Constipation — Beyond the Basics with Gastroenterologist Dr. Leonard Weinstock

Today Dr. Leonard Weinstock is back to discuss all things constipation.  We go way beyond magnesium, fiber, and vitamin C.  This episode digs into what you can do for constipation if some of the basics fail, from the perspective of a practicing holistic MD gastroenterologist.

Dr. R’s Fast Facts

  • A patient must have experienced at least 2 of the following symptoms over the preceding 3 months:
    • Fewer than 3 bowel movements per week
    • Straining
    • Lumpy or hard stools
  • 20% of Americans are constipated
  • Often constipation is caused by not enough fiber or water consumption
  • There are some simple solutions for constipation
    • Diet; avoid processed foods, elimination diet-allergens (gluten, dairy, soy)
    • Increase your fiber; fruit/veg intake
    • Drink more water
    • Consider low FODMAP
    • Exercise
    • Probiotics
    • Magnesium, vitamin C, bile…
    • Checking if constipation is a side effect of a medication you are taking

When non-responsive, more advanced consideration includes:

  • Treating SIBO….
  • Blockages, Wurn Therapy, pelvic floor therapy
  • Blockages in rectum
  • Weakness of colonic, rectal, and/or anal muscles
  • Non-relaxing peubo-rectalis, pelvic floor disorder
  • Rectocele
  • Lack of secretion of certain gut hormones, can happen with aging
  • Colonic inertia
    • Nerves/mm malfunction, poor peristalsis (lazy colon)
    • Sitz marker test can be used to evaluate
  • Postural orthostatic tachycardia syndrome (POTS)

Categorizing constipation

  • IBS constipation – occurs with discomfort and pain
  • Primary idiopathic constipation
    • No pain, most likely anal or muscle problem

Medications to consider

  • Opioid modulators: low dose naltrexone
  • Serotonin modulators: prucalopride (Resalor), Tegaserod
  • Chloride channel activators: Amitiza (lubiprostone), Linzess (linaclotide)‎, Trulance (plecanatide)

Other notes
Remember, oftentimes exotic diagnoses respond well to simple and standard therapies


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Episode Intro … 00:00:39
LDN Conference … 00:01:24
Simple Constipation Therapies … 00:03:50
Advanced Constipation Therapies … 00:05:20
Electrolyte Secretion … 00:11:47
Categorizing Constipation … 00:12:51
Exams and Diagnosing … 00:14:34
Colonic Inertia and Sitz Marker Test … 00:17:26
Dyssynergic Constipation … 00:19:21
Inertia Treatments, Methane Production … 00:21:20
(click gray Topics bar above to expand and see full outline/time stamp)
Removing Blockages with Clear Passage Therapy … 00:23:59
Nerve Issues, POTS … 00:27:33
Antibodies and Prokinetic Medications … 00:31:38
Autoimmunity, Serotonin Receptors … 00:37:46
Dr. Ruscio’s Resources … 00:40:45
Ehlers-Danlos Syndrome … 00:41:44
Treating the Fundamentals … 00:46:17
Starting with the Gut … 00:49:18
Medications to Consider … 00:50:41
Atrantil and SIBO … 00:56:22
Probiotics and Regularity … 00:58:22
Episode Wrap-up … 01:00:13

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Constipation — Beyond the Basics with Gastroenterologist Dr. Leonard Weinstock

Episode Intro

Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I am here with Dr. Lenny Weinstock, a gastroenterologist who’s been on the show before. And we’re having him back on today to talk about constipation.

Lenny, welcome to the show.

Dr. Lenny Weinstock: Thank you so much for having me, Michael.

DrMR: I have to give you a compliment that you are an incredibly funny lecturer. We lectured together a few times. We, a few months back, lectured at the Integrative SIBO Symposium in Chicago. And gosh, you had people just rolling on the floors laughing. You were absolutely hysterical as a presenter.

DrLW: Well, thank you. It’s luck, I guess. Sometimes people just step up to the plate. And I just see the foibles and just point it out.

LDN Conference

DrMR: Speaking of that, maybe that’s a good transition to—I know you mentioned before we started the recording that you’re putting together a LDN, Low-Dose Naltrexone, Conference. So since we’re on the topic, and since it would probably be worth the ticket just for the laugh factor for going to the conference—I’m positive people would learn a ton—do you want to tell people a little bit about that event that’s coming up?

DrLW: Oh absolutely. Linda Elsegood, who’s the head of the LDN Research Trust, has gotten, I think this is her third international conference with people all over the world coming in to give lectures, both live and on webinar and also pre-recorded talks, about LDN, their experiences, observations.

And low-dose naltrexone is an incredible medication, part of my repertoire since 2005. And I don’t think I could practice without it, quite honestly. It’s helped so many patients. Thank God that I’ve learned about it from a compounding pharmacist who came into my office one day in 2005 and said, “You know Dr. Weinstock, you might find this to be helpful for your patients.” Literally, that’s what she said and what turned out to be the case.

So in Portland on September 22nd, 23rd, and 24th, we’re going to have this conference. There’s going to be a lot of people talking about LDN and under a variety of different situations. I’ll be talking about irritable bowel syndrome, SIBO, and also how I use utilize naltrexone in irritable bowel syndrome. Some of that touches on chronic constipation, so there’ll be some information about that as well. So we might wind up talking about that today because constipation is a tough condition for many people.

DrMR: That’s why I wanted to get into some more granular details regarding constipation. And I’m excited to get into some of those details. Real quick though, is there a website for people to find out more about that?

DrLW: Yeah. So it’s LDNResearchTrust.org.

DrMR: So there you go guys. Check that out if you want to learn more about LDN. And I’m sure that it will be a fantastic seminar, and you can also attend via webinar if you can’t get to Portland physically.

