Constipation

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Table of Contents
Symptoms Of IBS-C
Causes Of IBS-C
Redundant Colon
Fibre
Fats
Sorbitol
Prunes
Psyllium (Ispaghula)
Probiotics, Food Intolerances & IBS-C
Medication For IBS-C
Abdominal Massage
Putting It All Into Practice
Diarrhoea With IBS-C
Mucus
Posture
What Can I Do If I’m Desperate?
Further Reading And References

Symptoms Of IBS-C

IBS-C is constipation dominant IBS.

Common signs symptoms of IBS-C include:

bloating that may be accompanied by pain
a feeling of excessive gas
feelings of something heavy in your stomach
three or less bowel movements per week
more than one quarter of stool is hard or lumpy
a feeling of incomplete evacuation

Bloating and pain may go away temporarily after a bowel movement, but these symptoms tend to come back.

IBS causes significant bloating and pain which regular constipation is unlikely to.

(1)

Causes Of IBS-C

Causes of IBS-C include:

food passing slowly through your intestine
issues with intestinal bacteria, hormones, or chemicals
problems with communication between your brain and your bowel
family history of IBS-C or other digestive issues

(2)

Redundant Colon

The average colon (large intestine) is 120 to 150 centimetres (roughly 47 to 60 inches) in length. A redundant or tortuous or elongated colon is one that is abnormally long, particularly in the final section (called the descending colon). (3) To enable the extra long colon to fit in the abdominal cavity a redundant colon often has additional loops or twists and turns (4).

Redundant colon may have similar symptoms to IBS, but medically is a health condition in its own right. It can often be diagnosed whilst investigations are conducted for IBS and may be diagnosed by your doctor as IBS or in particular IBS-C, since such a colon often presents with IBS-C like symptoms. However, some people with a redundant colon never have any symptoms or issues from it (3). Gastroenterologists may find performing a colonoscopy on a tortuous colon very challenging due to the loops and turns and may be unable to complete the procedure. The gastroenterologist may recommend a virtual colonoscopy, also known as computed tomography colonography (CTC) instead if a redundant colon is found during colonoscopy and cannot be completed.

Having a redundant colon may be genetic, though some will have one due to no known cause. (3)

Whilst a redundant colon does not create health problems directly, it can lead to “slow transit time” leading to constipation due to food needing to travel a greater distance. Diet alterations may help a redundant colon, according to the November 2013 issue of Molecular Medicine Reports, as laxatives don’t seem to improve constipation caused by slow transit in this situation.(5)

Most nutrients are absorbed before food reaches the colon and the colon removes water. Since food has further to travel, passing slowly through the colon, too much water is absorbed, causing stools to be hardened. (6)

Fibre

One of the most important treatments for IBS-C with or without redundant colon is fibre. In regards to redundant colon and constipation in general, the emphasis seems to be on insoluble fibre. Insoluble fibre bulks out your stool and speeds up transit time, which is necessary to combat the impact of a redundant colon. However, the U.S. National Library of Medicine states that soluble fibre pulls water into the digestive tract and turns into a gel-like substance during digestion. The result is a slowing of digestion and decrease in transit time.

Sources of insoluble fibre include:

vegetables, like dark, leafy greens
fruits (including the skin)
root vegetables (especially the skin), like potatoes and beetroot
whole grains
wheat bran
seeds
nuts

Much of your fibre intake should come from insoluble fibre, but it is more ideal to intake both soluble and insoluble fibre.

Sources of soluble fibre include:

oats
oat bran
dried beans and peas
flaxseed
nuts
barley
oranges and apples
carrots

(5)

However, when considering IBS and specifically IBS-C, soluble fibre might be better tolerated.

