Another Bowel Movement Q Please

I have chronic IBS-Constipation, I am currently taking 8mch of Amitiza 3x/day.

I don't know how much it is helping, im very irregular.

my Q- when i do go, my poop comes out in very small clumps, sort of black or tar like, and it does not come out easily.

what would this indicate? anything w fiber, too much or too little?

thank u!

Black stool could mean there is blood in it.  It would be very wise to check with a doctor about this.

IBS is an idiopathic condition which means that your physician should have ruled out every other possible condition (Chrohn's, bowel cancer, colitis and a host of other possible conditions) that was causing your symptoms prior to prescribing Amitiza.

From what I can gather you are attempting to gain weight. Do you have chronic anemia as well? And if so, were you ever tested for celiac disease prior to being given the diagnosis of IBS?

Chronic constipation, low weight and anemia are symptoms of celiac disease.

The fact that the stools are small clumps is not unusual with constipation as the stool spends so much time in the colon all the water in the stool is reabsorbed through the colon wall, drying up the stool so it becomes small and hard.

As Shalem has pointed out, black or tarry stools are a sign of some kind of damage that is occurring higher up in the colon (bacteria have time to turn the blood from red to black in that case). Now, there can be a variety of reasons for this but it is definitely important to see your doctor so he or she can determine the reason.

yes, right now my bmi is about 19 but im eating so its not bc of lack of food.

ive had numerous colonoscopies, i dont have cancer, celiacs, im assuming he checked others like chrons or colitis?  my thyroid is ok and i dont think im anemic, my blood tests have been fine.

i go to the doctor almost monthly and had a colonoscopy at the end of aug.

anything i can do?

thank u

Celiac disease requires a specific blood test and you must be eating a diet high in gluten (wheat, barley, rye) for at least 3 weeks prior to the test. Because of the need to be eating a lot of gluten, there can be a lot of false negatives. Maybe confirm that your physician is confident this has been ruled out.

Crohn's disease usually appears before the age of 35. It is believed to be an auto-immune disease that causes quite severe inflammation of the colon, however the symptoms are more usually diarrhea and not constipation (although not always). Blood is common in the stools for Crohn's. However, there is some recent good evidence that is actually a bacterial infection underlying the condition (Gastroenterologist Dr. Thomas Borody in Australia has done some amazing clinical trials treating Crohn's with a suite of antibiotics).

Crohn's is actually one of several types of colitis (ulcerative, fulminant, ischemic..and numerous others). Most types of colitis involve bouts of intense pain and tenderness in the abdomen, joint pain, fatigue, loss of appetite and fever.

As you have had numerous colonoscopies, these kinds of inflammatory colon conditions would have been readily apparent and so have, at this point, been ruled out.

The other possibility is parasites. To rule out the most common, a series of stool samples need to be taken over 3-5 days (current guidelines indicate only one is necessary, but the guideline was developed on the premise that intestinal parasites are rare in North America which is turning out to be an incorrect premise). Many ground water systems across the US and Canada are contaminated with wild animals feces contaminated with zoonotic strains of microbes.

Most physicians will ask if you have traveled to developing nations, but they may neglect to ask whether you have traveled to rural areas of your own country supplied by well water and whether you had broad spectrum antibiotics prior to noticing the onset of all your gastro-intestinal symptoms. There is evidence that broad spectrum antibiotics remove all your commensal bacteria (the good ones) and leave it vulnerable to being populated with illness-causing strains instead.

I can suggest www.badbugs.org as a starting point for reviewing your current symptoms with the possibility of parasitic infection.

Keep your fluids up and see your doctor as soon as possible. You may find it helpful to go in with a list of questions so that you can feel confident you know what has been ruled in and out and what might be still to investigate. Best of luck.

thanks hedgren, r u a doctor btw? u always have such a plethora of adivce on so many diff topics!

when i started having stomach probs it was bc of a parasite, i think, rota or roda virus, what was like 14 yrs ago tho aand it was causght bc i had constant bouts of diarhea.  over the yrs it has gone from that, to IBS-D, IBS-combo, now IBS-D.  i have acid reflux and a "slow colon" as well.  for my coloscopy i drank the prescribed golytley, took laxatives, and then 2 enemas (all prescribed by the doctor) i STILL was only halfway cleaned out.  WTF there has to be something wrong, but what?

