Laxatives and stomach cramps

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While laxatives may relieve constipation associated with some illnesses, such as irritable bowel syndrome (IBS), and opioid-induced constipation, many people use them in the setting of eating disorders. Laxative overuse may occur in an attempt to lose weight, or gain a sense of control over an eating disorder. Laxatives can cause numerous side effects when taken under the auspices of an eating disorder, including painful stomach cramps.

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The Effects of Laxative Overuse and Misuse on the Stomach

Reports show many people who misuse laxatives may do so as a symptom of their anorexia nervosa (AN) or bulimia nervosa (BN). This laxative abuse may be carried out in an attempt to manage weight, and can even appear due to career pressures, such as those experienced with athletes, or models who need to stay within a particular weight range. Another vulnerable group consists of individuals who are middle aged or older, who suffer from constipation, but continue to overuse laxatives either from habit or medication side effects. In this case, they can develop types of purging disorders. These are not the exclusive reasons for laxative abuse, but they are the primary ones that have been reported thus far (4). 

This article will discuss the different types of laxatives, their mechanism of action within the body, and when it is appropriate to use them. When used improperly, especially in the setting of ED, they can cause significant harm. Be sure to discuss this with your healthcare provider or local pharmacist if you think you may need to take laxatives for any reason. 

There are four main classes of laxatives: osmotic, stimulant, bulk-forming, and stool softeners. (1)

Osmotic laxatives

Osmotic laxatives are poorly absorbable substances, meaning they pass through the Gastrointestinal (GI) tract relatively undigested. They draw water into the intestinal tract, which helps to hydrate, soften, and gently propel fecal matter along the tract. The process by which the soluble, non-absorbable substances draw water into the lumen is called osmosis. When used inappropriately, they can cause uncomfortable diarrhea, bloating, and in some cases, significant water loss and dehydration. 

These types of laxatives are most commonly used for cleansing the colon in preparation for a colonoscopy, or to remove toxic substances, like in the setting of liver failure (hepatic encephalopathy). For those who take Milk of Magnesia in the setting of kidney disease, the magnesium is partly excreted through the kidneys, so this is not recommended. (1,2,3)

Stimulant laxatives

Stimulant laxatives may be prescribed for treatment of constipation, but this category of laxatives tends to be the most commonly misused form of laxatives due to their rapid onset of action. They stimulate nerve bundles within the intestinal tract, called the auerbach plexus and myenteric plexus. These nerves control the natural slow moving muscle contractions that propel food from mouth to anus. This smooth muscle contraction is called peristalsis. Stimulant laxatives also decrease how much water is absorbed from food within the lumen of the bowel. (1)

They can cause considerable abdominal pain, cramps, nausea, and vomiting. 

With treatment that addresses laxative weaning, some symptoms can be resolved, but someone who has misused stimulant laxatives for a long time could struggle with constipation and gut dysmotility permanently. (7)

Bulk-forming laxatives

These agents help to retain fluid in the stool and increase stool weight and consistency. Individuals on these types of laxatives need to drink ample amounts of water. Even slight amounts of dehydration can result in bloating, pain, and even a bowel obstruction (where stool becomes completely impacted). Some do note common side effects like nausea, vomiting, and diarrhea. (1)

Stool softeners

This group includes sodium or calcium salts that act as anionic surfactants. This lowers the surface tension at the oil-water interface of feces, which allows water and fats to better penetrate the stool and mix. This softens fecal matter, making defecation easier. It is commonly recommended for those who should avoid straining, like after surgery. Because they do not exert stimulant actions, they are not technically considered a laxative. Onset of action takes a bit longer, usually between 1-3 days after ingestion. (8)

There are prescription medications that are not intended primarily for laxative effect, but to help an underlying cause of constipation like chronic slow transit constipation. 

Side effects of laxative abuse

The most common medical problems associated with laxative abuse include electrolyte and acid/base changes. Chronic diarrhea causes the body to lose important fluids and electrolytes, which places undue pressure on the heart and kidneys. For those with anorexia nervosa who may already have the beginnings of heart and kidney damage, using laxatives can further exacerbate harm. (1,4,7)

When excessive amounts of fluid are lost through diarrhea long term, hormone cascades activate to compensate. If someone abruptly stops using laxatives, the renin-aldosterone hormone system continues to tell the body to hold fluid. This will cause someone to develop significant swelling, called edema. This can make someone feel bloated, which may trigger a return to laxative abuse. They will also likely struggle with painful rebound constipation. The cycle can be difficult to break, and should be done with the help of a medical professional. (1,4,7)

When trying to correct this, medical tests and labs should be performed to check the status of serum electrolytes and acid/base status. After an individual begins treatment to address their eating disorder, a healthcare provider will likely have the person switch to something safer, or steadily decrease the dose. This stepwise fashion of carefully withdrawing laxatives helps the body to re-establish normal bowel movements, and is the best and safest way to alleviate stomach cramps from laxative abuse. (1,4,7)

It can take a few weeks to months to regulate normal bowel cycles again. Recovery is a journey and takes time. If you are struggling to break the cycle of laxative overuse, reaching out for support is an important step towards healing. At Within Health, we educate our clients on what symptoms and side effects to anticipate, so they can heal from laxative abuse, and any underlying eating disorders.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Laxatives - StatPearls - NCBI Bookshelf. (n.d.). Retrieved October 27, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK537246/ 
  2. Liu, L. W. C. (n.d.). Chronic constipation: Current treatment options. Canadian Journal of Gastroenterology and Hepatology. Retrieved October 27, 2022, from https://www.hindawi.com/journals/cjgh/2011/360463/ 
  3. Popular osmotic laxatives list, drug prices and medication information. GoodRx. (n.d.). Retrieved October 27, 2022, from https://www.goodrx.com/classes/osmotic-laxatives 
  4. Roerig, J.L., Steffen, K.J., Mitchell, J.E. et al. Laxative Abuse. Drugs 70, 1487–1503 (2010). https://doi.org/10.2165/11898640-000000000-00000.
  5. Joo JS, Ehrenpreis ED, Gonzalez L, Kaye M, Breno S, Wexner SD, Zaitman D, Secrest K. Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited. J Clin Gastroenterol. 1998 Jun;26(4):283-6.
  6. Xing JH, Soffer EE. Adverse effects of laxatives. Dis Colon Rectum. 2001 Aug;44(8):1201-9. 
  7. Gibson, D., Benabe, J., Watters, A. et al. Personality characteristics and medical impact of stimulant laxative abuse in eating disorder patients—a pilot study. J Eat Disord 9, 146 (2021). https://doi.org/10.1186/s40337-021-00502-9.
  8. PDR Search. Colace Capsules (docusate sodium) dose, indications, adverse effects, interactions... from PDR.net. (n.d.). Retrieved October 27, 2022, from https://www.pdr.net/drug-summary/Colace-Capsules-docusate-sodium-1023 
  9. List of laxatives + uses, types & side effests. Drugs.com. (n.d.). Retrieved October 27, 2022, from https://www.drugs.com/drug-class/laxatives.html

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