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Constipation and Laxatives

Constipation continues to be a problem for up to 30 percent of the population.

This is not something new. Even during the time of Hippocrates, people were worried about their bowel movements. It was recognized then that eating unrefined foods gave better bowel movements and better health.

Dictionary defines constipation as difficult, incomplete, or infrequent evacuation of dry hardened feces from the bowels. For some it means straining to have a bowel movement, to others a process of passing hard stools, or infrequent passage of stools, or inability to defecate at will.

A study of healthy people in Great Britain found that 99 percent of the population had between three bowel movements a week and three bowel movements a day.

Constipation is associated with (not necessarily caused by) inactivity, low calorie intake, number of medications being taken, low income, and a low education level. Constipation is also associated with depression as well as physical and sexual abuse, says an article in Gastroenterology.

Constipation can be due to slow transit of low quantity of stool which fails to stimulate the colon to move in orderly fashion. There may also be uncoordinated movement of the colon near the rectum or dysfunctional pelvic floor which causes pseudo-obstruction.

The Gastroenterology article says that about 60 percent of patients with constipation have irritable bowel syndrome with normal colonic transit time (or slightly delayed only). About 30 percent have pelvic floor dysfunction (with or without slow transit), and 10 percent has slow transit only.

Management of constipation starts with history and physical examination, review of patient’s current medications, basic blood work and investigation of the colon to rule out bowel blockage.

If everything is normal then constipation may be easily corrected by increasing dietary fiber (bran, cereal, fresh fruit, and vegetables), intake of liquids and increasing physical activity.

If this fails then use of laxatives (agents which promote evacuation of the bowel) become necessary. Commonly used laxatives are described here briefly.

Bulk forming agents (psyllium, methylcellulose) are considered the safest. They work like a sponge – they soften stool by holding water in the fecal matter.

Stool softeners (docussate sodium) soften faces by lowering the surface tension of fluids in the bowel which seems to allow more water to remain in the stool.

Stimulants (senna, bisacodyl, cascara, castor oil) act by increasing the colonic muscle contractions. Long term use of these agents is discouraged because of the theoretical risk of damaging the nerve centers in the colon.

Lubricants like mineral oil (liquid paraffin) is chemically inert and not digested in the gut. It probably acts by lubricating the bowel. It may interfere with absorption of fat soluble vitamins such as A, D and K. Sometimes aspiration of liquid paraffin may cause pneumonia.

Lactulose is a synthetic disaccharide. It is not absorbed in the gut. Its mode of action as a laxative is not clear.

Magnesium and phosphate containing agents are considered saline laxatives. They work by drawing water into the large bowel. They should be used with care in patients with kidney and heart problems.

This is only a short list of common laxatives. There are numerous other off the counter laxatives which are used and abused by the general public. For most patients proper use of laxatives is all that is required. For a small minority, our options should go beyond laxatives and include behavioral treatment as well as new drugs.

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Docs for Cancer – CMAJ News

Excerpt from: CMAJ (Canadian Medical Association Journal)
September 2, 2003; 169 (5):

Doctors for Cancer? In a gesture of support for his patients, Alberta general surgeon Noorali Bharwani had his head shaved to raise $2200 for the Canadian Cancer Society. “We deal with so many cancer patients but we don’t have a way to empathize with them,” Bharwani said after his close shave. “This allows you to appreciate, at least in part, how they feel.” The Medicine Hat surgeon hopes the idea catches on with other Canadian doctors. He notes that police officers already have Cops for Cancer, through which they gather pledges before having their heads shaved. And not only do people appreciate the gesture, says Bharwani (bharwani@monarch.net), but being a one-man comb-free zone “is very nice for the summer.” -Barbara Sibbald, CMAJ

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Thyroid Nodule

Recently, I saw a young lady with a lump in the neck. . The lump moves with swallowing. That means it is in the thyroid gland

The young lady wants to know: Is it cancer? Why did she get it? What can be done about it?

