Improving bowel function in constipation

Introduction

Constipation can be used to describe both infrequent stool motions or frequent incomplete stool motions which are often hard and difficult to pass. If it has been m3 or more days since you passed a bowel motion, you are constipated. Both can cause discomfort and straining to pass stools. The following advice is aimed to help you to open your bowels regularly and with ease so that your bowel problems no longer interfere with your daily life.

Symptoms of constipation can vary from one person to another but can include:

• Difficulty and pain when having a bowel movement.
• Having to strain a lot when trying to open your bowels.
• Lumpy or small hard pellet like stools.
• Sensation of incomplete evacuation.
• Passing liquid stool when you still feel the solid stool remains in your bowel

What can cause constipation?

Your stool is formed of dead cells, bacteria from your gut, fibre, water and anything else which wasn’t absorbed by your gut after your food was broken down Muscle contractions in your large intestine push the stool towards your rectum (back passage) where they are stored until you are ready to open your bowels.

Constipation may occur if:

a) Too much water is drawn back into the body from the large intestine, making hard stools which are difficult to push,

b) Muscle contractions in the large intestine are too slow or weak, causing the stool to move very slowly. The stools may stay in the same place for hours or days and become hard and dry as more water is absorbed, the longer they stay in the gut.

c) There is insufficient bulk to what is leftover after absorption for your intestinal muscles to push against

Taking control of your bowel habit may seem difficult at times, especially when you feel under stress or when the problem has continued for a long time. There are many factors that affect bowel function; these include diet, physical activity and fluids. This booklet will provide advice on each of these topics.

There are many different suggestions in this booklet – you do not have to do them all at once, instead make changes one at a time so you know which are most effective.

Daily routine and positioning on the toilet

Establishing a daily routine can be really important to help with predictable bowel habits. When you have the urge to open your bowels try not to put off passing stool. Every day set aside 10 minutes for this, at a time when you will not be interrupted (preferably 15 to 20 minutes after your breakfast). Do not ignore the urge to pass a stool as this can make constipation worse as the bowel has longer to absorb water out of the stool so it is drier. Also do not strain to pass the stool quickly as this can cause haemorrhoids.

Check your sitting position on the toilet

If possible sit with your knees slightly higher than your hips as this will align your rectum better with your anus better than a standard seated position. It may help to use a small stool or some books to raise your feet. Lean forward with your forearms resting on your thighs and your back straight.

Identify the muscles you will use

Your waist muscles help to push and propel your stools out of your back passage. Place your hands either side of your waist. Now cough. Can you feel the muscles work? When you push down you need to feel these muscles expand so that your waist becomes wider.

Relax

Lower your shoulders. Breathe slowly and gently. Try to let go with all of your muscles and breathe so that your tummy moves in and out not your chest.

Now try to open your bowels

Do not hold your breath ie do not take in a big breath first.

• Slowly widen your waist. Then push from your waist downwards and backwards into your bottom, ensuring that your muscle in your back passage is relaxed and open. Do not strain.
• Relax for one second but only slightly. You should maintain a level of pressure with your waist, whilst not pushing with it.
• Push outwards and push downwards again. This should be repeated.

Remember

This will take time and practice.

Do not spend more than 10 minutes on the toilet.

Do not return to the toilet unless you have a definite urge to open your bowels.

Diet and fluids

The indigestible parts of the food pass through to your colon and are fermented by bacteria. This portion of the food is generally termed dietary fibre and is important for good bowel health.

There are two types of fibre that can be found in the diet, both have slightly different roles:

Insoluble fibre is found in the outer coat of cereals (e.g. wheat bran, brown rice, whole grains) and the skins or peel, pith and stalks of fruit and vegetables, nuts and seeds. These increase stool size which can help stimulate the gut to co contract so that the stool is moved down the colon to the rectum more rapidly.

