it for treating patients with persistent large-volume intestinal output. One can have 100 micrograms of octreotides injected subcutaneously three times/day with meals.

Opiates are the most effective means for slowing intestinal motility. Imodium or loperamide is metabolized by the liver and doesn’t cross the blood-brain barrier, limiting the side effect of dependence. Other opiates utilized include codeine or tincture of opium (10-25 drops every six hours). Anticholinergic drugs and opiate combos may also be beneficial in reducing opiate effects, with capsules containing 25 mg of opium and 15 mg of belladonna as a potent combination.

Traditionally, dietary recommendations to treat diarrhea are to eliminate lactulose (milk products), caffeine-containing drinks and diet products containing sorbitol, mannitol and xylitol. Medications that contain magnesium or sorbitol also contribute to diarrhea. Alternative treatments for diarrhea include charcoal tablets (four tablets every hour until diarrhea subsides). Charcoal absorbs toxins from the colon. Essential fatty acids found in fish oils and nuts aid in forming stool and are available in capsule form. Kelp (1,000 mg/day) can be used to replace lost minerals, and potassium (99 mg/day) is used to replace lost potassium. Acidophilus (1 tsp. in distilled water twice/day) is used to replace friendly bacteria, and garlic (two capsules three times/day) is used to kill bacteria and parasites.

The herbs for occasional bouts of diarrhea include blackberry root bark, chamomile, or raspberry leaves. Food supplements such as rice bran or raw foods, i.e., bananas, apples and yogurt, liquids or even rice water (which supplies B vitamins) are considered helpful in the cessation of diarrhea. Dairy products are discouraged due to temporary loss of enzymes needed to digest lactose. Carob powder — high in protein — helps to halt diarrhea. If diarrhea continues for over three days with fever and/or blood rectally, medical attention is needed for rehydration and further assessment of causation.

Marcia West, RN, BSN, is a staff nurse in the endoscopy department at Washington Hospital Health Care Systems in Fremont, Calif.

References

Mayo Clinic: Embody Health Guide to Self Care.

Phyllis A. Balch and James F. Balch, MD, Prescription for Nutritional Healing.

Sleisenger and Fordtran’s Gastrointestinal and Liver Disease seventh edition.