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Constipation

Constipation

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 empty. The stool consistency should be formed, the colour brown and the smell is not too strong. Bowel movements should occur 1 – 3 times a day.

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.

What is Constipation?

  • Incomplete emptying of the bowels. You may go every day but there is a sensation of not being empty, that there is more to go.
  • The sensation of wanting to go but nothing happening.
  • Hard, dry stools which require straining to pass.
  • Infrequent bowel movements, a day or more without going.
bristo stool chart

Bristol Stool Scale (BSS) scores. Stool forms 1 and 2 are strongly associated with slower transit and constipation.

Constipation is classed into 3 groups:

IBS – Constipation (IBS-C) – when there is abdominal pain, gas and bloating associated with constipation.

Slow Transit Constipation – is characterised by the slowed movement of the large intestine, thought to be caused by abnormalities of the nerves.in the gut.

Outlet dysfunction  – mechanical causes such as Hirschsprung disease, anal stricture, cancer, prolapse, and large rectoceles, or from pelvic floor dysfunction.

There may also be secondary causes, such as poor diet, lifestyle, stress, certain medications, diabetes, hypothyroidism, multiple sclerosis, parkinsons, pregnancy, and advanced age.

(Constipation is a very common symptom of hypothyroidism (underactive thyroid), which can slow down gut motility (movement). Because conventional lab ranges to diagnose hypothyroidism are so broad, many people with low thyroid function are misdiagnosed. If you have thyroid symptoms, like constipation, cold hands and feet, and fatigue, you should check for hypothyroidism from a functional blood chemistry perspective, which means not just testing TSH but also Free T3, Free T4 and Thyroid Antibodies.)

Chronic Constipation Causes

If you are here you have probably already tried drinking more water, increasing your fibre intake and all the other common advice, in mild or transient cases these things can work but you’ve probably been experiencing constipation for some time, many years maybe. To understand why you are so constipated and to effectively resolve it we need to understand what’s happening inside your gut and discover the root cause of your issues.

In clinic the most common causes of constipation I see are:

  1. Large intestinal Dysbiosis, and
  2. Small Intestinal Bacterial Overgrowth (SIBO)

Dysbiosis and Constipation

Dysbiosis is defined as a disruption or imbalance in the microflora of your gut. (Learn more about dysbiosis here)

Many studies show that people with IBS – C have a different gut microflora profile compared to healthy people.

Several studies have observed a decrease in lactic acid bacteria (mostly bifidobacteria) in the faecal microbiota of IBS-C patients compared to healthy people. (1,2,3,4,5,6,7)

Alterations of intestinal microbiota in patients with chronic constipation can be characterized by a relative decrease in Lactobacillus, Bifidobacterium, Clostridium leptum, Faecalibacterium prausnitzii and Bacteroides spp.) and an increase of potentially pathogenic microorganisms (e.g. Pseudomonas aeruginosa and Campylobacter jejuni) (8,9,10)

Lipopolysaccharide and Constipation

Overgrowths of gram negative bacteria will produce the endotoxin lipopolysaccharide which is thought to influence bowel motility (movement) by delaying gastric emptying and affecting the functions of sphincters. (11)

Short Chain Fatty Acids and Constipation

Short-chain fatty acids (SCFAs), such as butyrate, acetate, and propionate are produced in the colon by certain beneficial bacteria when they ferment carbohydrates. SCFAs have been shown to stimulate propulsive contractions in the large intestine and directly stimulate bowel colonic smooth muscle contractility and peristalsis.

The Roseburia–E. rectale group, a predominant butyrate-producing bacterial group of in the human gut were detected at significantly lower levels in IBS-C patients compared with healthy people, which may explain the decrease in concentration of butyrate in IBS-C patients. (12, 13)

If you have low levels of beneficial bacteria you may miss out on the benefits of SCFAs and their positive effect on bowel motility.

Bile Acids and Constipation

Your gut bacteria also plays a role in the deconjugation of bile acids. An imbalance or overgrowth of gut bacteria can alter how bile acids are processed.

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. (12)

Changes in the synthesis and the concentration of bile acids in the colon have been identified in constipated children (13) and in adults with IBS-C. (14,15)

People with IBS-C have a decreased concentration of deconjugated bile acids compared to healthy people or people with IBS-Diarrhea. (16,17)

The reduction of the secondary bile acids in the colon leads to slower bowel movement and less water being brought into the bowel and may result in constipation.

Methane and Constipation

In a study researchers found an abundance of methanogens (such as Methanobrevibacter smithii) was increased in harder stools, a finding that was consistent with the elevated methane gas production in patients with chronic constipation. (18)

Methane levels were reported to be higher in patients with slow-transit constipation compared with normal-transit constipation and non-constipated controls. (19, 20)

Methane has been shown to slow gastrointestinal motility, plus, the higher the volume of methane, the more severe the constipation. (19,20)

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.(21)

As you can see alterations in bacterial populations in our large intestine can affect many of its normal processes particularly bowel movement.

Testing

To check the health of the microbiome in your large intestine you complete a Comprehensive Stool Analysis which tests your stool for bacterial and yeast overgrowths plus the levels of your beneficial bacterial species, alongside other digestive markers. To learn more about the stool test and see a sample report go here.