Simple Constipation Therapies

Yeah, so constipation. And maybe one thing as we kind of start weighing into this conversation that I think should be mentioned is that constipation doesn’t only mean that you go several days… Usually the diagnostic criteria is fewer than 3 bowel movements per week. But it’s also for people who have a hard time moving their bowels or straining. So you could be going every day, but if you’re having a hard time going every day, then that also can classify you as constipation.

And I’m sure people have heard about some of the basic therapies. Things like diet, avoiding processed foods, potentially trying elimination diets where you avoid gluten or dairy or soy or some of these commonly irritating foods. Potentially increasing your fiber intake and eating more fruits and vegetables. Or if you’re someone who’s kind of fiber and prebiotic sensitive, you may want to try a low FODMAP diet. Exercise can help. There’s been some clinical trials that have shown probiotics can help. And there’s also natural laxatives, things like magnesium, vitamin C, and even bile. Bile is antibacterial and bile can also function as a laxative. In fact, too much bile can cause a condition known as bile acid diarrhea or bile acid malabsorption diarrhea.

So those are things I’m sure people have heard about to a greater or lesser extent. Definitely if they go on the internet and they start searching for solutions to constipation, those things are prone to come up.

Advanced Constipation Therapies

What I was hoping to do today with Lenny is get to some of the factors and things to consider when people have done some of those things and have been somewhat non-responsive. And so then I think we get more into things potentially like treating SIBO. Maybe thinking about blockages and using things like Wurn therapy to break down adhesions that may be occluding the abdominal lumen, certain medications. And really trying to pick Lenny’s brain, as a gastroenterologist, as to what is a good fusion of borrowing some of the best things from conventional and alternative medicine.

So, Lenny, I know I gave you a really wide lead in there. But where would you take us first as we weigh into some of these therapies for a constipation that may be non-responsive to some of the frontline therapies?

DrLW: Well, I would take a step back and I’d say, “Okay, let’s look at the framework. What are the causes? What’s the general approach to constipation just from the view of a standard gastroenterology approach?” Let’s take into the fact that 20% of Americans are constipated by the definition that you stated. 20%. That’s an incredible amount.

Many of the patients suffering from constipation are because they’re deficient in fiber and fluids, because if they’re not getting the engine running, they don’t have the right fuel for their automobile, so to speak, it’s not to going to run well.

So some of these things are simple. Literally adding fiber and fluids will help many patients with constipation. However, when fiber actually makes things worse, then you have to start thinking about dysbiosis, small intestinal bacterial overgrowth, or colonic inertia, where things are so slow with the colon that the bacteria ferment the fiber, causes discomfort and gas and things are actually worse because of that.

But you have to also consider the fact that 20% of those 20% who have constipation have functional outlet obstruction. So the anal muscles don’t relax. The puborectalis muscle, that is a sling in the low anal area, and that sling is important so that we don’t have incontinence. But if the sling doesn’t relax, the puborectalis doesn’t relax, then there’s an angle of the rectum that maintains itself. And then the stool can’t pass because you can’t go on a zigzag turn, so to speak. So that’s one of the most common conditions.

DrMR: Repeat the name of that one more time, Lenny.

DrLW: Non-relaxing puborectalis, and that’s a form of pelvic floor dysfunction. Sometimes you’ll get, with that disorder, rectocele. So the rectum bulges out. And many times, unfortunately, patients get surgery on the rectocele without addressing the primary cause, which is the sphincter muscle not relaxing.

So then you look at the basic thing for chronic constipation. So if you take out the portion of people who get better on a healthy diet, and you take away the proportion of patients who put in the factor of, “Okay, I need to have time for myself and privacy to have a bowel movement.” Because if you’re rushing around in the morning, and you’re in a hurry, you don’t have a good breakfast, and a hot drink to stimulate the gastrocolic reflex that stimulates a link between the stomach and the colon to be active, then you’re going to be in trouble. So you have to deal with that behavioral modification to have better bowel habit.

And then also you want to consider drugs and over the counter products that cause constipation. So patients get calcium channel blockers. They get calcium, cardiac medicines like Amiodarone or other things that slow down the bowels. That has to be taken into account.

So then you take away all these things, and you take away blockage by colon cancer. For instance, if it’s a new onset, you’re not dealing with somebody who’s had 20 years of static problems with constipation, then you’re dealing with chronic idiopathic constipation.

And then we start thinking in terms of all the things that define that. And it may be motility disorder. May be emptying disorder. It may be decreased secretion. So there’s a whole group of patients out there where I think there’s dysfunction of the hormone. There’s a natural hormone that causes secretion of electrolytes into the colon lumen. And that’s the chloride channel, for which drugs have been created to stimulate the chloride channel and improve secretion of electrolytes, which then draw in fluid.

And so I think one of my theories is that, especially with aging, that some of our abilities to produce this hormone get shut down in time or the receptors are reduced. And so that’s one of the causes for chronic constipation of aging. And so that’s a common problem.

Also with aging, we have basic things like lack of physical activity, decreased oral intake, and again, sometimes poor fiber. This is how a GI thinks. All the things that I just said are basically all the things that run through your gastroenterologist viewpoint, your basic standard GI standpoint.

Electrolyte Secretion

DrMR: So when you’re discussing the lack of secretion of electrolytes with the class of drugs, LINZESS-type drugs, this is the class of drugs that would be helpful if that mechanism were what underlined the constipation?

DrLW: Right. The GTC is where Linaclotide and the new one, Planclotide, are active. And then there’s the other chloride channel in it, but very rare, Lubiprostone, is active. The problem with those drugs, sometimes we get too much activity and diarrhea. So you can go from a person who’s moving their bowels once a week to having excessive watery diarrhea. Luckily, some new changes have come out in terms of doses, smaller doses, so we’re having a little less of a problem with these patients who try these drugs.

