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Doctor Jennifer
Doctor Jennifer, Doctor
Category: Medical
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Experience:  Surgery Fellow
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I'm going to try your site again. Was having difficulty with my card.Question: elderly congestive heart patient having same constant constipation problem before & after colonoscopy. I wrote up the case in attachment

Hi, I'm Dr Jennifer and I'm a surgery fellow. The attachment isn't showing up; could you try re-attaching it for me?

Customer: replied 6 months ago.
Hi Dr. Jennifer.1. What is a surgery fellow?2. I'm sending you the attachment.Thank you

Fellowship is the training period after residency where you take on a specific subspecialty; in my case, liver and pancreas surgery, after general surgery, which includes colon and rectal surgery.

Hang on a second while I read the attachment!

OK, to clarify, he's currently taking the metamucil and senekot every day, but is he taking the miralax/polyethylene glycol every day as well? Does the polyethylene glycol get results for him?

Customer: replied 6 months ago.
Since the colonoscopy the gastroentrologist directed him to take Metamucil. He found he was very thirsty & dry & his cardiologist has him on 1 litre maximum water restriction. Two weeks later, they found water accumulating again outside the lung. He was complaining of how dry he was feeling, thirsty and now crushingly fatigued. That's when I went to the Health Food store & asked for an alternative to Metamucil & they suggested organic psyillium but it's having the same effect (constipation/bloating, etc. which compresses against the lung & he is short of breath & at night difficulty breathing). The only difference is,he is not as thirsty but he's also taking 1 teaspon of organic psyllium in some applesauce with 1 cup of water.
Senekot & Powder:
Before the colonoscopy & after, he was directed by his family doctor that when he's feeling is unable to have normal bowel movement he is to Begin takig 1 Senekot at bedtime. If on the 2nd or 3rd day there is no movement, increase the Senekot tablets to 2 at bedtime. After 2-3 days if no movement to use the Lay-a-Lax (Peg powder) until he has a normal movement. Once that happens to return to the cycle of 1 Senekot at bedtime.

OK, metamucil is made up of psyllium fiber, but probably not organic. So I'm not surprised to hear it's having the same effects.

How often is he taking the senna and the PEG powder?

Customer: replied 6 months ago.
Underneath the paragraph I wrote about Metamucil, I wrote about the cycle with Senekot & the powder

Yes, I saw. Does the senna work for him, or does he progress every time to the miralax? Does the miralax work for him, and if so, how many days does it take?

Customer: replied 6 months ago.
Senna works but then it progresses to the powder. He's been on the powder for 2 days but he says he's going a bit about 2-3x a day. Each bit that's eliminated makes him less bloated & he can breathe a bit better.

Ok. The powder can actually be taken every day if it works for him, which is what I would recommend trying, and then skipped if he develops loose stools. Another approach you can add if needed would be rectal suppositories like dulcolax which act by directly stimulating the rectum to expel what it contains. Since he is suffering from bloating, I would consider stopping the psyllium fiber entirely for a few days to a week to see if that helps. Natural fibers like that can be turned into gas by colonic bacteria, which could be contributing to his discomfort; gas and bloating are common side effects.

Does that make sense? What can I clarify? If you're satisfied with my service, please consider giving me a 5-star rating!

Customer: replied 6 months ago.
1 I don't understand the info about the powder. I understood from the cardiologist at the Heart Clinic that he's to be on Senekot & use the powder ONLY when it progresses and then return to Senekot again. From what I understand from your text he could try skipping the Senekot & only take the powder. Does he take the powder every day? For how long is it safe to do so?#2) How long can he stay of the psyllium? When does he return to it? What do I have him doing if he's bloated & constipated (ie. just use the powder????) Can he stay of the psyllium/metamucil? Thanks

1) If the senekot helps him, he can continue to take it; however, many colon surgeons feel that its stimulant effects stop working after long term use. He can take the powder every day, yes. The powder is an osmotic laxative, meaning that it holds onto the water that you take it with and doesn't allow the colon to absorb it, therefore keeping the stool soft and preventing it from drying out; this allows the colon to move it along more easily. The major risk with it is if it causes his stool to be excessively loose, i.e. diarrhea, and he looses too much water and electrolytes from a large quantity of loose stool. It's for this reason that it should be held (not taken) if he has loose stool. It is safe otherwise to continue taking it daily, provided (as I understand from your document) he does not have any colonic narrowing or obstruction which would impede passage of stool.

