What is constipation?
Diet - the First Step
Choosing the right Laxative
Daily routines to promote regularity
What is constipation?

That may sound like a foolish question, but many people think of constipation as having infrequent bowel movements.  It is actually defined as having dry, hard stools that are hard to pass.  Many people have only a couple of bowel movements a week, but if they do so without straining, they are not constipated.

Normally food is liquefied in the stomach by digestive juices and moves through the small intestine in liquid form.  Nutrients are absorbed in the small intestine.  Waves of muscle contraction called peristalsis moves the remainder along into the large intestine.  In the large intestine, water is reabsorbed from the left over waste product, leaving just fecal material (stool) which is moved along and passed out of the body in a bowel movement.

Anything that changes the speed with which foods move through the large intestine interferes with the re-absorption of water and causes problems.  Rapid passage causes diarrhea, slowed passage allows too much water to be reabsorbed, leaving hard, dry stool that doesn't move easily through the bowel.

	Many medications affect bowel function.
	Certain foods, a poor diet or changes in diet can cause constipation.
	Constipation is very common in anyone with poor mobility because lack of activity and exercise slow bowel motility.
	Long delays in getting to the bathroom further complicate the problem by keeping the stool in the large intestine longer where it becomes drier and harder.
	There is some evidence that ALS can affect the autonomic nervous system as well as skeletal muscle and slow the entire digestive process.
	In ALS swallowing problems make getting a good diet and sufficient fluids difficult and the problem gets worse.
	Breathing problems make it difficult to take a deep breath and bear down, something we don't even realize is important in having a bowel movement until we cannot do it.

Because so many things contribute to constipation in the ALS patient, the solution may change over time.

How to Prevent or Treat Constipation

Although we joke about constipation, it is a miserable experience and should never be taken lightly in the ALS patient.  Loss of appetite from frequent constipation leads to weight loss, weakness and dehydration. Constipation can progress blockage in the intestines and nausea and vomiting.  (Vomiting is very dangerous for a person who cannot turn over when lying on his back because it causes choking.) The blockage can become so severe as to require hospitalization and possibly even surgery to correct.

Diet The first - and best - way to approach constipation is by improving your diet. Eat lots of high fiber foods. (Check with your doctor if you have other digestive or bowel problems or are on a special diet.) There are many high fiber cereals available and granola bars are convenient and easy to handle when feeding yourself begins to be difficult. Raw fruits and vegetables are also easy to eat sources of fiber if swallowing is not a problem. Drink lots of fluids. If you are using tube feeding, fiber is added to most tube feedings formulas. Check the label to see if your brand has added fiber. When diet alone isn't quite enough, try the old remedy of prunes or prune juice for occasional constipation. It really does work!

