Constipation accounts for between 1.8 to 8 million gastroenterology visits each year. Needless to say, you are not alone. 

Good constipation care involves

1. An adequate assessment and diagnosis. This avoids the “throwing spaghetti against the wall and hoping something sticks” approach 
2. Quick relief if possible, because your comfort matters just as much as treating your digestive condition
3. Prioritizing clinically meaningful results, so you see a difference from the effort you are applying.
4. Open communication. You should understand your treatment plan, the current approach to care and how to troubleshoot if need be. 

What assessments you may need

What causes constipation

1. Irritable Bowel Syndrome 
2. Small intestinal bacterial overgrowth
3. Functional chronic constipation 
4. Slow transit constipation 
5. Pelvic floor conditions/anorectal disorders 
6. Certain medications 

Diarrhea is considered any loose or watery stool, and requires a work up by your Naturopathic Doctor if it is happening more that 25% of the time.

At home you can monitor for:

• Having to wipe more than 4 times after a bowel movement (“messy stool”)
• Having to strain
• Experiencing Type 5, 6 or 7 stool as depicted in the image below 

Causes Of Diarrhea 

Below is a non exhaustive list of what I screen for in patients experiencing diarrhea at least 25% of the time 

• Bile Acid Malabsorption 
• Celiac disease 
• Inflammatory Bowel Disease (Crohns/Ulcerative Colitis) 
• Irritable Bowel Syndrome
• Small Intestinal Bacterial Overgrowth
• Microscopic Colitis 
• Medication
• Overflow Diarrhea 
• Infection 

Testing 

Testing may be necessary to differentiate between some of the conditions named above. I use my discretion on a case my case basis, and testing suggestions vary based on patient symptoms presentation. 

Possible testing may include 

• Fecal Calprotectin, stool 
• Bacterial culture, stool
• Ova& Parasites, stool
• Anti tissue transglutaminase, blood 
• Glucose breath test

Intestinal methanogen overgrowth is an overpopulation of methanogenic archaea in the bowels. These archaea (microbes) use hydrogen gas made by other microbes in their community to produce a secondary gas called methane.

Methane predictably impacts bowel functions which may induce bloating, gas, constipation and abdominal pain. 

Symptoms of intestinal methanogen overgrowth

• bloating (78%)
• constipation (51%)
• diarrhea (33%)
• abdominal pain (65%)
• nausea (30%)
• flatulence (56%)

Testing for Intestinal Methanogen Overgrowth (IMO) 

The most highly performed testing is a glucose breath test, which also screens for the presence of Small intestinal bacterial overgrowth (SIBO) at the same time. 

Although widely used these tests are not perfect. 

If the test returns positive, we can officially diagnose you with IMO

If the test returns negative, this means you may still have IMO, it was just undetectable on this particular test. 

Sample report 

An additional stool test that may be warranted is a culture and PCR which can detect levels of methanogenic archaea in the stool, representing populations within the colon. 

Sample report 

Why does this sound the same as Irritable Bowel Syndrome (IBS) 

The symptoms produced by IMO overlap with an IBS-constipation diagnosis, therefore it is possible patients can be misdiagnosed if an adequate assessment is not performed.  

A diagnosis of IBS-C increases the risk of developing Intestinal Methanogen Overgrowth over time. In this case, some patients have both these conditions in their bowels at the same time. Approximately 30% of Small intestinal Bacterial Overgrowth (SIBO) patients exhibit concurrent intestinal methanogen overgrowth (IMO).

Additional considerations 

Relapse of this condition is common, likely because the underlying risk factor was never well managed or treated prior to eradication. Relapse rates approaching 40% within the first year after treatment. 

Your treatment plan will always include management of risk factors and weak spots in bowel function to reduce risk of relapse.

Bacteria grow in high numbers within our digestive tract. This is a beneficial relationship for both humans and microbes. We feed the bacteria through our diet and gastrointestinal lining, and the bacteria produce beneficial byproducts that keep the digestive tract and potentially other organ systems healthy. Small intestinal bacterial overgrowth (SIBO) is defined as a disorder in which an excessive number of colon-specific bacteria are present in the small intestine, a region that is not typically abundantly colonised. 

The consequence is excessive levels of bacteria byproduct in the form of hydrogen gas, or hydrogen sulfide. These gases at high concentrations can begin to negatively affect gastrointestinal tract movement and sensation. 

Symptoms of SIBO , occur 25% of the time (about 2 days per week) 

• Diarrhea 
• Excessive gas 
• Feeling of fullness 
• Bloating 
• Abdominal pain 

You do not need to experience every symptom on this list to have SIBO considered as a possible cause of your symptoms. In addition, other bowel conditions can be present at the same time as SIBO can cause overlapping symptoms. For example, irritable bowel syndrome and SIBO can exist at the same time, both conditions can cause bloating and diarrhea. 

We cannot always predict which condition is the cause of which symptom until we begin to treat you. 

Testing for SIBO

Testing for SIBO includes a series of breath samples over the course of 2 hours. This test, if positive, confirms you do have SIBO. This test, if negative, does not rule out the possibility that you have SIBO. Therefore if you are negative, we may choose to treat you anyways. 

Sample report 

Additional testing that may be considered is blood testing for both Vitamin B12 and Vitamin D as deficiencies can occur in chronic SIBO cases. 

