Constipation: What's Normal and When Should You Be Concerned?

Dr. Scott Steele:

Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again, everyone. Welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the President of Main Campus and colorectal surgeon here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today we're going to talk to our expert, Dr. Monica Multani, who's a gastrologist at the Digestive Disease Institute at Cleveland Clinic, Florida. Monica, welcome to Butts & Guts.

Dr. Monica Multani:

Thank you guys so much for having me.

Dr. Scott Steele:

Today we're going to talk a little bit about constipation and getting things moving, but before we do that, let's give our listeners a little bit of background to you. Where are you from, where'd you train, and how to come to the point that you're here at the Cleveland Clinic?

Dr. Monica Multani:

Yeah, my name's Monica Multani. Like you said, I did my medical school training in Colorado and then I came to Florida, South Florida. I did my residency and my fellowship training at Larkin Community Hospital in South Florida. And then I joined the Cleveland Clinic campus almost exactly a year ago. So I'm really happy to be here as part of the gastroenterology department.

Dr. Scott Steele:

Well, it's great to have you. And as we talked about, we're going to manage constipation here today. And so at a high level, what exactly constitutes constipation versus someone who just has irregular bowel habits?

Dr. Monica Multani:

So the way that I think of constipation is it's fewer than three bowel movements a week or it's hard stools or it's straining, having to push really hard in order to have a bowel movement. That's going to be more than just having off days. So if you're having a few off days a month, that wouldn't qualify necessarily as constipation as in itself besides some of the stuff that I mentioned.

Dr. Scott Steele:

So are there different types of constipation? And if so, what kind of makes them different from one another?

Dr. Monica Multani:

That's a great question. The way I like to think about constipation is there's two major types in my brain. One of them is slow transit. So think the gut is sluggish, things aren't moving, whereas the other type is outlet dysfunction. So it's when the pelvic muscles aren't coordinating, you need certain muscles to relax and certain muscles to contract in order for stool to move out properly without it getting obstructed by those pelvic floor muscles. So that's where a gastroenterologist can tease out the difference between the two and see which ones our patients have.

Dr. Scott Steele:

Lots of different reasons why someone may be constipated, but what are the most common reasons that they get constipated that patients may not even realize?

Dr. Monica Multani:

Big one is water and diet. So dehydration is a very common cause for having constipation. In terms of the diet, a low fiber diet is also going to really slow down your bowel movements. Another big thing is ignoring the urge. So especially in this day and age, we find ourselves holding off going to the bathroom or not trying to... Sometimes you're in the wrong place at the wrong time, but that can definitely contribute to both types of constipation that I mentioned. Medications is another big one. Certain medications like pain medications, opioid medications, or certain calcium or iron supplements, those can also be very common causes that people may not realize that could contribute to constipation.

Dr. Scott Steele:

So you mentioned diet, fiber intake, as well as fluid, water intake, as something that we need to be able to regulate to be able to control or mitigate constipation. Is there a certain threshold that you'd like patients to take with each of those in order to avoid constipation.

Dr. Monica Multani:

Yes. Let's start with water since it's easier. I usually recommend 32 ounces of water a day at least. That is a full-time job in itself sometimes, so I recommend doing the best that you can. Any increase in water intake is only going to help.

Diet: fiber goals, we aim for somewhere between 20 to 40 grams of fiber a day, which also feels like a second job sometimes. The best places to get fiber is in your natural diet. So I recommend sources of what we call soluble fiber. There are different types of fiber: soluble versus insoluble.

Soluble fiber is going to be easily digestible and it won't cause bloating or sometimes even constipation itself. Those sources of fiber that includes oatmeal, flax seeds, chia seeds, berries. Those are some sources of good fiber. The insoluble types of fiber, that's going to be like beans, which have a ton of fiber but can cause a lot of bloating and discomfort.

So the key to finding the type of fiber that works for you can sometimes just be trial and error. And it takes about a week or two to know whether that source of fiber is a source of fiber that helps you or that can sometimes hurt you. Generally speaking, up to 40 grams is what we aim for.

And what I recommend to patients too is using supplements. So Metamucil or Benefiber are great supplements that are natural that you can incorporate, especially while trying to get your diet to the point where it has enough fiber in it. You can use the supplements as a bridging method.

Dr. Scott Steele:

Are some people more likely to struggle with constipation than others, and what might put them at a higher risk?

