In part 1 of this series, we touched on some of the causes of bowel dysfunction in the form of diarrhea. In this part, we’ll move to the other end of the spectrum, to constipation. According to the National Institutes of Health, constipation implies fewer than three bowel movements per week. In other words, healthy colon function isn’t defined by daily bowel movements that occur like clockwork. In fact, according to the American Society of Colon & Rectal Surgeons, the misperception that healthy regularity requires daily elimination has “led to overuse and abuse of laxatives.” Nevertheless, there are patients who eliminate fewer than three times a week, or whose stools are hard and painful to pass; and chronic, long-term constipation can result in health compromises far beyond the large intestine.
As with trying to improve or resolve any chronic condition, the first steps should involve a low-level, non-invasive strategies known to be highly effective. When it comes to constipation, the obvious place to start is ensuring adequate hydration and fiber intake. However, if patients are already consuming healthy amounts of water and fiber, then it’s likely those factors aren’t the ones causing the condition, so increasing the amounts of either won’t resolve the problem. Several other factors influence bowel motility, so if diet and fluid intake have already been addressed and corrected, but the patient is still experiencing constipation, then deeper digging is in order.
One often overlooked, underlying cause of chronic constipation is low thyroid function. With the prominent role the thyroid gland plays in regulating basal metabolic rate, sluggish function can lead to a slowdown in a wide range of processes, including the movement of waste through the colon.
A surprising new avenue to explore with regard to constipation is celiac disease and the less severe category of gluten sensitivity. Although both conditions are typically more closely associated with diarrhea, there are patients in which gluten reactivity results in the opposite. A small study of Dutch patients age 18 and under being treated for constipation that was unresponsive to laxatives found that a significantly greater proportion had celiac than typically occurs in the larger population (confirmed via intestinal biopsy). Of the seven patients who were found to have celiac disease, implementation of a gluten-free diet removed entirely the need for laxatives in two cases, and led to reduced laxative dependence in another three, with the remaining two patients requiring the same amount as before. Although this was a small study, it highlights the unexpected finding that diarrhea isn’t the only bowel complication that can result from gluten intolerance.
Another avenue for relief of chronic constipation is repopulating the bowel with pre- and probiotics. In our over-sterilized and sometimes germ-phobic modern world, we’ve moved away from the traditionally fermented probiotic foods that cultures around the globe have regularly consumed. Several studies show a dose-dependent improvement in intestinal transit time with probiotic supplementation, but results are often species-specific. The mechanism isn’t well understood, but it’s suspected that “increased levels of lactic acid-producing bacteria may lower the colonic pH and production of other short-chain fatty acids may stimulate peristalsis,” resulting in decreased transit time. The potential for different mechanisms to be at work and for effects to be strain-specific is a good reason to look to high-dose multi-strain probiotic supplements to help ensure the viability of the microorganisms.
Conventional constipation remedies such as over-the-counter laxatives and high-dose magnesium can help alleviate acute discomfort in the short term, but bowel distress can be a sign of dysfunction elsewhere in the body, and these other factors should be evaluated to identify and correct the underlying cause.
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