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.)

Researchers have found that in patients IBS, who were  methane positive on a lactulose breath test, there was a 100% association with constipation and that the higher the methane levels the more severe the constipation. (21)

SIBO is also associated with bloating, abdominal pain, gas and reflux which are commonly experienced in patients with chronic constipation.

High methane on a breath test is the most common finding I see in patients who present with chronic constipation.

Testing

To test for SIBO you complete a Lactulose Breath Test which measures levels of Hydrogen and Methane gas in your intestines. To learn more about SIBO Testing and see a sample report go here.

There is a reason for your constipation, research shows it is commonly related to bacterial imbalances in the gut, it just requires proper testing to figure out what is going on.

Constipation Treatment

With the results of your stool test and breath test we have a better understanding of what is causing your constipation; in the vast majority of people this will be a combination of a bacterial and/or yeast overgrowth in the small and/or large intestine, alongside an undergrowth of beneficial bacteria in the large intestine.

With this information in hand, a targeted, individualised treatment plan is designed for you, which incorporates:

  • Removing foods from your diet that cause inflammation and feed bacterial/yeast overgrowths. Learn more about the eating plan here.
  • Removing any overgrowths of bacteria and/or yeasts in your gut with herbal medicines..
  • Restoring beneficial bacteria and re-establishing healthy bacterial balance in your gut with prebiotic fibres/foods and probiotic supplements/foods.
  • Restoring bowel motility – some patients who have long term constipation may need to retrain the muscles and nerves of the bowel to fire again, I use herbal formulas to assist this retraining.

This does require work on your part, and restoring the gut takes time, but when the balance is restored your symptoms of constipation, bloating, gas, pain, etc. will be resolved.

What next?

To learn more about the testing, treatment details and to see if this programme is for you, it is recommended that you book a free 15 minute phone consultation. During this call you can learn more about the programme 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 the online calendar. Just click the link below, choose a date and time convenient for you, enter your details, and Matt will call you at your chosen time. Book here

References

  1. Friedman, G. Diet and the irritable bowel syndrome. Gastroenterol Clin North Am. 1991;20;313-324.
  2. 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.
  3. 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.
  4. 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.
  5. Codling c, et al. A molecular analysis of fecal and mucosal bacterial communities in irritable bowel syndrome. Dig. Dis. Sci. 2010; 55: 392-7
  6. Balsari A, et al. The fecal population in the irritable bowel syndrome. Microbiologica 1982; 5: 185-94.
  7. 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.
  8. Nourrisson C, Scanzi J, Pereira B, NkoudMongo C, Wawrzyniak I, Cian A, Viscogliosi E, Livrelli V, Delbac F, Dapoigny M, Poirier P. Blastocystis is associated with decrease of fecal microbiota protective bacteria: comparative analysis between patients with irritable bowel syndrome and control subjects. PLoS ONE. 2014;9(11):e111868
  9. Kirgizov IV, Sukhorukov AM, Dudarev VA, Istomin AA. Hemostasis in children with dysbacteriosis in chronic constipation. Clin Appl Thromb Hemost. 2001;7(4):335–338.
  10. Nourrisson C, Scanzi J, Pereira B, NkoudMongo C, Wawrzyniak I, Cian A, Viscogliosi E, Livrelli V, Delbac F, Dapoigny M, Poirier P. Blastocystis is associated with decrease of fecal microbiota protective bacteria: comparative analysis between patients with irritable bowel syndrome and control subjects. PLoS ONE. 2014;9(11):e111868
  11. Fan YP, Chakder S, Gao F, Rattan S. Inducible and neuronal nitric oxide synthase involvement in lipopolysaccharide-induced sphincteric dysfunction. Am J Physiol Gastrointest Liver Physiol. 2001;280(1):G32–G42
  12. Chassard C, Dapoigny M, Scott KP, et al. Functional dysbiosis within the gut microbiota of patients with constipated-irritable bowel syndrome. Aliment Pharmacol Ther 2012;35:828
  13. Gobert AP, Sagrestani G, Delmas E, et al. The human intestinal microbiota of constipated-predominant irritable bowel syndrome patients exhibits anti-inflammatory properties. Sci Rep 2016;6:39399
  14. Bajor A, Gillberg PG, Abrahamsson H. Bile acids: Short and long term effects in the intestine. Scand. J. Gastroenterol 2010; 45: 645-664.
  15. 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.
  16. 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.
  17. Rao Aj, et al. Chenodeoxycholate in females with irritable bowel syndrome – constipation: a pharmacodynamic and pharmacogenetic analysis. Gatroenterol. 2010; 139: 1549-1558.
  18. 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
  19. Attaluri A., Jackson M., Valestin J. & Rao S. S. Methanogenic flora is associated with altered colonic transit but not stool characteristics in constipation without IBS. Am. J. Gastroenterol. 105, 1407–1411
  20. Sahakian A. B., Jee S. R. & Pimentel M. Methane and the gastrointestinal tract. Dig. Dis. Sci. 55, 2135–2143 (2010).
  21. 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.
  22. 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).
  23. 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.
  24. 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
  25. 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
The Digestive Wellness Clinic
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