Insoluble fibre does not dissolve in water, but soluble fibre does. Insoluble fibre works on constipation by bulking out the stool and also acting on the mechanics of the gut to stimulate the transit of stool through the bowel (motility). However, a review of 17 randomised controlled trials of people with IBS who were supplemented with insoluble fibre such as corn or wheat bran, has shown that insoluble fibre did not improve IBS symptoms and may even trigger IBS symptoms. This is due to IBS sufferers being sensitive to sensations in the gut and having underlying abnormalities in gut motor function. Conversely, soluble fibre such as psyllium, ispaghula, or calcium polycarbophil significantly improved IBS symptoms. Like insoluble fibre, soluble fibre bulks out stools, but additionally holds more water, softening the stool, making passage easier rather than stimulating the mechanics of the gut, which IBS sufferers might be more sensitive to. (7)

There will be variation in each person’s reactions to fibre and different types of fibre, due to their varying characteristics and how they behave in our guts (8). This means trying both insoluble and soluble fibres to identify your tolerance to each. The ideal would be to have a mixture of the two. (5) There is an interesting article here: (20), which discusses different types of fibre and potential impact on IBS.

Any increases in fibre needs to be conducted on a gradual basis to allow your body to build up a tolerance to it.

An in-depth analysis of fibre in relation to IBS is covered under the Diet menu option in the Fibre section.

Fats

Studies have shown that increasing (healthy) fats can help increase transit time (21). This means that very low fat diets may work against constipation. I obtain fats from almonds and seeds at breakfast time and olive oil with lunch and dinner. About a third of our energy should come from fat. That’s about 70g for a woman and 90g for a man per day. Saturated fats should make up no more than a third of this. That’s 20g for women and 30g for men. (22)

Sorbitol

Sorbitol, a sugar alcohol naturally found in fruits, is a natural laxative by drawing water into the colon from surrounding body tissues (acting as a hyperosmotic), which softens stools, helping to relieve constipation. (56)

Sorbitol is a polyol which is also a FODMAP. Whether you are able to use sorbitol containing foods to help with constipation is determined by how tolerant you are to sorbitol. Here is a list of foods high in sorbitol:

FOOD	SORBITOL CONTENT IN GRAM / 100G
Sweets / candies for diabetics	35 – 95
Chewing gum, ‘sugar-less’	40
Chewing gum, ‘sugar-less’ per gum strip	1
Prunes	11
Horseradish sauce / wasabi	11
Pear, dried	9
Jams / marmalades for diabetics with sorbitol	8 – 10
Plums, dried	8
Rose hip	8
Apricot, dried	6
Peaches, dried	5
Blueberry jam	5
Blackberries, fresh	4
Apple, dried	3
Pear, fresh	3
Pear juice	2
Dried fruit mix	2
Plums, fresh	2
Cherries, fresh	2
Dates	2
Apple, fresh	1.5
Plum juice	1 – 6
Nectarines, fresh	1.3
Apricot, fresh	1.3
Peach, fresh	1
Raisins, sultanas	1
Dried coconut	1
Beer	0 – 0.5

Source: foodintolerances.org (57)

(57)

Prunes

Prunes contain both insoluble fibre in the skin and soluble fibre in the pulp and the juice (43).

Prunes vs Prune Juice

Prunes have 11.2–15.5 g per 100g of sorbitol which is more than double the amount found in prune juice (44). According to research, although high in sugar and calories prunes only have a small impact on blood sugar (70, 71). Prune juice is very high in sugar and calories having 182 calories and 42g of sugar per 256g cup of canned juice, which can lead to blood sugar issues and weight gain. Prune juice can assist constipation, though may be not as effective as whole prunes. A small study in 2007 found that drinking 125ml, or about half a cup, twice a day works as an effective laxative, at least in cases of mild constipation. Many studies discuss eating 100g or approximately 10 prunes a day for digestive issues. A side effect might be an increase in gas or flatulence. (44) This is down to individual tolerance. As with any food that you are not used to, it is best to start in smaller quantities and work up to a higher amount gradually to allow your body to get used to it.

Prunes vs Figs

Both figs and prunes are very high in nutrients. However, prunes are more effective for constipation since they contain a laxative called diphenylisatin (also known as oxyphenisatin) and a single prune contains more than 1g of sorbitol. (45) Nutritionally, prunes contain high levels of vitamins K, and B6, riboflavin and niacin, minerals potassium, iron, copper, boron (for bone health), reduces cholesterol and blood pressure levels and reduces the risk of colon cancer. (46) 9% (13 mcg) of the required daily amount of iodine is contained in 5 dried prunes. (48) Plums and prunes contain more phytonutrients than other common fruits such as peaches and nectarines (72). This includes polyphenols called anthocyanins, which may contribute to the prevention of cancer and heart disease. (49)

Prunes vs Psyllium

Prunes have proven to be superior to psyllium for improving stool frequency and consistency. (47). In a study, the consumption of 2 ounces/50 g of prunes every day for three weeks led to better stool consistency and frequency compared consuming psyllium (73).

