It is estimated that 50 percent of the healthy people have bowel problems. One of the most common complaints is constipation.

Constipation is hard to define. To some it means stool is too hard. To others it means stool is difficult to expel. Some have sense of fullness after defecation, some need to strain at stool frequently.

How often one should have a bowel movement?

Most people have between 3 movements per day and 3 movements per week. Some people consider that fewer than three movements a week without discomfort or dissatisfaction is normal.

Each day, one to two liters of semiliquid material passes from small intestine (ileum) to large intestine (colon). The material is composed of undigested food residue and intestinal secretions. There is nothing much left of nutritional value at this stage.

The liquid material is absorbed in the colon to convert the residue to solid feces. This advances to the rectum by the propulsive action of the colon, stimulated by the bulk of the stool.

The weight of stool in Western countries varies from 35 g. to 225 g. Water makes up 60 to 80 percent of the stool content.

What causes constipation?

Medications like narcotics and water pill can cause constipation. Dehydration, underfunctioning thyroid gland, increase in calcium level, spinal diseases, spastic bowel, bowel tumor, and narrowing due to various reasons may result in constipation.

Most cases of chronic constipation are due to habitual neglect of desire to go to the washroom because of sense of social impropriety, strange surroundings, poor toilet facilities, or illnesses which results in prolonged confinement to bed.

Constipation is a frequent problem in children under 6 years. The cause is not always clear. Most often, constipation is short-lived and of little consequence. In a British study, 5 percent of the children had constipation lasting for more than six months.

What’s wrong with constipation?

Constipation can create bloating and abdominal pain. Straining results in fissures and hemorrhoids. Increased pressure in the colon can result in pouches (diverticulosis).

Constipation is thought to increase the incidence of colon polyps and cancer. Since 1970, many studies have reported reduced risk of polyps and cancer with increased intake of fiber. But a recent study of 90,000 females followed for more than 16 years failed to confirm this.

Do we need to investigate cases of constipation?

Yes. If there is a recent history of change in bowel habit. If constipation is associated with rectal bleeding. If there is loss of weight, anemia, or suggestion of bowel blockage.

How can we manage constipation?

If investigations reveal no abnormalities, then careful education relieves lot of anxiety and discomfort. Do not ignore urge to defecate. Establish a routine at a given time each day. Physical exercise and increase in fluid intake helps.

Increase fiber intake with fruits, green vegetables, and cereal grains. Bulk laxatives, such as hemicellulose, psyllium extract, and all bran provides additional bulk.

Older individuals with poor muscle tone, minimal physical activity and other medical problems need more than bulk in the colon. Stool softeners, enemas and stimulant laxatives are required until a regular pattern is established.

So, next time you are constipated, make sure you get some relief with fluid and fiber. That is better than having an enema!

An after thought advisory: do not read this column before a sumptuous meal. It may result in nausea, vomiting and constipation!

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“Doc, I feel stressed out. Is this hurting my health?”

Dave works hard. Like most of us, he performs best when he is under certain amount of stress. Dave strives for excellence in everything he does. This certainly creates stress.

Work is not the only source of stress for most people. The pressures of modern day life keep everybody under stress. It has become part of our daily life.

Stress is an individual reaction to threats –either real or perceived.

Acute stress is in the nature of “fight or flight” or stress of major life events. Chronic stress is day-to-day stress which builds up over a period of time. Both can have long term consequences, writes Dr Bruce McEwen, Ph.D., in the New England Journal of Medicine.

Individuals who are chronically stressed exhibit fatigue, lack of energy, irritability, demoralization, and hostility. It is estimated that 60 percent of patients seen by family physicians have stress related health problems.

Sometimes stress is good. It energizes you. It can supply that zest for living.

“Doc, how does my body respond to stress?”

Dr. Bruce McEwen describes our body’s normal response to stress as ALLOSTASIS – the ability to achieve stability through change. This is critical to our survival.

