Strategies To Restore Bowel Function After Colon Cancer Treatment

Have you or someone you care about recently undergone colon cancer treatment and are now on the path to reclaiming bowel function? Regaining gut motility after colon cancer treatment is a challenging task. Delays in bowel restoration increase hospital stays by more than 29% for extended hospital stays.¹

This article unveils the most effective strategies to help you reclaim your digestive health and quality of life. 

Overview of colon cancer treatment

Treatment journey

The standard treatment for colon cancer is surgery, with a cure rate of 50%. Removing a part of the colon or complete colon is known as a colectomy.

After a colectomy, the end of the bowel is attached to a bag outside the abdomen through a stoma, a surgically created opening in the abdominal wall. Such ileostomy or colostomy allows the gut to heal and remove the waste externally without passing through the rectum and anus. 

In addition to surgery, chemotherapy, radiotherapy, and immunotherapy are essential modalities for colon cancer treatment. While these combination therapies provide better outcomes, they also increase the likelihood of bowel dysfunction post-treatment.²  Your doctor will discuss the treatment options based on your stage, recurrence status, metastasis to the liver or lung and existing risk factors. 

Type of treatment and its effect on the bowel

The changes in your bowel function depend on the type of treatment you have had. The effects of the treatment on the bowel are described here:

Surgery

Ideally, it takes around 2 to 3 days to return to normal colon peristalsis after surgery. Bowel manipulation, oedema, and blood loss during surgery accelerate the sympathetic function and slow down bowel motility.¹

Radiotherapy

Radiation can inflame the gut, causing mucosal breakdown and damage to colonic tissue through ionisation and production of reactive oxygen species. It may result in a range of side effects, such as diarrhoea and flatulence in the early phase of treatment, as well as ulceration, fibrosis and malabsorption in the long term.²

Chemotherapy

Chemotherapy enhances the likelihood of damage to non-cancerous gut tissue already affected by radiotherapy. Chemotherapy-induced life-threatening enterocolitis can result in haemorrhage, ischaemia, perforation and muti-organ failure.²

Immunotherapy

Immune-mediated T-cell activation can cause colonic mucosa erosion and ulceration. The common side effects are diarrhoea, pain in the abdomen and vomiting. Although rare, there are reports of immunotherapy-related colitis and bowel perforation.²

Understanding the changes in bowel function after treatment 

Approximately 25% of patients experience postoperative ileus (POI) or cessation of coordinated bowel motility following colorectal surgery.¹ Cancer treatment can influence how your bowel works. Regaining your normal bowel function after colon cancer can be a challenging process.

Challenges after colectomy

If you have had a partial or complete colon removal, it may take time for your body to adjust to the short bowel. The commonly faced issues that need attention are due to:^3,4,5

• Loss of absorptive surface area
• Rapid intestinal transit time
• Altered gut motility
• Excess release of digestive juices
• Weakness of pelvic muscle

Bowel symptoms after colon cancer treatment

Restoring the bowel can take a few weeks, and you may have one or more of the following symptoms:^6,7

• Higher frequency of pooping
• Alternating stool consistency
• Watery and loose stools
• Urgency in passing stool
• A feeling of incomplete evacuation
• Inability to defer passing stool
• Frequent defecation at night
• Need for using a pad
• Incontinence to bowel gas or stool

Dietary strategies to restore bowel function

What should you eat within the first few weeks after surgery?

Immediately after surgery, your digestive system is not prepared enough to handle routine food. Your medical team will assess and tailor the diet plan for you. Ideally, you should begin with a clear liquid diet and progress to a full liquid diet before transitioning to low-fibre foods.

Table1: Food included in the early phase after colectomy

Tips for restoring your bowel

• Discuss with your dietician regarding any underlying medical conditions that interfere with your diet plan, such as diabetes or hypertension
• Try small and frequent meals in place of three large meals
• Take time to eat slowly and chew properly
• Gradually shift to high-fibre diets after 4-6 weeks unless advised otherwise.
• Drink sufficient water and water-based food to maintain hydration
• Modify your diet according to your stool consistency
• Embrace your natural pace, and don't get discouraged if recovery takes longer than others

What to eat and what to avoid  during the early phase 

These are the list of food items that influence your gut health: ^3,8

•  Include well-cooked food without skins, such as broccoli, banana, pureed fruit, avocado, etc
• Add buttermilk, yoghurt, cranberry juice, parsley, and tomato juice to your diet to reduce the foul smell of your stool
• Avoid high-fibre diets such as whole grain bread, whole wheat pasta, weetabix, muesli, dried fruits, tiny seed-containing fruits, and peel-containing vegetables 
• Ensure that you consume only pasteurised foods to avoid contracting harmful infections
• Limit milk or milk-based products if you can’t tolerate milk
• Avoid food that produces extra gas, such as citrus fruits, cabbage, carrots, wheat germ, onion, beans, etc
• Include protein-rich food such as fish, eggs and tofu
• Take small high-energy snacks such as pudding, biscuits, etc
• Limit fizzy drinks, caffeine, artificial sweeteners and spicy food

When your gut is ready to resume a regular diet, your medical team will slowly introduce you to a high-fibre diet, fruits, vegetables and cereals.