Psyllium (Ispaghula)

Psyllium acts as a laxative by bulking out and softening stools by absorbing water in the intestines making stools more easily passable. It is considered more gentle than stimulant laxatives. (51) Stimulant laxatives include bisacodyl (also called by the brand name Dulcolax), senna (also called by the brand name Senokot) and sodium picosulfate (74). Since psyllium is poorly fermented in the colon, it is one of the few sources of fibre not associated with excessive flatulence. (51)

Psyllium vs Cellulose

In a study, the moisture content of the faeces from the rats fed psyllium seed husk (PSH) was higher than those fed cellulose. (54)

Dosage

10g of psyllium per day improved symptoms of abdominal pain or discomfort in the first two months of a three-month randomized, placebo-controlled trial of 275 patients with IBS. There was also improved symptom severity after three months’ supplementation. (7)

The optimum dose of psyllium husk for IBS is 20g per day. This is because a study found that 20g and 30g doses of psyllium husk were superior to 10g, but there was not significant difference between 20g and 30g doses. (50)

How To Take Psyllium

To allow your body to get used to psyllium husk, the first time you take it, measure half teaspoon of psyllium husk and increase the amount by a half teaspoon every few days until you are taking the recommended dosage
After one to two weeks, increase your dose to two teaspoons in eight ounces of water. Try to space your doses out throughout the day, if you are taking multiple doses of psyllium. For example, you could take one dose of psyllium husk in the morning, one at midday, and one in the evening
Mix the psyllium husk powder with eight ounces (0.2l) of water or juice. Stir it well for about 10 seconds. Add more liquid if it is too thick
The mixture forms a gel that can be difficult to swallow and create a choking hazard in its semi-sold form, so do not allow the mixture to sit after you have mixed it and drink the mixture immediately
Do not consume if your psyllium husk mixture is gel-like. Instead throw it out and mix a new batch. (52)
Your doses are best taken just after a meal and never take a dose at bedtime (53)

Psyllium Supplements

Fybogel: Each single dose sachet contains 3.5g Ispaghula Husk. Other ingredients are potassium bicarbonate, sodium bicarbonate, citric acid, riboflavin sodium phosphate, beta-carotene, aspartame (E951), orange flavour, saccharin sodium, polysorbate 80 and silica colloidal anhydrous
Ispagel: Each sachet contains 3.5 g ispaghula husk, sodium bicarbonate, orange flavour 501071 AP0551 (maize maltodextrin, alpha tocopherol and flavouring components), β -carotene 10%, Aspartame E951, citric acid anhydrous, Riboflavin 5 sodium phosphate.
Metamucil: Psyllium husk, maltodextrin, citric acid, natural and artificial orange flavour, aspartame, yellow 6

It seems that most commercial psyllium husk products contain a number of seemingly unnecessary and potentially unhealthy additives such as aspartame. There will be suppliers who provide pure psyllium husk, which you may consider a better option

Psyllium & Slow Colonic Transit

An observational study showed that response to psyllium was poor amongst those with slow colonic transit. However, 85% of patients without such abnormal physiology improved or became symptom free. Psyllium caused delayed gastric emptying and loss of appetite as side effects in some patients. (55)

I tried psyllium husk incrementing slowly over a number of weeks. However, my abdomen blew up into the size of a football and I became extremely bloated. This went down when I stopped taking it. Not everyone will get this effect though. Theoretically this may be due to me having a long, loopy colon which is associated slow transit as described above.