Soluble fibre is in the flesh of fruit and vegetables, oats, beans and pulses. It can be fermented by the bacteria to create useful products and will also soften and increase the bulk of the stool, making it easier to pass. They do this in part by forming a gel with water to lubricate the passage of the stool providing the person is sufficiently hydrated.

Increasing your fibre intake can help with constipation

The recommended daily fibre intake in the UK is 30g a day but most people do not manage this.

Fibre intake should be increased gradually (to minimise flatulence and bloating). Although the effects of a high fibre diet may be seen in a few days, it may take as long as four weeks for the benefits to be seen.

Particularly try and increase your intake of soluble fibre (oats, fruit, vegetables, linseeds) and try to aim for five portions of fruits and vegetables/day.

Fruit and fruit juices high in sorbitol can also help to prevent and treat constipation. These include: apples, apricots, peaches, pears, plums and prunes.

It has also been shown that eating 2-3 kiwis a day significantly increases the stool mass and helps with harder stools to minimise straining.

Below is some information about the different fibre contents of common foods.

If you have any gastrointestinal health problems or have regular episodes of abdominal pain or discomfort or bloating then discuss with your health professional about whether or not you should increase your fibre intake. Similarly, you should discuss with a health professional if there is any blood in your stools.

Fluids

Aim to drink at least 1.5 to 3L of fluids per day (you need more if you are in a larger body), to soften your stool and increase the speed of stool passing through your colon. Warm drinks can stimulate a bowel motion.

As you increase your fibre intake ensure you also increase your fluid intake.

Non fermentable bulking agents

If increasing your fibre has not helped or you have significant bloating when eating higher fibre foods, then a non-fermentable bulking agent such as linseed or flaxseeds, Cevelac or Normacol or psyllium husk/fybogel can help. Celevac, Normacol and psyllium husk are available to buy from pharmacies. Milled and golden/brown linseeds/flaxseeds can be purchased from larger supermarkets (in the /wholefoods section) and health food stores.

Linseeds/Flaxseeds

These are available as golden or brown or cracked or milled. All types are helpful.Sprinkle the seeds onto prepared foods such as breakfast cereals, yoghurt, salads or soups. Alternatively, they can be placed on the tongue and swallowed immediately with water or incorporated into baking.

Dose - Initially, try taking one tablespoon once a day, this can be split up into smaller doses spread out throughout the day. You can increase to two tablespoons if required. It can take up one to three months to see the full benefits of the linseeds.

Normacol (also known as sterculia)

Normacol granules are a vegetable gum from the karaya tree. They should be placed on the tongue and swallowed whole without chewing or crushing. Alternatively, they can be sprinkled over soft foods such as yoghurt or pureed fruit.

Dose - Initially, try one heaped 5ml teaspoon or one sachet twice a day after meals.

If you are still experiencing constipation after a few days try increasing the dose by an extra 5ml teaspoon or one sachet per day. Please ask your dietitian about a suitable change in dose if you are unsure.

Celevac (also known as methylcellulose)

Celevac is a pink chewable tablet. Celevac tablets swell in contact with water and should therefore be swallowed carefully; avoid swallowing whole.

Dose - Initially, try taking three tablets twice a day after meals. If you are still experiencing constipation after a few days, try increasing the dose to four tablets twice a day. Please ask your healthcare professional about a suitable change in dose if you are unsure.

Probiotics

There is some evidence that probiotics e.g. Bifidobacterium lactis may help with the symptoms of constipation. This strain of probiotic can be found in various products for example, ‘Activia’ yoghurts (2/day) or ‘OptiBac’ (choose the one for IBS C) (which is dairy-free). Bifidobacterium reduces gut transit time, as well as improving the associated symptoms of constipation such as tummy pain, wind and bloating. Supermarket, pharmacy or health food stores and the trusted internet sites sell probiotics. f you don’t see any benefit after twelve weeks then discontinue and you could consider trying an alternative.

