Chronic Constipation: Types, Causes and Evidence Based Solutions

By Tucson Functional Medicine on August 19, 2024 • 0 Comments

Constipation, either acute or chronic, can be described as difficult, infrequent, or incomplete bowel movements. The stool tends to be small and/or hard. Under normal circumstances, bowel movements should occur at least daily.

How do you know if you have constipation?

This chart, called the Bristol Stool Chart, is a way of identifying constipation. Constipation generally refers to poo that is type 1 or type 2 on the chart. The poo is often hard and difficult to pass.

Why Does Constipation Occur?

Three main mechanisms may cause constipation:

Normal transit constipation

Normal transit constipation (NTC) is a type of constipation where stool moves through the colon typically, but patients still feel constipated. Patients may experience difficulty evacuating their bowels, hard stools, bloating, and abdominal pain or discomfort. NTC is the most common type of constipation

Slow-transit constipation

Slow transit constipation (STC) is a condition that occurs when stool moves too slowly through the large intestine, causing a delay in passing stools. There are infrequent bowel movements, limited urgency, or straining to defecate. The colonic movements are slow.

Dyssynergic Constipation (Pelvic Floor Dysfunction)

Dyssynergic defecation, also known as anismus, is a functional pooping disorder that can cause constipation. It occurs when the muscles and nerves in the pelvic floor don’t coordinate properly to have a bowel movement. These muscles, which support the bladder, rectum, and other pelvic organs, must relax in a coordinated way to eliminate stool. When they don’t, it can be challenging to know when you’re ready to have a bowel movement, pass stool, or complete a bowel movement. These patients have a poor ability to coordinate these muscles during defecation.

I recommend finding a practitioner skilled in pelvic muscle rehabilitation (PMR)

Pelvic rehabilitation, also known as pelvic floor rehabilitation or pelvic muscle rehabilitation (PMR), is a noninvasive treatment that aims to strengthen the pelvic floor muscles and improve coordination.

Pelvic floor therapy can help constipation because the pelvic floor muscles control the passage of stool. It can help identify and address any imbalances, tension, or weakness in the pelvic floor muscles that may be contributing to constipation.

A small-scale 2022 study involving 34 people found that behavioral therapies, including pelvic floor muscle training, helped improve inflammatory bowel disease (IBD) symptoms, including constipation.

Here is a directory to locate a practitioner skilled in PMR

https://pelvicrehab.com/

What Are the Causes of Constipation?

According to Dr. Michael Ruscio, he provides a detailed overview on the four common causes of constipation

1: Insufficiency (Inadequate water consumption, lack of optimal amount of fiber, and poor exercise habits)

Adequate Water Consumption: Drinking enough water prevents constipation because it helps fiber work better and keeps your intestines smooth and flexible. When dehydrated, your large intestine draws more water from your stool, making it harder to pass.

It’s as simple as this: drink 8-10 glasses of filtered water a day or half your body weight in water per day. These straightforward guidelines can make a significant difference in your digestive health.

Fiber: Soluble fiber in foods like psyllium husk or ground flaxseeds can help add bulk to stool and promote regularity.

Consuming between 25-30 grams of fiber per day is recommended. I recommend Psyllium Husk and Modified Citrus Pectin.

Modified Citrus Pectin is a soluble fiber that turns into gel in your digestive tract in the presence of water. As such, it softens the stool and speeds the transit time of material through the digestive tract, reducing constipation.

Exercise and Movement are effective in improving bowel function and relieving constipation.

The Centers for Disease Control and Prevention (CDC) recommends that adults get 150 minutes of moderate-intensity aerobic exercise per week to help relieve constipation. This could be 30 minutes of exercise daily, at least five times a week. If you’re short on time, you can break up your activity throughout the day, such as taking three 10-minute walks instead of one 30-minute walk 2 hours per week.