i have another appt in about 1.5 months i think, i go for routine check-ups and was there recently.  i think i eat a lot of gluten and dont think there was a mistake in the celiac test.  for crohns, well i never have diarhea, the idea of having that sounds amazing rt now.  i dont have joint pain, loss of apetite, or fever altho i do have pain and inflamation. we dont have well water, i live in a developed area, where i work is a city, nothing is rural that i go to for a parasite, and i dont have diarhea as ive said.

thank u

have you tried something like fibogel or lactolose ?

tessa-what is that? a laxative? it does not sound like a US product that i am familiar with?

thanks

Yes, but obviously I'm not providing advice because I have nothing to go on in a virtual setting like this -- it's just giving you some ideas for discussing with your doctor.

So, given that your digestive issues began with a rotavirus infection, I would suggest revisiting celiac disease. Even though you were and are eating a gluten-heavy diet, a false negative is not out of the question. Assuming two blood tests were done (testing for separate immunoglobulins) for accuracy, then 10% of the tests still provide false negatives.

One of the most common triggers for becoming gluten-intolerant (if you have the genetic pre-disposition) is an intestinal infection.

I would still strongly recommend seeing your doctor before a month and a half has gone by if the black, tarry stools are a new symptoms since your visit in August. 

Here in Canada, where we do not offer biopsy-confirmed celiac patients any tax refunds for gluten-free foods (unlike the US and the UK), many patients simply attempt a gluten-free diet to see if it resolves symptoms. You could try a gluten-free diet for six weeks and see what that gets you. Many notice a marked initial improvement in all their gastro-intestinal symptoms within 3 days but persevere for six weeks either way to be sure.

And although it does not appear you have been exposed to contaminated water, it's not a bad idea to rule out common parasites (A. lumbricoides, G. llamblia) that can also be the result of eating raw fish (sushi) or even improperly washed vegetables at a restaurant. This has likely already been covered off, but it doesn't hurt to confirm with your doctor.

Then there is H. pylori -- that's the one that causes stomach ulcers and I expect that was ruled out early (breath test) -- the symptoms you have listed are not a close match either.

And finally, if you and your doctor have already ruled out everything else, have you undergone an endoscopy? That's basically going in the other way to look at what is happening up in the small intestine, rather than a colonoscopy which scans the large intestine.

I really hope this helps.

hi hedgren-

no worries, im not taking ur advice as official or what not bc u say ur a doctor, just as i dont want ppl to ask my professional psychological advice either.

ive had the tarlike, sort of sticking to me and barely coming out bowel movements a while now actually.  i will ask about celiacs again and mention that 16 yrs ago, lol, i had the rotavirus.

attempting a gluten-free diet, im not 100% sure what has gluten to begin with but 6 weeks is an awfully long time! i have celiac symptoms?

i dont eat raw fish or meat and actually barely eat out.  i dont recall ever doing a breath test tho for anything (H. Pylori)?

i get an endoscopy every 2 yrs for the acid reflux.  ive had lesions in the past which have healed, but continue to have symptoms+take medication daily.

thank u!

i looked up some symptoms of celiacs, well i dont have diarhea and when i do go to the bathroom, the stool sinks to the bottom, it doesnt float.  so im not thinking its celiacs now at all.

Your diffuse symptoms do fit celiac disease.

The steatorrhea (floating stools) and diarrhea are only present for some with celiac disease. Constipation for others is the only symptom. For still others the only symptom is anemia, or fatigue and joint pain, or weight loss. It's all over the map.

The reason I suggest celiac is that it is one of the few gastro-intestinal conditions that does involve constipation as well as some of the upper-GI symptoms you mention in your last post such as acid reflux (again not seen in all patients). All the other inflammatory bowel diseases tend to lean way more towards diarrhea and to be distinct from any upper GI symptoms.

In fact, many untreated celiacs begin with diarrhea in the early phases and then it progresses into alternating between diarrhea and constipation and then finally is only constipation. It's because celiac disease has such a broad array of symptoms that don't all present in all patients that it is often misdiagnosed as IBS (and of course, IBS isn't even a diagnosis, it is a lack of a diagnosis).

