A person's diet should contain enough fiber to ensure adequate stool bulk in order to prevent constipation. Vegetable fiber, which is largely indigestible and unabsorbable, increases stool bulk and reduces the risk for constipation; certain components of fiber also absorb fluid into the solid phase, making stools softer and facilitating their passage. Fruits and vegetables are recommended, as are cereals containing bran taken to tolerance.

One of the most important steps I recommend in order to reduce the risk for constipation is to drink plenty of fluids. The most important time to drink water is upon awakening. Drink one or two glasses of room temperature or cold water to stimulate peristalsis, and hence reduce your risk for constipation the rest of the day.

Laxatives should be used carefully. Some may interfere with absorption of various drugs by binding them chemically (eg, tetracycline, Ca, phosphate) or physically (eg, digoxin on cellulose matrices). Rapid fecal transit may rush some drugs and nutrients beyond their optimal absorptive locus.

Bulking agents (eg, bran, Psyllium, calcium polycarbophil, methylcellulose) provide fiber and are the only laxatives acceptable for long-term use. They act slowly and gently and are the safest agents for promoting elimination and preventing constipation. Proper use involves gradually increasing the dose--best taken tid or qid with sufficient liquid (by adding 20 oz/day of extra fluid) to prevent impaction --until a softer, bulkier stool results. This approach produces natural effects and is not habit forming. Bulking agents normalize both constipation and diarrhea. You may also consider glucomannan.

Wetting agents
Wetting agents include detergent laxatives such as docusate which soften stools, making them easier to pass. They break down surface barriers, allowing water to enter the fecal mass to soften and increase its bulk. Increased bulk may stimulate peristalsis, which moves the softened stool more easily. Mineral oil softens fecal matter, resulting in more easily passed stool mass, but it may decrease absorption of fat-soluble vitamins. Wetting agents and mineral oil act slowly; either may be useful after MI or anorectal surgery and when prolonged bed rest is required.

Osmotic agents are used to prepare patients for some diagnostic bowel procedures and occasionally to treat parasitic infestations. They contain poorly absorbed polyvalent ions (eg, Mg, phosphate, sulfate) or carbohydrates (eg, lactulose, sorbitol) that remain in the bowel, increasing intraluminal osmotic pressure and drawing water into the intestine. The increased volume stimulates peristalsis, which moves the water-softened stool easily through the bowel. These agents usually work within 3 h.

Secretory or stimulant cathartics (eg, cascara sagrada, senna and its derivatives, bisacodyl, phenolphthalein, castor oil) are often used to cleanse the bowel for diagnostic tests. They act by irritating the intestinal mucosa or by directly stimulating the submucosal and myenteric plexus. Some are absorbed, metabolized by the liver, and returned to the bowel in bile. Peristalsis and intraluminal fluid both increase, with cramping and passage of semisolid stool in 6 to 8 h. With continued use, melanosis coli, neuronal degeneration in the colon, "lazy bowel" syndrome, and serious fluid and electrolyte disturbances may occur.

Relistor for Opioid-Induced Constipation
FDA has approved Relistor (methylnaltrexone bromide) to help restore bowel function in patients with late-stage, advanced illness who are receiving opioids on a continuous basis to help alleviate their pain. Such patients include those with a diagnosis of incurable cancer, end-stage chronic obstructive pulmonary disease from emphysema, heart failure, Alzheimer’s disease with dementia, HIV/AIDS or other advanced illnesses. Opioids can interfere with normal bowel elimination function by relaxing the intestinal smooth muscles and preventing them from functioning. Relistor acts by blocking opioid entrance into the cells thus allowing the bowels to continue to function normally.

Constipation questions
Q. Which supplements are of benefit for constipation?
   A. Consider cascara sagrada, psyllium and glucomannan fiber.

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