Constipation and IBS
The perfect poo
Ideally, a bowel movement is effortless (no straining) and should take a minute or less. You should have the feeling of being completely evacuated. The stool consistency should be semi-solid and uniform, the colour brown and the smell not too strong. Bowel movements should occur 1 – 3 times a day, 18-24 hours after a meal.
That may seem like an impossible dream to you right now. However, it is possible to experience these types of bowel movements even if you have been chronically constipated for years. The first step is discovering what is causing your constipation.
Why extra fibre is not the answer
When you are constipated one of the first pieces of advice you will hear is to increase your fibre, and for some people this will do the trick.
However, while getting adequate fibre from foods like fruit and vege’s is very important, adding extra fibre in forms like bran, psyllium husks and fibre supplements may not be the answer and in some people may cause more digestive distress. Two recent studies highlight this point.
Research done at Addenbrooke’s Hospital NHS Trust, Cambridge, UK linked fibre with abnormal gut fermentation and determined that a fibre-free diet could significantly reduce symptoms of IBS and intestinal gas. (1)
A systematic review of the effectiveness of including different types of fibre in the diet of IBS patients being treated for constipation found only marginal benefits. In some cases, fibre actually worsened IBS symptoms. (2)
“Fiber overload has long been regarded as worsening factor of IBS symptoms through decreased small bowel motility or intraluminal bulking.” (3,4)
Even though our bodies cannot digest fibre, bacteria that live in our large intestine can.
For healthy people, the fermentation of fibre in the large intestine is considered healthy. Unfortunately, for people with digestive problems, consuming too much fibre may cause excess fermentation. If increasing fibre and water intake hasnt helped with your constipation, then you may have something else going on…
How dysbiosis may be causing your constipation
Dysbiosis is defined as a disruption or imbalance in the microflora of your gut. (Learn more about dysbiosis here)
Studies show that people with IBS – C have a different gut microflora profile compared to healthy people.
Stools are made up of 75 percent water and 25 percent solid matter. About 30-50 percent of the solid matter consists of dead bacteria.
Several studies have observed a decrease in the lactic acid bacteria (mostly bifidobacteria) in the faecal microbiota of IBS-C patients compared to healthy people. (5,6,7,8,9,10,11)
Changes in the microflora community alters the fermentation process of carbohydrates and hence the production of gases, such as methane and hydrogen.
Methane has been shown to slow gastrointestinal motility (movement) by 59% in animal studies, plus, the higher the volume of methane, the more severe the constipation. (12,13)
Methane production is limited to only a few species of bacteria and archaea, with the predominant producer being Methanobrevibacter smitthii. A study showed that patients with IBS-C have elevated amounts of methane on their breath and M. smithii in their stool.(14)
SIBO and Constipation
Small Intestine Bacterial Overgrowth or SIBO is, as the name implies, an overgrowth of bacteria in the small intestine. (learn more about SIBO here.) SIBO is confirmed in patients who return positive hydrogen or methane levels after a lactulose breath test.
Researchers have found that in patients IBS, who were methane positive on a lactulose hydrogen breath test, there was a 100% association with constipation and that the higher the methane levels the more severe the constipation. (15)
Bile – the missing link?
Bile is a fluid produced by the liver that aids in the digestion of fats in our small intestine. Bile acids are known as endogenous laxatives (endogenous meaning originating from within the body) because they stimulate peristalsis (movement) and bring water into the colon. (16)
In fact a condition known as Bile Acid Malabsorption is known to cause chronic diarrhea. This condition is caused by excess bile salts entering the colon rather than being absorbed in the small intestine, increasing water reabsorption and colonic movement and causing diarrhea.
Changes in the synthesis and the concentration of bile acids in the colon have been identified in constipated children (17) and in adults with IBS-C. (18,19)
People with IBS-C have a decreased concentration of deconjugated bile acids compared to healthy people or people with IBS-Diarrhea. (20,21)
The reduction of the secondary bile acids in the colon leads to slower bowel movement and less water being brought into the bowel, resulting in constipation.
How do I find out what’s causing my constipation?
Depending on your presenting symptoms and history there are a few tests we may use to discover what is causing your constipation and other symptoms, including:
How is it treated?
Once we have a better idea of whats causing your constipation, we begin a treatment plan using diet, herbal medicines, nutritional supplements, exercises and lifestyle changes. This plan works by:
- Removing foods from your diet that cause inflammation, feed the wrong bacteria and irritate the gut wall.
- Removing any abnormal growth of bacteria, yeasts and/or parasites in your gut.
- Restoring beneficial bacteria and re-establishing healthy bacterial balance in your gut.
- Improving motility and restoring digestive secretions.
