Digestive Wellness Protocol for Hard Stools: A Resource for Practitioners


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by Fullscript’s Integrative Medical Advisory Team

Approximately five to 30% of individuals in Western countries suffer from constipation. (8)(19) Symptoms of constipation and constipation-predominant irritable bowel syndrome (IBS-C) can significantly impact an individual’s quality of life. (14) Treatment for constipation and IBS-C may include dietary and lifestyle modifications, as well as certain dietary supplements, such as inulin, probiotics, and psyllium husk.

woman holding her stomach in pain

Causes and risk factors associated with constipation include being female, infection in the digestive tract, and low dietary fiber intake.

What is constipation?

Constipation is an intestinal dysfunction characterized by hard stools, abdominal pain, abdominal swelling or distension, and a feeling of incomplete elimination. (19)

Constipation may also be a symptom of irritable bowel syndrome (IBS), a group of functional disorders that affect the digestive system. The pathophysiology of IBS is complex but may involve an imbalance of gut microbiota (5) and dysfunction in gut-brain communication. (9) Several mechanisms of the condition have been identified, including altered motility and transit, psychosocial factors, and heightened sensitivity of the intestine or colon. (14) The different types of IBS include:

  • IBS-D: diarrhea-predominant
  • IBS-C: constipation-predominant
  • IBS-M or IBS-A: a combination of both diarrhea and constipation (9)

Causes and risk factors

Several causes and risk factors have been associated with constipation and IBS-C, including:

  • Low dietary fiber intake (4)
  • Insufficient hydration
  • Certain health conditions (e.g., celiac disease, diabetes, hypothyroidism, Parkinson’s disease)
  • Certain medications (e.g., antacids, anticonvulsants, calcium channel blockers, diuretics)
  • Iron-containing dietary supplements
  • Physical inactivity (11)
  • Gender: increased risk in females (15)
  • Ethnicity: increased risk in non-Caucasians
  • Age: increased risk in the elderly (10)

Signs, symptoms, and complications

Symptoms of IBS may appear, disappear, and change over time. (14) The signs and symptoms of IBS-C and general constipation include:

  • Hard or compact stools
  • Increased effort to eliminate
  • The sensation that elimination is incomplete
  • The sensation that elimination is obstructed
  • Stool frequency less than three times per week (19)

Constipation may result in fecal impaction (4) and increase the risk of colorectal cancer. (19) Comorbidities of IBS include chronic fatigue syndrome, fibromyalgia, gastroesophageal reflux disease, anxiety, and depression. (9)

Integrative protocol for hard stools

Inulin

Inulin is a prebiotic fiber present in the roots and rhizomes of various plants, such as chicory, garlic, and artichoke. (19) Inulin resists digestion by human digestive enzymes, meaning it passes through the small intestine to reach the colon, where it is fermented by bacteria. (8) Prebiotics, including inulin, have been shown to alter the composition of intestinal microbiota by increasing beneficial Bifidobacterium and Lactobacillus. (15)(19) Several mechanisms have been proposed to explain the beneficial effects of prebiotics in cases of constipation, including modulation of gut microbiota, reduction of intestinal pH, and increases in bowel movements, stool weight, and water content in the colon. Further, supplementation of inulin may also decrease pathological Clostridium bacteria. (15)

Chicory flowers and dried roots laid over a wooden backdrop

Inulin is commonly derived from the roots of chicory, a medicinal herb.

Research findings:

  • Transit time, stool frequency, stool consistency, and hardness of stool were improved (15)
  • Total overall Clostridium species colonization of large intestine decreased (15)
  • Total inulin-type fructans of 4 g per day improved stool consistency in constipated children aged 2 to 5 years old (4)(8)

US: Search for Inulin in the Fullscript catalog.
CAN: Search for Inulin in the Fullscript catalog.

Jars of sauerkraut and pickled vegetables with herbs.

Food sources of probiotics include sauerkraut, kimchi, unpasteurized pickled vegetables, and yogurt.