2) If withdrawing the psyllium improves his symptoms, I would stay off of it. Psyllium is a bulking agent, similar to the PEG powder, but organic and susceptible to digestion by colonic bacteria. It effectively works in the same way. The only other difference is that psyllium can also absorb bile salts, and by that method lower cholesterol levels. I noticed that he is not on a cholesterol lowering medication, so this may be a benefit. But it sounds like his discomfort is severely impairing his quality of life, so if the psyllium is causing it, the benefit isn't worth it.

If he feels bloated and constipated, if he's not taking the PEG powder he can add that; if he is taking that daily, I would try the dulcolax suppository.

Does that make sense?

Customer: replied 6 months ago.
Can you suggest an alternative to the dulcolax suppository as he has large arthritic hands & doesn't have much feeling in them (neuropathy issues). My Mom is 93 with arthritic condition & can help with the suppositories. They live on their own & have no personal support worker. There's only me & he won't let me touch him as I'm his daughter and it's indignant to him.

I understand, these can be difficult issues to deal with when it's family! Dulcolax comes in a pill form also, but like senna, it's a stimulant laxative, so when taken orally can cause cramping as it acts.

Another option, which I try to avoid unless necessary because it also causes cramping, is magnesium citrate, which comes in the green glass bottle. It is also a stimulant (and tastes bad!) but will really clean you out if necessary. These can be back-up plans for when the usual medications (with less side effects) aren't working.

Customer: replied 6 months ago.
Will the options affect the retention of fluid that he suffers with from his congestive heart condition?

Ideally, no. The pills don't add any excess water to his intake, so they are fine; the miralax I would take only with the amount of water indicated, and no more, to avoid excess water that the powder won't hold onto.

The risk with the stimulant laxatives is more that he'll lose excessive fluid from loose stool, rather than the opposite.

Customer: replied 6 months ago.
He does have loose stools. I don't quite understand the connection of the 'risk' & loss of excessive fluid. Can you explain this please so I am clear about what's happening.

Additionally, if he has loose stool with any of his constipation medications, he could lose electrolytes (like potassium and magnesium, particularly) which he is already at risk for being too low; milk of magnesia is another constipation medication which can keep his level sufficient and may help the constipation, though on the spectrum of medications we've discussed it's fairly mild.

As to risk of loss of excessive fluid, heart failure management is a delicate balance of fluid intake and output. He's on diuretics to prevent fluid overload, since his heart failure causes his kidneys to retain too much water, which then backs up in his lungs. But if he drinks too little water, or has diarrhea, or loses too much water from another cause, he can because dehydrated in terms of his blood volume, regardless of how much water has backed up in his lungs.

It's for this reason heart failure patients are fluid restricted and asked to closely monitor their weight (to look for increases which indicate fluid retention), but if something else occurs to disrupt an even fluid balance (like excessive diarrhea or vomiting), his kidneys can be injured from dehydration.

Heart failure is a complex problem! I'm sorry if this is confusing. Is that any clearer?

We use "loose stool" to mean stool that's not formed or is liquid. "Diarrhea" means when you have excessive loose stool, i.e. frequent and large amounts. So, you can have a single or two loose stools per day and not have diarrhea and be in no danger of losing excessive fluids. Any clearer?

Customer: replied 6 months ago.
Thank you Dr. Jennifer. Now, I'm understanding this better. I feel, at times, so helpless in understanding it all and then how to help him.If I can you one last question, why is having so much constipation problems when his diet is filled with vegetables/fruits and the colonoscopy shows no obstruction/cancer? He was diabetic for about 10 years & they removed the glyberide medication in Nov./2018 and has been monitored up until now and they have him off diabetic medication.

You're very welcome, of course! And that's a very common feeling. Heart failure in particular is complicated to manage, and it complicates any other condition we try to manage because the balance of medications is so delicate and requires frequent adjustment. So it's a struggle for us too!

So, I'm glad to hear he is eating well! It's true that the first step in treating constipation is increasing dietary fiber, but in older people with multiple medical problems, it often isn't enough. Constipation is frankly the rule among the elderly, rather than the exception. We don't fully understand why, but it probably has to do with the general slowing of metabolism we experience as we age.

Customer: replied 6 months ago.
Thank you Dr. Jennifer. I feel so much more at ease with your information. I feel so bad seen an active man so bedridden for over 1 week. I thought for sure they would help him at the hospital, but once they found the heart ok, they sent him home and I live out of town, so I've been there for 2 weeks & came home last night. I cooked them meals so he can continue to rest until he becomes less constipated.All the best in your residency and thank you again!

You're welcome! And best of luck to you and your parents. They're lucky to have you!

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