All doctors can have an impact on the constipation crisis: A discussion with Dr. Haider Warraich

John J. Murphy, MDLinx | August 31, 2017

Background
Constipation is a very common problem in the United States, with prevalence estimates as high as 28%. It occurs in more than 1 in 6 adults overall, and in about 1 in 3 adults over age 60—yet only a minority of patients seek treatment for it. Even so, ambulatory visits for constipation have doubled from 4 million per year in 1993 to 1996 to nearly 8 million per year in 2001 to 2004, according to the most recent available data.

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Constipation occurs in more than 1 in 6 adults overall, and in about 1 in 3 adults over age 60—yet only a minority of patients seek treatment for it.

Constipation is generally defined as reduced frequency (less than three stools per week) or difficulty defecating (straining, incomplete evacuation, hard/lumpy stool, prolonged time to stool, or need for manual maneuvers).

When these symptoms occur for 3 months or longer without known cause, it is termed chronic idiopathic constipation (CIC). The estimated prevalence of CIC in adults is about 1 in 7 (14%). CIC is more prevalent in adults age 65 and older, and is about twice as common in women as in men.

In short, you're probably seeing patients for other conditions and don't know or suspect that many of them are dealing with uncomfortable, even painful, constipation.

This, in fact, was an eye-opener for Haider Warraich, MD, a fellow in cardiology at Duke University Medical Center, in Durham, NC. Besides being a physician, Dr. Warraich is a writer, and the surprising subject matter of constipation inspired him to write a recent article about it on STAT.

In this interview, Dr. Warraich explains why doctors should be more cognizant of chronic constipation in their patients, and what they can do to help them. He also notes that chronic constipation can be so severe that, in rare cases, certain patients can even die from it—a truly awful way to go.

MDLinx: Was there a specific case that inspired you to write the STAT article?

Dr. Warraich: Back when I was an intern, one of the first patients I took care of in the ICU was an elderly woman who had a heart attack, which we found was due to chronic constipation. She had developed fecaliths and eventually passed away before she could get surgery. Since then, I have always found constipation an interesting medical dilemma, one that we have many fixes for yet somehow it easily goes unrecognized.

MDLinx: Why is a cardiology fellow interested in writing about constipation?

Dr. Warraich: I am prone to becoming interested in issues that span beyond my particular specialty, but constipation is such a common issue that it affects almost every specialty.

MDLinx: What are some reasons why all doctors should take chronic constipation more seriously?

Dr. Warraich: As physicians, we go to such great lengths to make our patients' quality of life better, and sometimes we might ignore the relatively simple interventions at our disposal. Furthermore, a lot of constipation is actually caused by medications we prescribe to patients, making it imperative that we do our best to treat what is a frequent and uncomfortable side effect.

MDLinx: Some patients will speak freely about their constipation, but others won't talk about it until questioned. Why is it a taboo subject, and how do you know to ask patients about it?

Dr. Warraich: Constipation is certainly a taboo subject, making it even more important that physicians are comfortable bringing it up and talking to their patients about it. To me, it's an issue that should be part of everyone's checklist when taking a medical history.

MDLinx: In addition to laxatives and fiber, there are several prescription drugs now for chronic constipation. Can you speak to their effectiveness?

Dr. Warraich: There is a recent review on constipation in JAMA by Dr. Andrew Wald, which I found very useful. Many of the traditional laxatives have never been formally tested, although the best evidence base is for polyethylene glycol. I was actually surprised to find out that many recently developed prescriptions drugs were tested against placebo and not a laxative. Certainly, prescriptions drugs have a role if patients fail over-the-counter treatments, but at that stage patients likely need to be referred to a gastroenterologist.

MDLinx: You wrote: "The key to ending chronic constipation is by treating the colon like the highly intelligent organ that it is."? Why do you refer to the colon as a highly intelligent organ?

Dr. Warraich: Unlike the bladder, the colon is very adaptable. When people are in uncomfortable situations, lack privacy, or are traveling, the colon will accommodate to the person's needs. However, this very adaptability also makes it prone to being slowed down by psychological cues that might be unintentional. 

MDLinx: You noted that the colon can "learn" some of those psychological cues, but can also unlearn them through retraining.

Dr. Warraich: During my research for the article, I learned about dyssynergic constipation, in which people paradoxically contract their anus when they need to be relaxing it. The first-line treatment for this type of constipation, which is surprisingly common, is actually biofeedback and not laxatives. 

MDLinx: In the introduction of your article, you described a patient who apparently died from constipation. Can a person actually die from constipation?

Dr. Warraich: I don't want to be alarmist, but constipation can be dangerous if patients have very severe symptoms—frequently from opiate use—and have some form of structural defect in the abdomen. That patient had cancer which had metastasized to the abdomen and [he] used chronic high-dose opiates. That combination, though, is very common in oncology patients and was a very shocking turn of events. We were on the verge of sending the patient for flexible sigmoidoscopy to disimpact him, but were too late.

MDLinx: On a somewhat related note, what inspired you to write a book about "modern death??"

Dr. Warraich: Like almost every intern and medical resident, I found myself dealing a lot with patients at the end of life. While I got very good at the logistics around the end of life, I wanted to know more about just how things got to be the way they are. I was also interested in learning about the research that had been done in this space and didn't really find a book or other source where I could find answers to many of the questions I and other doctors have. I had written individual articles for The New York Times and other media, but knew that I needed something more in depth to tackle this topic fully.

About Dr. Warraich: Haider Warraich, MD, is a fellow in cardiology at Duke University Medical Center and the Duke Clinical Research Institute, in Durham, NC, and author of "Modern Death: How Medicine Changed the End of Life."

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