The body provides this stability by activating four systems – nervous, cardiovascular, metabolic, and immune systems.

Our capacity to respond to stress depends on two things: 1) how we perceive a particular situation, 2) general state of our physical health.

Whether one perceives a situation as a threat, either psychological or physical, is crucial in determining the behavioral and the physiologic response, writes Dr. McEwen. The ability to adjust to repeated stress is also determined by the way one perceives a situation.

Physical condition of our body is important to combat adverse effects of stress. Rich diet, use of tobacco, alcohol, and lack of exercise can exacerbate chronic stress.

Body responds to stress by turning on an adaptive response and then shutting off this response when the threat is gone. If the system is inefficient in shutting off the response then the body is overexposed to stress hormones. This is not good.

Stress hormones cause anxiety, increase the heart rate (palpitation), increase blood pressure (hypertension), and increase blood sugar level. Repeated exposure to stress hormones may lead to heart disease, obesity, and diabetes.

Repeated stress also affects brain function (memory loss), and suppresses immune system (compared to acute stress where immune system is enhanced).

Dr. McEwen says that in laboratory animals, inefficient response to stress is due to the aging process. But this has not been proven in humans. It is possible that the ALLOSTATIC system wears out or becomes exhausted over a lifetime due to repeated exposure to stress.

“Doc, what can I do to combat stress?” asks Dave.

One has to learn coping skills, recognize one’s own limitations, take time off and relax. Eat a low fat diet, quit smoking and exercise regularly.

Dr. Peter Hanson, author of “The Joy of Stress” writes: Strive to maximize success by investing your energy and time in all four quadrants of your life – financial sufficiency, personal happiness, sound health, and respect on the job. Earn the respect of your peers, the loyalty of your friends, and the love of your children and spouse. Be spontaneous. Be funny.

It’s all mind over matter; if you don’t mind, it don’t matter. So don’t worry, be happy! Dave smiles and leaves the room humming…don’t worry….be happy…….

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.)

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Chest Pain

You are relaxing or doing some activity at home. Suddenly, you experience chest pain and shortness of breath. What is your immediate reaction? Dial 911 and call an ambulance? Get in your car and drive yourself to emergency department (ER)? Have a family member drive you to ER? Or pop some antacid pills in your mouth and wait?

Well, while you are scratching your head for an answer, let us ask the question to Dr. Hal Canham, ER Physician at Medicine Hat Regional Hospital (MHRH) and Medical Director of Medicine Hat Ambulance Service.

“As a physician, I may be able to judge if my chest pain is of cardiac (heart) or non-cardiac origin. If I am not sure, then I will dial 911 and ask for an ambulance. My advice to people in general is to call 911 immediately if they experience chest pain. There may not be time for self-diagnosis,” says Dr. Canham.

Each year, close to half a million people in Canada come to ER with chest pain. Some have acute life threatening illness. Others may have nothing seriously wrong with them. Some may have history of coronary heart disease. Others may not.

What about Medicine Hat?

In an 18 month period (June/97 to Dec/98), the ER Department at MHRH sees 53,548 patients. Out of these, 50 patients are confirmed to have heart attack and are eligible for thrombolytic (clot busting) therapy.

Dr. Canham studied these 50 cases. What did he find? “A major concern became apparent immediately. Of the 50 patients with diagnosis of heart attack, only 15 had called for an ambulance! This confirmed our impression that there is underutilization of the ambulance service for chest pain patients in our community.”

Why call an ambulance? Isn’t it faster for me to jump in my car and rush to ER?

If your chest pain is due to heart attack then the outcome of your illness may be dictated by: 1) the speed and mode of transportation to ER, 2) your previous history of cardiac problems, 3) rapid evaluation of your condition by ER physician, 4) the use of “clot busting” drugs in a timely fashion.

In 1997, the Medicine Hat Ambulance Service purchased new cardiac monitors and defibrillators. The aim is to speed up the delivery of “clot busting” drug to eligible cardiac patients.