Dr. Monica Multani:

Older adults certainly have a more difficult time with constipation and movement of bowels. Some things that also would predispose you to constipation would be a sedentary lifestyle. So think movement leads to movement. Getting up, exercising also stimulates your bowels to move. So those patients are at a higher risk if you're more sedentary for constipation.

There are certain medical conditions like diabetes or hypothyroidism, which is when the thyroid isn't functioning as well as it could, and it could be slowing down the intestinal tracts and that can also put you at a higher risk for constipation. So those are some things that you could tease out with your primary care doctor.

Dr. Scott Steele:

So you mentioned that everyone should be increasing their fluid intake/water or their fiber intake. Is there a time when you would recommend patients to see a doctor instead?

Dr. Monica Multani:

Yes. When it's serious, the sorts of times that you need to see a physician, if you're seeing significant weight loss, especially if you're not intentionally trying to lose weight. Blood in the stool is always something that needs to be escalated to a physician. If the constipation is chronic, despite all the changes that we mentioned, increasing your fiber, increasing water intake, but you're still having less than three bowel movements a week or having to strain, it's definitely time for a medical evaluation at that point. Sometimes we can tease out more diet changes or sometimes we have to resort to medications to help with bowel movements.

Dr. Scott Steele:

Monica, let's talk a little bit about over-the-counter laxatives. Are they safe to use, and how do you know which type is right for your situation?

Dr. Monica Multani:

Yes, they are safe to use. There's different types. So the most common ones are the bulk-forming ones. That includes ones that include psyllium. And what that's doing is it's drawing water and electrolytes into the stool to bulk in it so you don't get those small, pellet-like poop that comes out and it's harder to push. They're more gentle. They're easier to use on a more regular basis and they're safe to use.

There's also the type that are called stimulant laxatives. So think Senna; that's pretty common in a few of the pills we prescribe. It's also common in some teas that claim to be a laxative or help move bowels. Stimulant laxatives are safe to use, but I'd recommend using them only in short term because they can cause changes in the bowel. So it's okay to use them just on a short-term basis.

The important thing that I like my patients to know that laxatives are not addictive, which means some people are afraid that if they take laxatives on a regular basis that they won't be able to go to the bathroom without a laxative. That scientifically has proven not to be true. So it is safe to take laxatives, particularly the bulk-forming ones.

Dr. Scott Steele:

So truth or myth, truth or myth, can stress or mental health affect your bathroom habits and contribute to constipation?

Dr. Monica Multani:

Absolutely. There's a strong connection between the brain and the gut, and we are very firmly affected by stress and other things that basically slow down the rhythm of the gut. So I would say it's a truth, and you can see that kind of anecdotally on a day-to-day basis. Traveling can be stressful and oftentimes people have slowing of bowel movements or constipation on trips. That seems to be a big factor for people: stress and mental health.

Dr. Scott Steele:

We also talk a little bit about having good bowel hygiene. So what daily habits can people be doing to lower their chances of getting constipated?

Dr. Monica Multani:

The hydration is a big one like we discussed, and then having a high-fiber diet that's also really important. Regular meals is going to be important as well. I usually ask my patients to aim for about three meals a day with one snack. That keeps your intestines moving.

Exercise like we discussed before, having a regular exercise routine is so beneficial to your physical health, to your mental health, which can contribute to your gut health, as well as just keeping the intestines moving. Those are some things to consider inside the bathroom. Some other things to consider is not sitting on the toilet for too long. That can lead to hemorrhoids. Having to push and strain for more than a couple minutes I think is also contributing a lot to constipation.

And I do also sometimes recommend to my patients the Squatty Potty, which is like a stool or just a stool that you can put in front of the toilet. What it does is it brings up your knees and puts you in a better anatomical position to have bowel movements. So that's kind of an easy thing that you could do at home and those are some things you could do on a regular basis to have better bowel movements.

Dr. Scott Steele:

So can constipation be a sign of another underlying medical condition?

Dr. Monica Multani:

Yes. So the ones that I mentioned, hypothyroidism as in problems with a thyroid, diabetes, those can be hidden factors. If you've had surgeries before, those can also sometimes contribute to constipation. It's important to get a medical evaluation if you're still trying to have regular bowel movements, but everything that I've mentioned above isn't really working. It's important to see if there's any underlying causes.

