Download Managing Diarrhea and Constipation

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NUTRITION 411
Managing Diarrhea and Constipation
Nancy Collins, PhD, RD, LD/N, FAPWCA
athroom habits are not something most people feel comfortable discussing, but as healthcare practitioners it is
important that we not overlook this topic when speaking with
patients. When questioned, a large percentage of patients
admit to problems with diarrhea, constipation, or alternating
bouts of both. These problems not only may affect a patient’s
nutritional intake, but also may interfere with wound healing.
Caring for and dressing wounds on the sacrum and coccyx
can be much more difficult if the patient has frequent bouts
of diarrhea. Constipation can cause straining, hemorrhoids,
and much suffering if not resolved. For these reason both of
these conditions deserve a closer look.
Preventing Dehydration
The main goal in the treatment of diarrhea is to prevent
dehydration and electrolyte imbalance. Potassium and sodium
loss should be corrected as soon as possible by providing a
proper oral rehydration solution. Water does not contain the
necessary electrolytes for oral rehydration therapy and sugary
juices, such as apple juice, may worsen diarrhea. Caffeinated
and alcoholic beverages also should be limited. Proper solutions may be homemade or purchased from a medical nutrition supplement company. Sports drinks such as Gatorade
also may be used for rehydration. Sodium, potassium, chloride, blood urea nitrogen/creatinine ratio, and albumin should
be carefully monitored. Patients with a history of hypertension
or heart failure should be monitored closely when given highsodium solutions.
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can cause black stool and false melena. A fecal occult blood
test can be administered to rule out false melena.
Constipation
Constipation is a symptom; it is not a disease unto itself.
Constipation is defined in many ways. One common definition states that constipation is a decrease in the frequency of
bowel movements, accompanied by prolonged or difficult passage of stools. There is no accepted rule or correct number of
bowel movements per week. Many people think they are constipated when in fact they are following their own individual
pattern. It is not mandatory to have a bowel movement every
single day. For some people, regularity may be a bowel movement only three times per week; for others, it may be daily
bowel movements.
Sometimes, patients express concern when they don’t have
a bowel movement every single day. Reassurance should be
given but it is also important to remember that after 3 or 4
days without a bowel movement intestinal contents may
harden and may be harder to pass. For this reason, it is imperative to take these concerns seriously and provide some useful
tips to relieve the situation.
Causes of Constipation
Constipation can be caused by many different problems
and situations. A diet low in fiber is often the easiest cause to
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Diarrhea
Diarrhea is characterized by frequent loose or liquid stool
and is a symptom of many disorders and diseases. The first
step in treating diarrhea is to identify its cause. Table 1 lists
several common causes of diarrhea. The three most common
types of diarrhea are watery, fatty, and small-volume. Identifying the type of diarrhea may help determine its cause.1
Watery diarrhea occurs when the amount of water and
electrolytes moving into the intestinal mucosa exceeds the
amount absorbed into the bloodstream. Watery diarrhea may
be classified into two subtypes: osmotic or secretory. To determine which type is present, determine whether the diarrhea
abates with fasting. Osmotic diarrhea is relieved by fasting; secretory diarrhea is not. Watery osmotic diarrhea usually accompanies lactose intolerance, dumping syndromes, and
enteral feeding intolerances. Watery secretory diarrhea is a
sign of bacterial enterotoxins and viruses.
Fatty diarrhea, or steatorrhea, usually accompanies conditions associated with malabsorption, such as chronic pancreatitis or short-bowel syndrome. Small-volume diarrhea may
accompany diverticulosis of the colon. Bloody stool or black
tarry stool may indicate a more serious condition and should
not be confused with common diarrhea. Black tarry stool, or
melena, usually indicates that blood is coming from the upper
part of the gastrointestinal tract. Maroon or red bloody stool,
called hematochezia, usually suggests that blood is coming
from the large intestine or rectum. These conditions warrant
prompt medical attention and testing. Occasionally, the ingestion of black licorice, lead, iron supplements, or blueberries
Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at
[email protected]. This article was not subject to the Ostomy Wound Management peer-review process.