Probiotics

Probiotics are live microorganisms found in fermented foods and dietary supplements that confer beneficial effects to the host once consumed. Research has demonstrated that certain strains of bacteria may improve symptoms of IBS, antibiotic-associated diarrhea, gastroenteritis, and Clostridium difficile infections. (5) Probiotics may address constipation through their ability to improve intestinal motility, modify gastrointestinal microflora, and alter biochemical factors in the gut. (6) When applied clinically, it’s important to consider the specific strains of probiotics used as studies have shown that the benefits of a specific strain may not apply to other bacterial strains, even from the same species. (5)

Research findings:

  • Abdominal pain, abdominal discomfort, overall relief, stool consistency, and frequency all improved with Bacillus subtilis and streptococcus faecium use (3)
  • Bifidobacterium lactis was shown to increase up to two bowel movements per week (6)
  • Lactobacillus reuteri significantly improved pain, bloating, abdominal discomfort, gas, and overall defecation benefits (13)
  • Bifidobacterium longum improved constipation symptoms in elderly patients (7)(13)

US: Search for Probiotics in the Fullscript catalog.
CAN: Search for Probiotics in the Fullscript catalog.

Psyllium seeds in a glass bowl on wooden background.

Psyllium husk is produced from the seeds of several plants in the Plantago genus.

Psyllium Husk

Psyllium husk, a commonly used soluble fiber supplement, is produced from the seeds of certain plants in the Plantago genus. The seeds are milled to remove the hulls and the remaining husk and seeds are used to formulate dietary supplements. There is a significant interest in psyllium due to its potential for the prevention and treatment of IBS, irritable bowel disease (IBD), and diverticulosis, among other conditions. Psyllium husk is water-soluble and promotes large bowel function by forming bulk in the stool. (16) The primary active constituent in the seed is the mucilaginous hydrocolloid, which is made up of mostly arabinoxylans. Psyllium husk should be mixed with water, and increased water intake is commonly recommended when increasing the consumption of soluble fiber in the diet. (17)

Research findings:

  • Psyllium is consistently shown to increase stool frequency (1)(2)(12)(18)
  • Overall improvement in stool consistency and pain on defecation (1)

US: Search for Psyllium Husk in the Fullscript catalog.
CAN: Search for Psyllium Husk in the Fullscript catalog.

Key takeaways

Constipation is a common condition that can impact digestive health and overall quality of life. Research shows that dietary supplements including inulin, probiotics, and psyllium husk may benefit individuals with constipation. A protocol using natural supplements can be used therapeutically on its own or as an adjunct to existing treatment. If you are not an integrative healthcare provider, we recommend speaking with one to learn whether these supplements are ideal for your wellness plan.

If you are a practitioner, consider signing up to Fullscript. If you are a patient, talk to your healthcare practitioner about Fullscript!

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Disclaimer

The Fullscript Integrative Medical Advisory team has developed or collected these protocols from practitioners and supplier partners to help health care practitioners make decisions when building treatment plans. By adding this protocol to your Fullscript template library, you understand and accept that the recommendations in the protocol are for initial guidance and may not be appropriate for every patient.