As you have acid reflux and lesions with perhaps other upper GI symptoms as well, then H. pylori might be one to confirm has been ruled out. It won't explain the lower GI symptoms, but if it explained the upper GI then so much the better.

The test is the urea breath test. The patient consumes urea that is labelled with either carbon-13 or carbon-14. If Helicobacter pylori is present, the bacterium's urease enzyme breaks down the urea in the stomach. The labelled carbon dioxide is subsequently absorbed in the blood and exhaled. What happens is you breathe into a straw for the baseline. You drink the lemon-flavored urea concoction and then 20 to 30 minutes later you breathe into a straw again.

A gluten-free diet is not that hard. Gluten is not all starches -- it is only wheat, barley, rye and oats (although oats milled in gluten-free factories are considered safe for celiacs in many countries now).

It's better to think of it as a replacement diet as there are replacements for all your traditional wheat/barley or rye based foods out there today. You can buy gluten-free cereals, cakes, cookies, pastas and find gluten-free alternatives to other items that usually contain the gluten-grains. Things like corn, potatoes and rice are fine -- so there's plenty of salty snack food choices as well. It does require a bit of label reading. While soy beans (they're a legume not even a grain) and soy flour are fine, soya sauce is not because it is fermented with wheat. Use tamari instead of soya sauce for the same flavor option. You could check out www.celiac.com for more information on food choices.

thank u again!

i will copy this info down and call my doctor monday, also talk w my parents for advice, im 26 btw.

ive had acid reflux since i was 12, when i had the diarhea only, but the progression u described is rt on.  ibs also has a broad range of symptoms.

i will ask about H Pylori bc i dont beleive ive had that test, ive done a test where i drink something, i think barium, supposedly tastes like a pina colada and then they take xrays i think, another where i ingest rubber bands and they watch how long it takes to go thru me, it was supposed ot take 1 wk, it took me over 2.

i eat wheat, i stay away from oats as they r binding for me, but i stick to wheat, white bread, and bran mostly i think.  ive seen many gluten free products but never actually "looked" at them.  i was so relieved when the test came back that i did NOT have celiacs.

All I can say is if it is celiac disease (i.e. you had a false negative) and you go gluten-free, you will be so incredibly relieved because all the miserable GI symptoms go away.

Many patients when they are first diagnosed with celiac disease are initially overwhelmed and believe it is a lifelong sentence of restriction and denial. Instead, they are stunned at the miraculous return to health they experience and find they really want for nothing because there are so many replacements for the wheat-based foods they used to have.

The only down side, honestly, is that store bought gluten-free bread generally sucks (if you make at home it seems to turn out just fine). However, General Mills has a huge number of its scientists working on developing a gluten-free bread that is edible and can be made on an industrial scale -- the reason they are expending effort and dollars on this is because celiac disease is expected to increase markedly in our population for a variety of reasons.

Some other things for you to think talk about with your parents:

Are there any gluten-intolerant family members on either side?

Is there a history of colon cancer in the family (another indicator there may have been undiagnosed family members with celiac disease -- celiac disease can progress to colon cancer in later life if the patient is undiagnosed and continues eating gluten throughout their lives)?

You can also confirm with your parents your genetic origins. The ability to digest wheat is a modern genetic mutation. In societies where wheat has been consumed longer, there are more people with the genetic mutation that enable them to digest wheat. If your family origins are Northern European, and particularly the British Isles or Ireland, then wheat was introduced very recently into those populations. There are more people from there who have the HLA gene sequence that can cause an inability to digest the gluten in wheat, barley and rye.

You can have a genetic mouth swab test to find out if you, and your parents, have the HLA typing. It does not tell you if you actually have celiac disease, but it does tell you that you have the potential to develop it at any point in your life. Celiac disease can be active at birth; it can be triggered by hormone changes (puberty, pregnancy, menopause); it can be triggered by intestinal illness as I've already mentioned; and it can also be what is called silent celiac disease (which just means you have the HLA gene sequence but it has not been turned on). Some recent studies indicate it can even be triggered simply because of the amount of wheat that is consumed in the modern diet (stressing the body until the genes become active).

