My tried and tested methods for relieving even the most stubborn constipation presentations.
What is constipation? Lets get technical:
Infrequent passage of hard stools accompanied by straining, peri-anal or abdominal discomfort with a feeling of incomplete evacuation.
The Basics #101
Almost every constipation guide will list the basics, so I’m going to reiterate them here given just how important it is that you meet these essentials first. But if you’ve ticked these boxes and you still aren’t getting any relief, then keep reading. I promise, when it comes to constipation, I’ve got you covered.
1. Water - Adequate fluid intake to soften stool. Aim for 2-3 litres of filtered water daily.
2. Fibre - Are you achieving 25-30g of fibre per day? Fibre can help ease constipation by improving the consistency and volume of the stool. It works by increasing the water content of the stool, making it softer and easier to pass. Fibre also helps to stimulate peristalsis, which is the wave-like contractions of the digestive muscles that move food through the digestive tract.
3. Sleep - Are you getting 7-9 hours of sleep per night? Just like your circadian rhythm controls your sleep wake cycle, it also regulates your gastrointestinal physiology including cell proliferation, motility, digestion, absorption, and electrolyte balance.
4. Exercise - Gentle walking can be an effective way to relieve constipation. Physical activity, such as walking, helps to stimulate the muscles in the digestive tract, promoting bowel movements and reducing symptoms of constipation. Aim for a brisk walk of at least 20-30 minutes each day to help improve gut motility and alleviate constipation.
Tips for more stubborn constipation:
If you’ve ticked all of the above with no relief then check out these tips:
5. Spacing meals apart (minimum 4 hours between meals) - No snacking. Supports activity of the migrating motor complex (MMC). The MMC is a. cyclic electrical and motor activity pattern that occurs in the gastrointestinal tract during periods of fasting. It is responsible for clearing the gastrointestinal tract of residual debris and preventing bacterial overgrowth. The MMC is also thought to play a role in stimulating appetite and regulating hunger.
6. Kiwi Fruit - Two large and ready-to-eat green variety kiwifruits with skins (approx 150 g per kiwifruit) consumed twice daily was shown to increase water retention in the small bowel and ascending colon and increase total colonic volume. Kiwifruit swell to over three times their original volume. Approximately 1.5 times that of psyllium. An increase in stool frequency and looser stool consistency is achieved as a result.
7. Magnesium - The standard therapeutic dose for Magnesium is 300-400mg daily. When it comes to constipation I push the boundaries and it works! You can safely go up to 1200mg per day (be sure to take this at night, you’ll wake up in the morning needing to go. For relieving constipation magnesium works by increasing the osmotic effect in the intestinal tract and drawing water in. This creates distension of the colon which results in an increase in peristaltic movement and bowel evacuation.
8. PHGG (Partially hydrolysed guar gum) - A type of soluble fibre that can help to alleviate constipation by improving the consistency and volume of the stool. It works by increasing the water content of the stool, making it softer and easier to pass as well as speeding up colonic transit time.
9. Vitamin C flush - A vitamin C flush is also known as an ascorbate cleanse. This is best done in the morning on an empty stomach. Everyone varies depending on how much Vitamin C you require. I find that if you start off with 1 teaspoon (3g) or 2 teaspoons (6g) (if chronically constipated) dissolved in 1⁄2 cup of water or diluted juice. Repeat the process every 15 minutes until you achieve a waterfall-like bowel motion. Vitamin C flush achieves a major clear out so is only indicated in extreme constipation or when wanting to detox effectively.
10. Anthraquinone herbs - Herbs that work by stimulating peristalsis (contractions of the bowel) that move the stool along. Anthraquinone herbs include - Cascara, Senna, Aloe vera, Yellow dock and Rhubarb. Always remember to pair with carminative herbs, such as chamomile to prevent griping. Anthraquinone herbs should be used as a last resort and for a short term only as you can develop dependance on these when used for longer periods. They are however exceptionally powerful and can assist with rebuilding healthy bowel habits when used correctly.
This is not an exhaustive list, but will be helpful for even the most chronically constipated individuals.
It’s important to remember that constipation is a symptom and a sign of a deeper problem. The above methods are great for getting your bowels moving and providing some relief, but to get to the root cause of your issue functional testing is usually required, so that you don’t have to rely on symptom management and can live your life free from constipation and the constant worry that comes with planning your life around passing a bowel motion.
