Movie Sequels


When Hollywood has a success, it’s only a matter of time until Sharknado 2 hits the box office. However, if I were to ask if you have seen the sequel to the movie Constipation, the response would invariably be “No, number two hasn’t come out yet!” 

Constipation is defined as infrequent passage of stool, which may be hard and dry when it does finally exit, and while incredibly common, and usually benign, it can, to continue cinematic analogies, foreshadow serious medical conditions that merit urgent intervention.

The word originated about 600 years ago, so our ancestors figured out something bad was occurring—or rather wasn’t occurring—and it probably derives from combining two Latin words, com, meaning “together,” and stipare,” to “pack or cram.” Says it all, really! To understand what is going on here, think about two analogies; the first, if blowing up a long balloon and then crimping halfway along as it is partially inflated, the upper part will distend and the lower becomes relatively flaccid. Also, consider your house plumbing; from sink or bath plugholes, or toilet bowls, there is effectively a long pipe that heads either into the sewer or the septic tank. A blockage anywhere along this pipe will prevent anything heading downstream and, eventually, foul contents might well up into your home, making unpleasant noises in the process.

The human gut is similar to a pipe, starting at the mouth, transiting esophagus (gullet), stomach, small bowel and colon (large bowel), and ending at the anus. The gut has several natural pinch points that control ingress and egress, first, the mouth, then a valve where the esophagus meets the stomach, another, the pyloric valve, which controls food leaving the stomach, another, the ileocecal valve, where small bowel meets large, and of course, the anus. In total, the gut is around 15–20 feet from top to yes, bottom, and interestingly, in females it is a foot or so longer, possibly to help absorb additional nutrients during pregnancy.

In aircraft, we always want to go faster, because, well, faster is better! It may also be the case with pooping. So, what is a “healthy” time for food to pass from plate to bowl? And yes, that was intentional. Slow transit times are usually due to a fiber-poor diet that can eventually lead to constipation. Additionally, internal bowel pressure waves rise with such constipating diets, leading to diverticulosis, weak spots developing in the bowel wall that can become inflamed, bleed, or even burst. And if that was not reason enough to increase your fiber intake, lengthy contact of certain foodstuffs with the gut wall may increase the incidence of nasty diseases like cancer. Sadly, it takes Americans on average 30–40 hours to recycle their food, and in some cases maybe even 5 days. The purpose of the colon is both to store feces, prior to bombs away, and to extract water, so the longer poop stays inside, the more fluid is sucked out, making the stool harder to excrete and requiring straining, which has its own sequels—damage to delicate anal flesh, hernias, and even passing out!

There is the old and insightful joke about the pilot who tells their doctor they are constipated and can easily spend an hour sitting on the throne, whereupon the physician asks, “Do you take anything?” and the response, “Usually a book.” If you have time to read while waiting to defecate, you are constipated. This may be a rather disagreeable visual, but if you head to the head to make a deposit, it should resemble a touch-and-go, quick and effortless with no need to strain to get airborne!

If constipated, symptoms other than not being able to defecate might include bloating (think of that balloon), cramping, episodic abdominal pain, and eventually loss of appetite, nausea, and vomiting together with eructations, the rather splendid medical word for belching, which, if the constipation goes on for long enough can smell foul. Sometimes, if chronic, there may be episodes of diarrhea, watery waste flowing past the obstructed, and very hard, feces.

Causes are numerous, so as I consider the numerous ways bowels get blocked, it calls to mind the constipated mathematician—he worked it out with a pencil! But the constipated accountant couldn’t budge it. Women tend to have fewer regular bowel motions than men, and while many people develop travelers’ diarrhea (“The Beast With Many Names,” AOPA Pilot magazine, August 2011, page 6), some become constipated; new bugs in the intestinal microbiome, jet lag, and dehydration might all contribute.

There are a few inherited causes of constipation, but as there are not too many neonates reading these articles, or flying for that matter, we can pass on them for today.

One infectious cause of constipation that merits inclusion is Chagas disease, caused by the Trypanosoma cruzi bug passed to humans by triatomine bugs. These were traditionally found in Mexico and other parts of Central and South America but are now also causing problems in the US. This illness can be dormant for many years, and then present either with heart failure or cardiac rhythm problems, or severe constipation and difficulty swallowing. 

Several neurological conditions can delay gut transit times leading to constipation, including multiple sclerosis, Parkinson’s disease, stroke, and diabetes.

Blockages of the gut due to a problem outside the bowel wall may have many causes, but is most commonly due to adhesions, scar tissue left over from prior illness or operations. In fact, this was the cause of death of Lisa Marie Presley, who died earlier this year. Blockages within the wall may be from a tumor, lack of blood supply, diverticular disease, and many other significant reasons.

Anyone with a cat will know that they sometimes cough up a hairball; humans who consume hair, either from a nervous tic or due to a psychiatric condition, can develop a bezoar, effectively a hairball! These accretions can also come from seeds or foreign items swallowed maybe years before as a child. One specific kind, a diospyrobezoar, comes from eating unripe persimmon fruit, and these can be treated by drinking cola—frankly the only time I would recommend drinking the stuff!

As ever, avoidance is better than cure. A diet rich in fiber, plenty of fluids, and regular exercise go a long way to preventing constipation and all its sequels—trust me, there are more of them than the Fast and Furious films, and they are even less fun!

If constipation is a new symptom, it is always sensible to obtain a medical opinion to exclude serious causes; a change in bowel habit is one of the most common ways for colon cancer to declare itself. If neither stool nor gas can pass, this is obstinate constipation, suitably called obstipation, and always merits a doctor’s appointment.

If just a passing issue, or a non-passing issue I should say, a glycerin suppository or phosphate enema may get things moving but should not be taken with any frequency as they do carry risks. You know the one about the doctor who laughed at a pilot who thought suppositories were like pills? I guess she took it the wrong way!

Oral laxative medications can provoke evacuation by a variety of means:

  1. Increasing the bulk of waste by adding cellulose, ispaghula, or other fibers, but these take a few days to have an effect
  2. Stool softeners that pull water from the bowel into the colon, the content of which the magnificently named dioctyl sodium sulfosuccinate was my favorite to recommend as it tends to be gentle and effective
  3. Stimulants like senna or bisacodyl work quite fast, but can cause cramping discomfort
  4. Osmotic laxatives, which also work to pull water into the bowel, thereby making feces looser and easier to pass—the most common is lactulose, which is an artificial sugar, broken down in the bowel and which attracts water. Another osmotic laxative is polyethylene glycol, which has the same production derivation as the antifreeze in your car; it is very powerful, and doctors use it to prepare the bowel for colonoscopy.

As usual, if feeling unwell for any reason, self-ground until recovered; with even a temporarily obstructed gut, flying is not a great idea, as diminished atmospheric pressure at altitude will lead to trapped gas expanding, causing discomfort…and maybe even a sudden resolution of the constipation, which would not be pleasant for anyone on board!

Forgive me for using so many corny constipation jokes; while not my favorite, they are a solid number 2! Sailors know that the roof over an aft cabin is called the poop deck—no, it has nothing to do with that—it merely derives from French for the rear of the boat. Constipation can, as stated, be no laughing matter, so if your poop is not shipshape, hail your doctor and what follows will hopefully be more satisfying than most movie sequels. Fly well, poop well!

You can send your questions and comments to Dr. Sackier via email: [email protected] and listen to his weekly podcasts at:
Jonathan Sackier
Dr. Jonathan Sackier is an expert in aviation medical concerns and helps members with their needs through AOPA Pilot Protection Services.

Related Articles