The Real Reason You Have Functional Constipation or IBS-C
I see a lot of clients in my clinical practice that have finally decided to beat constipation. Many have been labelled years ago as having IBS-C or Functional Constipation and encouraged not to look any further. For those that don’t take that advice, we almost always find an underlying (and treatable!) root cause that can explain their constipation.
This post is for everyone who has been ‘diagnosed’ with IBS-C or Functional Constipation (or self-diagnosed) and haven’t yet found the right education and/or courage to identify and treat their underlying root cause. This post isn’t for those of you who just need to drink more water, exercise or eat more fibre to get your bowels moving. We’re talking long term, recurrent constipation that persists in spite of doing all the right things and trying every home remedy under the sun.
Here is a summary of what we are going to cover:
> What exactly is IBS-C and Functional Constipation?
> What’s wrong with these definitions?
> What’s the difference between a symptom and a root cause?
> The top 3 root causes of IBS-C that your doctor probably isn’t testing for.
> Why you need to test for your root causes so you can heal.
Definition of IBS-C and Functional Constipation
Let’s get the definitions out of the way. As outlined in the Rome III diagnostic criteria:
Constipation dominant IBS:
1. Recurrent abdominal pain/discomfort for 3 or more days, that is associated with 2 or more of the following:
> Improvement with defecation
> Onset associated with fewer stools
> Onset associated with harder stools
2. Lumpy or hard stools (Bristol Stool Form Scale 1–2) for ≥ 25% of defecation.
1. Two or more of the following symptoms:
> Straining ≥ 25% of defecations
> Lumpy or hard stools for ≥ 25% defecations
> Sensation of incomplete evacuation for ≥ 25% of defecations
> Sensation of anorectal obstruction/blockage ≥ 25% of defecations
> Manual maneuvers to facilitate ≥ 25% of defecations
> ≤ 3 defecations per week
2. Loose stools are rarely present without use of laxatives.
3. Diagnostic criteria for IBS not met.
What’s wrong with these definitions?
Let’s forget for the moment the overlap and confusion caused by having two separate definitions for basically the same symptom set. The bigger problem is having a definition for a symptom (constipation) but labelling it as a definitive condition. As if identifying you have constipation somehow then allows you to understand and treat the underlying root cause. Neither of these two definitions do that.
What they do, is create a scenario in which many people feel they now know their problem and stop searching for the actual underlying root cause and something they can fix. This causes me a great deal of frustration and sadness in my practice, particularly when helping women who have been told years ago that they have IBS-C and therefore just struggled along, not realising they had a gut infection or similar underlying root causes that can actually be treated. They should not have had to put up with constipation for all these years.
What’s the difference between a symptom and a root cause?
A symptom is the outcome or result that you notice. Like constipation. A root cause is the reason that it is occurring. Constipation is a symptom and it has a root cause. And you can’t fix constipation simply by identifying that you have constipation. You can only fix constipation once you identify WHY you have constipation. We will list these very soon…
If you only know the symptom, you can only focus on suppressing those symptoms in the short-term. Using laxatives is a great example of only temporarily suppressing the constipation symptom. And while you may notice some improvement, your constipation will likely remain, return or progressively worsen, unless the underlying root cause is identified and treated.
Why you need to keep asking ‘Why?’
Here’s just one example that I commonly experience in clinical practice of how continuing to ask “why?” can start to get you closer to the real cause of your constipation, and closer to a solution that actually works:
Symptom: I have bloating and constipation
Why? #1: Because I eat certain foods like high-FODMAPs
Why? #2: Because the archaea in my GI tract are fermenting the carbohydrate from the food in my small intestine and producing methane
Why? #3: Because I have small intestinal bacterial overgrowth (SIBO)
Why? #4: Because my migrating motor complex (MMC) is not functioning correctly
Why? #5: Because I had food poisoning overseas last year, and after my immune system attacked and killed that bacteria, it is now attacking my MMC, causing SIBO (the root cause of IBS-C and bloating in this case)
I really hope that this example illustrates the point that if you stop at the first ‘Why?’, you might be eating a restricted low-FODMAP diet forever, or taking laxatives forever, constantly trying to manage symptoms as your health deteriorates. Only once you start to ask better questions (or more Why’s), can you get the answers you need to finally understand and heal your constipation symptoms.
