What you need to know about constipation after surgery

Recovering from surgery can be an unpleasant process, whether you’re going through the rehab associated with a knee replacement or simply waiting for your body to feel normal following an outpatient procedure. During recovery, the last thing you want is an additional discomfort. However, whether your surgeon discussed it with you or not, many people experience constipation after surgery. Knowing what to expect and making a plan can diminish the effects of this uncomfortable surprise. Read on to find out how.

Is it normal to be constipated after surgery?

“It’s quite common, even expected, for patients to be constipated immediately after surgery,” says Jemiel Nejim, MD, an anesthesiologist at Hospital for Special Surgery in New York. There are a variety of factors that contribute to post-surgery constipation (also called post-operative constipation), each of which generally has a larger effect on the incidence of constipation than the type of surgery itself, excluding intra-abdominal and bowel surgeries.

While many surgeries including obstetric, gallbladder removal, and tonsillectomy can cause constipation, intra-abdominal and bowel surgeries are well known to cause post-operative constipation. “Bowel and some abdominal surgeries may cause an ileus in which the normal pulsations of the bowel stop working,” says Michael Philbin, MD, a surgeon at Edina Plastic Surgery in Edina, Minnesota. 

Lack of physical activity, pre-surgery dietary changes (including water restriction), and anesthesia given during surgery all contribute to constipation. In addition, medications used to control pain post-surgery can cause constipation. For example, research indicates that 40-60% of patients taking opioid medications, commonly prescribed for pain post-surgery, experience constipation as a side effect.

What causes constipation after surgery?

With other procedures, there are several underlying factors that can cause post-surgery constipation. 

Anesthesia

The anesthetic regimen administered during surgery is likely to have an effect on constipation during recovery. “Anesthesia is a broad term that describes a number of different medications,” Dr. Jemiel Nejim says. “Both the type of anesthesia and the surgical duration affect the likelihood of postoperative constipation. Surgeries that last longer in duration tend to be associated with a higher predisposition to constipation.” 

Some practices focus on using regional anesthesia over general anesthesia, which helps to reduce the number of drugs used and thus may reduce the likelihood of constipation after surgery.

Postoperative pain medications

Post-surgery constipation is also often a result of opioid pain medications, given either as part of the anesthesia or for pain relief following the surgery, according to Dr. Philbin. 

According to Inara Nejim, Pharm.D., a clinical pharmacist at Hospital for Special Surgery, “Medications from the opioid drug class, such as Percocet, oxycodone or tramadol, are a cornerstone foundation in managing postoperative pain, and one of their well-known side effects is constipation.”

Behavioral factors

Even in daily life, dehydration is one of the most common causes of constipation. Following surgery, the body requires plenty of fluids to aid in recovery. Without them, constipation is likely to occur, so make sure to drink lots of water. 

The same goes for nutritional intake: Not everyone may have an appetite after surgery, but continuing frequent oral intake, especially fiber-rich foods is key to helping things move along. 

Finally, a lack of physical activity, another known cause of constipation, is common after surgery. Dr. Philbin recommends working with your doctor to understand when, and for how long, you’re able to safely begin to move about during recovery to help alleviate inactivity-related constipation.

When should I worry about constipation after surgery?

While constipation immediately following surgery is common, especially if you are subject to some of the above factors, there are some warning signs to look out for that could indicate a more serious problem.

According to Dr. Philbin, you can expect constipation to last for a few days, depending on how active you are allowed to be and the amount of post-op pain meds needed. Abdominal pain due to bloating after surgery is also quite common and could be a result of trapped gas or excess fluids, according to Dr. Jemiel Nejim. These fluids tend to be excreted naturally within a few days. Mild tummy bloating can be helped by eating smaller, frequent meals and increasing physical activity. In addition, taking simethicone medications, which work by breaking up big gas bubbles in the gut into smaller bubbles, making them easier to pass, can help with bloating and gas.

If you experience significant pain or bleeding, or if constipation lasts longer than three days, seek medical treatment. Prolonged constipation can lead to hemorrhoids, anal fissures, and in very rare instances medical conditions such as ileus or intestinal obstruction, which require further medical interventions.

What helps with constipation after surgery?

The good news is that there are plenty of ways to alleviate constipation caused by surgery, especially if you make a plan with your doctor ahead of time. Whether via pre- or post-surgery dietary changes or by knowing the over-the-counter treatment options, being prepared will make the process a little easier.

Before surgery

“If someone has concerns before surgery regarding potential constipation, the best thing to do is to speak up and openly talk about those concerns before surgery,” says Dr. Jemiel Nejim. This is especially true for those who already suffer from chronic constipation. If there are medications that traditionally work well for you, identify these with your medical team prior to surgery. If allowed by your physician, increase your fiber intake or begin a regimen of stool softeners prior to surgery if constipation is a concern.