Categorizing Constipation

DrMR: Sure. And Dr. Rao had made that comment when we had this discussion with him a few weeks ago. And you make some fantastic points. And I’m wondering, can we organize these into maybe subtypes? One of the things that Satish Rao had commented was he kind of organizes primary constipation into 3 subtypes. He kind of breaks it down in his head to: IBS constipation subtype, slow-transit constipation subtype, and then dyssynergic subtype.

And it sounds like you may even add…you may modify that slightly, but I’m wondering, as I try to organize how we pick into these, can you organize some of those thoughts that you have into a couple of different buckets?

DrLW: Well first of all, it is important to dissect whether it’s IBS with constipation or chronic idiopathic constipation. And the main way you deal with it is recognize that IBS, the primary symptom is discomfort or pain. And then you get constipation straining, decreased number of bowel movements. And then the difference in…of course, you’re going to have pain if you haven’t moved your bowels in a week.

But in people who have chronic idiopathic constipation, pain is not the primary symptom, constipation is. And as the obstipation worsens over time, then you get discomfort. So that’s the clinician’s viewpoint of how to distinguish between IBS-C and chronic idiopathic constipation.

Exams and Diagnosing

DrMR: That helps us make the distinction between IBS subtype and primary idiopathic subtype. Now, what I’m picturing in my mind is someone who has a local gastroenterologist. They may be a really nice gentleman or woman, but perhaps they’re not really digging on behalf of their patients. So the patient is trying to bring to them some ideas.

And so I’m trying to help the listener, whether they be a natural clinician who’s maybe co-managing with a provider or maybe a patient who’s just their own healthcare advocate. Try to organize some of those things that you mentioned, like a blockage in the rectum, weakness of the rectal muscles, the non-relaxing puborectalis, the lack of secretion of electrolytes.

How do you start working through this from the perspective of maybe like a differential diagnosis? Or trying to work down the path to determine what, of all those thoughts that go through your head, are the one that’s really afflicting someone?

DrLW: Oh, absolutely. Well, it’s challenging at times. But a good careful history and a physical exam, basic labs, which is a blood count, are the first steps. Reviewing the drug list and also checking that their thyroid and their calcium has been checked. Because hypercalcemia, although hyperparathyroidism is relatively rare, constipation is a big issue. Hypothyroidism is common and certainly needs to be excluded in patients that you’re evaluating for chronic constipation.

Patients who are anemic, have any blood, obviously, they all need a colonoscopy. If you’re dealing with a patient, however, who’s a forty-year old woman who’s been constipated for twenty years, colon cancer, you’re not going to think of as the first problem. You’re going to want to certainly check if their thyroid’s been evaluated with a TSH. You’re going to check their Medlist and you’re going to do a physical exam and rectal exam. And you also can learn something by rectal exam. Some people are talented enough to do a rectal exam. Ask the patient to push down, to try to relax, and then sometimes you can feel them tightening up.

The other way to screen for pelvic floor dysfunction is to simply ask, “Do you ever get the sensation that you can’t evacuate the rectum? Or do you have to do special maneuvers to strain to try to get the stool out?” Those questions may lead towards doing anal manometry or balloon defecation, namely putting a catheter with a balloon to see if they can pass the balloon. That will further your diagnosis of pelvic floor dysfunction.

Colonic Inertia and Sitz Marker Test

DrMR: Okay, so maybe to draw a distinction there, and let me know if I have this wrong, but if someone is moving their bowels every day, every other day. Let’s say, they’re moving them somewhat frequently, but they’re having this difficulty with passing or strain or the feeling of incomplete evacuation. Does that flag for you more so there may be a blockage, a muscular problem compared to someone who’s just not going for 3, 4, 5, 6 days?

And would that person potentially have something like a problem with some of the hormones and have a hormone deficiency? And do you start, when you hear maybe one of these compared to the other, are you able to start partitioning what direction you’re going to go in if you hear one of these scenarios versus the other? Would you say that is a guiding flag for people or no?

DrLW: You’re spelling it out nicely. I think that when you talk about colonic inertia, you’re just talking about people who have just slow activity. They say, “I just haven’t moved bowels. I don’t feel like it. I’m getting distended, but I haven’t moved my bowels.”

And you can dissect that further with a very simple test. It’s called a Sitz marker test. It’s a very common thing used by gastroenterologists and internists. What is given to the patient is a capsule that’s got twenty-five little rings in it that are radiopaque, so the plain X-ray sees that. And you have the patient swallow.

And then on day 3 and day 5, you take a simple plain X-ray. And if the rings are scattered around the colon or more on the right side of the colon or in the mid colon, they’ve got colonic inertia. If they’re all in the rectum, then you know you’ve got a pelvic floor dysfunction and emptying disorder.

Dyssynergic Constipation

DrMR: Is colonic inertia different than dyssynergic constipation? Or is that saying the same thing?

DrLW: Colonic inertia refers to the actual muscles throughout the colon. So the nerves or the muscles of the colon are malfunctioning. And that’s a process where there’s poor peristalsis, whereas dyssynergia refers to one of the forms of pelvic floor dysfunction, where the anal muscles don’t relax like they should.

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Inertia Treatments, Methane Production

DrMR: Okay so, regarding some of the findings that may be present if someone does have colonic inertia, is this where biofeedback therapy comes in, pelvic floor therapy, potentially Wurn therapy? Is this where we start steering someone in the direction of some of these therapies?