Probiotics, Food Intolerances & IBS-C

There is some evidence that a gut bacterial imbalance (dysbiosis) plays a part in the symptoms of IBS-C in some people (9). This may contribute to gas, bloating, pain and food intolerances. Fibre is the first port of call for constipation and IBS-C. Some high fibre foods may contain FODMAPs which feed gut bacteria. If you are having issues gradually expanding fibre in-take, you could try Alflorex probiotic to help shift your gut microbiome towards more good bugs. This may make you more tolerant to both FODMAPs and fibre. Additionally, the Bifidobacterium in Alflorex digest complex carbohydrates (75), which may help to improve fibre tolerance.

If that doesn’t work you may need to consider other probiotics. Failing that you could consider low FODMAP high fibre foods by conducting a FODMAP elimination and reintroduction diet. You will need to try to retain as many FODMAPs as you can in the diet, since a reduction in FODMAPs may lead to a reduction in fibre and prebiotics reaching your colon. This could have consequences for constipation in turn. (10) Although there seems to be evidence that a personalised low FODMAP diet can help people with either IBS-D or IBS-C. (11)

Medication For IBS-C

Bulking Agents

These are complex carbohydrates that travel to the colon where they help to retain bowel fluids. They can make stools bulkier and softer and stimulate peristalsis (muscle contractions that move food through the digestive tract). It is important to drink plenty of water with them. Since they may feed bacteria, they may initially increase gas, bloating and pain, which should settle as your body gets used to them. Bulking agents should be tried first, as they are more suitable for long term use.

Generic Name	Brand Name
Bran	Trifyba
Psyllium or Ispaghula husk	Fybogel, Isogel, Ispagel, Metamucil,Regulan
Sterculia gum Methylcellulose	Normacol Celevac, Allergy Research, Nutricology

(12)

I have found dietary fibre cellulose less gas forming, thus giving fewer side effects.

Osmotic Laxatives

These are sugars or sugar alcohols or salts that draw water into the colon, increasing the softness of stools making them easier to pass. More water needs to be consumed with them.

Generic Name	Brand Name
Lactulose	Duphalac, Lacitol, Lactugal, Regulose

(12)

Although Lactulose is used as a treatment for constipation, it may make IBS symptoms worse since it tends to produce substantial amounts of gas and abdominal pain. Lactulose would therefore be less suitable for IBS sufferers. (25)

Purgatives

These retain water in the colon, are normally used to clear impacted stool and are best taken under GP supervision, as regular use can deplete the body of salt and water.

Generic Name	Brand Name
Macrogol powder or polyethylene glycol plus salts	Idrolax, Movicol, Laxoberel, Picolax
Macrogol powder or polyethylene glycol plus salts	Citramag
Magnesium Sulphate	Epsom Salts
Magnesium Hydroxide	Milk of Magnesia, Andrews Liver Salts

(12)

Stool Softeners

Used to lubricate and soften very hard stools. Oral consumption of related oils can risk aspiration into the lungs and pneumonia, especially in the elderly. There is also the chance of anal seepage.

Generic Name	Brand Name
Liquid Paraffin
Sodium Docusate	Dioctyl
Docusol	Norgalax

(12)

Stimulant Laxatives

These help to trigger peristalsis, but may increase pain and are generally not recommended for IBS.

Generic Name	Brand Name
Senna	Manevac, Senakot
Bisocodyl	Dulcolax

(12)

Stimulant laxatives such as senna and bisacodyl can move stool along your bowels by triggering contractions in the bowels, but the bowel can become dependent on this and possibly stop functioning normally (76). Avoid using stimulant laxatives for more than a week unless your doctor advises otherwise (77).

Drugs

These are only available on prescription.

Generic Name	Brand Name
Lubiprostone – stimulates intestinal secretion through chloride channel receptors. (84)	Amatiza
Prucalopride – introduced in 2010 as prokinetic agent which increases the movement of food through the digestive tract. Peristalsis is stimulated by it acting on serotonin receptors. (85)	Resolor
Linaclotide – introduced in 2013 to stimulate secretion and peristalsis in addition to reducing intestinal sensitivity and pain. (86)	Constella
Elobixibat – inhibits the uptake of bile acids in the gut, increasing gut concentrations of bile acids, accelerating intestinal passage and softening stools. (87)

Mixtures

These include bulking agents with irritant laxatives:

Name	Contains
Manevac	Isphagula bark, plantago seeds and senna pods
Senokot-S	Senna and psyllium
Normacol plus	Sterculia gum plus stimulant Frangula bark

(12)

Suppositories and Enemas

These tend to be used more for hard, impacted stool:

Name	Action
Glycerine suppositories	Isphagula bark, plantago seeds and senna retain water, soften the stool and stimulate a bowel action
Carbalax	Uses sodium phosphate to draw fluid into the bowel by osmotic action
Relaxit	Has osmotic effects by containing sodium citrate, sodium lauryl sulphate, sorbic acid, glycerol and sorbitol, a mix of osmotic laxatives and a detergent
Dulcolax suppositories	Stimulates rectal peristalsis with bisacodyl
Micralax	Retain fluid in the bowel with sodium citrate and sorbitol

(12)

Healthline.com also provides a useful table regarding medications for constipation:

Type	Generic and brand names	Forms	How fast?	Safe to use long-term?	Available as a generic?
bulk-forming	psyllium (Metamucil, Konsyl), calcium polycarbophil (FiberCon)_^*1, methylcellulose fiber (Citrucel)	powder, granules, liquid, tablet, packet, wafer	a few days	yes	yes
lubricant	mineral oil (Fleet Mineral Oil Enema)	enema, oral liquid	6 to 8 hours	no	yes
osmotic	magnesium hydroxide (Phillips Milk of Magnesia), magnesium citrate, polyethylene glycol (Miralax), sodium phosphate (Fleet Saline Enema), glycerin (Fleet Glycerin Suppository)	enema, suppository, oral liquid	30 minutes or less	yes	yes
stimulant	bisacodyl (Dulcolax), senna/sennoside (Senokot)	enema, suppository, oral liquid or capsule	6 to 10 hours	no	yes
stool softener	docusate (Colace, DulcoEase, Surfak)	Enema, suppository, oral tablet, capsule, or liquid	1 to 3 days	yes	yes

Source: healthline.com (2019) (26)

(26)

^_*1IBS Researcher Note: Calcium polycarbophil can help IBS patients with constipation or alternating diarrhoea and constipation and is especially useful if patients have bloating as a major complaint. (27) It is contained in Fibercon & Equalactin- reviews here and here. This product only seems to be available in the US.

Additionally, there has been research published in the journal Neurology regarding those who use laxatives long term have more than 50% greater chance of developing dementia. The risk is even higher for those who use osmotic laxatives and those using a number of different types of laxative. This may be due to regular laxative use changing the gut microbiome impacting signalling from the gut to the brain or toxins that are produced in the gut that may affect the brain. More research is needed to confirm these findings. At this stage it is to be noted that the research has identified an association between laxative use and dementia and not necessarily the fact that laxatives cause dementia. Ideally, though, constipation is better managed through dietary measures and lifestyle changes than by taking laxatives if this is at all possible. (69)

Abdominal Massage

Self abdominal massage can not only help relieve constipation, but also has the following benefits:

the need for long-term laxative use is minimized
helps to relieve gas
reduce the likelihood of needing medical attention for constipation
helps you and your muscles to relax, which may ease your bowels.

(60)

Further information about how to do this can be found here: (60) (61) (62).

A massage belt specifically for constipation called MOWOOT has been developed (63) (64) (65). However, the cost is highly prohibitive (66) (67).

In the US, there is a vibrating pill that is available on prescription called Vibrant. This is a small medical device in capsule form that is taken daily to stimulate peristalsis. It was approved by the FDA in August 2022. (68)

Putting It All Into Practice

Since I have IBS-C and a redundant colon, my diet contains a substantial amount of fibre. However, many people may only require a fraction of the fibre that I consume. It is a case of introducing fibre to the level that achieves the required result and to a level that you can tolerate. My rationale is that I would prefer to have regular bowel movements from diet rather than laxatives. I found that if I didn’t treat my IBS-C, I would suffer from overflow diarrhoea, where liquid food seeps around impacted stool, which could leave me tied to the house.