Dr. Scott Steele:

That's great. And so at what point do you say that this serious medical concern that needs to see professional treatment, is it more of the it's not getting better or is it some of these other symptoms like blood or changes in the bowel movements, thinning of the stools? What do you feel?

Dr. Monica Multani:

Weight loss is a big one, like unintentionally losing a lot of weight, blood in the stool. Sometimes that can look like bright red blood or sometimes that could be black, tarry stools. Like I mentioned, having to strain and some of these conservative measures aren't working, having less than three bowel movements a week. Those would be some things that I would definitely want to escalate to a medical professional.

Dr. Scott Steele:

And I know we talked about lifestyle changes, about watching your medications, about the fluid and about the fiber intake, but any overview of some current treatment options for constipation that might not follow those parameters that you're doing everything there and you're still struggling?

Dr. Monica Multani:

Yeah, I think we definitely talked about the laxatives and the fiber. Some things that I've mentioned to people that may help a little bit more with symptoms of bloating that are natural that could also be contributing to constipation, peppermint or peppermint oil so it can come in a tea. It relaxes the sphincters, which are these muscles. They're kind of the doorways in between certain parts of the intestines and peppermint relaxes those areas so it allows gas to pass through better.

Something else that I find helpful for some of my patients is papaya. It's a natural digestive, and I believe you can also get it as extract in pill form. And so that is going to be a great thing to consider. Recent literature has shown that two kiwis a day is equivalent to one laxative. And so that's something that you could start incorporating as well. And those are some other natural things to consider that add to good gut health that might help with constipation.

The last thing I like to consider for my patients are probiotics, which is good bacteria. We can introduce that in pill format because there's quite a few good over-the-counter pills for that, or you can obtain it naturally. So kefir or yogurt has a very high source of probiotics. There's also the consideration of prebiotics.

So probiotics is the good bacteria. Prebiotics are what good bacteria eat. So good sources of prebiotics are going to be kimchi or sauerkraut, anything fermented that is going to basically aid in the probiotics or the good bacteria in your system. And I believe that has a good factor in helping with bowel movements and just overall good health.

Dr. Scott Steele:

Fantastic. And so now it's time for our quick hitters a chance to get to know you a little bit better. So first of all, salt or sweet?

Dr. Monica Multani:

Definitely sweet. Yeah, for sure.

Dr. Scott Steele:

What was your first car?

Dr. Monica Multani:

My first car was a Ford 250 long bed truck. I think it was just the car that my dad thought I would be safest in. So I rode that one around through high school.

Dr. Scott Steele:

Wow, fantastic. And so if you could have a superhero power or a superpower, what would it be?

Dr. Monica Multani:

The one I would choose would be to fly. My husband is a pilot, so I am envious that he can just take himself straight into the sky. So I think my superpower would be that just without an engine or anything. That would be pretty incredible for me.

Dr. Scott Steele:

And finally, if you could go back in time and maybe around the time that you finished medical school and give yourself a piece of advice, what would that be?

Dr. Monica Multani:

That it's important to continually be a learner. That's something about me that I would like people to know. Whether it's inside my field or outside of my field, picking up a new book or a new skill or trying something different, it's important to exercise that muscle to learn.

And that's something that I would tell my younger self to do. That's really aided me a lot in my career and just in my personal life. So just continue to be curious and continue to be open to learning something new.

Dr. Scott Steele:

Fantastic. And so give us a final take-home message to our listeners regarding managing constipation.

Dr. Monica Multani:

Yes. Start tomorrow by increasing water. If there's just one thing you can do differently, water would definitely be the take-home message. It's the MVP of this. So start there.

But if you're running into issues and you're still not able to feel good about your bowel movements, it's never a wrong time to escalate to see. One of us as a specialist because whether, like I said, whether that's dietary changes or whether that's certain medications, we're there to help to just help with the good gut health. But if anything, water would be the best place to start.

Dr. Scott Steele:

That's fantastic. And so for more information on the Digestive Disease Institute at Cleveland Clinic Florida, please call 877.463.2010. That's 877.463.2010.

You can also visit clevelandclinicflorida.org/digestive for more information. That's clevelandclinicflorida.org/digestive. Monica, thanks so much for joining us on Butts & Guts.

Dr. Monica Multani:

Thank you guys, so much. Looking forward to seeing you guys in clinic.

Dr. Scott Steele:

That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.