The Gut Health Podcast

Everything you need to know about constipation (Guest: Darren Brenner, MD)

• Kate Scarlata and Megan Riehl • Episode 6

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Join us on The Gut Health Podcast as we uncover the many facets about constipation with the distinguished gastroenterologist, Dr. Darren Brenner. Think probiotics are the cure for your sluggish digestive system? Think again. Dr. Brenner dispels common myths and reassures us about the safety of stimulant laxatives like Senna and Bisacodyl when used correctly. Together, we'll redefine what it means to be constipated, acknowledging that not everyone needs the "perfectly formed" daily bowel movement to be healthy.

Dive into the often-missed topic of pelvic floor dysfunction and how it contributes to constipation. Dr. Brenner breaks down the complexities of functional defecation disorders and dyssynergic defecation, emphasizing the urgent need for early diagnosis and the role of specialized physical therapy. The conversation doesn't shy away from discussing the significant impact of trauma on pelvic floor health, advocating for open, empathetic communication between patients and providers to create a supportive therapeutic environment.

For those over 45, we highlight red flags in constipation that you shouldn't ignore, from unexplained weight loss to sudden changes in bowel habits. Learn the distinctions between Small Intestinal Bacterial Overgrowth (SIBO) and Intestinal Methanogenic Overgrowth (IMO) and how they can exacerbate your symptoms. Finally, take home practical tips on nutrition, stress management, proper toileting behavior, and the importance of regular exercise. Dr. Brenner even shares his expert strategies to help you maintain great elimination habits, a healthy  gut and overall well-being.

Check out some great constipation references/resources below:

The psyllium powder Kate uses is Kate Naturals (not Kate Farms), here is an Amazon link to the product.

Brenner, D et al. Best Practice for the Management of Chronic Idiopathic Constipation and Irritable Bowel Syndrome with Constipation: A Roundtable Discussion and Review.  The American Journal of Gastroenterology 117(4S):p S1, April 2022

IBS-C: New & Novel Management: Webinar via Tuesday Night IBS
A multi-disciplinary approach to IBS with constipation.

Axis, A et al Gastroenterology and Endoscopy News, 2024. Emerging Treatments for Chronic Constipation and Defecation Disorders.

Review article: do stimulant laxatives damage the gut? A critical analysis of current knowledge.


This podcast was sponsored by

Learn more about Kate and Dr. Riehl:

Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast

Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.

The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

Kate Scarlata :

This podcast has been sponsored by Ardelyx. Maintaining a healthy gut is key for overall physical and mental well-being. Whether you're a health-conscious advocate, an individual navigating the complexities of living with GI issues, or a healthcare provider, you are in the right place. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food and the gut. Come join us. We welcome you.

Dr. Megan Riehl:

Hello friends, and welcome to the Gut Health Podcast, where we talk about all things related to your gut and well-being. We are your hosts. I'm Megan Riehl, a GI psychologist.

Kate Scarlata :

Hi, I'm Kate Scarlata. We have an exciting podcast for you. Today, w e are talking all about constipation, a condition that impacts up to one in five Americans. A recent survey study showed that three out of five people living with constipation never discuss their symptoms with a healthcare provider, and we are here to change that, because there's many new and novel therapies for constipation, including taking vibrating capsules that can help improve your exit strategy.

Dr. Megan Riehl:

So our guest today is a professor of medicine at Northwestern University and has Wolverine roots, go blue, and I've had the privilege of working with him very early in my career. Dr. Darren Brenner is a beloved gastroenterologist to his patients and has a true understanding for the complexities of living life with GI disorders. Not only does he travel the world lecturing on disorders of gut-brain interaction, like IBS, which we talk about a lot and more, he is a researcher and an expert in GI motility and pelvic floor disorders. We are thrilled to have him with us today and we have no doubt that everyone listening will be entertained while we explore this topic of not pooping or constipation. So welcome, Dr. Brenner.

Darren Brenner, MD:

Thanks Megan, thanks Kate. Yeah, it's amazing what I do for a living, isn't it?

Dr. Megan Riehl:

Yeah, who would have thought, you know? But we love it.

Kate Scarlata :

We do love it. All about poop. So, in the world of gut health, we really like to break through the misconceptions and myths out there because, as you know, tiktok is full of them. So we would love to have your expertise here. Can you myth bust for us what's something you'd like to dispel with our audience?