DrLW: So when you’re dealing with a lazy colon…and I tell patients they’ve just got a lazy colon. That’s how I explain colonic inertia to patients. I tell them unfortunately there are not a lot of great treatments for this. There are stimulant laxatives. There are the laxatives that cause increased secretion and sometimes they can increase transit. But I also tell them that we need to check to see if they’re a methane producer, to see if they have methane in their colon or small intestine that is slowing down the colon. And this is a very neat observation that actually was first made in 1982 that showed that children who produce methane were more likely to be constipated.

And Dr. Pimentel took it further with his studies to show that methane levels above 3 were associated with constipation. And treating these levels with antibiotic therapy improved constipation. And they studied it in dogs, where they actually infused the dog’s intestines with methane and it slowed transit down. So it showed definitively that methane in the system, whether it be in the gut or as it was shown in the animals or possibly produced by the bacteria in response to the bacteria fermenting carbohydrates, causes constipation and slow motility.

So treating that methane production by either changing the microbiome with transplants as an extreme or changing it with a herbal remedy such as Atrantil or occasionally giving antibiotic therapy with dual antibiotic therapies, Rifaximin, Neomycin or Rifaximin, and Metronidazole, can be helpful.

Removing Blockages with Clear Passage Therapy

DrMR: And of course, this is where things kind of start to overlap. And maybe something I’ll offer the audience that’s going through my head as I listen to this. It’s a good idea to probably start with some of these foundational things like we talked about before. Your diet, probiotics, treating SIBO. Because of course, all of these things, diet, probiotics, can also help with SIBO and the methane level. So you don’t necessarily have to jump right to the most in-depth evaluations and you may be able to get some yardage out of the basics. So don’t forget about the basics.

But coming back to kind of the larger point of this call is for people who maybe have not responded fully to the basics. You are doing some work with the Clear Passage or the Wurn therapy in your office. Or at least time we spoke, I know you were geared up to do that. Can you tell us a little bit about your experience with that?

And maybe also if you can, try to give people, if you’ve noticed, a few key red flags or indicators that someone may want to get an evaluation with them, what those are if you’ve found there to be any consistent flags.

DrLW: Well, first of all, it always seems to me that what they’re aiming for is adhesions affecting the small intestine more than the colon. But let’s talk about what they do. So basically, Clear Passage is a physical therapy organization started by Larry Wurn, who started doing physical therapy for infertility and breaking up adhesions manually in and around the fallopian tubes so that fertility could increase and/or IVF could be more successful.

And then he was approached by patients who were dealing with adhesions elsewhere that caused small bowel obstructions. And so he treated those patients and started seeing results decrease incidents of ER visits and small bowel obstructions. So that’s been helpful in that regard.

And you’ll see on his website testimonials, one by a gentleman who had severe constipation, who said that that treatment dramatically improved his constipation. Now, it’s not clear to me exactly how that is, although, today I had 2 extremely difficult colonoscopy patients where adhesions were trapping their colon. And conceivably, that could impact and cause constipation. The adhesions can involve the colon even though the classic knowledge is that they involve the small intestine.

Now, with respect to small intestinal bacterial overgrowth, there are a group of patients where the cause for SIBO is an adhesive process. And treating that with adhesiolysis, or by surgery, or adhesional physical therapy by Clear Passage or other physical therapies, can be very helpful in taking away that problem. And so if methane-producing bacteria are being trapped in the small intestine, that’s a situation where constipation may be improved.

Nerve Issues, POTS

DrMR: Okay so, we’ve talked about some treatments that are geared toward, I guess, the muscles. What about the nerves? And oftentimes the nerves and the muscles are connected, of course. Of course, when we say nerves, the nerves innervate the muscles and the muscles operate the intestines and help to contract and move things along.

I’m sure one of the first things that comes up to people’s minds is the antibody test for vinculin or CdtB antibodies. And I want to come back to that in just a moment. But before jumping to that, are there any other nerve things that people should be aware of? For example, more progressed type 2 diabetes may have constipation due to neuropathy. Are there some common nerve things that people should be aware of?

DrLW: Yes. So postural orthostatic tachycardia syndrome, POTS, most often in women, and occurs in one to three million women in the country. And this is a sympathetic overdrive, which may be due in part due to an autoimmune phenomenon which stimulates the sympathetic nervous system.

And with stimulation, 2 things that happen. Number 1, you lose the peristalsis, because the vagus nerve, the parasympathetic system, is responsible for peristalsis and the sympathetic battles that. What also happens is that the sphincter muscles increase in tone with increased sympathetic activity.

And so some of our refractory patients who have pelvic floor dysfunction, non-relaxing puborectalis muscles, are actually POTS patients. And so pelvic floor dysfunction is very common in POTS patients. And I believe it’s something to the order of 40% of POTS patients, who were studied at Mayo Clinic, had pelvic floor dysfunction.

So that is pretty important right there. But the patients who have this condition had tachycardia, dizziness with standing, their pulse increases thirty points when they go from lying to standing. And then they feel light-headed or dizzy. They have palpitations. They can pass out, headaches, blurred vision, because they can’t contract their pupils. Memory problems, brain fog’s very common, which actually directly relates to the nerves. And then constipation is common. 15% of patients with POTS have constipation disorders. Neuropathy in other areas is common. So POTS is really hot.

And also, a study done at Stanford showed that 7 out of twelve patients with POTS had dilated loops of small bowel. So I’ve studied my patients in my clinic and found that 67% of the patients had an abnormal breath test. And many of the patients did improve with antibiotic therapy for SIBO. Ten out of fifteen patients had improvement in their GI symptoms. And actually 4 out of fifteen found that the antibiotic helped their POTS symptoms.

Immunotherapy has been used at Mayo Clinic, going for these patients who, what they feel is immune mediated motility disorders. Some overlap with POTS. And immune therapies have been effective.