Thyroid lumps or nodules are tumors, most of which are benign. But some are malignant and invasive cancers.

A solitary nodule, within an otherwise apparently normal gland, is of more concern than a thyroid gland with multiple nodules which is known as a multi-nodular goiter. Multi-nodular goiters are usually benign.

Thyroid nodules are more common in women. Single nodule is four times more common in women than men.

About 42-77 percent of nodules are simple cysts (colloid nodules); 15 -40 percent are benign tumors (adenomas); and only 8 – 17 percent are cancers. In men, the frequency of cancer in the thyroid nodule is more than 50 percent by 70 years of age.

Radiation treatment to the neck, or any radiation exposure near the thyroid gland, increases the risk of developing nodules. These nodules tend to develop long after the radiation exposure. Family history of thyroid cancer increases the likelihood of thyroid nodule being malignant.

How do we investigate a solitary thyroid nodule?

To start with, only one blood test is required –thyroid stimulating hormone (TSH) level – to check if the thyroid is functioning normally or is over-active.

If the thyroid function is normal then the next line of investigation is a fine-needle aspiration (FNA) biopsy. In nine reports (comprising 9119 patients) the FNA showed benign tumor in 74 percent of patients, malignant tumor in four percent, indeterminate results in 11 percent, and inadequate biopsy specimen in 11 percent, says an article in the New England Journal of Medicine (NEJM).

If the TSH is suggestive of an over-active thyroid nodule or the FNA biopsy result is indeterminate then a radio-nuclear scan should be performed to further check the status of the nodule. If it is “hot” – then it is overactive.

Ultrasound is a good test for thyroid lumps. It can tell us if there is more than one nodule; if the lump is solid, cystic or mixed; and it is the best method to determine the size of the nodule.

What is the treatment of solitary thyroid nodule?

If the nodule is hyper-functioning then it requires medical treatment. Surgery is rarely indicated.

If the needle biopsy is clearly benign and there are no other symptoms suggesting pressure to the surrounding structures, like difficulty breathing or swallowing, then the nodule can be observed with or without thyroid hormone therapy. The nodule may enlarge, shrink or disappear.

Main indications for surgery are: malignant or indeterminate FNA biopsy results, local symptoms, or the gland is so big that it changes the appearance of the neck.

The NEJM article says that in six reports (10,850 patients) the rate of surgery for a solitary thyroid lump varied from 14 to 61 percent.

Why such a big variation in the rates of surgery? For three reasons: differing rates of accuracy of FNA biopsy results among centers, surgeon’s own preference and differing views on whether patients with unclear FNA results should routinely undergo surgery.

So, a solitary thyroid nodule is not always malignant. But it should not be ignored. Appropriate investigations should be done to rule out cancer.

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Captivating Venezia (Venice)

I first read about Venice (Venezia), Italy when I was in high school in Tanzania. We were reading William Shakespeare’s Merchant of Venice. I never thought that one day I would get a chance to visit Venice, described by some to be the most beautiful and the most captivating city in the world.

It was last summer, we arrived at Venezia Santa Lucia train station on a Wednesday at 4.00 p.m. We had left Geneva at 9.05 a.m. So it was a long day. But traveling first class with prior reserved seats made the journey very comfortable.

As soon as we came out of the platform, we were approached by several “hotel agents”. We had booked our hotel which was supposed to be a walking distance from the railway station. But, in which direction? As we tried to make our way through these agents, a middle-aged man stopped us and said he was there to help us (i.e. tourists).

We gave the name of our hotel and he gave us the direction. The hotel was on the other side of the Grand Canal. As we came out, we could see the hotel from the railway station. But we had to carry our luggage and walk over a bridge which had lots of steps! I knew it would take more than five minutes to get there.

Venice is one of the most unusual places on earth. It is divided by a 1.8-mile-long waterway called the Grand Canal (Canal Grande). The canal is a magical highway – never fades. It divides the city in two and is crossed by three bridges.

