My friend, uh, his name is Akash, and he has a bit of constipation sin

My friend, uh, his name is Akash, and he has a bit of constipation since years, and... He has flatulence issues, but the thing is he gets pain. At right upper quadrant, and it slightly radiates towards the back. Only when he press...

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"biliary colic" AND diagnosis

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right upper quadrant pain worse on palpation chronic constipation flatulence causes

I hear you, but I want to be upfront: this is a symptom description, not a formal case, so I can't diagnose Akash. What I can do is walk through what fits and what doesn't, and what he should actually get checked.

What his pattern suggests

Right upper quadrant (RUQ) pain that radiates to the back is the classic description of biliary colic from gallstones (cholelithiasis). The Washington Manual of Medical Therapeutics describes it exactly this way: "a constant pain lasting for several hours, located in the right upper quadrant, radiating to the back or right shoulder," often triggered by fatty meals.

But there's a detail that doesn't fit perfectly: he says the pain comes only when he presses on the area. Classic biliary colic is usually spontaneous - it comes on its own (often after fatty food) and isn't something you need to provoke by pushing on your belly. Pain that only appears with pressure points more toward a few other things:

Gas trapped in the hepatic (right colonic) flexure - this is very plausible given his history. Years of constipation plus flatulence means gas and stool can distend the colon right where it bends under the liver, in the RUQ. A distended, gas-filled bowel loop is classically tender when pressed, and this can even mimic gallbladder or cardiac pain in presentation. This ties his constipation, flatulence, and RUQ pain into one picture rather than three separate problems.
Murphy's sign - if the pain on pressing is specifically over the gallbladder area and gets worse when he takes a breath in (inspiratory arrest), that's a specific finding pointing to cholecystitis (gallbladder inflammation, usually from a stone), not just simple biliary colic. Textbooks describe this as "inspiratory arrest with palpation over the gallbladder" - Sabiston Textbook of Surgery / Current Surgical Therapy.
Abdominal wall or musculoskeletal tenderness (e.g., costochondral irritation, muscle strain) - pain that is reproducible only by direct pressure and doesn't have any relation to meals, bowel movements, or breathing is often coming from the wall itself rather than an internal organ.
IBS with constipation (IBS-C) - years-long constipation plus bloating/flatulence plus vague abdominal pain is a common combination, and IBS pain can be diffuse and provoked by palpation over gas-filled bowel loops.

Why this needs an actual exam, not a guess

The reason a doctor examines the belly in person matters here: whether it's tender with breath-holding (gallbladder), tender only over a palpable gassy loop (constipation-related), or tender everywhere along a muscle line (musculoskeletal) changes the diagnosis completely, and I can't tell that from a text description.

What would actually help sort this out:

Abdominal ultrasound (checks for gallstones, gallbladder wall thickening, sonographic Murphy's sign)
Basic liver function tests
A physical exam specifically checking Murphy's sign
History detail: does the pain relate to fatty meals, does it resolve after passing gas/stool, how long does each episode last

Red flags that mean he shouldn't wait - if any of these show up, he should seek care urgently, not just "eventually":

Fever or chills
Jaundice (yellowing of eyes/skin) or dark urine
Pain that is severe, constant, and lasting more than a few hours (not just on pressing)
Vomiting that won't stop
Blood in stool or black tarry stools

For the constipation itself regardless of the RUQ pain cause: chronic constipation for years deserves its own workup too (fiber/fluid intake, thyroid function - hypothyroidism causes exactly this combo of constipation and flatulence per Sleisenger and Fordtran's Gastrointestinal and Liver Disease - and if he's over 45 or has any alarm features, a colonoscopy should be considered).

Bottom line: tell Akash to get an abdominal ultrasound and see a doctor for a proper exam rather than guessing between "gas from constipation" and "gallstones" based on symptoms alone - they can look similar but are managed very differently.

Usg abd and pelvis is completely normal. He also has anal fissure and his stools are hard majority of times

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"anal fissure" treatment

This actually clarifies the picture a lot. A normal USG abdomen and pelvis reasonably rules out gallstones, cholecystitis, and other structural hepatobiliary or pelvic causes as the source of his RUQ pain. Combined with an anal fissure and predominantly hard stools, everything now points toward one underlying problem: chronic constipation with hard, difficult-to-pass stools, and the RUQ pain is very likely a downstream effect of that, not a separate gallbladder issue.

How this all connects

Anal fissure - textbooks are consistent on this: it is "usually caused by passage of a large, hard stool" and patients with fissures "usually present with constipation followed by painful bowel movements with or without hematochezia" (Sleisenger and Fordtran's Gastrointestinal and Liver Disease; Sabiston Textbook of Surgery). Once a fissure forms, it triggers spasm of the internal anal sphincter, which causes pain with defecation, which makes the person subconsciously avoid passing stool, which worsens constipation and hardens stool further, which re-injures the fissure. This becomes a self-sustaining cycle.

