4.0 Constipation and Bloating with IBS

This is an overview of Constipation and gives you all of the background knowledge that you need to understand the problem. Our Diet Treatment Plans specifically are targeted to which symptoms you have whether they be Bloating alone or Diarrhoea/Constipation with or without Bloating.

4.0.1 Some important things to know:

4.0.1.1 Constipation is a difficult area because the word can mean different things to different people. Also, some types of constipation need special tests and treatment beyond just diet or the use of simple laxatives.

4.0.1.2 We will go through some key things to look out for and if you think that they apply to you, make sure that you highlight them to your doctor or nurse.

4.0.1.3 A “normal” bowel habit is to pass a motion anything between once / twice a day up to once every three days - You don’t have to go every day!

4.0.1.4 Everyone’s bowels change from time to time, even if we don’t change our diet

4.0.1.5 It is normal for stools to vary quite a bit in shape, colour and consistency

4.0.1.6 Age has nothing to do with bowel habit

4.0.1.7 Excessive straining, a sensation of a “lump coming down”, or the need to use a finger to help stool coming out needs to be discussed with your nurse / doctor

4.1 Alarm Symptoms with Constipation
Very important to know about before talking about IBS and constipation are what are called “alarm” features or “red flags”. If any of the list below applies to you, highlight it to your doctor as it is important that conditions other than IBS are looked into:

4.1.1 Unintentional weight loss that has not been explained

4.1.2 Bleeding on going to the toilet

4.1.3 Symptoms that wake you up in the middle of the night

4.1.4 A relative who has had cancer of either the lower bowel or ovaries

4.2 What is Constipation?

4.2.1 Regularly not going to the toilet for over three days.

4.2.2 Passing pebble-like or hard stools on more than a quarter of the occasions that we go to the loo (see Bristol Stool chart).

4.2.3 A less common form of constipation is where the bowels seem to swing from one extreme to the other, where little or nothing happens for some time, then diarrhoea comes. This is called “overflow” diarrhoea and is an important type to recognise.

4.2.4 The Bristol Stool chart: This is used to define stools that are “too hard”- Type (1 or 2). It is a strange thing for doctors to have put together but, this chart is useful to help us describe how things are.

4.2.5 Common symptms with Constipation:

4.2.5.1 Straining a little or a lot

4.2.5.2 Hard stools (a lot of the time)

4.2.5.3 Urges that don’t result in passing much stool (maybe just gas or “jelly”)

4.2.5.4 Not going to the toilet very much / having no urge to go (called "anismus")

4.2.5.5 Feeling that not everything has come out ("incomplete evacuation")

4.2.5.6 Bloating (sometimes described as “fullness”, “tightness”, “hardness”)

4.2.5.7 Tummy pain or discomfort

4.2.5.8 Tiredness, headaches or other seemingly unrelated symptoms.

4.3 What causes IBS and Constipation?
It is not known what causes IBS in general, but a lot more is known about constipation. One thing though, some medications can cause constipation: pain killers, calcium channel blockers (used for blood pressure and irregular heartbeats mostly). So, if you are taking medications, have a look at the information sheet that comes with them (but, don't stop anything without talking to your doctor first).

4.4 Types of Constipation
Generally, constipation is about how long it takes food waste to pass along (or, “transit”) the lower bowel.

4.4.1 A large proportion of us (60%) with IBS and constipation have “normal” transit constipation where our stools are just very hard and / or seem difficult to pass, but do pass all the same

4.4.2 Many of us (about one person in every six) get “slow” transit constipation

4.4.3 About a quarter of us have what is called “Pelvic Floor Dysfunction”, that is the muscles of our pelvis are not very well co-ordinated and this causes a "blockage". This is a key one to identify, if it applies to you.

4.4.4 IBS-Constipation and Chronic Idiopathic Constipation- what is the difference (if any!)? Something to mention here that you may come across if you've been Googling this stuff. There are two conditions that are really the same but are treated as being different and given different names when doctors are doing research and when drugs are licensed by governments. It's splitting hairs, but there you go! We have” IBS- Constipation” (IBS-C) which is when we get Constipation and tummy pain or discomfort together. "Chronic Idiopathic Constipation" where we just get constipation by itself, but no pain ("idiopathic" means nobody knows the cause).

4.5 Special types of Constipation
There are two special types of constipation to identify: “Blockage” (Pelvic Floor Dysfunction) constipation and “Overflow”. Many of us get some of these problems on occasions but, that is different to saying that we get this all the time. So, when reading the next few sections, apply the "on average...." rule to judge whether it is really describing what you suffer.

4.5.1 Blockage (Pelvic Floor Dysfunction) Constipation
It is very important for us to know whether we have the “Pelvic Floor Dysfunction” / “blockage” type of constipation as this may well need specialized tests at a hospital “Pelvic Floor” unit. These need are a bit more "work" to sort out but, the treatment is very successful. Other names for this type of constipation used by doctors are: Anismus or Outlet Obstruction.