Darren Brenner, MD:

Yeah, so I think this is something I see all the time. This is something patients come back with questions and physicians alike, and it's really some myths and misconceptions on things that work and don't work and can be safe or unsafe for treating constipation. And this is a multi-billion dollar industry with almost little to no regulation, especially in the gastrointestinal space. If somebody goes to the store and wants to look for a probiotic, the packages say promotes gut health or promotes gut immunity, but really can't make any claims about this particular illness. And there have been some recent studies that showed up to a quarter of individuals with constipation are trying to treat their symptoms with probiotics, in many cases probiotics alone, and, I'm sad to say, at least in 2024, there really isn't a lot of evidence or data to support that. So I guess that's my long-winded way of saying if you think probiotics are going to fix your constipation, it's very unlikely.

Darren Brenner, MD:

Now, on the flip side is the taboo, and this has been around for 40, 50 years. There've been lots of papers. We're still writing myths and misconceptions about the use of stimulant laxatives, things like Senna or Bisacodyl. We've been told that they'll cause cathartic colon or dead colons or atonic colons or long colons or melanosis coli or colon cancer, and the list goes on and on and on. But the reality of the situation is that in standard doses, these therapeutics are very safe and very effective. So if you're a patient who are taking standard doses of Senna or Bisacodyl, I don't want them to worry that anything is going to happen to their GI tracts or that these are, in any way or shape, harmful for them in the long term.

Kate Scarlata :

I am so, so glad you said that, because I get that question all the time and even when I'm amongst other gastroenterologists, I feel like some of them believe that there's a problem there, but the expert here is saying, no, don't worry about that. And I think that is a really important message for people out there who find that Senna really works for them, and then someone tells them dial it back, you can't be on that. So thank you for that. That's huge.

Dr. Megan Riehl:

It really highlights the individuality of everyone's gut and that your toolbox is going to look different from the next person, from the next person, from the next person.

Darren Brenner, MD:

Absolutely. I mean, I think that's the beauty of what we do. You know, people are asking for algorithms. We try to put these algorithms together, but, megan, to your point, everybody is an individual unto himself or herself, and so the treatments have to be different. I think that's what makes medicine, especially treating disorders of gut brain interaction, so fascinating.

Kate Scarlata :

That's right, I agree. So let's just dial it back with constipation. Can you define constipation for the lay audience? Because I have patients sometimes that say, oh, I didn't poop in the last 12 hours, so I have constipation. Or if they skip a day of pooping, they have constipation, but that's not true. Day of pooping, they have constipation, but that's not true, right?

Darren Brenner, MD:

That's right and it's just like we mentioned. It's different for everybody and I mean that from a practitioner and a patient standpoint. Unfortunately, to our conversation earlier about TikTok, the lay person has been taught that they have to have one perfect what looks like a sausage ball movement every day, and that's just not reality and I think that's actually more the exception than the norm. And so when we think about constipation, at least historically, we break it into a lot of different symptoms, because it's different strokes for different folks and absolutely frequency does play a role here, but normal. We have found, initially in Europe and more recently in the United States, that about 95% of the US population has a bowel movement anywhere between three times a day to three times a week. Now that sounds extreme, that norms can be three to 21 bowel movements a day, but that is the reality of the healthy average individual in the United States. We talk about texture. I think those of us in academia use the Bristol stool form scale. I think a lot of people and patients who focused on their bowels know what this scale is, but I don't think the average individual does, and it's a scale that defines stool based on its texture and not to gross anybody out during this podcast, but we really define constipation as things that look like milk duds or baby roof bars, and I've been using that analogy probably for two decades now, but it's because it really hits home. I think people can relate to what those types of stools look like.

Darren Brenner, MD:

We talk about subjective symptoms. Do you strain to go to the bathroom? Do you not feel like you get everything out when you go, which I think is one of the hardest things to overcome? Do you feel obstructed? Do you feel a heaviness or a pressure in your pelvic floor? You feel like you have to go to the bathroom and you just can't get it out. And then the taboo that nobody wants to talk about do you need to perform manual maneuvers and I hope nobody's watching this during breakfast, lunch or dinner because I'm going to describe these but we talk about manual disimpaction having to stick a finger into your bottom and try to rake or pull the stool out. Or, for women, we talk about splinting having to take a finger or two and put them in the vaginal cavity and push posteriorly, which reduces all kinds of anatomical variance that can obstruct the stool from coming out. And again, some people will come in with all of these, some one or two of these, and so it is a different I would say du jour for everybody.

