June 3, 2019

A major problem in modern America is constipation. I have avoided this topic for far too long because I assumed that it was well understood. Alas, I am finding that it is not. So here goes the story of the gastrointestinal bowel movement in all its glory.

Unfortunately, more and more people are constipated than ever before as sedentary behavior, low fiber refined diets and food sensitivities drive colonic dysfunction, for example, irritable bowel syndrome. Never does a day pass by in clinic that this conversation is missed. For the purposes of this article,

I am going to assume that all patients have been ruled out for diseases like Hirschsprung's and other anatomic abnormalities that can be repaired via surgery.

According to Dr. Mugie and colleagues: "The epidemiology of constipation in children was investigated in 19 articles and prevalence rate was between 0.7% and 29.6% (median 12%). Female gender, increasing age, socioeconomic status and educational level seemed to affect constipation prevalence." (Mugie et. al. 2011) In our clinic experience this number is closer to the 1 in 4 range.

According to the US Census Bureau, there were 73.7 million children residing in the United States in the year 2016. That means somewhere between 8,844,000 and 21,815,200 children have had or have issues with defecation every week. This is tragic considering this issue is entirely preventable.

 What is constipation? There is no consensus definition, however, the ROME criteria are the best accepted in that space. For infants and young children: Scybalous, pebble-like, hard stools for a majority of stools or firm stools two or less times/week; and there is no evidence of structural, endocrine, or metabolic disease. For older children and adolescents, the criteria are much broader as per Table 1 in the Rajindrajith article. Essentially, hard, painful, enormous or pebble like stools that are less than 2 times a week is one definition. Stooling in your pants or clogging toilets is another definition. Stool retention is also a risk factor and criteria for constipation. (Rajindajith et. al. 2016)

 In our clinic, I ask my patients a few very simple questions, 1) do you struggle to pass a stool and does it hurt often?, 2) do you clog your parent's toilets sometimes?, 3) does your stomach ache often around your belly button for 30-60 minutes and then you return to feeling fine?, 4) how often do you produce a bowel movement?, 5) do you refuse to go to the bathroom at school or outside of your house?. If the answer to any or all of these questions is yes, then you must consider that your child or you may be struggling with constipation.

 The next line of questioning has to revolve around what do you eat, how much water you drink and how much physical movement occurs on a daily basis. The disease risk promoting answers would be that you consume lots of refined, low fiber junk food/pizza/burgers/etc.., you drink very little water, you consume lots of dairy and that you sit on the couch for hours a day with little movement. Micronutritent deficiencies like low magnesium are associated with poor bowel motility. Each one of these modifiable risk factors can point to constipation as a disease issue.

 

Stress of the psychological variety is also a leading cause of reduced bowel activity as stress turns on the hormones like cortisol that reduce gut activity in order to shunt blood toward your brain and muscles. This is a major player in many children from intense households and lower socioeconomic status situations.

 Drugs can cause bowel slowing with opioids being the most notorious category as they affect the opioid mu receptors in the gut lining slowing all gastric emptying and intestinal peristalsis. See List.

 We cannot forget about the obligatory "genes" connection from your parents as a link. Therefore, asking about family constipation issues is a valid idea. There are definitely genetic predispositions to these issues.

 What does normal look like???

 In a fully functional GI tract, a human will consume water and food which is broken down in the mouth and stomach into smaller particles until they move downstream to the intestine where the bulk of our macro and micronutrients are absorbed. The remaining material is slowly transitioned to the colon where stool is formed for final defecation.

Simplistically, these events occur flawlessly when we are rested and unstressed, well fed with fiber based whole foods, do not take medicines, move often, drink water adequately, and consume adequate magnesium dietarily.

 When we perform this process poorly, we set ourselves up for poor elimination and the secondary consequences of stool withholding.

Next week is part 2

Move and eat fiber,

 

Dr. M

Mugie Best Practice and Research Clin Gastro
Van Den Berg American Journal Gastro Article
Rajindrajith World Journal of Gastro Article
Culbert Pediatric Clinics Article
Crowley Nutrients Article
Ramsay British Medical Journal Article
Micelli Sopo J Pediatric Gasrto and Nutrition

 

Erratum: Last weeks link to the CDC fo tick removal did not work. Here is a better Link.

Here is a bonus video on removal. Link