Again, judging this really boils down to: “how much do I strain?” and “how much ‘urge’ to go do I get?” There are a few things to look out for:

4.5.1.1 Excessive or prolonged straining (even with soft stools)

4.5.1.2 Needing to put finger pressure on the “muscle” in front of the bottom (in order to push things up)

4.5.1.3 Having to use a finger to help scoop the stool out

4.5.1.4 A lump appearing when we strain (sensation of “something coming down”)

4.5.1.5 Never getting the urge to empty the bowels

4.5.1.6 Never have a feeling that the bowel has been emptied

We all strain a bit, on occasions maybe more than just a bit, at the best of times but, if this list really does ring a bell with you, highlight it to your doctor or nurse.

Many things can cause this type of constipation (e.g. lack of pelvic-floor muscle co-ordination) and some of them may be “learned” habits such as never wanting to go to the toilet at work or outside of home.

A small number of us may have had an eating disorder and some have been abused- these are very real causes and the constipation can be treated very well, but you need to tell your doctor or nurse about your history.

4.5.2 Overflow Diarrhoea
Why does diarrhoea belong in this section? Imagine the constipation to be like a cork blocking things that is swept away by the pressure building up behind it. It’s an important one to know about, as we always think that the diarrhoea needs to be stopped, but to do this actually just makes things worse.

4.6 Are there special tests for Constipation?
Apart from general IBS tests, the answer is no, except in cases of “blockage” type constipation.

4.6.1 Investigating "Blockage" type Constipation
If the symptoms mentioned above ring a bell, these are the sort of tests done to investigate things. They would be done at a Pelvic Floor Unit under the guidance traditionally of a bowel surgeon (a surgeon because this is just the way that things developed over many years, not because surgery is usually needed). The tests may include:

4.6.1.1 An ultrasound of the anus (using a slender, round-ended probe)

4.6.1.2 Measuring the strength of the anal muscles (similar to having the ultrasound)

4.6.1.3 An enema X-ray ("defaecating proctogramme"). This involves passing a short tube into the back passage to pass in some thick paste (barium) and then asking you to pass this out, as if you were going to pass a normal bowel motion. The X-ray pictures taken show how our muscles are coordinating (sounds embarrassing to do but is done in a special private room, often by a nurse)

4.6.1.4 A test to measure how the nerves in anus are functioning

4.6.2 Some other tests that you might come across

4.6.2.1 There is a test that can show slow-transit, called a “shapes” test. We swallow tiny “markers” (that show up on X-Ray), with a different shape being swallowed each day. An X-ray is then performed later on in the week and we can see how much progress they have made. This test is often not done though as doesn't add a huge amount of useful information- and that is fine.

4.6.2.2 A Lactulose Breath test to check for Small Intestinal Bacterial Overgrowth (“SIBO”) can be performed because there is a theory that if the gut bacteria are producing an excess of methane gas, this can interfere with how the colon functions. The SIBO Breath test, however, is more commonly done for Diarrhoea or excess Bloating/Gas.

The breath test for SIBO is done after drinking some "lactulose". This has nothing to do with "lactose", although sounds very similar. (Lactulose is a man-made sugar that is not absorbed by the gut and so is free to be gobbled up by any bacteria. It is often used as a "gentle" laxative).

With SIBO, it is thought that the relatively small amount of NORMAL bacteria in the small intestine begin to grow in number and so the foods that we eat meet these bacteria earlier than they should. (Most of the bugs in the gut are in the lower intestine [the colon]). The bacteria can digest (ferment) foodstuffs resulting in gas and laxatives being produced.

Sounds like a good theory but the reason that this is a "grey" area is that if you actually go looking for these "excess/overgrowth" bacteria in people with positive breath tests, you only find them in a tiny number. Yet, giving antibiotics can help some people’s symptoms. Neomycin, a non-absorbed medication that only works within the gut lining, is the antibiotic of choice for methane production, although often given with another antibiotic, Rifaximin.

The Lactulose Breath test checks for the production of two gasses by the gut bacteria: hydrogen (the commonest one) and methane. Different antibiotics are used for targeting each of these.

4.7 Treating Constipation
The first thing to do is to make sure that your story doesn't suggest a "Blockage" or "Overflow" type, where the bowel may swing from one extreme to the other. This is made better by treating the constipation NOT the diarrhoea. It is again important to be sure that your doctor or nurse has picked up on this point, just in case it got lost talking about other symptoms such as pain, discomfort or bloating etc.

Overflow diarrhoea is treated by using fibre (a “bulking agent”) to bulk out the stools- make them larger and softer. Sometimes it is suggested to first clear the bowel out with a strong laxative, e.g. "Picolax" or a similar sodium picosulphate type laxative (both prescription), say at a weekend, and then to start taking the bulking fibre in the form of flax/golden linseeds - this particular fibre supplement is much less likely to cause excess gas than many others.