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Table 1. Common causes of diarrhea
Cause
Lactose intolerance, gluten intolerance, or excessive intake
of sorbitol, mannitol, or xylitol
Protein-calorie malnutrition Hypoproteinemia (albumin level <2.6 g/dL) is associated with
intestinal edema, which negatively affects luminal absorption
and may result in diarrhea
Bacterial contamination
Contaminated food or water may lead to infection with
Campylobacter, salmonella, shigella, or Escherichia coli
Viral infections
Rotavirus, Norwalk virus, cytomegalovirus, herpes simplex
virus, or viral hepatitis
Enteral tube feedings
Hypertonic formula, refeeding syndrome, contamination,
bolus feeding into small intestine, or lack of fiber in formula
Parasites
Giardia lamblia, Entamoeba histolytica, or Cryptosporidium
can enter the body through food or water and settle in the
digestive system
Drug reactions
Laxatives, diuretics, cholinergic drugs, antibiotics,
prostaglandins, liquid medications containing sugar alcohols,
warfarin, thyroid preparations, antiepileptics
Gastrointestinal diseases Inflammatory bowel disease, short-bowel syndrome,
HIV/AIDS, Crohn’s disease, chronic ulcerative colitis, bowel
resection, or malabsorption syndrome
Fecal impaction
Impacted feces prevent the passage of normal stool; only
watery stool is able to pass the point of impaction
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Food intolerance
35 g of fiber daily, while a person
who eats 1,700 calories each day
needs somewhat less fiber (about
24 g). According to the Harvard
School of Public Health,3 the average American consumes only 14
to15 g of fiber each day. This is
well short of the recommendation
and may lead to many other
health concerns such as colon
cancer, heart disease, diverticulitis,
and type 2 diabetes. Table 2 details
recommended amounts of fiber.
Inadequate fluids are another
common cause of constipation.
Liquids add fluid to the colon and
bulk to the stools, making bowel
movements softer and easier to
pass. Table 3 lists many other
causes of constipation. Table 4
lists some of the medications that
may cause constipation.
Table 2. General fiber intake recommendations2
Age (years)
Average daily
calories
Fiber intake
grams
Children
1,404
1,789
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1–3
4–8
Boys and men
2,265
2,840
2,818
2,554
2,162
1,821
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38
38
38
30
30
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9–13
14–18
19–30
31–50
51–70
70+
Girls and women
1,910
1,901
1,791
1,694
1,536
1,381
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9–13
14–18
19–30
31–50
51–70
70+
identify and luckily, easy to correct. The Institute of Medicine2
recommends that children and adults consume 14 g of fiber for
every 1,000 calories of food they eat each day. That means a person who eats 2,500 calories each day should consume at least
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Diagnosing Constipation
Most people with constipation do not require extensive diagnostic tests; a medical history and a physical exam usually
suffice. However, sometimes more extensive testing may be
necessary if symptoms are severe or a sudden change in bowel
movements occurs or blood appears in the stool. Most physicians will begin with routine blood tests and a digital rectal
exam. The stool will be tested for occult blood. If further testing is required, a barium enema x-ray and a sigmoidoscopy
or colonoscopy may be performed. A barium enema x-ray allows viewing of the rectum, colon, and lower part of the small
intestine. The night before the exam, bowel cleansing is necessary because even a small amount of stool can obscure
proper results. During the exam, the bowel is filled with barium so it will be visible on the x-ray. A sigmoidoscopy allows
viewing of the rectum and lower colon; a colonoscopy views
the rectum and entire colon. Both of these procedures use a
flexible, lighted tube inserted through the anus and rectum
into the colon.
Treating Constipation
The first line of constipation treatment is usually a change
in diet. Adding additional fiber to the diet is often the key to
keeping regular. This means additional whole grain breads, fresh
fruits and vegetables, bran cereals, oatmeal, and lentils and
beans. Processed foods should be slowly replaced with highfiber foods because there may be a temporary increase in bloating, fullness, and gas as the body adjusts to the additional fiber.
This feeling will go away if the high-fiber diet is continued but
it is advisable to increase fiber slowly. Drinking plenty of fluids
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Table 3. Causes of constipation
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Diet low in fiber
Inadequate fluids
Immobility and inactivity
Irritable bowel syndrome or spastic colon
Poor bowel habits (eg, ignoring the urge to have a
bowel movement)
Laxative abuse
Travel and change of schedule
Pregnancy
Hormonal disturbances
Fissures and hemorrhoids
Mechanical compression
Nerve damage
Medication interactions
Specific diseases such as multiple sclerosis and
Parkinson’s disease
of laxative includes Colace® (Purdue Products L.P.) and Surfak® (Pfizer). Lubricants grease the stool, enabling it to move
through the intestine. Mineral oil is a common example. The
final category of laxatives is saline laxatives. These act like a
sponge to draw water into the colon for easier passage of
stools. Examples of this type are milk of magnesia and
Phillips’ M-O (Bayer HealthCare LLC).