Laxatives There are many types of laxatives available without a prescription. For frequent or chronic constipation common to ALS patients it is very important to begin with the mildest types. Everyone's bowel pattern is different. Very few people need to have a daily bowel movement. Every other day or every third day is probably most common. Insisting on a daily bowel movement and using laxatives to try to attain it is asking for trouble! There are 5 basic types of laxatives: Fiber (Bulk) Fiber laxatives supply the fiber necessary to add bulk which holds water and makes it easier to move the stool through the bowels. Today's over-processed foods are low in fiber to begin with and when swallowing problems begin there is usually even less fiber in the diet. Fiber laxatives are very slow acting and are taken daily to prevent constipation rather than for relief of existing constipation. Fiber laxatives are generally the first laxative recommended for frequent constipation. Two well known brands are Metamucil and Citrucel.  Available without a prescription, some use natural fiber (agar, psyllium, kelp and plant gum.) Others are synthetic cellulose (methylcellulose). Natural and synthetic bulk-forming laxatives act similarly.   Because the fiber is not absorbed, they are ideal for long term use. Fiber laxatives are available as a powder,  (which is mixed with water or juice and generally needs to be drunk fairly quickly before it thickens to a goo), a tablet, or a wafer.  It is possible to be allergic or sensitive to flavorings or other additives. Some brands may also contain enough sugar as to cause problems for diabetics. For the ALS patient there are two concerns with this type of laxative; First, it is essential that fluid intake be very good. 8 ounces of fluid must be taken immediately with each dose and more throughout the day is needed for effective use. Taking fiber laxatives without enough fluid can cause intestinal blockage. Second, they are not to be used when swallowing problems begin.  Failure to drink enough water to wash down the fiber might allow it to begin to swell in the esophagus and this requires immediate medical attention.  Fiber laxatives can safely be given through a feeding tube, but the fiber needs to be promptly followed by flushing the tube with water to prevent clogging. Stool Softeners Stool softeners, also called emollient laxatives, also keep the water content of the stool higher which keeps it softer and allow it to move more easily through the bowels. Stool softeners are often ideal for ALS patients. Not only do they help keep the stool soft when fiber and  fluid intake is difficult, but they also are very helpful when breathing problems make it difficult to bear down and push. They do not cause frequent bowel movements, cramping or urgency but greatly reduce the amount of straining needed to have a bowel movement. Stool softeners are taken daily as a preventive measure rather than to force a bowel movement on a certain day. Stool softeners are available in pill or liquid form. Colace is the most commonly prescribed stool softener, but there are many non-prescription brands of the active ingredient, docusate, available, such as Surfak. Liquid docusate is also available without prescription but the pharmacist will probably have to special order it for you as it is seldom stocked by drug stores. (Note: liquid ducosate needs to be diluted in juice or it burns all the way down!!!!)   Hyperosmotics Hyperosmotic laxatives draw water into the bowel from surrounding body tissues, softening the stool. Of the three types of hyperosmolar laxatives the saline type is the most well known -- and disliked! Saline laxatives are harsh, fast acting, and total in effect. They are primarily used to completely clear the bowel in preparation for surgery or bowel exams.   The polymer type is a a large molecule that causes water to be retained in the stool to soften it and ; increase the number of bowel movements. It is not used long term.   Of the three types of hyperosmotic laxatives only one, lactulose, is useful for preventing constipation. It's action is so much less rapid and harsh than the saline that it is often used for long-term treatment of chronic constipation. Because it has sugar-like properties it may not be suitable for diabetics. Lactulose  is available only by prescription.   Lubricant Laxatives Lubricants use mineral oil to coat the stool for easier passage. Stimulants increase the muscle contractions (peristalsis) of the bowel which moves the stool along. Hyperosmotic laxatives encourage bowel movements by drawing water into the bowel from surrounding body tissues. This provides a soft stool mass and increased bowel action. Lactulose is another stool softener. It is only available by prescription, is a liquid, and may affect blood sugar in diabetics. In my experience it is more effective than Colace, and because it acts faster, it is easier to adjust the dose to a good balance between loose stools and effortless but controlled bowel movements. Another medication sometimes ordered is Reglan. Reglan works primarily in the stomach to empty it faster in order to reduce nausea, vomiting, or esophageal reflux. It's value in treating constipation is minimal. Stimulant laxatives increase the normal peristalsis to move the stool quickly and forcefully along. Most are intended to be fairly gentle result in a bowel movement within 6- 12 hours, but even these can cause cramping. Stimulant laxatives should be reserved for occasional use until other methods fail.  Frequent use of stimulant laxatives can actually aggravate constipation because the bowels become dependent on them for the stimulation for even normal peristalsis. Stimulant laxatives are available as pills that generally result in a bowel movement in 6-12 hours. If constipation is already making you uncomfortable, stimulant suppositories will provide relief within a hour but are likely to cause cramping Enemas are the last resort as a routine method of bowel management.  The repeated distension of the bowel will eventually cause loss of bowel tone which aggravates the problem.  This "eventual" problem is not a concern for the ALS patient who does not plan on going on a vent, but should be considered when planning a bowel program for long term use. Daily Routine Few people need to have a daily bowel movement but having a routine time when you can spend a longer period of time on the toilet is helpful. Although choosing a time is probably going to be more a matter of convenience for your caregiver, if you already have a certain time of day you are more likely to have a bowel movement, try to arrange for that time.   If having a bowel movement at a consistent time of day is important because you don't always have the necessary help to get to the toilet the rest of the day, you can encourage that schedule. Begin by using a suppository or stimulant laxative to promote bowel movements on the scheduled day at the chosen time.    After a week or so,  use the laxative only if you can't have a bowel movement on your own.  Within a week or two, you should be able to reduce reduce the stimulant laxative use to very infrequently. An unrushed and private bathroom trip is ideal, but safety and security need to be assured.  Having some type of buzzer or doorbell type button (available from Radio Shack) to call for help works well. Sitting upright and as comfortably as possible is also important.   Armrests and a seatbelt might be necessary for safety.  (The correct and safe angle for a seatbelt is diagonal as they are in cars:  The belt is around the hips and anchored lower.  A belt anchored behind you at stomach level will allow you to slide down through it  and end up tight around your chest.)  A padded toilet seat can be a lifesaver!  If you have a high-rise toilet, using a footstool and leaning forward over a pillow can help provide the necessary push. Drinking a cup of coffee or other hot beverage before or while in the bathroom will often help.