Investigations for constipation:
My favourite investigations for constipation include:
- Extensive pathology, including allergy screen
- Microbiome analysis - Often dysbiosis is present where there is an imbalance in the bacteria present in the microbiome. Testing is so important to identify what the imbalance is and further to specifically target treatment.
- Breath testing - Often we see an overgrowth of Archaea where excessive methane production augments contractility of the bowel, leading to constipation.
*** Enquire for more info if this is something that you’d like to explore further.
The easiest way to assess intestinal transit time is via a stool transit test which can be easily performed in the comfort of your own home.
Stool transit test
- Consume corn on the cob or dark coloured quinoa slightly undercooked
- Make note of the date / time when you start to see corn / quinoa appear in your stool
- Make note of when you stop seeing corn / quinoa appear in your stool
Ideal stool transit time is between 12 - 36 hours. With first corn / quinoa sighting being within 24 hours.
Causes of constipation
The root cause of constipation isn’t always linear. Below are some considerations:
- Dietary: Lack of fibre, Poor fluid intake
- Motility: Slow transit constipation, IBS, certain medications, recreational drugs
- Structural: Colonic carcinoma, diverticular disease (Diverticular stricture, Previous surgeries, obstructed defecation, haemorrhoids, fissures
- Anatomic/anorectal abnormalities – musculature, surrounding structure, nerve supply to bowel may be impacted. (Rectocele, MS, pelvic or rectal surgery)
- Dyssynergic defecation - also known as anismus, is a type of pelvic floor dysfunction that makes it difficult to pass a bowel motion, often leading to chronic constipation. It's characterised by the pelvic floor muscles failing to relax properly during defecation, which can cause straining and incomplete evacuation.
- IBD - Crohn’s, Ulcerative colitis
- Defecation: Obstructed defecation, anorectal disease
- Defecatory pain caused by anal tears, fissures, haemorrhoids, other local anus problems, etc - impacts the desire to defecate
- GORD
- Ehlers-Danlos syndrome
- Drugs: Opiates, anticholinergics, calcium channel blockers, iron supplements, aluminium- containing antacids
- Laxatives - Long term stimulant laxative use
- Neurological: SNS dominance, MS, spinal cord lesions, cerebrovascular lesions, Parkinsons, distress or other mental illness, fear of painful defecation, trauma, sexual abuse, HPA dysfunction.
- Metabolic/endocrine: Diabetes mellitus, hypercalcaemia, hypothyroidism (hypothyroidism and Hashimoto's), liver insufficiency, pregnancy, menopause
- Parasitic infection
- Eating disorder or past eating disorder
- Fear of public toilets - Withholding behaviour so they neglect urge to go. When the stool remains in the colon it becomes drier and harder to pass
- Past sexual or physical trauma - psychologist or somatic therapy - where you move trauma through the body
- SIBO, IMO, LIBO - Intestinal methanogen overgrowth is known to slow down motility
- IMO - During the fermentation of carbohydrates, archaea, such as M.smithii, feed off the hydrogen produced by bacteria and produce a by-product of their own; methane. As with hydrogen, methane gas in the small intestine will cause abdominal bloating, slowed transit time and ultimately, constipation
- Gut microbiome dysbiosis
- Pathogenic bacteria can give off neurotoxins to ‘paralyse’ the muscles around the intestines, slowing peristalsis (intestinal movement) so that the organisms don’t get removed with the stool as easily as they may have before. Constipation can then create an environment in which pathogens can further grow and proliferate.
- Diet - high protein, low carbohydrate or keto diets lack adequate fibre to support digestion. These types of diets are also very damaging to the microbiome in that they lack the food source for good bacteria in the microbiome located in the large intestine and these bacteria have a significant impact on peristalsis
- Mineral deficiencies - Zinc, iron, copper, magnesium
- H-pylori infection
- Food sensitivities - The most prevalent food triggers for IBS sufferers include reactions to gluten, dairy, eggs and nuts, amongst others. These include true allergies (IgE- mediated immune response) or more mild intolerances (IgG-mediated immune response) as well as enzyme deficiencies that can lead to conditions like lactose or fructose malabsorption.
- Sedentary lifestyle