Regular exercise is also a part of the treatment plan. Many
patients with wounds and other health challenges may not be
able to vigorously exercise but regular activity should be encouraged as tolerated. Creating a regular bathroom routine
also has proven useful for many people. For example, setting
aside 15 minutes every day after breakfast for undisturbed visits to the bathroom may encourage regularity. The urge to
defecate should not be ignored.
Table 4. Medications that may cause constipation4
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Narcotic pain medications such as codeine (eg,
Tylenol® #3, PriCara), oxycodone (eg, Percocet,
Endo Pharmaceuticals), and hydromorphone (Dilaudid, Purdue Pharma LP)
Antidepressants such as amitriptylene (Elavil, Astra
Zeneca LP) and imipramine (Tofranil, Mallinckrodt,
Inc.)
Anticonvulsants such as phenytoin (Dilantin) and carbamazepine (Tegretol, Novartis Pharmaceuticals)
Iron supplements
Calcium channel blocking drugs such as diltiazem
(Cardizem, Biovail Pharm) and nifedipine (Procardia, Pfizer Labs)
Aluminum-containing antacids such as Amphojel
and Basaljel (Wyeth Consumer Healthcare)
Practice Points
• Ask patients if they are having problems with diarrhea
and/or constipation.
• Suggest oral rehydration beverages to prevent dehydration with acute or prolonged diarrhea.
• Encourage patients with diarrhea to eat small meals and
snacks rather than big meals.
• Suggest foods such as bananas, white or brown rice, applesauce, toast, (ie, the BRAT diet) and crackers. These
foods contain soluble fiber, which is helpful in the digestion and absorption process.
• Caution patients about eating greasy, fried, or fatty foods
and adding butter, oil, or other fats to foods, which can
worsen certain types of diarrhea.
• Tell patients to avoid foods that may be hard to digest.
The gastrointestinal tract may be affected by foods that
are high in insoluble fiber (raw fruits and vegetables and
bran products), dried beans, cabbage, onions, nuts, and
carbonated beverages. Patients should avoid them if they
worsen symptoms.
• For constipation, encourage patients to increase fiber.
• Encourage regular bathroom time.
• Consider substituting medications if that is deemed to
be the cause of the problem. For example, one of the
newer and less constipating antidepressant medications
such as fluoxetine (Prozac, Eli Lilly) may be substituted
for amitriptyline and imipramine. ■
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with the new high-fiber diet is equally important.
Commercial bulking agents (fiber supplements) are
sources of natural or synthetic fiber. These products generally
are considered safe but are not a substitute for a proper diet.
Taken with water, the products absorb the water in the intestine and make stool bulkier and softer. Products in this category include Metamucil® (Procter and Gamble) and Citrucel®
(Bayer Health Care LLC).
There are many other types of laxatives. Laxatives are for
short-term use only; extended use can cause dependency. The
healthcare practitioner should determine which type of laxative to use and for how long. Stimulants cause rhythmic muscle contractions in the intestines. These products include
Correctol® (Schering-Plough), Dulcolax® (Boehringer Ingelheim Pharmaceuticals, Inc), and Senokot® (Purdue Products
L.P.). Stool softeners provide moisture to the stool. This type
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References
1. Escott-Stump S. Nutrition and Diagnosis-Related Care, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2008:393.
2. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids.
2002. Washington, D.C.: The National Academies Press. Available at:
http://books.nap.edu/openbook.php?isbn=0309085373. Accessed November 14, 2010.
3. Harvard School of Public Health. Fiber: Start Roughing It. Available at:
www.hsph.harvard.edu/nutritionsource/fiber.html. Accessed November
14, 2010.
4. Marks JW. Constipation. MedicineNet.com. Available at: www.medicinenet.com/Constipation/article.htm. Accessed November 14, 2010.
Coming next month: Nutrition for the Ostomy Patient
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