I am loathe to treat IBS as an illness because it is the medical community throwing its hands up in the air and going "we have no idea what is causing these symptoms." Now that's fine -- we can't know everything -- but it needs to be clearly communicated to patients as such and instead, the pharmaceutical industry is keen to provide life-long prescriptions (with all its attendant side-effects and risks) to treat a series of symptoms for which there is no identifiable cause.

So while it may or may not be celiac disease in this case, I believe all of us should be doing a heckuva lot more than slapping the IBS logo on a patient and sending them on their way. We need to keep working to identify the underlying causes of a series of GI symptoms that cause millions of patients real pain, grief and suffering. O.K. I'll step off my soap box now (it's one of those topics with me!).

Anyhow -- best of luck with all of it. We all have our biases so you can take my ideas with a huge grain of salt -- or a gluten-free snack ;-)

sorry i was forgetting you are in  the us you can buy it over the counter here in the uk its not a laxative but it losens the stools fibogel is an orange liquid drink not very pleasant but has done the dog for me, latolose is a syrup liquid you take 5mil 3 times daily h x

Hey,

I'm NOT as knowledgable on this as some of the posters above, however I wandered if you had been given movicol? It retains water in the stool. You can drink all you like but if your transit time is very slow then the stools dry out pretty badly anyway. Movicol (and lactulose too) draw water back into the bowel so the stool isn't hard and dry.

When I've had blockages of the gut (due to other health condition), the stool behind gets dry and hard and then worsens the blockage and constipation. This expands the colon so it over time gets less active and less responsive to being full and needing to empty.

If you combine a stimulant laxative with DAILY movicol (even when not blocked) it eventually gets everything moving along and keeps the bowels functioning.

That's only one perspective, but I would reccomend asking about long term movicol (it's the same substance as klean prep - macrogol, but you don't have as much at one time obvi.)

Hope you get to the root of this and get better once and for all x

thank u everyone!

HEDGREN-thanks, yes, very scared to think i could be gluten intolerant, after yrs of restricting bread and even yrs of having now eaten it on a daily regualr basis, im so scared to think i wouldnt be able to have it.  we dont have a histoy of colon cancer, gluten intolerance, not from ireland or wherever either, so im thinking not HLA. another member of the site has suggested im "just"  eating the wrong type of fiber, 1 being soluble the other insoluble and that maybe i need to eat the non whole wheat type and reduce the other, thoughts? i will ask about te false negative relult from the celiac test and see about having a high gluten diet b4 retaking the test.  when i asked why i still was not going to the bathroom, the doctor responded that i was working my way up and the meds dont work overnight.  ive been to countless docotors, its overwhelming, angering, and unfair to be honest.

TESSA-still unsure what u mean, ive tried "stool softeners", dont work or maybe what u mean,, something here called metamucil-an orange fiber poweder u mix w water and drink, could that be it? if so, doesnt work either.

SMASH-again, im in the US so not familiar w ur products, movicol?  i do have a slow colon so im guessing that would not be 4 me? i dont know lean prep either?

thank  u!

that sounds similar perhaps it is called something different in the us h x

Agru - it's the same thing as golytley :-) 

I think you misunderstood me - the macrogol/klean prep/whatever HELPS people like you with a slow transit time: because your main problem is the drying out, so you need something to retain the moisture in it. Enter movicol :-)

Seriously, ask for it. It is not absorbed so has no side effects. x

SMASH-golytely, as in whats used as prep for a colonoscopy? its a perscription here and it didnt even work for me when i had the colonoscopy! i used that, laxatives, and TWO enemas, i STILL did not empty out!

i really think there has got to be SOMETHING else wrong, not just chronic constipation.  i went to some natural food store today and got fiber pills and some sort of bacetria pills, took them both.

I would completely give up the medication. Laxatives are also a waste of time.  Just eat LOTS of FRUITS and VEGETABLES, WHOLEGRAINS AND BEANS. They are the most potent source of fibre and the only thing that are going to help it. If you are eating a lot of sugary foods, processed caffeine and alcohol that would also contribute. Opt for a really clean diet with little or no processed foods and you should see a bowel movement within a few days. Try prune juice, dried fruits, nuts, legumes (beans,lentils), wholegrains (oats, barley, rye, oat bran, wheat bran) and lots and lots of water.