Darren Brenner, MD:

When we meet these patients, I always like to talk about a specific type of constipation, because I do see these individuals regularly and I think they suffer for a long time and these are the people that are defined with diarrhea, because they come in and their chief complaint is I have 10, 15 bowel moments a day. When you start to tease out these other symptoms, they say I have 10 hard pellets or I'm straining, or I feel incomplete evacuation, and what they're really having in many instances is constipation with overflow. There are hard impacted stools at the bottom of the GI tract. The stuff above it gets looser and it finds a way to leak around it, and unfortunately, these people are treated with anti-diarrheals, which just makes the process worse. And so in many instances, when somebody comes in and we're not sure if they have constipation or diarrhea, I think your best friend can be an abdominal x-ray, because you'd be surprised how many times you will find that there's just a significant amount of stool in the colon, which will identify specifically that this is more constipation than diarrhea.

Kate Scarlata :

That's awesome. And when they go in for an x-ray, is it a KUB x-ray? What would they ask for with their physician?

Darren Brenner, MD:

It's a KUB and I think that can do a couple of things. I think we see as an overlap, where people are constipated, a lot of abdominal complaints like abdominal bloating and distension. These are two very different things and I think you can really differentiate between them with that KUB, because not only do we see the stool content of the colon but the gas content. So many times my patients come in and they say, as the day goes on, I look six, nine months pregnant, I'm full of gas. We shoot the film and I can bring them back to the office and say look, here's your abdominal x-ray, here's what the stool looks like, but there's no excess gas, which sends us in a completely different direction.

Kate Scarlata :

That's awesome. I'm glad you do that because, again, I think not everyone wants to do those x-rays and I usually am in favor of them because most of my patients actually have constipation, so it's kind of interesting. So there's different types of subtypes of constipation. You know IBS-C or chronic idiopathic constipation, slow transit what's all this "garb?

Darren Brenner, MD:

Sure, let's talk about the hodgepodge and how much I can confuse you when it comes to constipation. And I will preface that by saying that when we're in medical school or, I think, dietary school or psychology school, what we're always taught is this If you're not sure what's going on, take more history. And if you're still not sure what's going on, take more history. And if you're still not sure what's going on, take more history. And now I get to go back to all of my professors 20 years ago and say, when it comes to constipation, that may not necessarily be true Because unfortunately, what we have learned and what the clinical trial shows is this You're not going to be able to differentiate one person's constipation from another based on their subjective symptoms. But it is important to try and figure out what types of constipation are underlying the patient's symptoms, because I think the biggest fallacy is that somebody focuses on one subtype. They say aha, I think you have irritable bowel syndrome with constipation, and they focus right there. And when I think of constipation, I really define it along a Venn diagram, because there's a lot of overlap, especially at the academic centers. So if you ask me what constipation is, I'll tell you it's an overlap of four different subtypes.

Darren Brenner, MD:

And I start with the secondary causes of constipation. And yes, these are things that we can glean from a history and a physical exam. So, do you have a risk factor for obstruction? Are you of colon cancer screening age? Could this be, unfortunately, a mass or some sort of obstructive physiology? Could it be related to an endocrinopathy? Do you have diabetes, hypothyroidism? Could it be a medication? We talk about opioids and benzodiazepines, but in reality there are much more common therapeutics out there, especially in the cardiovascular class beta blockers, thiazides, ace inhibitors. And then we need to realize that older literature shows that if an individual is on six or more medications at any given time, that threshold of six increases the odds ratio that somebody will develop constipation. In my world, where I see a neuromyopathic disorder, scleroderma, parkinson's is a huge one MS, als, these are all things we can think about as causes, but I want to caution your listeners if you can define one of those, don't stop there, because then we want to think about the three other categories.

Darren Brenner, MD:

Kate, you mentioned one irritable bowel syndrome with constipation, and I call this one the trap. Okay, this is something that most young individuals come in they complain about constipation, a little bit of bloating. We snap our fingers, we say you have IBSC, let's treat that. And then 40 to 50 years later they come into our offices and we say it could be something else, like slow transit, constipation the best name in history because it defines constipation because things are moving too slowly through the GI tract.