Antibodies and Prokinetic Medications

DrMR: Now, with the vinculin in the CdtB antibodies, and for people listening, in case you haven’t come across this yet, essentially one of the things that Dr. Pimentel documented was after a bout of acute gastroenteritis, troublous diarrhea, stomach flu, food poisoning, you can have the initiation of autoimmunity in the gut that may damage the motility apparatus in the gut that can cause SIBO, can be one of the underlying causes of SIBO.

Now, I’ve been watching some of the data here and trying to cut through to, what’s the bottom line? And while this is fantastically interesting academically, what are the main takeaways clinically? And one thing that I came across recently—and, Lenny, I’d be curious to get your thoughts on this—was paradoxically, the IBS subtype of constipation, that subtype of patients, this testing was not shown to correlate significantly. However, there was a strong correlate with patients with diarrhea. And I believe also mixed type IBS.

What’s paradoxical about that is you would think that with people with constipation who have no or slow motility, that the corresponding treatment, which is often recommended for this condition, which is prokinetic therapy, you would think that those would fit together. Meaning, people have autoimmunity against their motility apparatus and therefore they then have constipation because things aren’t moving and they would do the best with some of these prokinetic medications. However, this study showed that it was the diarrhea type patients that actually might be potentially—I’m speculating here a little bit—better candidates for some of those drugs because the autoimmunity was more so present with them.

So I think there are still some things that we’re sorting out. But what are your thoughts in that regard, Lenny?

DrLW: Okay, so I think you have to look at the small intestine and look at the colon and say, “Hey, these are two different animals.” The anti-vinculin, for some reason, seems to affect the interstitial cells of Cajal. And that results in a decreased migrating motor complex. And that MMC is the powerful sweeper wave that starts in the stomach and goes down to the small intestine. But it doesn’t involve the colon.

So if we’re getting an autoimmune antibody that factors against the cleansing wave of the small intestine, then that’s going to factor into small intestinal bacterial overgrowth. And if you’ve got hydrogen producing bacteria and your breath test shows that you have a peak in hydrogen before ninety minutes, that adds up. You’re going to have bloating and diarrhea.

If you have a mix of methane producers in there, you may well have constipation, or mixed. But a lot of the methane production goes on in the colon. So, it’s said that 10% of us own methane producing bacteria. Now, most often, this is on a very small level, so we don’t actually see it, let’s say, on a breath test. But what I see most commonly with methane producers is that the methane levels on a breath test are a plateau level. So they’re going ten, fifteen, twelve, fifteen, twenty, fifteen, as you’d go along the breath test timing. And therefore, I think those are methane producers that have the bacteria in the colon. And we’re just seeing constant methane production because the colon is slow and the colon is bacteria digesting and fermenting the carbs that are in the stool continuously. So that’s why your first methane levels aren’t zero and then you’re going up to forty.

So with methane, I think the problem more often is in the colon. And that causes colonic inertia primarily. I think the neuropathy of the colon can be a disease like pseudo obstruction, or a myopathy can be present like with scleroderma. Or you could have diabetes affect you. Although, many of the patients with diabetes can have a diabetic diarrhea because of abnormal sympathetic and parasympathetic phenomenon. It actually damages the aginergic nerve so you have less sympathetic activity and therefore more diarrhea. That’s one of the thoughts behind diabetic diarrhea.

Constipation, to a lesser degree that I see. So you start to see diseases, muscle disease, nerve diseases, and perhaps there’s a role for imbalance of the opioid nerves in the gut as well contributing towards constipation too. I have some patients that I treat with chronic idiopathic constipation who have failed other therapies. And I treat them with low-dose naltrexone and it can make mild adjustments and improvement.

And then there are probably patients where the primary problem is in the serotonergic nerve. So serotonin are very important neurotransmitters in the gut nerves. We have drugs that used to be available to treat that. But we don’t really have good options in America to use for serotonin. We had tegaserod or Zelnorm, which was taken off the market. We’ve got a drug in Canada called Resolor or prucalopride, which is a serotonin agent that can help patients who have constipation based on problems with the serotonin pathway.

Autoimmunity, Serotonin Receptors

DrMR: I think there may be something there that is not yet fully discovered, which could be autoimmunity against the serotonin receptors in the gut. Or maybe it’s been discovered and I haven’t come across it. But I know there’s been at least 1 paper that looked at, in depression, serotonin receptors in the brain. And they actually showed a significant amount of antibodies against serotonin receptors in the brain in depressive patients. And this paper was speculating that perhaps one of the underlying pathophysiologies of depression is actually autoimmunity in the brain, autoimmunity against the serotonin receptor specifically.

So I wonder if there could be a subtype of constipative patients that have autoimmunity. Similar to like some patients who have autoimmunity to vinculin. They could have autoimmunity to their serotonin receptors and perhaps that’s why they respond very favorably to some of these serotonin modulating medications like tegaserod or prucalopride.

DrLW: It’s very interesting. I think more needs to be done in that regard. Autoimmune disease, gosh. It seems more and more we’re talking about autoimmunity. And it’s potentially exciting, because perhaps we’ll have some better treatments. I use LDN as a means to get at some autoimmunity because it decreases B cell activity, which produces antibodies and T-cells.

I’m writing up a paper now to submit it on a patient with refractory dermatitis herpetiformis in the setting of celiac disease, who went on a gluten-free diet. Skin could not get better. I gave her LDN for that in part and also for chronic pain from joint disease associated with Ehlers-Danlos syndrome and her skin got better.

Our theory is that we were affecting the memory B-cells with the LDN that kept on producing antibody to give her the skin lesion. So it’s very interesting. It affects the T-cells, which cause a lot of inflammation, especially in conditions like fibromyalgia. And it can affect the cytokines that are produced in that condition. There was a nice article about that by Gerald Younger.