An initial test would be to try ground flaxseed (linseed) on your breakfast, starting at 1/2 teaspoon and increasing at 1/2 teaspoon every 2-3 days until you build up to 1 tablespoon (which is the same as 3 teaspoons). You’ll need to ensure that you have a 200ml glass of fluid with each spoonful of linseeds taken (25). Note that the Monash University FODMAP app states that 1 tablespoon of flaxseed is low FODMAP, whereas 2 tablespoons are high in the FODMAP, GOS.

Any increases in fibre should be conducted on a gradual basis, starting with a small amount (perhaps 1/4 to 1/3 of a normal portion size) and then increasing the amount every 2-3 days, whilst recording symptoms in a food diary. Sometimes it can take 2-4 days for symptoms to appear. It may be necessary to cut back to a previous amount for longer if you are having issues.

I take Alflorex probiotic to increase my tolerance to fibre and FODMAPs in some of the foods that I consume. For instance polyols (sorbitol and mannitol containing foods), can be helpful in drawing water into the intestines to soften stools, but these are also FODMAPs. I also take Linaclotide which helps with IBS-C pain. When starting Linaclotide my IBS pain reduced by 50%-60%. Subsequently starting Alflorex reduced my pain to zero and the pain only comes back when I am reintroducing foods back into my diet and before my body adapts (or I have to give up on that food).

Here is my regime for IBS-C. Please note that every person is different and every person has a different tolerance to different foods and also different amounts of food so you need to find what works for you. This is why it is very important to keep a food diary. I keep mine on a spreadsheet including date, the items that I am introducing that day with quantities and in a separate column recording how my digestive system is behaving in terms of e.g. gas, bloating, nausea, stool type etc. I’d worked out that my transit time is about 48 hours so any results would have this delay.

Sample Diet

Breakfast
- Porridge: I started with 8 tablespoon of oats and 1.5 tea cups of water microwaved for 5 minutes. Since this didn’t help my IBS-C, I then replaced 1 of the tablespoons of oats with 1 tablespoon of oat bran and tried this for 2 days. I then continued this regime until I’d reached 4 tablespoons of oat bran with 4 tablespoons of oats. Since I wasn’t getting the result I wanted, I then followed the same process replacing each tablespoon of remaining oats with wheat bran sticks (All bran), ending up with a mixture of 4 tablespoons of oat bran and 4 tablespoons of wheat bran sticks, with 1.5 tea cups of water and microwaving for 5 minutes. Subsequently, I mixed in 2 tablespoons of chia seeds, 10 ground almonds and 1 tablespoon ground flaxseed (using a coffee grinder) to the porridge mixture, allowing this all to stand for 15 minutes so the chia seeds can form a gel. On top of this I place 8 prunes and consume
- There is lots of information about chia seeds including how to take, how much to take and how they assist with constipation in these links: (14), (15), (16), (17), (18). Don’t let this article put you off, it is just a warning to ensure that you soak chia seeds first: (19)
- Other high fibre breakfast options include Shredded Wheat or Nutribrex which is gluten/wheat free
- Some people may find that porridge made from rolled oats useful which is a source of soluble fibre, but personally I found this made me more constipated as described in my testing above
Before Lunch
- 1 orange (oranges are high in fibre to bulk out stools, vitamin C which softens stools and naringenin, a flavonoid that works as a natural laxative (34) (35)) or 2 kiwi which are also high in fibre and Vitamin C.
Before Dinner
- One of these high fibre fruits: 1 hard pear or 5 dried apricots or 100g raspberries or 100g blackberries. I bulk buy fruit and freeze where necessary to allow me to have this variety. I tend to cycle between these 4 fruits every 4 days, to avoid always having the same fruit one day after another. My theory is that this may help with longer term tolerance and also helps to increase bacterial diversity of the gut
- To add further calories and to assist with maintaining my weight, I also include with the fruit 2.5 tablespoon of buckwheat flakes plus 2 tablespoon of oat amazake. This adds a bit of satisfying sweetness to the snack without impacting blood sugar levels too much
At other meals
- High fibre carbohydrate and protein sources
  - Quinoa
  - Wholewheat bread (contains FODMAPs – fructans)
  - Whole grain pastas (e.g. Spelt – high fructan or Buckwheat which is gluten free/low FODMAP)
  - Potatoes with skins
  - Sweet potatoes which are higher in fibre than white potatoes plus they contain a natural osmotic laxative (mannitol) – note this contains FODMAPs, so it depends on individual tolerance – in the end I found that this wasn’t an option for me due to the mannitol content
  - Canned lentils or canned chickpeas thoroughly rinsed to remove the FODMAPs that leach into the water in the can
- Healthy Fats
  - Olive oil – 1 tablespoon with lunch and 1 tablespoon with dinner