2: Bacterial Overgrowth

A common cause of bacterial overgrowth is Small Intestinal Bacterial Overgrowth (SIBO)

Small Intestinal Bacterial Overgrowth (SIBO) can cause constipation. SIBO happens when large amounts of bacteria are in the small intestine, where food mixes with digestive juices, and nutrients are absorbed into the bloodstream. Usually, the small intestine has relatively few bacteria because of the rapid flow of contents and the presence of bile. However, in SIBO, stagnant food in the small intestine can become a breeding ground for bacteria.

SIBO can disrupt normal intestinal motility, slowing transit times and difficulty passing stool.

** I strongly recommend that your healthcare provider obtain objective evidence to determine if you have SIBO.

I commonly use the services of Genova Diagnostics

https://www.gdx.net/products/sibo

Genova’s SIBO Profiles are non-invasive breath tests that capture exhaled hydrogen (H2) and methane (CH4) gases following patient ingestion of a Lactulose solution to evaluate small intestinal bacterial overgrowth (SIBO) and intestinal methanogen overgrowth (IMO).

The SIBO-Constipation Connection

The relationship between SIBO and constipation lies in the disruption of normal gut motility caused by excessive bacteria in the small intestine. When bacteria overpopulate the small intestine, they can produce gas and other byproducts that interfere with the coordinated muscle contractions required for efficient bowel movements. As a result, stool transit slows down, leading to constipation. Excessive bacteria can compete with the host for available nutrients, further contributing to constipation.

Nutritional Strategies for SIBO-Related Constipation

Addressing chronic constipation associated with SIBO often requires a multifaceted approach that combines dietary modifications with targeted nutritional interventions. Here are some nutritional strategies that can help alleviate constipation in individuals with SIBO:

Low-FODMAP Diet: A low-FODMAP diet restricts certain fermentable carbohydrates that can exacerbate SIBO symptoms. This diet can help reduce gas production and bloating, which may alleviate constipation.

Monash University FODMAP Diet

Download the Monash University FODMAP App

: https://www.monashfodmap.com/ibs-central/i-have-ibs/get-the-app/

Probiotics: While probiotics aren’t suitable for all individuals with SIBO, specific strains may benefit some.

The following chart represents the most evidence-based probiotics for SIBO and improving bowel function

Bacterial deconjugation of bile acids is another essential feature of SIBO.

Bacterial deconjugation is a process that occurs when intestinal bacteria break down bile acids through an enzymatic reaction.

Deconjugation can be crucial in Small Intestinal Bacterial Overgrowth (SIBO). When deconjugation occurs, it can create free bile acids that damage the intestinal lumen and reduce micelle formation. This can cause the bile acids to be absorbed in the jejunum instead of the ileum.

Bile ox supplements can help constipation and act as a natural laxative in the human body. Bile acids, produced in the liver and released into the digestive system, help break down fats, absorb them into the body, and promote bowel movements. They do this by softening stool and speeding up how quickly it moves through the colon.

Bile acids can help with constipation by stimulating the intestinal walls and speeding up gut transit time. They do this by causing the colon to secrete fluids and electrolytes and by stimulating contractions in the colon.

Digestive Enzymes: Digestive enzyme supplements can assist in the breakdown of food, potentially reducing the substrate available for bacterial fermentation.

Herbal Therapies: Herbal antimicrobials like berberine, oregano oil, and neem may help reduce bacterial overgrowth in the small intestine.

Nutraceuticals: Nutritional supplements like magnesium citrate or oxide can be natural laxatives to promote regular bowel movements.

** Word of Caution: I strongly advise all readers to seek medical advice from a healthcare provider knowledgeable in the prescriptive and botanical approach to SIBO.

The Elemental Diet

An elemental diet can help with small intestinal bacterial overgrowth (SIBO).

An elemental diet is a liquid diet that provides the body with easily digestible nutrients. It reduces the amount of food in the small intestine, which starves the bacteria that cause SIBO symptoms. It also eliminates complex carbohydrates that feed bacteria, resetting the microbiome and alleviating symptoms.

Clinical studies have shown that an elemental diet can effectively reduce gastrointestinal symptoms and normalize lactulose hydrogen breath tests, often used to diagnose SIBO. One study found that 80% of subjects had a standard breath test on day 15 of the diet, and 85% had a standard breath test by day 21. Those who successfully normalized their breath test also saw a 66.4% improvement in bowel symptoms, compared to 11.9% for those who didn’t.

