Nothing in, nothing out: but is there more to constipation?
Doctors tend not to consider IBS a serious condition; that would be a mistake. Although most people seem to cope with the occasional inconvenience of it and live a normal life, others have a lifetime of pain and disability. Hilary is one of the latter. She writes as follows:
I am in my 60’s and have suffered from anorexia, severe IBS and constipation for 46 years. I experience severe abdominal pain daily. Over the years, I have been prescribed Fleet enemas, the Peristeen irrigation system, also Prucalopride, Laxido and antispasmodics. Laxido turns everything inside me to liquid causing a huge build up of abdominal pressure as everything gets stuck much higher up. My body mass index (BMI) is currently about 14 (a healthy BMI is between 19 and 25) When I saw my consultant recently, he advised me to try to gain some weight but I have no appetite and feel nauseous much of the time. It is so difficult to know how to get back into the driving seat of my life. I really feel at a loss as to know how to manage my symptoms – which medication to take when and what to eat. I wonder whether complementary therapies might help.
Hilary’s BMI is alarmingly low, and she has been ill for such a long time. Anorexia and constipation often go together. I tend to think of people with this combination as ‘nothing in, nothing out people’, though I am not sure the link is an obvious as that. Nevertheless, her doctor’s advice seems appropriate though I wonder if the drugs she is taking for her constipation may be making her more nauseous.
Confronted with letters like Hilary’s, I always have more questions than answers. Is nothing in ,nothing out a gastrointestinal ‘freeze’ response? Has psychological trauma caused her gut to shut down whenever society impinges or intrudes upon a vulnerable sense of self? Would this also include the intrusion of doctors and investigations? If so, is it associated with repressive symptoms? For many years, constipation was thought to be associated with depression and recent observations suggest it may also be associated with chronic fatigue. So is constipation a symptom that indicates a lack of engagement? There is no good data to substantiate these suppositions; they do not attract research funding and it is difficult for questionnaires to capture the meaning of individual experience within a population defined by a symptom.
Constipation can have many causes. It can, for example, rarely be caused by degenerative diseases of the colonic neuro-musculature and more commonly by some drugs, such as strong pain killers, antidepressants, calcium and iron salts. Most people, however, have what is termed ‘idiopathic constipation’. In other words, doctors do not know the cause. The distinction between IBS constipation and idiopathic constipation seems to me somewhat arbitrary.
In order to identify specific causes, which might lead to effective treatments, scientists have tended to divide idiopathic constipation up into different physiological abnormalities. These include: colonic inertia, outlet obstruction, spasm of the sigmoid colon and rectal insensitivity. When Mr David Kerrigan and Dr Wei Ming Sun, working in our ano-rectal research laboratory in Sheffield, investigated this, they found that most patients had a combination of abnormalities including impaired spinal reflexes. This suggested that in most cases, idiopathic constipation was caused by lack of integration in spinal centre for defaecation in the low spinal cord, probably caused by descending inhibition from the control centre in the brain stem. If that is the case, then perhaps lack of dietary fibre is not so much a cause of constipation; instead , but a diet rich in fibre and FODMAPs may help to stimulate a lazy and insensitive colon. As Dr Gerald Crean once commented, ‘if constipation is caused by fibre deficiency, then pain is a disorder of aspirin deficiency’.
Abnormal responsiveness in the brain stem centre for defaecation suggests that psychological factors, such as a dramatic or traumatic change in circumstances, represses the urge to defaecate. Bowel habit changes from day to day in most of us despite a consistent diet. A change in environment, such as going to stay in an unfamiliar place can make many constipated. A disappointment or tragic event may have the same effect. A major traumatic event can presage constipation that may last for years. Bowel function, in common with sleep, work, activity or eating can easily adopt patterns that may last for years and resist change. They defend the status quo. That is why doctors tend to ask about ‘bowel habit’.
After a lifetime of consolidation, it may seem unlikely that Hilary’s constipation will reverse with a change of circumstances or psychologic therapy, but I have seen some remarkable reversals in people who had been stuck for years. My colleague, Dr Ghislain Devroede told of a patient, who developed constipation and anorexia after she had been sexually abused by her father. When her father died, she wrote him a letter, placed it in the coffin and forgot about it all. Two weeks later, her constipation abated. One of my patients told me that that her constipation was cured when she finally summoned up the courage to leave her coercive husband.
Another patient was referred to me almost as a last resort by a surgeon, who was considering total colectomy for severe longstanding constipation. Susan arrived in my clinic in the middle of summer dressed in a warm winter coat and a scarf that covered half her face. She would not make eye contact and responded in monosyllables to my enquiries. There was no spontaneity and I struggled to maintain any engagement. At our third appointment, I ran of questions to ask and we sat in silence. I felt relaxed and watched the birds in the trees outside the window. At the end of 50 minutes, I announced that it was time to finish. She looked shocked and almost ran out of the room. To my surprise, she returned the following week. She threw off her coat and scarf, sat down and glared at me, ‘I don’t come all this way to see you if you are not going to say anything’. I mumbled an apology, but she hadn’t finished. ‘I felt so angry after last time, that I have had diarrhoea all week’. Now this was the woman who had been solidly constipated for 14 years. Over the next few weeks, she told me her story. It had started when her fiancée ended their relationship and she returned in shame to her somewhat controlling and intrusive family. Her diarrhoea abated after her disclosure but herr constipation didn’t come back. When I saw her six months later, she left the family home, changed her job and met somebody new. Constipation no longer featured.
Experiential causation is always difficult to prove by population studies, and there is no scarcity of other feasible suggestions. Always a rich source of original ideas, Dr Mark Pimentel has recently reported that methane generated by colonisation with methanobacter brevi may inhibit colonic motility and cause chronic constipation. But is this a cause of constipation or a factor that would tend to maintain it? Is colonisation by methanobacter the result of slow transit?
Hilary asks about complementary therapies. Any therapy that relaxes the system and reduces rumination and catastrophic thinking, will help her find the mindful space to see what happens in context. This particularly applies to therapies that work on the mind/body such as hypnotherapy, therapeutic massage, reflexology or acupuncture. Colonic hydrotherapy would seem to be the most obvious therapy as long as it is not conducted too frequently. I know several colonic hydrotherapists, who run a very careful and ethical practice in colonic hydrotherapy, but I am not sure any of them would wish to risk this procedure is somebody who is so underweight.
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