Ulcerative colitis is a relapsing and remitting autoimmune condition. Your Naturopathic Doctor is in an exceptional position to help support 

• Reducing diarrhea 
• Improving ulcerations found on colonoscopy 
• Improving abdominal pain 
• Managing overlapping irritable bowel syndrome where applicable 
• Reducing frequency of active flares 
• Supporting mental health 

How does a Naturopathic Doctor treat Ulcerative Colitis 

There are three clear objectives on your Naturopathic Doctors mind when you come into our virtual clinic including

• Short term: induce remission (symptoms and colon tissue) 

• Medium term: maintain remission
• Long term: preserve quality of life and reduce relapse frequency

Each objective is followed by a unique treatment plan. We have scientific data showing benefits in nutrition, supplements including botanical herb use, mental health and lifestyle support blended with your medication. 

What testing can be done? 

A colonoscopy is the gold standard for diagnosis, and yearly colonoscopies are often recommended in conjunction with pharmaceutical care. 

Additional testing is divided into two categories 1) assessing your response to treatment 2) monitoring anemia and nutrient deficiencies. Below is a non exhaustive testing list I am able to check and may ultimately suggest, this varies on a case by case basis. 

Stool testing 

• Fecal Calprotectin 

Bloodwork 

• Albumin 
• CRP 
• CBC 
• Ferritin , Serum iron/TIBC 
• Vitamin B12 
• Vitamin D 

Additional concerns your Naturopathic Doctor will assess for 

~30% of patients in remission report IBS-like symptoms. IBS symptoms can often feel like Ulcerative colitis symptoms making it difficult for those living with Ulcerative Colitis to rebuild confidence and trust in their bodies. 

I will run a fecal calprotectin stool test to differentiate if your symptoms are either IBS or Ulcerative colitis affording us the ability to avoid unnecessary treatment and use evidence directed care.  

Fecal calprotectin is also useful in monitoring Ulcerative Colitis treatment response and in detecting relapse.

Unpleasant symptoms after a meal, or ingesting specific food/food groups are incredibly common. There are an abundance of reasons why these reactions occur, each involving a different arm of the immune system, or the state of the digestive tract. 

I often encourage my patients to be open to the process of deciphering which type of reaction they are experiencing, as this prevents unnecessary restriction of food and overbearing food rules.  

These reactions can be acquired, and in some cases unacquired. Other times it may be a permanent state and we work to find you better forms of management that fit your lifestyle. 

Food intolerances 

A lack of tolerance to a food is not inherently driven by the immune system, it is driven by the state of the digestive system. In this case the digestive tract has lost the ability to digest key components of a specific food or tolerate certain indigestible food components in the bowels in large amounts. 

Conditions that fall under this category include 

• • Lactose intolerance – inability to efficiently digest the lactose enzyme in dairy products, this intolerance lives on a spectrum 
  • Histamine intolerance – the inability to digest histamine in a food due to a reduction in the enzyme required to digest histamine in the digestive lining. 
  • FODMAP intolerance – reduction in the ability to digest, or tolerance of large particles in the bowels within a specific fermentable food group

• Non celiac gluten intolerance

Food allergies 

A food allergy is an immune sensitivity to a food protein that produces clinical symptoms of a food allergy. These allergies can be one of two immune reactions. 

First is IgE mediated, which can cause anaphylaxis and require the individual to carry an EpiPen.  Immune sensitivities can be tested through a skin prick/scratch test typically performed through an Allergist. The sensitivity alone is not enough to diagnose the allergy, patients must also experience symptoms of an allergy when they ingest the food culprit. 

• Symptoms start within 2 hours of exposure 
• They can include hives, flushing, shortness of breath, throat tightness, swelling of the lips and tongue, heart palpitations, dizziness, nausea, stomach cramps
• Most common IgE mediated food allergies: Peanut, tree nut, shellfish, egg, milk allergy; alpha-gal (meat protein)

The second is non IgE mediated, which does not lead to anaphylaxis and is rare in adults but is increasing in prevalence. There is no non-invasive treatment to diagnose these allergies beyond an endoscopy. 

• Symptoms can take 6-48 hours to present 
• Symptoms mostly in digestive tract disturbance including vomiting, nausea, difficulty swallowing food as it may be painful of feel like it is getting stuck in their throat, abdominal cramping, diarrhea or constipation  

Food sensitivities 

A food sensitivity is an abnormal immune reaction by the IgG arm of the immune system to exposure to specific food proteins. This IgG arm is designed to prevent us from developing IgE food allergies but building tolerance to a food protein. 

We see this in children exposed to peanuts early on in life, their IgG rises significantly, and they are less likely to develop an anaphylactic reaction to peanuts later in life. I say this to persuade people to not demonize an IgG reaction (a positive on a food sensitivity test) and instead look at it through a different lens. 

Available testing involves a food sensitivity test. A positive on IgG antibodies are the immune system’s memory of “foods it has met,” like a guest list, not a list of enemies. If there are a large number of positives on a food sensitivity test, the solution is not to remove the foods, they are simply signalling that immune support is likely required. 

Food driven conditions 

Celiac disease – the immune system attacks the digestive tract lining every time gluten is ingested 

Symptoms that may suggest an assessment is warranted 

Intestinal 

• Feeling full quickly 
• Chest fullness after eating/difficulty deep breathing 
• Heartburn 
• Bloating below breast bone 
• Pain/tenderness below breast bone 
• Abdominal pain 
• Excessive flatulence 
• Diarrhea 

Immune 

• Fatigue after trigger food 
• Joint pain 
• Headaches 
• Sinus congestion after meal 
• Heart palpitations