Thursday, September 21, 2006

Post-op: bowel activity

When bowels are handled and disturbed, as happens during a hysterectomy or any other abdominal surgery, they shut down activity for a period of time. This is why women are often surprised to find that they are limited to only liquids for the first day or so after their hyst: this gives the bowels a rest and doesn't overwhelm them before they are ready to resume activity. Eating too soon will only cause the undigestible food to back up, producing vomiting that is not a real appealing prospect for anyone who has just had abdominal surgery--not a pleasant thing to contemplate.

How do we know that our bowels are returning to function? Our caregivers can hear the sounds of sloshing when they listen with a stethescope, and before long, we can feel or hear the passage of gas. This is such an important recovery milestone that it is one of the criteria for discharge: we have to actually pass gas to demonstrate that our bowels are capable of taking up their digestive functions again.

For many women, this signals the most frustrating and uncomfortable part of recovery, however: dealing with gas and constipation. Narcotic drugs, low physical activity levels, a low-fiber diet, not drinking enough, and, for those who are users, lack of caffeine all contribute to impaired bowel motility and enhance these gas and constipation effects.

But those causes also provide us with a good set of things we can do to limit these unpleasant symptoms of our bowels recovering. 

First of all, getting off of narcotics and making the transition to, usually, anti-inflammatories, removes that direct bowel-slowing effect. Obviously, this needs to be balanced against pain control needs, but it's a good reason to be sure that we really need the level of relief narcotics provide.

Activity is a big but simple thing we can do to help out. Regaining bowel activity is one of the reasons we're up and about so rapidly after surgery. And it's the reason why, when we complain about gas, the answer we're likely to receive is "walk" and then "walk some more." While anti-gas medications can help somewhat by breaking the gas up into smaller collections, nothing will get it moving out of our system but the bowel function that is stimulated by walking. Walk and toot, and those gas pains will be, literally, left behind.

Diet, once we've passed that all-important first gas, is the key to getting things back on a proper functional basis. While liquids and undemanding foods are the thing while we're waiting to regain function, once things are working, our bowels need the stimulus of something to work on. Fiber provides that: bulk to keep our stools soft and moving. That means that early postop meals should include fruits and vegetables in good measure, even when our appetites are still weak (a normal symptom of bowels that are still feeling puny). It's common to do more nibbling than meal-eating in the first week or two postop, and that's fine, so long as those nibbles are chosen with bowel recovery in mind. Dried fruit is a great snack that doesn't require preparation and can be kept handy; precut vegies and dip are another snack that can be easily stored and comes to hand readily even when family and friends aren't around to help us to meals. Making good dietary choices like this will go a lot further to remedy our discomforts than just indulging in junk food.

With all of that fiber, though, we have to drink plenty of liquids. Fiber alone is a fine way to create rocks, but that tends not to be a very pleasant experience when the time comes for *cough* disposal. Drinking lots of fluids means that the fiber will be moist and flexible as it transits our guts, and that makes for the best stimulatory effects. What kinds of fluids? Coffee and caffeinated beverages are okay as a morning kick-off (and if you've been a serious coffee drinker, your bowels may be addicted to this signal), but when continued all day, have an overall dehydrating effect due to the stimulation caffeine gives the kidneys (and contributes to bladder cramping, by the way--another frequent postop complaint). Instead, fruit juices, fizzy waters, diet drinks and just plain water are better choices. Some women feel that the carbonation in these drinks causes more gas problems. While most gas is actually removed from the drinks in the stomah (that's why we're belching), if it seems a problem for you, then by all means avoid fizzy drinks. But women in general don't need to automatically do this unless they know they are prone to this problem--fizzy is fine, especially if you do belch up that gas (yeah, recovery isn't pretty).

How much drinking is enough? Watch the color of your urine: palest yellow is good; anything significantly colored (unless you've just taken your B vitamins) suggestes that you could benefit from another glass of something. Sipping away at a glass every hour or so is a good plan that doesn't take a lot of effort.

New research has also given us another tool: chewing gum. Research has shown interesting results on how chewing gum may return bowels to greater activity a whole day or more before they would do so using more conventional management techniques. While we're lying around being less active it's probably a good idea to make that sugarless gum for our teeth's sake, but I think that a little gum sounds like something easily done and not likely to be harmful even if it doesn't help spectacularly. But please, while you are still in the hospital and on dietary restrictions, do check with your surgeon before reaching for your gum--there may be other reasons why this might be inadvisable in your particular case.

And what can we do once we're home and dreading that first scary bowel movement or struggling with constipation? First of all, use all of the techniques above to make sure things are as easy on your bowels as possible. These considerations aren't just for while you're in the hospital--carry them over for the first several weeks of recovery, at a minimum. If you haven't been eating fiber, for example, adding some dried fruit (and plenty of fluid, remember, to make it work) to your diet can have amazing results within a day. If you've been sitting on the pot without success, get up and walk laps around the house, around the yard--whatever you're up to at your level of activity recovery.

It's tempting to just reach for a medication for help with this. It's true that if you've allowed yourself to become significantly constipated that something may be necessary to help out your normal bowel capability. But laxatives are not a good substitute for fiber and activity--they just are things that can help you make good use of those tools.

And not all laxatives are created equal. Please don't use the old-style mineral oil laxatives--they have been demonstrated to cost you critical vitamins that you need for healing right now. Instead, call your surgeon's office and ask what their recommendations are for post-op laxatives. In fact, if you're reading this preop and know you have a tendency to constipation and want to shop for something to have on hand postop in case it's needed, ask beforehand what your surgeon thinks provides the best kind of stimulation for your own surgery and body. Let me be more specific: too harsh a laxative or too much laxative may cause such strong bowel contractions that you can be in significant pain or even may risk damage to your surgical site, depending on the exact surgery you had. Ditto the use of enemas or laxative suppositories: for some women, rectal penetration is as risky as vaginal in early recovery, so don't just assume that because you can buy these products without prescriptions, they hold no risks for you.

And remember that laxatives are not a maintenance strategy. They provide a short term major boost to activity, but that doesn't get around your need to redevelop good bowel habits for your recovery. Use a laxative once or twice if nothing else has proven productive, but at the same time, start putting those simpler, less glamorous steps in place to give your bowels what they really need to be healthy: fiber, fluid, and plenty of exercise.