There are a variety of elemental diet formulas. I have found success with Physicians’ Elemental Diet from Integrative Therapeutics

https://integrativepro.com/products/physicians-elemental-diet?variant=47686039667002

Some healthcare providers recommend 2-3 weeks on an elemental diet; however, I have unfortunately seen low compliance and recommend 1-4 days and check to see if there is an improvement in bowel function.

Prokinetic agents

Prokinetic agents promote intestinal motility and are used for severe constipation-predominant symptoms associated with irritable bowel syndrome with constipation (IBS-C) or chronic idiopathic constipation (CIC)

They work by increasing the frequency or strength of contractions in the gastrointestinal tract, which improves motility and can help with constipation symptoms.

** Word of Caution: I strongly advise all readers to seek medical advice from a healthcare provider knowledgeable in the Prokinetic agents

Dr. Michael Ruscio has written an excellent detailed article on prescriptive and natural prokinetic agents

https://drruscio.com/prokinetic-agents.

3: Abnormal/Altered Structural Abnormalities of the Colon (Tortuosity in the colon)

Tortuosity in the colon, or a redundant colon, can cause constipation. A redundant colon is a congenital condition that causes the colon to twist and loop to fit inside the body, often making it longer than 5 feet. This can lead to constipation, as well as other symptoms like bloating, abdominal pain, impacted stool, gassiness, and cramping.

A redundant or tortuous colon is an abnormally long colon that cannot fit inside the body without looping or twisting. There is no apparent cause, but it can lead to complications and gastrointestinal problems, including constipation.

The following photo shows a worsening of tortuosity in the colon going from left to right.

Treatment to consider:

Abdominal Massage

Some people with a tortuous colon may benefit from abdominal massage, which can help with constipation and promote bowel movements.

Here are some abdominal massage techniques you can try:

Clockwise circles

While lying down, place your palm on your abdomen and make small, clockwise circles around your belly button. You can gradually widen the circles to cover your entire abdomen.

Smooth strokes

Place your hand below your breastbone and glide it down the length of your abdomen. Repeat the movement with your other hand and continue for several minutes.

Firm circles

Press firmly into your belly and slide your hand in a circular motion toward your ribs, across your belly, down to your left hip bone, and back across the bottom of your belly. Repeat ten times.

L-shape

Apply moderate pressure from the right side of your ribcage, underneath the ribcage to the left, and down to the front of your left hipbone, forming the letter “L.”

U-shape

Stroke 10 times from the front of your right hipbone up to your right ribcage, across to your left ribcage, and down to your left hipbone, forming the letter “U“.

Clockwise circular finish

Finish with 1-2 minutes of a clockwise circular massage 2-3 inches away from your belly button to stimulate your small intestine.

The following short three-minute video from the work of Dogan, Gursen, Akbayrak, Balaban, Vahabov, Uzelpasac? and Ozgul explained in their paper titled Abdominal Massage in Functional Chronic Constipation: A Randomized Placebo-Controlled Trial reveals 28% to 70% reductions in constipation severity.

https://www.youtube.com/watch?v=Hcjo9gLxJsw

I also want us to consider the potential of developing adhesions in the intestines from a variety of GI and neurological issues contributing to chronic constipation.

I suggest reviewing the following for more information on the effective treatment for breaking up adhesions

: https://clearpassage.com/

Consider Biofeedback Therapy

Biofeedback therapy can help constipation by training the rectum and pelvic floor muscles to achieve regular bowel movements. Biofeedback therapy can also help with other bowel problems, such as fecal incontinence, rectal hypotension, and difficulty emptying the bowel

4: Gut-Brain and Constipation

The brain and gut are connected, which can play a role in constipation. Research shows that the brain and the gut are intimately connected, sharing bi-directional communication, which makes up the “brain-gut axis.”