Prunes

Studies have shown that, in severe cases of constipation, eating 9-10 prunes a day increased stool frequency, softened stools and reduced straining. However, they can be associated with an increase in symptoms of gas. They increase the water in the stool with sorbitol, and increase fibre intake.

Kiwis

Consuming 3 kiwis a day has been shown to reduce the need for laxatives in patients who are constipated with no adverse effects from the increase in fibre e.g. gas.

Exercise

Regular exercise helps regulate bowel motions. Even gentle exercise can stimulate peristaltic movement (the movements of your bowel wall to push the stool towards the rectum).

Consider increasing your current exercise regime but make sure you drink fluids after any strenuous exercise to stay well hydrated.

Ways to increase your activity levels

It is recommended that we all do a minimum of 150 minutes (two and a half hours) of moderate intensity physical activity every week. Moderate-intensity aerobic activity means you should feel warm, maybe break a sweat but should feel comfortable enough to maintain a conversation. Examples of good aerobic activities include brisk walking, swimming and cycling.

Although 150 minutes may seem like a lot many people it may help to break this down into 30 minutes on five days a week.

These are some suggestions to get you started:

• Walk/cycle to work or build exercise into your lunch break – a swim, yoga class or brisk walk outside.
• Avoid driving short distances and walk or cycle instead. Alternatively, park a little further away and then walk to your destination.
• Walk while on the phone - if you know a call on your mobile phone will last more than 10 or 15 minutes then walk while you talk.
• Try a new sport with a friend, you can help support and motivate each other. Instead of going for a coffee with a friend then you could meet for a walk.
• Pick something you like. If you enjoy an activity you are much more likely to adhere to it in the long run.

What can I do if I am still constipated?

If you are still constipated after following the suggestions, you may wish to consider using laxatives. These are medicines that encourage bowel movement. However, they should not be considered until you have tried all the advice above. They are often taken for short periods of time, until bowels are regular. Many laxatives that may be recommended can be purchased over the counter (OTC) from your pharmacy or prescribed by your doctor.

Laxatives may be taken by mouth (orally) or they may take the form of a ‘suppository’ and be inserted into your back passage. There are several types of laxatives:

Please speak to your doctor before starting to take laxatives, as some types may interfere with other medications you are taking.

It is important that you increase your fluid intake if you are taking any of the above laxatives. Your doctor, pharmacist, or nurse will be able to discuss with you the best sort of laxative for you. It is important that you take your laxatives at the dose recommended by your prescriber and keep them updated as to the effects if the constipation doesn’t resolve.

Further information on how to use these laxatives and their possible side-effects can be found in the manufacturer’s information leaflet that comes with the medicine. Please read this and ask your doctor, nurse or pharmacist if you have any questions.

Abdominal massage

Some people find that massaging their abdomen can help relieve discomfort and bloating. It can also help reduce the need for long term laxative medication. Abdominal massage can be done by yourself or by a partner or friend. It involves a series of gentle hand strokes and kneading on your abdomen as illustrated below. It can be done lying, sitting or standing and takes about 10-20 minutes.

Step 5: As step 4, but moving up the stomach

Step 6: Repeat steps 4 and 5

Abdominal massage is not recommended for those with a history of:

• Malignant bowel obstruction or abdominal growth.
• Ulcerative colitis or Crohn’s disease.
• An unstable spinal injury.
• Recent scarring or abdominal surgery.
• It is also not recommended if you are pregnant.
• If you have an abdominal hernia (e.g. hiatus, umbilical or inguinal) then massage can be used with care.

Benefits

This leaflet is designed to help you improve your bowel function. If you have any problems with the exercises, or if you do not understand any part of the information sheet, please ask your nurse to help you.

Follow your routine daily and you should begin to see good results within a few weeks.

How do I contact my healthcare professional if I have any questions?

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(NB: you must complete an email consent form in order to receive emails from your dietitian. Your dietitian will provide you with this)