Managing your diet after colostomy or ileostomy

Frequent changes in stool consistency, ranging from diarrhoea to constipation, is common after surgery. The formed stool released into the stoma pouch produces a foul smell.⁸

Over time, once your digestive system gets adjusted to the stoma and your bowel function comes to normal, you can experiment with your diet, and your balanced diet should target the following:

• Providing sufficient nutrition and adequate hydration
• Regularising your bowel movements
• Maintaining the consistency of your poo
• Controlling foul odour
• Reducing bloating and gas
• Controlling peristomal skin erosion

Good toileting habits for bowel restoration

You have the power to modify your bowel function, and it all starts with effectively emptying your bowel. Here are some essential toilet habits that you may consider:

• Discuss with your nurse regarding effective toilet habits 
• Try to hold on to the poo unless there is a strong urge to defecate
• Avoid sitting on the toilet for a long time without passing stool
• Maintain a good posture for early emptying and reducing strain
• Avoid straining that could put extra pressure on pelvic muscles 

Medication to regulate your bowel

Despite diet modification, you may have trouble restoring your bowel movement. Management of your bowel post-surgery includes:^3,4

1. Rehydration using intravenous infusion in case of features suggestive of dehydration.
2. Adding antidiarrhoeal drugs such as loperamide hydrochloride and codeine phosphate to reduce intestinal motility and slow transit time
3. Nutrition infusion  to manage and improve poor nutritional status
4. Magnesium infusion to replenish magnesium depleted from early high-output stomas.
5. Antisecretory drugs such as omeprazole to get relief from excessive digestive juice secretion during the early phase after surgery.

Continuous diet monitoring, medication, and frequent follow-up are crucial for restoring bowel function at the earliest. Additionally, it has a key role in preventing long-term complications such as metabolic diseases, bone disorders, and vitamin deficiencies.⁴

Lifestyle modification for bowel wellness

Physical activity and strengthening exercises

Did you know radiation and surgery can weaken pelvic floor muscles, making it difficult to control bowel movements or gas? It's not something most people like to discuss, but it's a reality for many. Therefore, it is essential that your pelvic floor muscles are functioning correctly and you have control over your anal sphincter. 

Research has shown that pelvic floor muscle training is a highly effective way to accelerate the recovery of bowel symptoms in the six months following surgery.⁵ Here are some of the tips for reclaiming both the bowel and physical health after colorectal treatment:

• Consult your physiotherapist for your routine exercise based on your surgery and needs.
• Start slowly with walking and gentle exercises
• Gradually increase the duration and intensity of your exercise
• Shift to pelvic floor muscle training to regain control over faecal incontinence and urgency.
• Do not strain or put extra pressure while passing stool

Quitting smoking 

Although smoking does not directly affect your bowel, nitric oxide released from nicotine relaxes the colonic smooth muscle and slows down your bowel movement.⁹ Post-treatment may interfere with bringing the bowel function to normal. If you are looking to quit smoking, there are resources available to guide you.

FAQs

How common are bowel function changes after colon cancer treatment?

As many as 50% of patients experience bowel dysfunction for up to a decade after treatment.¹⁰

How long to stay on a low-fibre diet after colon surgery?

Ideally, you can shift to a regular diet by the end of 4 weeks.

What are the predictors for slow return of bowel after colorectal surgery

Our bowel functions tend to slow down and take a longer time to recover in conditions such as:¹¹

• Old age
• Post-chemoradiotherapy 
• If you had a history of abdominal operation
• Long duration of colorectal surgery
• Pre-existing vascular or respiratory disorder 

Summary

Surgery, radiotherapy, chemotherapy, and immunotherapy can significantly change your bowel function. Your gut takes time to heal and function properly after colon cancer treatment. Making changes to your diet and lifestyle can have a significant impact on your digestive system. To retrain your bowels, start with a liquid diet, transition to a low-fibre nutrient-rich diet, and later shift to high-fibre foods. Quitting smoking, strengthening your pelvic muscles, and taking appropriate medication are all proven methods that can help you achieve your goal.