  1. Ashraf, W., Park, F., Lof, J., & Quigley, E. M. M. (2007). Effects of psyllium therapy on stool characteristics, colon transit and anorectal function in chronic idiopathic constipation. Alimentary Pharmacology & Therapeutics, 9(6), 639–647.
  2. Cheskin, L. J., Kamal, N., Crowell, M. D., Schuster, M. M., & Whitehead, W. E. (1995). Mechanisms of constipation in older persons and effects of fiber compared with placebo. Journal of the American Geriatrics Society, 43(6), 666–669.
  3. Choi, C. H., Kwon, J. G., Kim, S. K., Myung, S.-J., Park, K. S., Sohn, C.-I., … Park, H. (2015). Efficacy of combination therapy with probiotics and mosapride in patients with IBS without diarrhea: A randomized, double-blind, placebo-controlled, multicenter, phase II trial. Neurogastroenterology & Motility, 27(5), 705–716.
  4. Closa-Monasterolo, R., Ferré, N., Castillejo-Devillasante, G., Luque, V., Gispert-Llaurado, M., Zaragoza-Jordana, M., … Escribano, J. (2016). The use of inulin-type fructans improves stool consistency in constipated children. A randomised clinical trial: Pilot study. International Journal of Food Sciences and Nutrition, 68(5), 587–594.
  5. Drouault-Holowacz, S., Bieuvelet, S., Burckel, A., Cazaubiel, M., Dray, X., & Marteau, P. (2008). A double blind randomized controlled trial of a probiotic combination in 100 patients with irritable bowel syndrome. Gastroentérologie Clinique Et Biologique, 32(2), 147–152.
  6. Ibarra, A., Latreille-Barbier, M., Donazzolo, Y., Pelletier, X., & Ouwehand, A. C. (2018). Effects of 28-day Bifidobacterium animalis subsp. lactis HN019 supplementation on colonic transit time and gastrointestinal symptoms in adults with functional constipation: A double-blind, randomized, placebo-controlled, and dose-ranging trial. Gut microbes, 9(3), 236–251.
  7. Martínez-Martínez, M. I., Calabuig-Tolsá, R., & Cauli, O. (2017). The effect of probiotics as a treatment for constipation in elderly people: A systematic review. Archives of Gerontology and Geriatrics, 71, 142–149.
  8. Micka, A., Siepelmeyer, A., Holz, A., Theis, S., & Schön, C. (2016). Effect of consumption of chicory inulin on bowel function in healthy subjects with constipation: A randomized, double-blind, placebo-controlled trial. International Journal of Food Sciences and Nutrition, 68(1), 82–89.
  9. National Institutes of Health. (2017, November 1). Definition & facts for irritable bowel syndrome. Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/irritable-bowel-syndrome/definition-facts
  10. National Institutes of Health. (2018, May 1). Definition & facts for constipation. Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/definition-facts
  11. National Institutes of Health. (2018, May 1). Symptoms & causes of constipation. Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/symptoms-causes#medicines
  12. Noureddin, S., Mohsen, J., & Payman, A. (2018). Effects of psyllium vs. placebo on constipation, weight, glycemia, and lipids: A randomized trial in patients with type 2 diabetes and chronic constipation. Complementary Therapies in Medicine, 40, 1–7.
  13. Riezzo, G., Orlando, A., D’Attoma, B., Linsalata, M., Martulli, M., & Russo, F. (2018). Randomised double blind placebo controlled trial on Lactobacillus reuteri DSM 17938: Improvement in symptoms and bowel habit in functional constipation. Beneficial Microbes, 9(1), 51–60.
  14. Torii, A., & Toda, G. (2004). Management of irritable bowel syndrome. Internal Medicine, 43(5), 353-9.
  15. Waitzberg, D. L., Pereira, C. C. A., Logullo, L., Jacintho, T. M., Almeida, D., da Silva, M. L. T., & Torrinhas, R. S. M. d. M. (2012). Microbiota benefits after inulin and partially hydrolized guar gum supplementation: A randomized clinical trial in constipated women. Nutricion Hospitalaria, 27(1), 123-9.
  16. Wärnberg, J., Marcos, A., Bueno, G., & Moreno, L. A. (2009). Functional benefits of psyllium fiber supplementation. Current Topics in Nutraceutical Research, 7(2).
  17. World Health Organization. (1999). WHO Monographs on selected medicinal plants – Volume 1: Semen plantaginis. Retrieved from: https://apps.who.int/medicinedocs/fr/d/Js2200e/22.html
  18. Yang, J., Wang, H. P., Zhou, L., & Xu, C. F. (2012). Effect of dietary fiber on constipation: A meta analysis. World Journal of Gastroenterology, 18(48), 7378.
  19. Yurrita, L. C., Martín, I. S. M., Ciudad-Cabañas, M. J., Calle-Purón, M. E., & Cabria, M. H. (2014). Effectiveness of inulin intake on indicators of chronic constipation; a meta-analysis of controlled randomized clinical trials. Nutricion Hospitalaria, 30(2), 244-52.