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Constipation

Constipation is a common condition in the digestive tract when stool is difficult to pass. Bowel movements may be infrequent, there may be difficulty during defecation including straining or there may be a sensation of incomplete bowel evacuation.

The causes of constipation including medications such as narcotics, low activity of the thyroid and elevated levels of calcium in the blood. There are rare genetic disorders but the most common cause of constipation remains unclear. Certainly lack of fibre is not a cause, lack of exercise or lack of water intake is definitely not the cause of constipation in the general population. It is still under appreciated that constipation may be associated with abdominal pain which is relieved on defecation, with bloating, tiredness, reflux, nausea and increased flatulence.

At the Centre for Digestive Diseases long standing research in this area has indicated that the most likely cause of the common variety constipation found in the majority of patients is caused by an infection with a bacterial agent that has entered the bowel through the mouth and has begun to coexist with normal human bowel flora. Its presence in the bowel flora is marked by the production of molecules within the bowel which affect the enteric nervous system so partially paralysing the bowel. If the constipation agent produces severe paralysis the bowel may not empty for days or weeks. Most commonly very mild forms are present and people tend to overcome this with simple methods such as excessive fibre or even chemical laxatives such as naturally occurring teas which may contain senna. However, worldwide the research on constipation has been extremely slow because it has been hidden by an overwhelming belief both in the lay and medical population that it is the lack of fibre which causes constipation. We now know that nothing can be further from the truth since removal of fibre from the diet of healthy patients does not cause constipation.

The actual causative agent or agents are yet to be detected. However it appears that constipation is almost certainly caused by agents which respond to antibiotics which also kill clostridia. So there is a high chance that a type of a clostridium (clostridia produced neuro-toxins (e.g. Clostridium tetuni, Clostridium botulinum, Clostridium difficile, Clostridium perfringens) and so constipation may be simply a chronic infection with a clostridium that carries a spore and so it is difficult to eradicate with antibiotics. The most powerful evidence for this is published indication that Vancomycin which is not absorbed in the GI tract when taken by mouth, can dramatically reverse constipation. [The effect of oral vancomycin on chronic idiopathic constipation. Aliment Pharmacol Ther 1995/9:63-68) Vancomycin] Vancomycin can be combined with other agents such as Metronidazole or Rifampicin to strengthen the affect upon a constipating agent and to give the patients relief from there straining and bloating. Interestingly, the paralysis of the large bowel may be accompanied by partial paralysis of the small bowel so preventing gas moving forward and causing bloating. Such circulating active molecules produced in the colonic flora can also partially paralyse the stomach and this causes Gastroparesis and in some patients vomiting and also paralyses the lower oesophageal sphincter causing reflux. In a subset of patients’ partial paralysis of the gall bladder causes reduced ejection of bile, precipitation of cholesterol and formation of gall stones.

This generalised motility inhibition in the GI tract with one or two geographical areas in the GI tract posing as the symptom inducing area – has puzzled researchers for many years. Diet, allergy, stress and other mechanisms have been invoked to explain all of this. However in patients who respond very well to specialised antibiotics such as Vancomycin or Rifampicin combination the reversal of dysmotility is so dramatic that it is quite clear that the bowel flora plays the major role in this common and chronic condition.

At the Centre for Digestive Diseases we use these principles to treat patient's chronic constipation in an attempt to give them quality of life.


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