Constipation can cause the enteric nervous system (ENS) to send signals to the brain, triggering feelings. The ENS is sometimes called the “second brain” because it contains millions of neurons directly affecting gut activity.

The stress response triggers the release of corticotropin-releasing factor (CRF), which has been shown to alter gut motility and sensitivity. During periods of stress, the body’s “fight or flight“ response can suppress digestion and slow down the movement of food through the GI tract, leading to constipation.

Action Steps to Reduce the Fight or Flight“ Response and Improve Bowel Function

1: Spend Time in Nature

Spending time in nature may improve gut health and bowel function.

2: Meditation

Studies have shown that meditation can improve gut health, which may also improve bowel function.

Meditation, a powerful tool, can directly influence the gut-brain axis at both the brain and gut levels. By regulating stress hormones that can disrupt gut bacteria, meditation aids in restoring balance and reducing inflammatory markers.

3: Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy (CBT) can be used to treat constipation in several ways, including:

CBT can help improve bowel symptoms, quality of life, and psychological distress in people with IBS, regardless of subtype. CBT is a short-term, collaborative therapy that focuses on modifying behaviors and changing thought patterns to affect mood and physiological symptoms. Stress and anxiety can aggravate bowel symptoms, and CBT can help with these negative emotions.

The Link Between Vagus Nerve and Constipation

The human brain, with its staggering 86 billion neurons, is a marvel of nature. Equally fascinating is the human gut, housing an intricate network of 200-600 million neurons, known as the enteric nervous system (ENS). The vagus nerve , a vital communication channel, carries electrical signals from the gut to the brain, playing a crucial role in gut health.

When the body is stuck in a sympathetic-dominant state, or the fight, flight, or freeze response, for an extended period, the vagus nerve can lose its “tone.” This tone is crucial as it instructs the intestines to contract, facilitating normal peristalsis, the movement of food through the gut. A weakened vagus nerve can slow down gut motility, leading to constipation.

In a state of chronic stress, or when dealing with constipation, the vagus nerve’s tone weakens. This underscores the profound connection between our mental and physical well-being, as both stress and constipation can impact vagal tone.

Activating Your Vagus Nerve

Recent neuroscientist research has identified the following strategies for stimulating the vagus nerve and getting our neurons firing again.

Gargling and gagging
Singing and humming
Alternate nostril breathing and deep breathing
Cold exposure
Exposure to sunlight
Meditation
Laughing
Music therapy supplements (probiotics and omega three fatty acids)
Body work such as massage, acupuncture, cranial sacral therapy
Essential oils-Vagus Nerve Kit (https://shop.vibrantblueoils.com/product/vagus-nerve-kit/)

The following two tools have been effective in improving Vagus function:

1: Rezzimax Tuners (https://rezzimax.com/)

2: Hoolest (https://hoolest.com)

Here is a summary of the key takeaways to effectively address constipation from an evidence-based perspective:

1: Adequate Water- half your body weight in water per day

2: 25-30 grams of Fiber (High fiber food and Psyllium Husk and Modified Citrus Pectin)

3: Exercise and Movement-150 minutes of moderate-intensity aerobic exercise per week

4: SIBO- get evaluated and properly treated (FODMAP Diet, Probiotics, Enzymes, Prescriptive and Herbal Therapies, Elemental Diet, Prokinetic agents

5: Abnormal/Altered Structural Abnormalities of the Colon (Abdominal Massage and Biofeedback Therapy)

6: Identify and treat the Brain-Gut Connection (Time in Nature, Meditation, CBT, and Vagal Nerve Rehab)

Additional Secondary Causes of Constipation to Consider:

Other types of constipation include secondary constipation, which can be caused by medication, chronic diseases such as hypothyroidism and diabetes, and neurological conditions such as Parkinson’s disease and multiple sclerosis.

It is crucial to be aware that chronic constipation may be an early warning sign of a patient developing Parkinson’s disease.

Implementing the information thoroughly outlined in this article can significantly improve bowel function and reduce the incidence of constipation.

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References:

Chronic Constipation: Types, Causes and Evidence Based Solutions

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