Along the banks of the canal are the palazzi, or palaces, which were built by wealthy merchants and their families. Most of these were built between the 12th and 18th centuries. The owners decorated these palaces as a dazzling display of their power and wealth.

No cars, taxis, motorcycles or trucks are permitted within the city of Venice. If you arrive in a wheeled vehicle to Venice then you have to leave your vehicle in a parking lot on the outskirts of the city. From there you enter Venice by boat or on foot.

Venetians use boats instead of cars to travel through the town, because there are more waterways than walkways. There are water taxis and water buses. Instead of streets, there are 120 canals. There are traffic lights as well. And there is water police, enforcing law and order and traffic control. Docks and bridges connect the canals to the land.

Water bus, water taxi or gondola drops you off to the landing point nearest your destination then you have to walk. There is lot of walking to do.

To build houses and office buildings is not easy. First, you have to drive wooden poles, called pilings, deep into the firm clay of the lagoon. Then timbers are attached to the pilings and buildings are constructed over them.

What did we do?

Out of our three weeks in Europe, we had kept two nights for Venice. That came down to one evening and one full day. We knew that would not be enough. But we wanted to have a glimpse of the city and see what it is all about – how do people travel and work and live in this unusual city.

After we checked-in in our hotel, we decided to explore the surrounding areas by foot. The canal is like a busy highway during the day time. As the darkness arrives, the city gives an aura of romance as reflected lights twinkle on the water. There are multitudes of shops and restaurants catering to the tourists who flock this place like birds. Of course, nothing is cheap. Even pizza is expensive!

Next day, after breakfast, we were offered free water taxi (compliments of Murano Gallery) to visit the island of Murano and the Murano glass factory. We took up the offer and spent couple of hours at the gallery. Glass is a true Venetian specialty, made for centuries (since 1291) on the island of Murano. The furnaces were moved away from the city as a fire precaution.

There were eye popping, breathtaking colorful glass pieces from very small to giant size glasses, stemware, bowls, vases, chandeliers and other artifacts. No photographs were allowed inside the gallery. Nothing there was within my prize range! The sales person, who gave us a guided tour, was very persuasive. But we resisted the temptation.

From Murano, we took a water taxi to San Marco square. It was full of tourists. It is a beautiful open space. We took a stroll around the square and saw many monuments which have played important role in the development of Venice. The important monuments are: a 15th century Torre dell’Orologio (Clock Tower) and its zodiac clock, the beautiful Libreria Sansoviniana (Sansoviniana Library) and two columns near the waterfront, topped by the lion of St. Mark and St. Theodore with his crocodile emblem.

We took a day pass for the water bus and did some more site seeing of our own. There are many guided water-taxis and walking tours available. For example, Casanova and the Age of Decadance focus on the life and times of Casanova. A time of illegal gambling parlors, of masked courtesans and spies, of corruption and political intrigue.

Other tours show you the Jewish Ghetto and life of Marco Polo. Rialto and Merchant of Venice and Venice Ghost Walk, where the ghosts of the past and present day will keep you company as your guide will tell the stories as you walk along the dimly lit deserted streets of Venice – as your shadows get longer, you can hear the foot steps coming behind you!

We managed to cover a lot of Venice walking and using the water bus pass – very economical way to do it if you go with your family. It was a hot day. After a brief afternoon rest at the hotel we took a Grand Canal Boat Tour at 5.30 pm (there is another one at night at 9 pm). That was great fun – maximum of eight people in a luxurious motor boat lasting 70 minutes. It takes you through the Grand Canal and some lesser known canals.

As the darkness fell, we went on our walk along the canal near the railway station. They are open till late in the evening.

After a good night’s sleep, it was time to pack and walk to the railway station. Our next stop was Florence. We felt we needed more time to enjoy this beautiful and unusual city. A day and a half was worth it but not enough! One day, we hope to go back.

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