Constipation

Constipation is a condition in which a person has difficult or infrequent passages of feces.

Constipation may be functional or a symptom of underlying pathology, and may be acute or chronic, lasting days, months or years. It usually results from a delay in transit within the colon from a wide variety of diseases.

Constipation may occur at any age but is far more frequent in infancy and old age.  Adults should be aiming for at least one formed stool per day. 

The stool should be 20-30cm long, soft, well formed, easy to pass and not overly offensive with odour.  Many people are chronically constipated and are not aware, passing a small hard stool each day or even 1-2 small loose stools daily.  Often the loose stools are a result of food intolerances, caffeine, parasites or gut dysbiosis.

Causes and Risk Factors of Constipation

• Inadequate fibre intake / diet high in refined foods
• Inadequate fluid intake
• Lack or change in physical activity (often occurs with illness or travel)
• Psychological factors, particularly stress and depression
• Food allergy / intolerance
• Bowel dysbiosis / lack of beneficial gut bacteria
• Sluggish liver
• Long term laxative abuse
• Pharmaceutical drugs: antacids, anticholinergics, anti-depressants, anti-histamines, calcium or iron supplements, calcium channel blockers, cholestyramine, codeine, NSAIDS, narcotics, tranquilisers, sedatives, diuretics
• Structural abnormalities: anorectal fissures, thrombosed hemorrhoids, tumours
• Endocrine or metabolic disorders: hypothyroidism, hyperkalaemia, hypokalaemia, pregnancy
• Neurological disorders: Parkinson’s disease, cerebrovascular events, spinal cord injury
• Smooth muscle or connective tissue disorders: amyloidosis, scleroderma
• Congenital impairments: aganglionic megacolon, neuromuscular bowel impairment

Differential Diagnosis

Before treating constipation as a primary condition, it is important to rule out underlying medical or psychogenic causes including:

• Inflammatory bowel disease (usually associated with blood and mucous in stools)
• Diverticular disease
• Anal fissure / haemorrhoids (usually associated with bright red blood in stools)
• Gut dysbiosis / infections
• Hypothyroidism
• Hypokalaemia / hypercalcaemia
• Lead poisoning
• Depression
• Intestinal obstruction
• Colorectal cancer

TREATMENT STRATEGY FOR CONSTIPATION

Identify and address underlying causes:

• Gut dysbiosis, gut infections etc.
• Dietary & lifestyle factors
• Food allergy and sensitivity
• Laxative/medication use (NB prescription drugs must only be discontinued under supervision of a medical practitioner)
• Stress, depression
• Underactive thyroid or other underlying disease
• Re-educate bowel
• Stimulate digestive function
• Replenish bowel microflora
• Tone gut wall (atonic constipation)
• Decrease smooth muscle spasm (spasmodic constipation)
• Address psychological issues / support nervous system

Diet plan guidelines for Constipation

• Identify and address food allergies and sensitivities
• Increase fibre intake from both insoluble and soluble sources:
• Insoluble fibre prevents constipation and forms the basis of soft, bulky stools. It is found in the majority of fruits and green leafy vegetables, whole grains and nuts and seeds.
• Soluble fibre adds bulk to stools and promotes growth of healthy bacteria in the gut. It is found in onions, chicory root, Jerusalem artichokes, oats and oatmeal, apples and strawberries and psyllium
• Psyllium husks, chia bran, oat bran or pectin added to foods can help relieve constipation
• Fibre intake should be increased slowly (to avoid side-effects) to at least 30 g/day for men and 25 g/day for women
• Eliminate refined foods
• Ensure adequate fluid intake: at least 2L daily (especially with increased fibre intake)
• Include laxative foods:
• Prunes or figs soaked in water or prune juice: contains compounds that act as stool softeners
• Other dried fruits such as raisins, pears and figs help promote intestinal motility
• Include foods to stimulate digestion:
• Bitter foods: radicchio, rocket, endive, artichoke, lemon juice
• Lemon juice in warm water on rising followed by abdominal massage
• Apple cider vinegar with meals
• Include probiotic foods to balance gut flora: yoghurt, sauerkraut, kefir, kombucha

Supplements that support Constipation

• Psyllium, chia bran, or pectin fibre supplements – careful with fibre supplements as they can make the constipation worse if not dosed correctly and with adequate hydration
• Probiotics: Bifidobacterium lactis HN019 and Bifidobacterium animalis DN-173 010 have both been found to significantly increase gut transit time after 2 weeks supplementation
• Digestive enzymes may be useful, particularly where there is undigested food in the stool
• Magnesium: in spasmodic constipation or where there is nervous tension

Herbal medicine treatment that supports Constipation

• Gall bladder stimulants: barberry, St. Mary’s thistle, yellow dock, globe artichoke, dandelion, turmeric, celandine, black walnut
• Bowel tonics (for atonic constipation): cascara (low-dose: 25 drops 4 x day for 2-3 wks, then 3 x day for 2 wks, then 2 x day for 2 wks, then once daily for 2 wks); rhubarb (small dose)
• Laxatives (short-term only): aloe, cascara, rhubarb (large dose), licorice, butternut
• Carminatives – (should always be prescribed with herbal laxatives): chamomile, peppermint, cinnamon, fennel
• Digestive stimulants: ginger, gentian, angelica, centaury, agrimony
• Nervines: chamomile, oats, skullcap, verbena, valerian
• Antispasmodics (spasmodic constipation): valerian, chamomile, cramp bark, wild yam
• Bulking agent (spasmodic constipation): slippery elm

FUNCTIONAL MEDICNE TREATMENT OF CONSTIPATION

Constipation is a condition that can have many causative factors.  Short term constipation often occurs from an acute illness or when there are sudden changes in diet and lifestyle.  These changes will often resolve themselves when the external circumstances return to normal. 

Chronic constipation needs addressing through identifying underlying pathological imbalances and assessment of diet and lifestyle.  Many of the patients we see at Advanced Functional Medicine have gut infections, intestinal permeability and a lack of beneficial gut flora. 

Comprehensive stool testing is recommended along with SIBO breath testing to uncover many possible causes of the constipation.

If you or a family member are suffering from constipation or other digestive disorder, would like your gut tested or want more information on your digestive issue we would love to hear from you, please write a comment below.

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