The Post-Op Poop

Poop isn’t exactly the most glamorous topic, especially after cosmetic or reconstructive surgery, but it’s a big deal.  If you search online about “after surgery” the majority of articles that come up have to do with being constipated, patients who haven’t pooped for a week or intestinal cramping.  

Why?  

Because all surgeries are stressful.  It doesn’t matter if it’s major surgery or minor surgery.  The physical act of having some kind of surgery can place a major toll on your body.  And anesthesia adds to the issue. Even if you just get anesthesia and without any surgery, you are still at risk for post-operative poop problems.

Constipation is a well known and highly anticipated side effect of surgery that no one really tells you about before you go into surgery.   Yes, of course there are always patients who fly through the post surgical period and have return of bowel function super quickly. But for those patients, who don’t, constipation can make the healing process incredibly uncomfortable.

And it may surprise you to discover that most people have some type of issue with constipation after surgery.  It may take longer than you think for your bowels to return to normal functioning.

So let’s go over a few things to get you prepared.


1. Why do you get constipated after surgery?



As I said before, surgery is a stress to the body, which releases a chemical called cortisol. When the body is under stress, cortisol directs the brain into fight or flight response.

You remember the saber tooth tiger example right?  When our ancestors were confronted by a threat, the body would use the stress response to redirect all its energies into “getting away”. The response essentially includes redirecting blood flow to the brain and heart and minimizing blood to non-essential organs - such as the stomach and intestines.  

After all, you don’t need to digest your lunch when you are running for your life, it can wait. And the body is smart enough to know that.

But here’s the thing.. This response still occurs.  Whenever the body is put under stress, cortisol is released and directs the brain to conserve blood flow.  The brain will minimize blood flow to the stomach and intestines - which is a good thing in certain situations, but a problem after surgery.

As this fight response diminishes and normal blood flow and function return, everything should go back to the way it was.  But it may take some time and there are factors that will make the process even slower - such as having a history of diabetes.  Or having other abdominal conditions such as irritable bowel disorders.

Diets that are poor in fiber and lacking adequate hydration will also slow down the process.  

Have you ever had a rock hard poop before?  Well that is a dried out bowel movement. It means that you aren’t adequately hydrated.  In order to have a soft, formed bowel movement, you need movement of the intestines → technically called peristalsis → you know it as passing gas and lots of water and fiber on board.

 

2. Are some people more likely to get constipated than others?
 


Yes of course.  Everyone’s body is different and is affected by a variety of factors.  However, there are certainly some common elements that are consistently known to cause constipation.  Here’s a few of them:

→ Narcotic pain relievers are notorious for slowing down bowel function.  

In fact the worst cases of constipation that I have ever seen were related to narcotic use. Narcotics certainly have their place, but there are many medications and alternative therapies that you can use to minimize the amount you take.

→ General anesthesia.

General anesthesia puts your whole body in a sleep state.  The body is capable of storing certain anesthetics in adipose tissue (fat tissue), so it could wear off much more slowly in certain patients.  The intestines are typically the last organ to “wake up” from anesthesia. The length of time that a patient is under anesthesia will ultimately affect this process.

→ Inflammatory states.

Having an inflammatory state can cause cortisol release.  Inflammatory states can be caused by trauma, infections, and stress.  Patients who live in chronic inflammatory states are more prone to ulcers, cancers, heart disease, diabetes and various types of infections.  If you have a chronic inflammatory state prior to surgery, your chances of having constipation after surgery will be higher.

→ Physical inactivity.

Inactivity is a huge factor in constipation.  There is a fine line between getting lots of rest after surgery and moving about.  The first few times that you get up to move around might not feel great, but it’s important.  Moving around not only helps stimulate peristalsis, but it can also prevent other complications such as blood clots in the legs or developing post-operative pneumonia.

→ Diet.

A diet that does not have enough fiber or fluids will be a huge factor in developing constipation.  It may help to start a high fiber diet several days prior to surgery. A high-fiber diet may include whole grains, fresh fruits, vegetables and beans.  You might not like prunes or prune juice today, but when you’re constipated you will beg for them, because they work! You might want to consider having some in the house just in case.
 