Supplements

Ginger extract
- 30 drops of ginger extract in a little water before bedtime to aid motility
- You may need to work up the dose to say 7 ginger extract drop increments each night.
Optifibre
- Optifibre contains Partially Hydrolysed Guar Gum (PHGG).
- PHGG acts a prebiotic increasing the good bacteria, Lactobacilli and Bifidobacterium and helpful by-products (short chain fatty acids) assisting in restoring microbial balance to the gut. In a study, this action helps to relieve IBS symptoms including pain and distension. (36) (40) (41) The increase in Lactobacilli and Bifidobacterium leads to a reduction in the PH (increase in acidity) in the intestine. A more acidic environment reduces the formation of harmful bacteria by-products (37)
- In a study, flatulence was observed as a side effect, but this declined within the first week of taking PHGG and then stopped (37)
- A study supports the administration of 6 g/day PHGG for IBS patients (38)
- Up to 15 grams seem to be tolerated, but if side effects do occur they tend to include mild digestive issues such as gas, diarrhoea, bloating, and cramps (39)
- Precautions and interactions with guar gum are mentioned here: (42).
- Optifibre caused me excess gas, but that was only when I took the full dose. Note that the product comes with instructions of how to take it and to work up the dose. I found that I could tolerate 4 teaspoons in a mug of water before meals. However, latterly and since I have expanded my diet further, increasing fibre in my diet, I have became less tolerant to Optifibre, since I experience excessive gas even in smaller amounts with my new dietary regime. I have found there are certain meals that require extra fibrous support, such as when I consume potatoes, which I find to be more constipating. In these cases I take a heaped teaspoon of Dietary Fibre Cellulose mixed in water prior to that meal. Cellulose is less likely to produce gas (78). In the case of Optifibre, this is how I worked up the dose so that my body could get used to it and to reach a level at which I wasn’t experiencing too much gas from it:
  - 2 level teaspoon Optifibre before lunch & dinner for 3 days
  - 2 level teaspoon Optifibre before breakfast, lunch & dinner for 3 days
  - 3 level teaspoon Optifibre before breakfast, lunch & dinner for 3 days
  - 3.5 level teaspoon Optifibre before breakfast, lunch & dinner for 5 days
  - 3.75 level teaspoon Optifibre before breakfast, lunch & dinner for 6 days
  - 4 level teaspoon Optifibre before breakfast, lunch & dinner

Exercise

How much exercise?
- Exercise helps with motility and triggering bowel movements (80)
- For example, for those aged 19 to 64, the UK government recommends 150 mins of moderate exercise (e.g. walking as if you are late for an appointment) or 75 of intense exercise (e.g. jogging) per week (79)
- I try to run for 25 minutes three times a week
- If you have mobility problems, but are able to walk, even walking can help
- I sometimes have a bit of a walk around after breakfast to get things moving

Fluids

6 to 8 cups or glasses of fluid a day (81)
- You need to ensure that you are drinking enough fluids (this is around 2 litres of fluid per day)
- Water is ideal for hydration
- Note that bowel movement frequency can decrease with very low fluid intake (500ml per day). However, in healthy individuals increasing fluid intake beyond normal recommendations does not increase stool output. Although a study of those with functional constipation consuming enough fibre (25g per day) and having 2 litres of fluid a day, decreased laxative use and increased bowel movement frequency compared to those consuming 1 litre of fluid a day. Increasing fluid intake does not improve constipation on its own. (82)

I have found useful having most of my food at meal times, leaving 4-5 hours of not eating between meals, eating my fruit snack before a meal. This means that your digestive system has time to process each meal. Additionally, there are a number of mechanisms that help propel food through the intestines (83). One of these mechanisms is something called the MMC (migrating motor complex) which sets off ‘cleaning waves’ that sweep food waste from your small intestine into your large intestine (83). This only happens when you have an empty stomach (83). When people snack regularly, it prevents the MMC from working properly and could hinder this ‘cleaning’ activity. I also find the larger meals help to push things along better than drip feeding through snacking.

