All the above symptoms and more are repeatedly experienced by patients suffering either from irritable bowel syndrome with constipation (IBS-C) or functional chronic constipation (CC). These have also been confirmed by a number of studies, many of which also show a decrease in quality of life of IBS-C sufferers, even more so than in patients with IBS-diarrhea (IBS-D).
Irritable bowel syndrome (IBS-C) and functional chronic constipation (CC) are two of the most common functional GI disorders. In both cases, the individual suffers from constipation, however the two disorders are distinguished by different criteria (based on the ROME criteria) and, on paper, should actually be mutually exclusive. In the clinic, the two conditions tend to be more difficult to separate but the following general guidelines apply.
Based on the updated Rome IV criteria, IBS-C is characterized by 1 day/week of abdominal pain on average during the last three months, with symptoms having initiated at least six months before diagnosis. This pain should also be associated with two of the following:
1. Pain related to defecation;
2. Change in stool frequency, and;
3. Change in stool appearance.
With CC, the new Rome IV criteria include minor pain and or/bloating, but these are not the predominant symptoms. The main symptom is constipation that involves straining, lumpy or hard stool, three or fewer spontaneous bowel movements per week, the feeling of incomplete emptying of bowels when going to the bathroom, a feeling of blockage in the large intestine, and the use of manual methods to aid with defecation.
There’s a lot of folklore and myth about constipation, what causes it and what relieves it, and patients tend to be overwhelmed with information, often not knowing what to believe. They will try different methods, many times unsuccessfully, which adds to their feeling of discomfort, despair and even tendencies for depression.
In the paper “Irritable bowel syndrome and chronic constipation: Fact and fiction” published in the World Journal of Gastroenterology by Massimo Bellini, Cristina Stasi and their colleagues, the scientists take aim at a number of common misconceptions revolving around constipation. We have selected to discuss the seven most common ones, hoping to clarify some of your own.
1 - I should have a bowel movement every day.
This is a misconception that leads to a lot of stress in many individuals. Every person’s bowel movement is different. Beware that a decrease in the regularity of bowel movement does not immediately label someone as being constipated. You can check the Bristol Stool Chart in our website’s Resources section for more information on healthy stool frequency and consistency.
2 - Bowel constipation increases risk of colon cancer.
Extensive surveys and statistical analysis from several studies have shown no increase in the cases of colon cancer in patients with constipation. The paper further recommends that unnecessary colonoscopies in patients who present with constipation but have no other symptoms that could signal colon cancer should be discouraged.
3 - Eating citrus fruit causes constipation.
There is a general consensus in thinking that citrus fruit causes constipation and sometimes they are even recommended in order to tame diarrhea in patients. This is actually false as citrus fruit contains a lot of pectins (both in the flesh and the skin of the fruit). Pectins are indigestible but soluble fibers that end up controlling and helping in cases of constipation instead of making it worse. The one and only fruit that needs to be avoided in cases of constipation is the banana, when unripe and green. Green bananas contain a lot of tannins and resistant starch and can contribute to constipation by inhibiting gut secretions and movement of food through the gut (peristalsis).
4 - Consuming a lot of fiber and drinking lots of water improves constipation.
Fiber is a very tricky business as extra fiber consumption has shown to help some individuals but exacerbate others’ problems. Some data has demonstrated that soluble fiber such as psyllium and guar significantly help some individuals with constipation, while insoluble fiber such as bran, for example, may even exacerbate the symptoms of some patients. When considering fiber, the type and cause of constipation should be taken into account. For example, in patients where the stool takes a long time to pass through the gut, extra fiber seems to worsen the condition as it can slow down the movement of the colon even more and also increase the mass of the stool, making it more difficult to move. Thus, approach fiber with caution.
Furthermore, a number of people suffering from constipation force themselves to drink more than 2 liters of water a day thinking that it will alleviate the symptoms. However, there is no data out there to show that such an increase in water consumption has any significant effect on stool consistency or frequency of going to the bathroom.
5 - The repeated use of laxatives causes health problems and also a dependency to them.
Use of laxatives can never become an addiction per se, as these ingredients never cross the blood brain barrier in order to reach the brain. However, some patients who repeatedly use laxatives can become very dependent on them. In a small group of very constipated patients, tolerance over time may arise, but for most patients there is no correlation between prolonged laxative use and the need to use a higher dose over time.
6 - Herbal medications and supplements are better and safer alternatives to treating constipation.
This is a tricky subject and patients should be particularly careful. There is a tendency that whatever is herbal is healthy and will provide benefits (or at least could not possibly cause any harm if it’s natural) compared to other drugs. This makes people not consider any interaction that this remedy could have with their current medication. Also, they tend to forget that these remedies are not controlled, so there’s not information about their origin, their modes of action and effectiveness, or any controlled studies that provide information about their safety. Beware that there’s always a risk when you take something that is unsupervised by a professional.
7 - Lack of physical activity is the root of the problem.
For certain, physical activity aids the movement of the gut, thus people who carry out more physical activity tend to have a lower frequency of constipation and can manage it much better. However, physical activity alone cannot be the solution for all cases. In young but severely constipated individuals, it does not make much of a difference. Obviously, in those cases, other factors are at the root of the problem. Studies have shown that the elderly can benefit from exercise; however, there’s a number of factors affecting their constipation (medicines, food they consume, Alzheimer’s and other forms of dementia, psychological state, etc.,) which should also be considered and addressed.
Massimo B., Gambaccini D., Usai-Satta P., De Bortoli N., Bertani L., Marchi S., Stasi C. (2015) Irritable bowel syndrome and chronic constipation: Fact and fiction. World J Gastroenterol; 21(40):11362-11370.
Simren M., Palsson OS, Whitehead WE. (2017) Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice. Curr Gastroenterol Rep; 19(4):15