Strong laxatives do not suit everyone and the use of them can be dangerous if you have heart or kidney problems; they are by prescription only in UK. They can also make the contraceptive pill not work. You should first discuss this approach with your doctor or nurse if you have concerns.

If none of the above applies, then we can put together “Normal” and “Slow Transit” Constipation as the treatment is much the same:

4.7.1 Diet: What we eat has a big role, essentially in “optimizing” the stool- making it soft and bulkier and out Diet Treatment Plans will do this (whether you have added gas or not). Fibre is the big central idea. Diet though, may not be enough by itself.

Many of us are helped by increasing fibre along with fluid intake. Drinking lots of water by itself will not help much (drinking litres above our requirement amount adds nothing other than making us pee lots!) and increasing fibre by itself may actually make things much worse (the fibre can set hard like cement if there is not enough fluid about). The message is that fluid and fibre together is the key.

One thing about fibre, it often needs to be taken for a few weeks before you see results. Also, some forms of fibre can make us very gassy whereas others much less so (we discuss this elsewhere). The idea is to make the bowel motions, softer, bulkier and easier for the gut to pass. Another thing to mention here is that for some of us, fibre can make discomfort worse due to a stretching effect on the bowel wall due to the bulkier bowel motions.

It can be difficult to ensure the best amount of fibre every day so packets of fibre such as Optifibre (Nestle) gives the benefits of fibre, but without gas formation.

4.7.2 Laxatives: If increasing fibre and fluid doesn’t work fully, the next step is to add a simple type of laxative such as Milk of Magnesia or an “osmotic” type of laxative such as lactulose; then building up the dose gradually. A “stimulant” type of laxative (such as senna or bisacodyl) is best not used. The next step-up from lactulose is to use a PEG laxative such as "Movicol" ("Miralax" in USA).

4.7.3 Motility drugs: When the combination of Diet and a trial of two different types of laxative does not work, that is when the motility drugs pruculapride and linaclotide are used. One side effect of these can be Diarrhoea!

4.7.4 Toilet sitting position: Whatever about fibre and laxatives, it is important for any of us with constipation caused by IBS to look at how we go to the toilet.

This seems bizarre but, not when you think about the complex actions that our pelvic muscles go through to make it all happen.

4.7.4.1 Our normal position, which really does not help the bowels to empty:

4.7.4.2 Better to Lean forward…:

4.7.4.3 and, get our knees above our hips:

4.8 Other Treatments: Some people go for colonic irrigation but, this is expensive, not very comfortable and doesn’t provide any extra benefit to that provided by a strong laxative like sodium picosulphate, Epsom salts etc.

4.8.1 Biofeedback Therapy: We have mentioned other symptoms such as absolutely no sensation of needing to go to the toilet, straining or, a sensation of incomplete clearing, or of “something coming down”. If you have any of these problems, the dietary and “toilet training” approach is good and often works, but, if things do not improve it is important to discuss them further with your doctor or nurse and see whether a referral to a Pelvic Floor Unit for investigation and possible Biofeedback therapy.

There is a very important treatment for severe constipation including "Blockage" (Pelvic Floor/Outlet obstruction) when diet and simple laxatives don’t work. It is called Biofeedback Therapy.

Biofeedback brings together diet, pelvic floor excercizes (relaxing and co-ordinating muscles of the pelvis), how we go to the toilet as well as psychological aspects, even acupuncture and on occasions, nerve stimulation.

The psychological aspects of constipation can be very, very important for some of us. If you think that this might have a bearing in your case, then do talk with your doctor or nurse.

Biofeedback is a long established technique, performed in the top Pelvic Floor Units worldwide and clinical trials show it to work very well. We do not all need it but when required, it can work very well for many of us.

4.9 Alternative and Complementary medicine: Some of us find alternative therapy to be helpful - in fact, up to 50% of us with IBS try something "alternative".

It is difficult to know what works but certainly, as with most treatments, some things work for some people and not for others.

In using alternative approaches, it is important to think about the balance between the costs (which you will have to pay), any potential side-effects and likely benefits.

It is important to be especially cautious in using some alternative medications, in particular Traditional Chinese Herbs and Ayurvedic medicine: Chinese herbs can be contaminated with heavy metals (e.g. lead) and up to a quarter of Ayurvedic medicines available can be spiked with other drugs. Also, do not use non-prescription drugs (even as creams) during pregnancy and avoid them if you are on other medicines as there might be interactions.

Green Tea Extract (a concentrate, not the tea we buy in ordinary shops) can be toxic to the liver. Herbal remedies should be avoided by anyone with liver disease.

Honest and un-biased information about alternative medication is available from the American website: www.ConsumerLab.com.

In the UK, NICE (a government advisory committee for healthcare) states that treatments such as aloe vera, reflexology and acupuncture are to be avoided as a treatment for IBS. That having been said though, it is possible that acupuncture could help with IBS-related pain though not helping other problems like diarrhoea/constipation, bloating, etc.