Darren Brenner, MD:

And then obstructive physiology, what we call evacuation or functional defecation disorders, which can be anatomical problems rectus seals, enterus seals, intussusception which can anatomically block the stool from coming out. And then the most common one we talk about, which is dyssynergic defecation, or pelvic floor spasm, or a nismis where the muscles in the pelvic floor do not work and so when you try to go to the bathroom, instead of those muscles opening up to allow stool to come through, then they open a little bit, not at all, or go into spasm and impede the ability of stool to come through. Then they open a little bit, not at all, or go into spasm and impede the ability of stool to come out. And it's very important early in the course to define this disorder, because this is the disorder that will not respond to therapeutics like laxatives, and I think we're going to come back to this a little bit later.

Dr. Megan Riehl:

And it won't respond to some of our behavioral strategies. It really requires, then, bringing on that pelvic floor physical therapist. And so you make such a huge point here that especially we see this constipation more prevalently with women. And so if they're told you have constipation and then they're not consulted by a pelvic floor physical therapist or their gastroenterologist hasn't done a physical exam or some of the additional workups that are available, like diphagraphy or anal rectal manometry, these patients are going to suffer more for longer and that's a disservice.

Darren Brenner, MD:

And that's part of our concern as practitioners. Our algorithm hasn't changed in 20, 30 years and when we talk about diagnostic testing, the average individual will probably get a colonoscopy, but the first test recommended is anorectal manometry and blue expulsion testing. Realistically, the first test recommended is a digital rectal exam, but I think we do a very poor job training our trainees on how to do that. I always say the digital rectal exam is only as good as the finger that's performing it and thus, if you're not comfortable doing that exam, we really don't want you invasive. We can use the anorectal manometry to better define anorectal physiology. And, Megan, you opened that door talking about the pelvic floor and I will walk through this door anytime I've given the opportunity.

Darren Brenner, MD:

So please allow me to tangent a little bit, because I always say in my lectures and I always say when we're talking about these types of things, I want to talk about something that's near and dear to your heart and that is a history of trauma, whether it be physical, sexual or emotional trauma or abuse.

Darren Brenner, MD:

Because the reality is, the vast majority of practitioners do not ask about this, and this plays a fundamental and key role in constipation, because the reality of the situation is this. If your patient has a history of physical, sexual, emotional abuse or has undergone or gone through some form of trauma and they have constipation, the pretest probability that their pelvic floor doesn't work, based on clinical literature and anecdotal experience, is higher than 90%. And while with pelvic floor problems we recommend the physical therapy, the reality of the situation is, if we do not mind pardon the pun that brain-gut connection, these patients with physical therapy have little likelihood of success for improving their constipation symptoms. So I beg all of your listeners, I beg all of my colleagues around the world when you see a patient with constipation, ask about this, because you will have to target and focus on that brain-gut interaction associated with the trauma as well.

Dr. Megan Riehl:

That's such an important point and, to your point, sometimes we're not comfortable doing the rectal exam, and then there's an even higher prevalence that are not comfortable to have that conversation, and so I also beg of you, as a listener, to advocate for yourself to let your physician know if you do have a history of trauma, and even if your provider hasn't necessarily asked about it, they likely will be very able and capable of making your experience with either your medical procedures or subsequent questions more comfortable. So it's a two-way street. You know we want people advocating for themselves, but it's such a good point that physicians, especially in this area, and primary care doctors and NPs and APPs, we do have to be very mindful of that connection between our brain and our gut and our life experiences.

Darren Brenner, MD:

And please do advocate for yourselves. I ask all of my patients, as a matter of fact, if they have a history of trauma, I let them see the manometry catheters, feel them, touch them, know the experience, walk through the process, because in many cases these individuals are not comfortable undergoing the procedure and they're not going to be comfortable undergoing pelvic floor physical therapy. It is a very invasive intervention and they have to be aware of what's going to happen within that clinical practice and in many cases and I thank you and all of your colleagues for this brain, gut, behavioral therapists get involved and we start there and then we go backwards to the diagnostic testing and the treatment associated with pelvic floor dysfunction.

Dr. Megan Riehl:

And even if you're somebody that doesn't have a history of trauma and you're feeling a little bit anxious about a doctor that says, okay, I'm going to do a rectal exam now, or you know it's time for a colonoscopy, you're not alone in feeling anxious about this, and we, even in our book Mind your Gut, we put in a colonoscopy coping kit to highlight, you know that you could ask for certain music, you can do some breathing exercises, you can ask as many questions as you want to your gastroenterologist prior to any of these procedures and you'll feel more comfortable. So those with a trauma history, and certainly the many that do not have a trauma history, we want you to be comfortable. Your relationship with your gastroenterologist is as about as close as you can be, and so you want to have a really good therapeutic dynamic across the spectrum of your time working together.