- Strengthening and supporting liver function.
To learn more about the testing and treatment options available to you we recommend you take a free 15 minute phone consultation with our Naturopath. During this call you can learn more about our treatments and have any questions you may have answered. This call is to determine if we are a good fit for one another rather than a history or complete consultation. There is no obligation, and no strings attached.
It is quick and easy to book your free 15-minute phone consultation using our online calendar. Just click the link below, choose a date and time convenient for you, enter your details, and our Naturopath will call you at your chosen time. Book here
- Bijkerk CJ, Muris JW, Knottnerus JA, Hoes AW, de Wit NJ. Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2004 Feb 1; 19(3):245-51.
- Markland AD, Palsson O, Goode PS, Burgio KL, Busby-Whitehead J, Whitehead WE Association of low dietary intake of fiber and liquids with constipation: evidence from the National Health and Nutrition Examination Survey. Am J Gastroenterol. 2013 May; 108(5):796-803.
- Francis CY, Whorwell PJ. Bran and irritable bowel syndrome: time for reappraisal. Lancet. 1994;344;39-40.
- Friedman, G. Diet and the irritable bowel syndrome. Gastroenterol Clin North Am. 1991;20;313-324.
- Si JM, Yu YC, Fan YJ, Chen SJ. Intestinal Microecology and quality of life in irritable bowel syndrome patients. World J. Gastroenterol 2004; 10 (1): 802-5.
- Mallinen E, et al. Analytics of the fecal microbiota of irritable bowel syndrome patients and healthy controls with real time PCR. American J. Gastroenterol 2005: 100: 373-82.
- Keckhoffs APM, et al. Lower Bifidobacteria counts in both duodenal mucosa and fecal microbiota in irritable bowel syndrome patients. World J. Gastroenterol 2009; 15: 2887-92.
- Codling c, et al. A molecular analysis of fecal and mucosal bacterial communities in irritable bowel syndrome. Dig. Dis. Sci. 2010; 55: 392-7
- Balsari A, et al. The fecal population in the irritable bowel syndrome. Microbiologica 1982; 5: 185-94.
- Matto J, et al. Composition and temporal stability of gastrointestinal microbiota in irritable bowel syndrome – a longitudinal study in IBS and control subjects. FEMS Immunol. Med. Micriobiol. 2005; 43: 213-27.
- Chassard C, et al. Functional dysbiosis within the gut microbiota of patients with constipated – irritable bowel syndrome. Alimentary Pharmacology and Therapeutics 2012; 35; 7: 828-838.
- Pimentel M, Lin HC, Enayati P, et al. Methane, a gas produced by enteric bacteria, slows intestinal transit and augments small intestinal contractile activity. Am J Physiol Gastrointest Liver Physiol. 2006 Jun;290(6).
- Chatterjee S et al. The degree of breath methane production in IBS correlates with the severity of constipation. Am J Gastroenterol. 2007 Apr;102(4):837–841.
- Kim G, Deepinder F, Morales W, Hwang L, Weitsman S, Chang C, Gunsalus R, Pimentel M. Methanobrevibacter smithii is the predominant methanogen in patients with constipation-predominant IBS and methane on breath.Dig Dis Sci. 2012 Dec;57(12):3213-8
- Pimentel M, etal. Methane Production During Lactulose Breath Test Is Associated with Gastrointestinal Disease Presentation. Digestive Diseases and Sciences, Vol. 48, No. 1 (January 2003), pp. 86–92
- Bajor A, Gillberg PG, Abrahamsson H. Bile acids: Short and long term effects in the intestine. Scand. J. Gastroenterol 2010; 45: 645-664.
- Hoffman AF, et al. Altered bile metabolism in childhood functional constipation: inactivation of secretory bile acids by sulfation in a subset of patients. J. Pediatric Gatroenterol. Nutr. 2008; 47: 598-606.
- Abrahamsson H, et al. Altered bile metabolism in patients with constipation predominant irritable bowel syndrome and functional constipation. Scand. J. Gastroenterol. 2008; 43: 1483-1488.
- Rao Aj, et al. Chenodeoxycholate in females with irritable bowel syndrome – constipation: a pharmacodynamic and pharmacogenetic analysis. Gatroenterol. 2010; 139: 1549-1558.
- Shin A, et al. Bowel functions, fecal unconjugated primary and secondary bile acids, and colonic transit in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol. 2013 October; 11(10): 1270–1275.e1
- Wong B, etal. Increased Bile Acid Biosynthesis Is Associated With Irritable Bowel Syndrome With Diarrhea. Clin Gastroenterol Hepatol. 2012 Sep; 10(9): 1009–15.e3.
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