RUQ pain with a normal scan - with gallstones and pelvic pathology excluded by ultrasound, and given his gas/flatulence history, the more likely explanation is gas and stool loading in the hepatic (right colonic) flexure, sometimes called hepatic flexure syndrome. A distended, stool- and gas-filled colon segment sitting right under the liver is tender when pressed and can mimic biliary pain, but shows nothing on ultrasound because it is a functional/luminal issue, not a structural organ problem.

What actually needs to happen now

1. Break the fissure-constipation cycle first - this is the priority since it is likely driving everything:

Stool softening: bulk laxative (psyllium/methylcellulose) plus adequate fluids; osmotic laxative (e.g., PEG/lactulose) if stools remain hard
Topical treatment for the fissure itself: 2% topical diltiazem cream or GTN (nitroglycerin) ointment - textbook first-line medical treatment (Sleisenger and Fordtran's Gastrointestinal and Liver Disease). A recent 2025 systematic review confirms topical calcium channel blockers (diltiazem/nifedipine) and GTN remain the standard first-line conservative options, with botulinum toxin or lateral sphincterotomy reserved for fissures that don't heal (PMID: 41493321).
Warm sitz baths after bowel movements, which relax sphincter spasm
Most acute fissures heal within weeks with this approach; if it becomes chronic (>6-8 weeks) or keeps recurring, he'll need a surgical referral for options like botulinum toxin injection or sphincterotomy

2. Address the constipation itself, not just the fissure symptom:

Increase dietary fiber gradually (sudden high fiber can worsen bloating/flatulence) and fluid intake
Regular physical activity
If he's straining a lot or stools remain hard despite fiber/fluids, it's worth ruling out contributing causes: hypothyroidism, low physical activity, certain medications, or in rare cases a pelvic floor/defecatory disorder (dyssynergia) - this last one specifically causes chronic hard stools that don't respond to simple fiber/laxatives and needs anorectal manometry to diagnose

3. He should still see a doctor in person for a rectal exam - a fissure is usually visible/palpable on inspection, and this also lets them confirm it's a simple fissure and not something else (though with his history it's almost certainly a straightforward fissure from hard stool).

Red flags that would change this picture and warrant more workup (colonoscopy, etc.): bleeding beyond a little on the tissue/streak on stool, unintentional weight loss, family history of colorectal cancer or IBD, fissure not in the typical posterior midline location, or no response to conservative treatment after several weeks.

Bottom line: the normal scan is good news. The story now fits one coherent explanation, chronic constipation with hard stools, rather than two unrelated problems. Treating the constipation aggressively (fiber, fluids, osmotic laxative if needed) should improve the fissure, the flatulence, and likely the RUQ discomfort together.

Should I give him mg oxide or hydroxide or glycinate for hard stools?

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magnesium oxide vs magnesium hydroxide vs magnesium glycinate for constipation comparison

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"magnesium oxide" AND constipation

For hard stools specifically, magnesium oxide or magnesium hydroxide are the appropriate choices, not glycinate. Here's why they differ:

Magnesium oxide - best fit for daily constipation management

This is the one with actual trial data behind it. A 2021 RCT and a Nutrients review both support magnesium oxide for chronic constipation, and it's used in the U.S. and widely in Japan/East Asia as a standard laxative (PMID: 32969946, PMID: 33525523). It's poorly absorbed in the gut, so the unabsorbed magnesium stays in the intestine and osmotically pulls water in, softening stool. It's slower-acting (6+ hours) but gentler than hydroxide, so it's more suited to regular daily use for someone whose stools are hard "the majority of the time," like Akash. Typical dose is around 400 to 800 mg once or twice daily, but this should be tailored, not just started blind.

Magnesium hydroxide (Milk of Magnesia) - faster, more of an occasional cathartic

Also a saline/osmotic laxative (same water-pulling mechanism), but it acts faster and more forcefully, closer to an as-needed rescue dose than a maintenance regimen. Katzung's and Lippincott's Pharmacology both classify it alongside magnesium citrate/sulfate as a saline cathartic. It's also alkalinizing (used as an antacid too), which matters less here but is part of why it's not the first pick for everyday long-term use.

Magnesium glycinate - wrong tool for this job

This form is chelated to the amino acid glycine specifically so it's absorbed well into the bloodstream rather than staying in the gut. That's great if the goal is correcting a magnesium deficiency, or for its calming/sleep effects, but it means much less magnesium is left in the intestine to pull water in, so its laxative effect is weak and unreliable. Don't rely on it to fix hard stools.

Practical recommendation

Start with magnesium oxide as the daily option for softening stool. One caution worth flagging: magnesium salts (oxide or hydroxide) are cleared renally, and in anyone with reduced kidney function they can accumulate and cause hypermagnesemia - textbooks specifically warn about this with renal impairment (Brenner and Rector's The Kidney; ROSEN's Emergency Medicine). Since Akash is presumably young and otherwise healthy, this is a low risk, but if there's any history of kidney disease, get that checked before regular use, and don't combine with other magnesium-containing antacids on top of it.