So let’s get into the root causes. It’s not an exhaustive list by any means, but these are definitely the most common root causes of constipation I see in my practice.
Root Cause #1: Gut Infection
When we talk about gut infections, I’m referring to infections anywhere from the stomach right through to the small intestine and the colon. They are caused by pathogens, the most common being:
> Parasites: Blastocystis hominis, Entamoeba histolytica, Giardia lamblia, Cryptosporidium parvum, Dientamoeba fragilis.
> Bacteria: Helicobacter pylori, Citrobacter, Campylobacter, Clostridium difficile, Klebsiella pneumoniae.
> Fungi/Yeast: Candida albicans.
Overseas travel, food poisoning, overly affectionate pets or an outbreak in your town’s water supply can all give you a nasty bug. Unfortunately, pathogens are just a normal part of life in every country on Earth, it’s whether your immune system is strong enough to fight them off that really matters. It’s why we have stomach acid, good bacteria in our gut and an immune system to fight back and keep these ‘bad guys’ at bay. But, if you are stressed, intoxicated, fatigued, have food sensitivities or any other illness or health condition (even the common cold!), your immune system is likely to be compromised, increasing your risk of a gut infection with potentially lasting effects, like IBS symptoms.
Prior use of antibiotics (often used to kill another gut infection) is also a very common cause of gut infections, particularly Candida or overgrowths like SIBO. While antibiotics can sometimes be effective at killing the primary bacterial infection, by destroying all the good bacteria at the same time, they also create an environment for opportunistic pathogens and overgrowths to proliferate and cause long-term chronic conditions.
While most people associate a GI bug with diarrhoea, constipation is a common symptom that is less noticeable but tends to last a lot longer and cause more chronic side-effects. 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.
Root Cause #2: Small Intestinal Bacterial Overgrowth (SIBO)
I’ve written a three part series on SIBO, but here’s the abbreviated version. SIBO is characterised by an increased number and/or abnormal type of bacteria in the small intestine. Because these bacteria generally live in the large intestine, they are mostly species that ferment carbohydrates into hydrogen gas (H2) or archaea (not technically bacteria) that produce methane gas (CH4).
While both hydrogen and methane types typically result in abdominal bloating and distention, as with IBS sufferers, SIBO types are divided into one of three different categories; diarrhoea-dominant, constipation-dominant or alternating variations of both… sound familiar? Well that’s because, according to some studies, as many as 85% of those diagnosed with IBS actually have SIBO.
The diarrhoea-dominant SIBO is generally the result of carbohydrate-fermenting bacteria that produce hydrogen gas in the small intestine. The constipation sufferers, on the other hand, generally have archaea, to blame. 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, plus a much bigger problem – slowed transit time and ultimately, constipation.
Root Cause #3: Food Sensitivities & Inflammation
Clients with food sensitivities commonly present with many of the common IBS symptoms, including constipation. The most prevalent food triggers for IBS sufferers I see 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.
Recent research has suggested that food allergy and intolerance should be considered a possible cause of IBS. In my own clinical experience, I’ve definitely found food intolerances and malabsorption to be a very common contributing factor to IBS-C symptoms. It is also worth noting that food intolerances are themselves, often caused by some of the conditions discussed above, particularly a gut infection and the subsequent leaky gut (I’ve written a whole blog post on the connection between leaky gut and food sensitivities here).
So while food triggers can definitely make symptoms worse, generally they’re not the end of the line, but rather a sign of a deeper root cause. And when that underlying root cause is identified and healed, avoiding foods forever should not be needed.
How to find out your root cause
Testing! It’s so important to test so you know your exact root causes for IBS-C or Functional Constipation. Once you know what they are, you can treat and heal. The most common testing I complete for my clients who suffer with IBS-C or Functional Constipation are:
- Stool testing for gut infections
- Breath testing for SIBO
- Dry blood spot testing for food sensitivities
And once you have the answers, your path to a properly functioning colon becomes a lot clearer (pardon the pun).
This week, the key takeaway is that there is always a reason you don’t have regular, complete or well formed bowel movements. It’s Science 101: Cause and Effect. Don’t let anyone tell you that you have Functional Constipation or IBS-C without also identifying the actual root cause of your symptoms; something you can actually treat.
And while you’re finding the root cause, you can use the strategies in my Constipation E-Guide (subscribe below for your copy) to get things moving and ease the symptoms.