After surgery

According to Dr. Inara Nejim, one of the best ways to prevent complications of untreated constipation at home is by having an honest conversation about medications during the discharge process—and during follow-up phone calls. A nurse will usually go over all of your prescriptions and can explain how to effectively manage constipation at home using diet and over-the-counter medication. 

If you are going to start a fiber supplement, make sure you also increase your fluid intake accordingly, as bulk fiber supplements can worsen constipation if you don’t drink sufficient fluids. Your doctor should advise you on a gradual treatment approach to reducing constipation, beginning with stool softeners and gentle senna-based laxatives—and if no benefit, advance to other stimulant laxatives such as Dulcolax. 

Diet

If your symptoms of constipation are minor or haven’t lasted very long, it may be possible to alleviate the condition with home remedies, like adding key foods that are known to help with constipation:

• Fluid intake: When your body is hydrated enough to draw water into the colon, bowel movements are easier.
• Chia seeds: As chia seeds move through the body, they take on a gel-like consistency, which can help prevent hard stools.
• Lentils, beans, and chickpeas: These high-fiber foods promote healthy digestion and help encourage regular bowel movements.
• Whole grains: Whole grains contain more fiber than white breads or pastas and can be more beneficial in moving things along.
• Citrus fruits: Oranges and grapefruit are high in vitamin C, which is known to draw water into the colon, keeping stools softer and easier to pass.
• Prunes or prune juice: This fruit contains fiber and high amounts of sorbitol, which has laxative effects.
• Leafy greens: This type of veggie is high in magnesium, which helps draw water into the gut.
• Psyllium husk: It is a bulk-forming laxative, derived from Plantago ovata plant’s seeds. It is commonly available over the counter and is very effective in constipation. A refined powdered version of psyllium husk is available as Metamucil. 
• Caffeine: Hot, caffeinated beverages like coffee and tea stimulate the bowels and stimulate digestion. Just be sure you’re drinking plenty of water, too, since caffeine is a diuretic.

If you’re experiencing constipation after surgery it’s best to avoid foods that are high in fat and/or low in fiber content, including:

• Chips 
• Fried food
• Meat 
• Dairy
• Frozen meals 
• Processed foods 

Medications

If the above solutions still leave you feeling backed up, the next line of defense is stool softeners or gentle laxatives.

• Stool softeners: These medications (such as Colace) work by drawing water into the stool and making it easier to pass, says Dr. Philbin. Stool softeners can take 24 to 48 hours to work.
• Fiber laxatives: These supplements (such as Metamucil, Fibercon, and Citrucel) also increase the water content of the stool, helping it to move through the colon. Fiber laxatives take 12 to 24 hours to provide relief.
•  Polyethylene glycol laxatives: These osmotic laxatives (such as Miralax or milk of magnesia) work by bringing water into the lumen of the bowel, making stools easier to pass. Osmotic laxatives take 12 to 72 hours to produce results.

If these medications fail to provide relief, the next line are mildly stimulating laxatives, suppositories and then, if necessary, enemas.

• Stimulant laxatives: These medications (such as Dulcolax and Senokot) cause the intestines to contract and trigger a bowel movement. Stimulant laxatives take six to 12 hours to work.
• Suppositories: There are different types of suppositories, and the most commonly used are stimulant laxatives, like Dulcolax. Many draw water from the bowel into the most hardened areas of the stool while triggering the intestinal muscles to contract, working together to cause a bowel movement. Suppositories typically take 15 to 60 minutes to provide relief.
• Enemas: This class of medication works by introducing different types of fluid (from tap water to stimulating medication) directly into the intestines, softening and loosening stool. Enemas typically take only a few minutes to produce results.
• Prescription medications: There are also prescription-strength treatments for constipation, including those for opioid induced constipation (OIC). Talk to your healthcare provider if you feel that these are necessary.

Exercise

Physical activity can help get things moving when you’re constipated. Healthy individuals should aim for 150 minutes of movement per week, consisting of strength training and cardiovascular activities. If you’re new to exercise or recovering from surgery, be sure to start slowly and check with your doctor first.

Take an inventory of your medications and supplements

Dietary supplements and prescription medications may contribute to constipation. If you’re concerned that any of the supplements or medicines you’re taking are worsening your symptoms, ask your provider for advice.

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Constipation is never fun, especially when it’s in combination with recovery from surgery. However, by making a plan with your doctor before surgery, knowing the causes, optimizing your diet, and having an over-the-counter backup plan in mind, you can get things moving again and alleviate uncomfortable symptoms more quickly.