3. Can you prevent constipation after surgery?
 


The best way to prevent constipation after surgery is to be proactive before surgery.  Starting that high-fiber diet a week or two in advance can certainly help you avoid post-operative constipation.  Also remember to drink plenty of fluids, preferably water. Drinks with caffeine in them act as diuretics and will dehydrate your body.  Try some infused waters or teas without caffeine such as turmeric tea or ginger tea. Not only do they provide a good source of water, they are tasty and have anti-inflammatory properties, which can help in chronic inflammatory states.

In general, avoid foods that are known to cause constipation such as dairy products, white breads or rice, and processed foods.

If you are at high-risk of developing constipation after surgery, consider taking stool softeners 2 days prior to surgery.  Make sure your surgeon orders stool softeners immediately after surgery as well. Don’t be afraid or embarrassed to talk about poop with your surgeon or nurse.  Trust me we are well versed on this topic and talk about it all the time. This is a perfectly normal topic of conversation for us. Sometimes I even forget it’s not a normal conversation for non-medical people and start talking about bowel movements at family dinners, which never goes over well.

Trust me, you don’t want to have a new incision and then strain to have a bowel movement. This is pure agony.
 


4. What do you do if you develop constipation after surgery?
 


Despite the best of efforts, constipation may still occur after surgery.  Sometimes it’s an unavoidable problem. Treatment for constipation after surgery includes stool softeners such as docusate sodium (Colace) or laxatives such as psyllium (Metamucil).

If you develop a severe case of constipation you may need a stimulant laxative such as a suppository or an enema.  A severe case of constipation would be a lack of a bowel movement for several days with nausea or decreased appetite and abdominal pain or cramping.  You may feel a sense of fullness and be uncomfortable. The longer it goes on the more problematic it can be.

Your post-operative period is not officially over until you have that bowel movement.
 


5. When does constipation become a medical problem?
 

Constipation isn’t just uncomfortable or a minor problem.  It can develop into serious and life-threatening if left untreated.  Narcotics and general anesthesia can cause a post-operative ileus - which is basically a shut down of the intestines.  A shut down of the intestines can lead to a blockage and obstruction of the gut. This means no food material, gas or liquid can pass through.  

A post-operative ileus would require hospitalization for treatment with intravenous fluids, possibly decompression of the stomach with the placement of a tube in the nose and close monitoring.

This is why you should not be afraid to discuss your bowel movements with your surgeon.  It’s important to let the surgeon know. It’s absolutely normal not to have a bowel movement for the first 24-48 hours after surgery, but you should start passing gas relatively quickly.  It will be the one thing any medical professional will ask you.

Please note, if you are passing gas it is highly unlikely that you have a post-operative ileus.  This is an important distinction for the surgeon or nurse to make.

Other problems that constipation can cause are hemorrhoids, rectal bleeding, rectal pain, anal fissures and rectal prolapse.  The tissue in the rectum can be torn if you strain too hard trying to get hard stool out. The straining and the hard stool can cause tears in the rectum that can bleed.  The straining can also physically force the rectum out of the body.

If you are straining so hard you may need additional medical attention.  Please call your surgeon and let him or her know.

If you are taking stool softeners or laxatives, you should expect relief in a couple days.  You should have results from a suppository or enema within 24 hours.

Here are some tips of what you should do when you leave the hospital or surgery center.

 

  • Drink plenty of water.
     

  • Walk around at least 3 times during the day.  You’ll find you can walk longer and further the 2nd and 3rd time around.  Pick a point to reach and then try to go a little further each time.
     

  • Try lying on your side to encourage movement of gas
     

  • Eat slowly and small amounts at a given meal
     

  • After meals, sit up in a chair for 30-60 minutes
     

  • Suck on hard candy
     

  • Drink from a straw to make it easier to drink fluids
     

  • Get a toilet seat that is raised for easy movement on/off toilet.  Even if you only use this for 2 days, it’s worth the expense. If you have to get up from a seated position on a low toilet, expect to use your abdominal muscles. This can put a lot of strain on your back as well.
     

  • Know who is there for you.  Who can you call for help? How do you get a hold of the “on-call” surgeon if you need to?

Talking about poop after surgery with Shawnna Cannaday, Nurse Practitioner in the Gastroenterology Division.

Catie HarrisComment