One thing worth mentioning: for chronic constipation, polyethylene glycol (PEG, e.g. Miralax) has the strongest evidence overall and is generally the first-line recommendation in most GI guidelines, with magnesium salts as a reasonable alternative. If magnesium oxide doesn't give consistent results within a week or two, PEG would be the next step rather than switching between magnesium forms.

Magnesium oxide I can get without prescription, but is it possible to get MiraLAX without prescription in US?

Yes. MiraLAX (polyethylene glycol 3350) is available over-the-counter in the US, no prescription needed. It's sold in most pharmacies (CVS, Walgreens, Walmart, etc.) both under the brand name and as generic "PEG 3350" or "polyethylene glycol 3350 powder," which is significantly cheaper and works identically.

Quick practical notes for using it:

Typical adult OTC dose: 17 g (one capful) dissolved in 4-8 oz of any beverage, once daily
It's tasteless and doesn't cause the cramping/urgency that magnesium salts sometimes do, which is part of why it's often preferred for daily long-term use
Effect usually shows up in 1-3 days, not immediately
Safe to use for extended periods, that's actually how it's designed to be used for chronic constipation, unlike stimulant laxatives (senna, bisacodyl) which aren't meant for daily long-term use

Since he already has an anal fissure from hard stools, PEG is arguably a better first choice than magnesium oxide here: it softens stool reliably without the GI cramping/gassiness that magnesium salts can add on top of his existing flatulence issue. There's no harm in trying either, and no need to pick just one permanently, but if you want a single starting point, I'd go with generic PEG 3350 over magnesium oxide.

What about the doors of magnesium oxide also tell me the dose of miralax

Magnesium Oxide - Dosing

Standard adult dose for constipation: 400-800 mg once daily, though tablets commonly come in 400 mg increments (some brands sell 250 mg, 400 mg, or 500 mg tablets)
Can be taken as a single dose or split into two doses (e.g., 400 mg twice daily) if higher amounts are needed
Take with food to reduce stomach upset
Effect is usually seen within 6+ hours to a day (it's on the slower, gentler end compared to magnesium hydroxide/citrate)
If no improvement after a few days at 400 mg, can increase toward 800 mg, but I wouldn't push it higher than that without medical guidance
Adequate water intake alongside it matters, since it works by drawing water into the bowel

MiraLAX (PEG 3350) - Dosing

Standard adult dose: 17 g of powder (one capful, using the cap that comes with the bottle) dissolved completely in 4-8 oz of water, juice, coffee, or any beverage, once daily
Taken once a day, any time of day, with or without food
Effect typically shows up in 1-3 days, not the same day, so don't judge it after one dose
It's meant to be used daily and consistently for chronic/ongoing constipation, not just as a one-off rescue dose
If stools stay hard after 3-4 days at the standard dose, it can be reasonable to try up to twice daily, but if there's no response at all within a week, that's worth flagging to a doctor rather than escalating further on your own

Practical suggestion for Akash

Don't combine both from day one. Pick one, give it 3-5 days, and see how he responds:

If you want gentler on the gut with less added gas: start with MiraLAX 17 g once daily
If cost/availability favors magnesium oxide, start with 400 mg once or twice daily

Since he already has flatulence and an anal fissure, I'd lean toward starting with MiraLAX first, then reassess. If stools are still hard after about a week, that's the point to loop back to a doctor rather than keep adjusting doses indefinitely on his own.

What about the dose of magnesium oxide also tell me the dose of miralax

I already covered this exact question in my last message. Here it is again for quick reference:

Magnesium Oxide - Dosing

Standard adult dose for constipation: 400-800 mg once daily (tablets typically come in 250 mg, 400 mg, or 500 mg strengths)
Can be a single dose or split into two (e.g., 400 mg twice daily) if needed
Take with food to reduce stomach upset
Effect takes 6+ hours to a day to kick in
If no improvement after a few days at 400 mg, can increase toward 800 mg, but don't go higher than that without medical guidance
Needs adequate water intake alongside it

MiraLAX (PEG 3350) - Dosing

Standard adult dose: 17 g of powder (one capful) dissolved fully in 4-8 oz of any beverage, once daily
Any time of day, with or without food
Effect shows up in 1-3 days, not the same day
Meant for daily, ongoing use for chronic constipation, not a one-time rescue dose
If stools stay hard after 3-4 days, can try twice daily; if there's still no response after a week, that's worth flagging to a doctor rather than pushing the dose further

For Akash specifically: given his flatulence and anal fissure, start with MiraLAX 17 g once daily first since it causes less gas/cramping than magnesium salts. Give it 3-5 days before judging whether it's working.

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