And we’re just seeing it more and more. We have to understand. Why do we have all these syndromes, these idiopathic syndromes? It would be nice to keep on looking trying to find sources. And some of them are going to be due to an abnormal microbiome. Some of them are going to be due to autoimmune diseases. We just need to keep on looking.

Dr. Ruscio Resources

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And finally, if you’re a healthcare practitioner looking to learn more about my functional medicine approach, you can visit drruscio.com/review. All of these pages are at the drruscio.com URL, which is D-R-R-U-S-C-I-O dot com, then slash either ‘gethelp,’ ‘gutbook,’ or ‘review.’ Okay, back to the show.

Ehlers-Danlos Syndrome

DrMR: And I’m so glad that you mentioned both low-dose naltrexone and Ehlers-Danlos syndrome, because I wanted to ask you about both of those. First, just tell me, are there any therapies in particular you found to be helpful for Ehlers-Danlos syndrome?

And for the audience, Ehlers or “Elers”—depending on who you ask and how you pronounce it—syndrome, is a syndrome wherein there is a lot of…just to put it very simply—and you may want to expound on this, Lenny—there’s a lot of elasticity in joint and connective tissues. So these people tend to be hyperflexible, hypermobile. And oftentimes they can have that same thing happening in their internal organs and in their intestines. Because things aren’t held in position very well in terms of their abdominal organs, things can start to sloth in, partially press on and or occlude the small and large intestine and cause problems with motility and flow.

It seems that there may not be a ton of therapeutic options for these folks, although I have not looked very deeply. So, Lenny, curious to hear your thoughts on this one.

DrLW: Okay well, Ehlers-Danlos, I’m just getting into that. It’s complicated. But the extremes, you’ve got the hypermobility syndrome where people are “double jointed” and they can have displacement of joints. They can have hernias after surgery. They can have dental crowding. They can have lax skin.

Internally, they can have small intestine that droops down, and that’s one of the causes for small intestinal bacterial overgrowth. Other studies have shown protein deposition in the small intestine as a possible cause for small intestinal bacterial overgrowth.

Centrally, they are known to have increased pain centrally. So their microglia that are attached to nerves are hyper. I don’t know why. But that increases pain throughout the body and pain in the joints. And it’s more than just their joints are lax and they are needing braces. Otherwise they are stretching the ligaments causing pain. But there may be a central factor. And that’s where LDN could have a role, because it decreases what we call the toll receptor activity, which activates the sensory nerves.

DrMR: Was this different than toll-like receptors or is this just the same?

DrLW: Toll-like receptors, yeah. So that’s thought to be a mechanism of action. I just saw a patient Monday, who was the basis of a case report that’s on my website. So if you want to look, a very interesting case in a patient who had complex regional pain syndrome where ultimately, we diagnosed all of her problems to be due to Ehlers-Danlos syndrome.

She had sleep apnea that was due to relaxation of the tissues around the neck and the mouth. She had small intestinal bacterial overgrowth. Both of those conditions are known to cause inflammation. And we felt that the inflammation was maintaining a chronic inflammatory state and maintaining an 8-year history of complex regional pain, which was totally disabling.

And with treatment for those things, namely, a better sleep apnea device, a good treatment for a small intestinal overgrowth, which she never had. And low-dose naltrexone to both a factor for central and visceral hypersensitivity and act as stimulatory medicine. She’s been in a remission from her complex regional pain syndrome, which is almost unheard of.

A copy of our paper is on www.GIdoctor.net. So that’s where I have all my research papers posted. And so some of the things that we talked about are on that as well.

Treating the Fundamentals

DrMR: Okay. And let me ask you this, Lenny, just because one of the things that I’m starting to see is, I sometimes deal with these conditions like Ehlers-Danlos that doesn’t necessarily have a great treatment protocol for it, is sometimes you just focus on treating what you can treat, like you mentioned, with a better sleep apnea device and treatment of SIBO and some LDN. And you get very good results.

So it’s not to say because there’s a syndrome that doesn’t have a sanctioned or a well-established treatment for it, that someone may not experience very impressive symptomatic improvement by just treating the fundamentals. Is that something that you’ve also seen?

DrLW: Oh, absolutely. I think 60% of the drugs that pediatricians give are off-label. So they’re not studied by the FDA and drug companies. They’re just given off label. We do a lot of off-label therapy in GI all the time.

And then all modalities that you use. Some have been studied quite a bit, but often not a double-blind study. And so the herbal remedies are a phenomenon. Today I saw a patient with severe POTS, very interesting. Bloating, brain fog, and fluid retention and bad breath were a lot of the symptoms in addition to tachycardia.

I treated him with Rifaximin. He had diarrhea and he got worse. So I treated him with herbal therapy. Dramatic improvement. Stopped the bloating completely. His breath got better. The brain fog went away. All of this fluid retention that he had for an unclear reason went away.

And he’s doing very well, although 2 weeks after stopping the herbal therapy, he got worse. But he was loath to adding prokinetics, but now he’s willing. So he’s going to start both, the erythromycin and the naltrexone, and be ready to give another go at herbal therapy if the symptoms come back. But it was pretty impressive.

As a trained gastroenterologist at Washington University, where everything was scrutinized to the nth degree and nobody believed anything unless there were 4 double-blind placebo-controlled studies, I’ve gone way to the other direction of just trying things. Because a lot of things don’t work in GI and so you just need to try and try.

And even using modalities that I’ve never been trained in, but I’ve learned at the SIBO conferences about herbal therapies. And it is very interesting and it’s important to have an open mind.

