DEMYSTIFYING DIGESTIVE TRACT SYMPTOMS: Abdominal Pain, Diarrhea And Constipation In The Language Of Gut 

Vikas Khurana, MD, MBA

Chapter 1: Introduction

Why Colon Is Misunderstood, Slandered And Maltreated

“No organ of the body is so misunderstood, so slandered, and so maltreated as the colon. No wonder that the colon is unhappy.” These words by Arthur F Hurst are still as true as they were in 1935. Most of the bathrooms in the developed world will have a book.  We read in bathrooms. Magazines, newspaper, books and we even have bathroom libraries.  Why? Why do we read in bathrooms, pleasure or a necessity? The reason is very simple. We are in there a long time, a very long time. So we have to look at the underlying reason as to why we have to be in there for so long. It turns out, many and most of us are suffering from bowel disorders.  Constipation is a common problem in adults and it is one of the most common causes of general suffering. Chronic Recurrent Abdominal Pain, though not fatal, is debilitating, in both adults and children alike. It can present itself in various ways starting from occasional hard stools to severe abdominal pain.

Most of the patients will respond by saying that they suffer with constipation “just like a normal person”, yet when were the last time bowel habits were discussed with a normal person; in other words, who taught us what a normal bowel habit is? What needs to be understood with constipation is that it creeps upon us very slowly. Just as we are never able to pinpoint the exact day that our kids grew and only notice the growth when we compare pictures after a while, incremental progression of constipation manifests in a similar fashion. The problem is that we do not have a picture of our health to compare it to. We do not have a picture that shows our energy levels and how well we feel over weeks, months, and years, as we do not record it and cannot comprehensibly measure it. The way we feel this week will become the baseline picture of our health for the next week.  Hence, when people develop constipation over years, it usually goes unnoticed.

To understand the purpose of this book you will first need to understand how scientific literature works and how research papers are written. A question by a researcher leads to generation of a hypothesis based on which an experiment is designed. The results are then assembled, context and the surrounding thought processes are layered with the results based on our current understanding of the topic, and finally, conclusions are drawn to advance our learning. In this entire process the only hard fact is the result of the experiment; the discussion and conclusions are based on our current understanding of the topic and are just a figment of our imagination. Several things in our environment such as current thought processes, prior experience, and other factors may influence the interpretation of results making our conclusions biased. If we find additional evidence, facts may be interpreted very differently due to new evidence. A simple example will illustrate this point better. In the dark, a round long thing is the rope but add to that information a fang, a tail, slime, movement and a bite: it is a snake. Depending on what we see routinely and what makes up the current wisdom, will allow us to interpret whether the round long thing is a snake or a rope. If we see a movie about snakes just before being blindfolded, we determine it is a snake, even if we were actually handed a rope. Chronic recurrent abdominal pain with negative workup and other unexplained digestive track symptoms are all twisted shoots of our faulty understanding of physiology. Today’s research is replacing and modifying yesterday’s theories as new evidence becomes available and this journey of discovery and refinement is eternal.

This book is written for patients and parents who want to understand the symptoms and discomfort associated with these conditions in scientific terms. Doctors now-a-days become far too entangled in numerical percentages and abbreviation jargon. Add to this the time pressures created by our health care system this leaves a normal person confused as to what he might have.

Another complicating factor is the widespread state of denial in acknowledging constipation. Laxative is a taboo and people do not want to talk about what comes out of “the other end.” The classic image we have of a person with constipation is that of an old lady who shouts at anyone and everyone. This image, coupled with the fact that most people don't want to acknowledge that they are getting older, cause people to deny constipation as a problem.  They subconsciously ignore the transitory state of bowel dysfunction, which they assume will get better on its own.

 

“Irritable Bowel Syndrome” is one of the most commonly diagnosed condition that has become the waste paper diagnosis for abdominal pain. If the patient presents with abdominal pain, nausea, dizziness, anxiety, clay like stools three to six times a day and the known workup including upper endoscopy, colonoscopy, CT scans, abdominal X-rays, capsule endoscopy, stool or blood tests do not explain these symptoms, it is labeled as “Irritable Bowel Syndrome or IBS”. The fact remains that billions of dollars have been spent in search of a magic cure for this condition without much success. Many of the patients suffering from unexplained gastrointestinal symptoms were labeled as Irritable Bowel Syndrome during at least some period of their life.

I have also noticed that people who used to get constipation and have used a laxative believe that they can outgrow their constipation. Constipation is both self-treated and treated by doctors. Also doctors have limited time now so patients are left to fend for themselves. There are definitely some kinds of constipation that are episodic and are related to medications and other reasons. Most often constipation is idiopathic (without a known reason), which is idiotic for the doctors and pathetic for the patients. It is idiotic because we cannot find a real cause, and pathetic because patients continue to suffer. For those taking medications that cause constipation, it is likely they will continue to need the medications for long term. I have seen many patients who were prescribed a medication with constipation as a side effect, and then forgot about it. As constipation grows slowly and the last week’s picture of our health will become the baseline of our health picture for next week, constipation is ignored and forgotten. People try to connect their symptoms with what they ate, yet this link is difficult to establish due to its slow development.

Human memory for diet does not span for more than few days. If the symptoms do not occur within twenty four hours of eating food, people do not relate their symptoms with their diet. Still, people will try to explain their symptoms based on what they ate. How can our brain comprehend if the constipation we are suffering from today is the result of what we ate three days or even a week ago? The relationship of food and symptoms becomes confusing as bowel upset may indeed be related to the food taken few days ago. The result is that people end up with unexplained abdominal pain, nausea and heart burn like symptoms.