There is some advice about lifestyle changes for IBS-C here: (13).

Diarrhoea with IBS-C

Sometimes constipation can become progressively worse over time resulting in a mass of hard stool blocking the rectum. The rectum becomes stretched and enlarged so the rectum muscles don’t work so well and can’t push the stool mass out. When this happens, liquid stool can gather behind the mass and then leak around its edges resulting in what appears to be diarrhoea. However, this is what is known as overflow diarrhoea or paradoxical diarrhoea, due to it being alongside constipation. It is also possible to have uncontrollable faecal incontinence in this situation, where liquid stool can leak out without warning. This type of diarrhoea can only be treated by preventing constipation. (30)

Theoretically, some people who believe they suffer from IBS-M (mixture of constipation and diarrhoea), may actually be suffering from constipation with overflow diarrhoea. If this is suspected, it is worthwhile working on the constipation to find out whether emptying the bowels more regularly stops the diarrhoea.

Mucus

It is normal to have mucus which is not usually visible in the stool. Researchers are not sure why mucus is more excessively produced by the lining of the intestine and becomes more visible in the stools of IBS sufferers. (32)

Although I haven’t found any research to back this up, my guess is that more mucus might be produced with IBS-C to try to help ease out hard stools. One thing to remember is that mucus in your intestines is important and plays a big role in looking after the health of your intestine:

Mucus is a defence layer in your intestines, collaborating with the immune system, helping to maintain stability in the intestine by protecting against mechanical injury and toxic substances, enzymes and bacteria. Studies suggest that mucus has direct immunological effects due to glycans which bind directly to immune cells
The intestines secrete approximately 10 litres of mucus a day
Mucus binds with water to act as a moisturising and lubricating agent for the intestinal lining epithelial cells protecting them during the movement of contents through the intestines
Cleans intestinal surfaces binding with and removing debris and bacteria by flushing them away via intestinal flow
Allows the diffusion of ions, water, nutrients and gases so they reach cells involved in digestion (enterocytes)
Interacts with the gut microbiome, providing nutrients and attachment sites

(33)

Posture

Having the right posture when opening your bowels can help – there is a useful diagram here (58). Some may find a squatty potty helpful (59).

What Can I Do If I’m Desperate?

If you really get stuck you can try magnesium oxide (23). I used to take MyVitamins Magnesium Oxide for a regular bowel movement when having to be low fibre. Each tablet contains 100mg of magnesium oxide, which is useful in finding your tolerance level. I used to start around 800mg at bed time on an empty stomach, then increment by 100mg (1 pill) each night until I got a response the next morning or the morning after. Most of it goes straight to your bowels where it draws in water to bulk out stools.

This worked well when I was low fibre, but when I started to introduce fibre it became more unpredictable (either not working well enough or too well), so I had to cease taking it.

Magnesium oxide is a saline/osmotic laxative, which can be useful for short-term constipation. If used long term, these types of laxatives can lead to dehydration or cause an imbalance in other minerals. (29)

Caution when taking antibiotics, since magnesium oxide might inhibit antibiotic absorption if antibiotics are taken too soon before or after a magnesium supplement. It is advised to take antibiotics at least two hours before or 4 to 6 hours after a magnesium supplement. (28). Magnesium oxide can also interact with certain drugs.

Symptoms Of IBS-C

Causes Of IBS-C

Redundant Colon

Fibre

Fats

Sorbitol

Prunes

Psyllium (Ispaghula)

Probiotics, Food Intolerances & IBS-C

Medication For IBS-C

Abdominal Massage

Putting It All Into Practice

Diarrhoea with IBS-C

Mucus

Posture

What Can I Do If I’m Desperate?

Further Reading And References

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