Our paramedics are now able to do 12-lead cardiac monitoring in patient’s own home immediately on arrival. This test is transmitted “live” to ER physician to diagnose heart attack before the patient arrives. The ER physician is then ready with “clot busting” drug if the diagnoses are confirmed.

There is also another important reason to call 911. Early in the course of a heart attack, patients are at risk of having the heart stop (cardiac arrest). The chance of surviving this is better in an ambulance with paramedics at hand then in your own vehicle.

Dr. Canham, what is your message to the people of our region?

“The Medicine Hat Ambulance Service is truly an extension of our ER Department and rarely is this more apparent then when you are experiencing chest pain or shortness of breath. Be aware of symptoms suggestive of a heart attack and call 911 early!”

Pain is the most frequent presenting symptom. It is deep in the chest, described as “heavy”, “squeezing”, and “crushing”. The pain may radiate to the neck or the arms. There may be weakness, sweating, vomiting or giddiness. Symptoms may vary. So do not waste time on self-diagnoses. One telephone call may save your life!

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Ingrown Toenail

“An ingrown toenail can make a big, burly guy wince and hobble like a wounded puppy,” says Dr Don Powell, president and founder of American Institute for Preventive Medicine.

Well, you wouldn’t call Andrew big and burly. He is a regular school kid who is not having fun with an ingrown toenail.

Andrew, accompanied by his mother Susan, is waiting for me in one of my examination rooms. Andrew is 13, and has trouble with one of the big toe nails. It has been digging into one corner of the overhanging skin resulting in infection and pain.

“Dr. B, Andrew is tired of pain and antibiotics. Besides the cost of the medication, Andrew has to miss many activities involving running and excessive walking,” says Susan. “Can you help?”

First, let me tell you something about fingernails and toenails.

The nails are appendages of our most versatile organ – skin. Besides nails, the skin has three other appendages – hairs, sweat glands, and sebaceous glands. Nails protect the tips of our fingers and toes.

The nail has a free end which we trim on regular basis. The two sides of the nail are under the skin folds. The root is at the base where the growth occurs. The average rate of growth of the nail is 0.1 mm a day or 3 mm per month. About 11/2 inches a year.

Fingernails grow faster than toenails. Both grow faster in the summer than in the winter. The nails grow rapidly in “nail biters” and slowly in people confined to bed. The growth is faster in males than females. Certain illnesses can arrest the growth.

What can go wrong with the nails?

The nail can be a window for physicians to suspect other illnesses. Normally, nails are flat and light pink. They are pale in anaemia. Nails in general and big toenail in particular can be sites of many problems. One of the common one being ingrown big toenail with infection and pain.

Infection of the toenails can be very serious in anyone who has diabetes or circulatory problems. It can result in gangrene and amputation.

“Dr. B, why do I have ingrown toe nail?”

Ingrown toenail of the big toe usually occurs when sweaty feet are encased in tight shoes. The situation gets worse when the nail is trimmed short and the corners are curved down. The side of the nail curls inwards and grows to form outer spikes. This causes painful infection of the overhanging nail fold.

Andrew looked puzzled. “Dr. B, what can I do about it?”

Keep your feet nice and clean. Wear roomy shoes and clean cotton socks. Allow the outer corners of the nail to grow over the skin margins placing small piece of cotton soaked in an antiseptic just under the outer corners of the nail. Cut your nails straight.

If all this fails then surgical treatment becomes necessary. Simple whole nail avulsion or wedge removal of the nail can result in more than 50 percent recurrence rate. The best results are obtained by removing the root at the same time. This is done under local anaesthetic in a doctor’s office.

About 10 days of tender loving care of the big toe after the surgery usually results in satisfactory outcome. There is about 10 percent or less recurrence rate.

Andrew was ready for the surgical remedy. This was accomplished with satisfactory results.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.)

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!