To be fair to patients and health professionals, unlike other ailments, the symptoms in constipation are often concealed and difficult to verbalize. Almost all findings are based on patient’s experience of pain or nonspecific symptoms. Correlating the relationship between patient’s symptom and their disease process is difficult. Add to that the time pressure on the health provider and non critical nature of the bowel disease. The result is that healthcare providers have stopped listening to the patients and are too quick at labeling patients with a diagnosis. I feel that the art of prevention and advice for lifestyle changes is vanishing from medical advice. Doctors are under pressure to see too many patients and hence too busy to talk about constipation. Healthcare providers have a mental hierarchy and priority for symptoms and diseases, and the result is that constipation is left for the patients to manage themselves. This book helps patients understand the disease process better and provides them with information to manage their disease better.

 The book is for those patients who are too embarrassed to talk about this topic and sometimes ignored and hence continue to suffer.

*Clinical Story*

1.1. “Elvis Presley And Chronic Constipation”

Elvis Presley, the rock star legend, died in 1977. Dr. George “Nick” Nichopoulos, his personal physician for over a decade talked about it in his memoirs. According to Dr. Nichopoulos, Elvis suffered from constipation for many years. Elvis’s bowel problems were severe and caused him a great deal of discomfort during his life. His constipation was investigated thoroughly but the exact cause of his colonic disease was never determined. Elvis used to have intermittent distention of his abdomen which was believed to be weight gain. Different treatment regimens were tried, many medications worked for a short time and then they stopped working. In Dr. Nichopoulos own words “I realized during the autopsy how much more severe Elvis’s discomfort must have been than I had realized”. At autopsy it was found that Elvis’s colon was massively dilated and was filled with stool. The colon still contained barium on autopsy, a chalky white substance used to study the colon by x-rays, which was given to Elvis several months ago.

A Fox News article quoted Dr. Nichopoulos. “The constipation upset him quite a bit because Elvis thought that he could handle almost anything, he thought he was really a man’s man and he wasn’t going to let something like this stop him… he thought that this was a sign of weakness and he wasn’t going to be weak.”

Dr. Nichopoulos also believes that Presley’s prominent weight gain in the years prior to his death was due to his severe constipation. “It was really a physiological problem. During the last few years we were going back and comparing pictures, some of them were taken just two weeks apart but he looked like he’d gained 20 pounds when the only difference was that he had a good healthy bowel movement and then lost a lot of weight from that,” Dr. Nick explained. “Usually you pass it all in two or three days, but at the autopsy we found stool in his colon which had been there for four or five months because of the poor motility of the bowel.”

Lesson Learned: constipation does not discriminate for name and fame. It can affect almost anyone and we have not figured out a good explanation about why this happens, how can it get so bad, how it can be treated and what can we do to prevent it. Intermittent weight gain due to stool collecting in the abdomen is a real thing. The situation for our patients has not changed much since 1977.

 

When I studied constipation in medical school two decades ago, all the medical articles and their interpretations were held as gospel truths. Things changed when I suffered an attack of severe constipation myself while traveling overseas and lost much time trying to get comfortable. This attack gave me reasons to believe that I could only fully understand the ramifications of constipation if I can correlate my experience with the scientific literature.  That's when I started looking at the same evidence in a very different light and my patients added their experience to my interpretations. The chapters that follow will discuss the existing evidence with a different logical interpretation. First we take a look at the physiology of digestion. 

-Ask the Doc -

Q. 3.3. I get diarrhea every time I eat. Before, the antidiarrheal medications were working, but now they do not. Why does this happen?

Figure 3.1. Healthy stool flow (top) and overflow diarrhea in colon with Stool Impaction (bottom)

Dr. Khurana says: People who get constipated and ignore the constipation will eventually end up having “overflow diarrhea”. Think of it like a river flow being blocked by rocks falling in its path. Eventually the water spills over the rock and starts flowing. Once the rock is removed the river size returns back to baseline. Similarly, the constipated hard stool blocks the flow of stool through the colon. Eventually the body's response is to make the stool liquid by secreting fluid and electrolytes which leads to the trickling of the fluid around the hard balls of stool, leading to diarrhea. Yet the real problem was always constipation. Once the patient is treated with laxatives and the hard balls of stool removed, the symptoms return to baseline. Antidiarrheal medications may exacerbate the symptoms by worsening the constipation and working against the corrective response of the body. Eventually, the body overcomes the effects of antidiarrheal medication and it is no longer possible then to control diarrhea with anti-diarrheal medications.

Laplace Law And Colonic Physiology

To understand colonic dysfunction it is important to understand how hollow viscous organs function and understand Laplace Law (Basford, 2002). Nowhere else have these principles being researched more than in the case of the heart. In other words, to understand constipation, one must understand congestive heart failure. It is well studied and researched that when the chambers of the heart dilate they become less efficient in pushing the blood out of the heart. This concept stems from Laplace Law, the principle of physics that states that pressure decreases as distention occurs in the heart chambers. The same is applicable to the colon, another hollow viscous organ. While colonic movement occurs once a day, and heart movement occurs a hundred thousand times a day, the physiological principles driving the movement do not change. Colonic movement is impacted in the same way as the heart when excessive dilation of the hollow viscous organ takes place. To move anything in the colon, a fixed amount of muscular pressure has to be generated to cause the stool to be pushed forward. As the stool starts collecting in the colon, the colon starts dilating which translates to the thinning of the bowel wall. This leads to a thinned out muscle which is unable to generate pressure to move the stool in the colon. Or in other words, relatively the pressure generated by the thinned out muscle is incapable of moving the total amount of stool present in the colon. Eventually the colonic muscle fails, as the maximum amount of pressure it can generate does not move the stool at all. This leads to colonic failure or as newly described in this book “Congestive Colon Failure (CCF)” 

Figure 2.6. Laplace Law And Colonic Function: Congestive Colon Failure Explained!