Starting with the Gut

DrMR: Absolutely. And that’s a great couple of examples you gave there of the power of the gut. And that’s why, as I continually speak with different types of healthcare practitioners and try to make it a point to make our care more cost-effective and more efficient, one of the principals I hop on is the importance of starting with the gut. Because you can see many seemingly unrelated and non-digestive symptoms clear when you address an underlying gut problem. And you just gave a couple of great examples with breath, fluid retention, and brain fog improving after addressing someone’s gut health. In complete agreement with you there. And I’m constantly humbled by the far reaching impact of the gut.

One final stop I wanted to make, Lenny—

DrLW: Let me just ask you—

DrMR: Sure.

DrLW: Have you seen fluid retention or lymph retention in patients with SIBO?

DrMR: In a small number of cases, yes. I have.

DrLW: Wow! That’s fabulous, because I’ve not yet until this gentleman today.

DrMR: Yes, I’d say gosh, maybe we see 5 cases a year that just have some edema or sometimes patients describe it as bloating. And you ask them further and they say, “Well, my hands and my feet feel bloated.” It’s really more fluid retention than it is bloating, but sometimes they describe it as that. But yes, I’ve seen a couple of cases of that.

DrLW: Wow! Fantastic.

Medications to Consider

DrMR: So medications. Now, low-dose naltrexone, and we also have prucalopride, also known as Resolor, and AMITIZA or Lubiprostone, and LINZESS. And let’s maybe start with Naltrexone. And I know I’m keeping you on the line here for a while, so if at any point you have to go, just let me know. I want to respect your time.

But I did want to get some thoughts from you on these medications. And maybe some guidelines for—maybe there’s a practitioner out there who’s trying to help their patient. They are not well trained in some of these medications and are looking for some direction. And so here they would come. Or maybe a patient has a doctor who’s open-minded, but looking for some guidance in terms of how to advise on some of these medications. So let’s go through some of the medications that you find to be most effective.

DrLW: Okay. Well, I do find for chronic idiopathic constipation that the chloride channel activators are helpful. And—

DrMR: So this is going to include LINZESS or Linaclotide?

DrLW: Plecanatide, which is Trulance, and AMITIZA, which is lubiprostone. So we’re dealing just with colonic inertia. And then the stimulatory laxatives sometimes are what you require, such as the Sena compounds. And I’m not averse to continuing Sena even though that they can cause darkening of the colon lining or melanosis.

And the Resolor. Problem with that, insurance doesn’t cover. It’s more indicated for IBS-C, but potentially has value. When I’ve exhausted things, there’s no methane to treat, I’ve got LDN. I prescribed it to thirteen patients between 2015 and 2016, who had idiopathic constipation. I only got 6 people who sent back their questionnaire. 33% of the patients had marked moderate response to the LDN. A third had mild response and a third had no response. So small numbers, but at least for those few patients, there was a dramatic response and they had tried every other modality available.

I do have Cisapride, which is a stimulatory medicine that releases the acetylcholine at the nerve endings. I’ve generally reserved that for severe gastric paralysis activity and small bowel motility disorders. But it is indicated for constipation that’s very severe. It has to be given by a physician who has a FDA-guided program to give it and there aren’t many of us on that program. But I do have that motility agent.

And then certainly going towards biofeedback ideas. That’s where it’s aimed at the anal area. So not only is it biofeedback, but putting the legs up on the stool so that the angle is better are things that can help a patient. But then again, think about the refractory patients. Screen them for POTS. Check their orthostatic pulse. It’s the easiest thing in the world to do. Or even just ask them, “Do you get dizzy or light-headed with standing?”

Those are many of the things that I do. A lot of the people will use GlycoLax or a PEG as a means just to water down the colon. And magnesium’s not a bad idea. So magnesium is an asthmatic laxative that’s cheap, inexpensive. A lot of people do well with magnesium pills or even Milk of Magnesia.

DrMR: Do you find similar types of the patients respond to magnesium as may respond to some of the G-coupled receptor modulators to help with getting more fluid into the colon or are they different?

DrLW: Well, I think perhaps the ones that respond to magnesium are the milder patients. Although, you can take care of mild, moderate, or severe constipation in many patients. Actually, if you look at the drug study for Linaclotide, 15 to 20% of patients met the goals versus 5% of placebo patients. 5 to 7%. There were 2 different studies. It was 3 to 5 times improvement in drug versus placebo. But guess what? 20% is 20%. That shows you that a) there are other factors involved, b) that it’s very complex. Constipation is complex and you keep on trying things.

The milder cases, believe it or not, I think there is role for probiotic therapy, lactobacillus regularis that’s in yoghurt. And possibly, Bifidobacter as well in combination, I think are helpful. I’m interested to hear your viewpoint on that. And also I’d love to hear your experience with the conquer… I don’t know how you want to put it on this show, whether you went to plug it or not plug it. But the products for methane. I’d love to hear your point of view on these things now.

Atrantil and SIBO

DrMR: Sure. And you mean with the Atrantil?

DrLW: Yeah.

DrMR: We’ve been enrolling patients in, or I should say, randomly assigning patients to, essentially SIBO patients, where we’ve been either giving them Atrantil as a standalone herbal therapy or the standard antimicrobial protocol that I’ve been using for the past several years. And we’re tracking their SF-12s pre-post and IVS severity score pre-post and their SIBO breath test pre-posts.

So we’re crunching those numbers right now. We were tracking the data a little bit differently before. Initially what we were doing was we were adding the Atrantil in addition to the standard herbal protocol that I would use, to see if it produced any additional benefit. And it got kind of challenging to be able to tell. Because I think we get such a good response already with herbal protocol that we use that I think the potential utility of Atrantil was masked by that. So I decided to break them out.

And I think now we might only have 6, 8 patients who we’re collecting data on. So it’s a little early to tell. We definitely see some response. It definitely—and this is just my own inkling, I haven’t crunched any of the numbers yet—but there are certainly patients that we see a good response on the Atrantil that seems to be proximal to what we see with the herbal protocol. Whether it has any noticeably beneficial impact on constipation where standard herbal therapy doesn’t, I can’t say. I think we’ll probably end up finding they’re somewhat equivalent in their effectiveness, but I’ll be curious to see if we show a higher improvement in the methane. I’m open.

But right now what I would say from my initial look at some of the patients that I’ve been doing this with is, Atrantil is probably going to be about as effective as some of the standard herbal treatments, but we’ll continue to collect data. And when we get a full data set, we’ll publish that and see what the numbers show.

Probiotics and Regularity

Regarding probiotics, I definitely see some patients that see a nice improvement in their regularity when they use probiotics. I typically use 3 different classes of probiotics. I can’t say I’ve seen one probiotic work better or worse for constipation, except for a small exception.

So I typically use a Lacto/Bifido blend that’s kind of similar to be VSL#3, or a Saccharomyces boulardii or a soil-based organism formula. Saccharomyces boulardii can sometimes be constipating, and I think people have probably heard about that because it’s got some pretty impressive studies for diarrhea and also for IBD. So Saccharomyces boulardii for some people is constipating.

But then sometimes Lactobacillus and Bifido bacterium blends can also be a little bit constipating for people. But ironically, for some people with constipation, they see a nice improvement in the regularity and they are more regular. The most common side effect I see is bloating and that typically goes away pretty quickly if someone discontinues.

So yeah, I found probiotics to be effective. And I think I’ve shot you a couple of studies, Lenny, where they’ve documented, in randomized control trial fashion, a benefit on regularity with probiotics. But I don’t think it has to be incredibly prescript because I’ve seen a few different formulations work in the published literature for constipation.

So I come back to trying to make this simple and looking at probiotics and maybe 3 classes: Lacto/Bifido blend, Saccharomyces boulardii, soil-based. And then the fourth would be maybe the E. coli Nissle 1917, but you can’t get that in the States unless you go online to like a Canadian vendor and have it shipped in. So I don’t use that a ton. But those are some of my thoughts in terms of what I’ve seen.

DrLW: All right.

Episode Wrap-up

DrMR: So more to learn always, but I’m glad we had this dialogue, Lenny. And thank you for hanging on the line. I know we went a little late here. But super appreciative of all the work that you’re doing. And every time we talk, I’m always impressed with how you’re tracking data, publishing data, publishing these case studies, publishing these reports, which is just fantastic. Because I think you’re putting such great data into the field to help practitioners have some evidence to pull from to try to get patients who aren’t healthy, well, with some of these therapies that you are exploring. So thank you so much for all the work that you are doing.

And will you tell people one more time the website for the LDN conference and then your website in case they want to try to plug in and follow some of your work?

DrLW: Sure, absolutely. So www.LDNresearchtrust.org, and then my own website is www.GIdoctor.net.

DrMR: Awesome. Well, Lenny, thank you again for taking the time, my friend. I really appreciate it.

DrLW: Okay, thank you so much, Michael. Have a good night.

DrMR: You, too.

What do you think? I would like to hear your thoughts or experience with this.

Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.

Discussion

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12 thoughts on “Constipation — Beyond the Basics with Gastroenterologist Dr. Leonard Weinstock

  1. Thanks for a fantastic interview and for your interview is Dr Satish Rao. So many nuggets to take away. I would love to see a podcast discussing vegans, vegetarianism and constipation. I work with many constipated folks and I see a growing trend of these dietary types walk through the door with chronic constipation. I have my theories but would love to dissect it even further.

  2. Thanks for a fantastic interview and for your interview is Dr Satish Rao. So many nuggets to take away. I would love to see a podcast discussing vegans, vegetarianism and constipation. I work with many constipated folks and I see a growing trend of these dietary types walk through the door with chronic constipation. I have my theories but would love to dissect it even further.

  3. This was a fantastic podcast. Very informative and breaks down the subject of constipation into many possible areas to explore. Thank you Dr. Ruscio for taking these deep dives with Dr. Weinstock and Dr. Rao these past weeks. I am hopeful knowing there are doctors who know recommending more fiber is not working for many of us suffering from this chronic condition.

  4. This was a fantastic podcast. Very informative and breaks down the subject of constipation into many possible areas to explore. Thank you Dr. Ruscio for taking these deep dives with Dr. Weinstock and Dr. Rao these past weeks. I am hopeful knowing there are doctors who know recommending more fiber is not working for many of us suffering from this chronic condition.

  5. Dr. Ruscio,
    Another brilliant podcast near and dear to my life…
    Keep spreading the word on this topic.
    Not many physicians are aware of the complexities of disorders that contribute to constipation.
    I have commented before to chime in on how my specific case has evolved as multiple contributing factors were identified; like peeling back the layers of an onion.
    Colonic Intertia –> Pelvic Floor Dyssenergia/Anismus –> Diastatis Recti
    Happy to say, my symptoms keep improving as I discover more pieces to my puzzle.
    There is a lot more to constipation presentation for many patients like me.
    .
    Thank you for covering topics like this one; no one else I know does.

    Best,
    Rachel

  6. Dr. Ruscio,
    Another brilliant podcast near and dear to my life…
    Keep spreading the word on this topic.
    Not many physicians are aware of the complexities of disorders that contribute to constipation.
    I have commented before to chime in on how my specific case has evolved as multiple contributing factors were identified; like peeling back the layers of an onion.
    Colonic Intertia –> Pelvic Floor Dyssenergia/Anismus –> Diastatis Recti
    Happy to say, my symptoms keep improving as I discover more pieces to my puzzle.
    There is a lot more to constipation presentation for many patients like me.
    .
    Thank you for covering topics like this one; no one else I know does.

    Best,
    Rachel

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