Kate Scarlata :

I love that and I would say, you know, I love that you show or go through the testing with your patients, because I'd certainly had patients just arrive at the testing and like what are we doing here? So I think if you're a listener as a patient or you're a listener as a provider, it is important that you ask what the test entails and, as a provider, I always prep my patients like this is the test, this is what they're going to be looking for. It's important part of understanding your pelvic floor, but expect the following so that they can decide you know, or at least be prepped and not surprised. So one other question I wanted to talk about you have an individual with constipation. What are some other red flags that would really prompt you to say we need to do further investigations here? Something else is going on beyond just constipation.

Darren Brenner, MD:

Yeah, great question, Kate. I think, first and foremost, if you're over the age of 45, request that colonoscopy. I can pretty much assure the gastroenterologist is going to want to do that. That is the new screening age and we're going to want to take a look to make sure there's nothing obstructive. Now that does not and I stress the term not mean that if you come in with new onset constipation over the age of 45, that it is due to colon cancer. I have found that very, very infrequently in my career. As a matter of fact, having probably seen 20,000 people with constipation, I can find the number of colon cancers that I have identified on less than two hands. Okay, so I don't want you to worry. But that would be the first thing.

Darren Brenner, MD:

Let us know if there has been recurrent or an increase or crescendo in bleeding, if this is an acute change, if there's unexplained or unintentional weight loss. These are big triggers that we want to know about. These are things that may indicate something else may be going on. But think about lifestyle factors as well. Have you changed your diet? If you change your diet, you shift your microbiome. If you shift your microbiome, it may change the motility, secretory and sensory patterns of your GI tract? Or have you tried a new medication? Like I said, we talk about the big ones, but there are hundreds of medications out there that can cause constipation. So let us know, and let us know if something has changed, because we may be able to correlate that specific change with your new onset symptoms and allay your fears very quickly.

Dr. Megan Riehl:

All right. So those are those red flags, and our listeners are going to get really good at understanding what those are. Again, we don't want you to have a ton of anxiety. If you do have a red flag, it just is a good indicator that, hey, you need to check in with a doctor and we'll go from there. It doesn't have to mean that there's a cancer, and that certainly is something that a lot of people stress about, which leads me to a segue here to the brain-gut connection. So you've mentioned this constipation can be a disorder of gut-brain interaction. So tell us a little bit from your gastroenterologist brain and perspective how does the brain-gut connection impact constipation, and tell us a little bit about what stress does to that.

Darren Brenner, MD:

Yeah. So you know, when I think about the brain-gut connection, I think about stress as it relates to constipation. I really take it out of the what's called slow transit constipation component, irritable bowel syndrome. We all know that stress exacerbates those symptoms and I worry about my stress patient when it comes more so to the disorders of the pelvic floor, and then I get into what I call the sick cycle. Pardon the pun again, but I think we as practitioners for many years have poo-pooed constipation as a nuisance disorder and if you really take care of these individuals, you see it's much more than that. It significantly impacts quality of life.

Darren Brenner, MD:

I can't get out of my house, I can't leave the porcelain throne. I spend six, seven, eight hours a day on that toilet and when I'm not on the toilet, on the couch perseverating about said toilet because I feel like there's still stool in there. I'm afraid to go somewhere. What if I get the urge? What if I'm out to dinner with my friends and I'm in the bathroom for 30 minutes? Is somebody going to come checking on me because I think I fell in the toilet or somebody flushed me down the drain? These are things that, realistically, I have heard over and over again. And the problem is when you start to feel the stress and you start to lose the quality of life from those types of symptoms that can increase what we see in the pelvic floor Spasm of the muscles or an inability to relax because the brain talks to the pelvic floor. You have to coordinate these two. Just as much as I'm moving my hands right now, these are skeletal muscles. I'm coordinating them in a voluntary but very involuntary manner. I'm not thinking about it. I have no idea what muscles these are anymore. I forgot that a long time ago from basic anatomy. But the muscles that I'm wiggling in front of all of you right now are identical to the muscles in my pelvic floor the puberectalis and external anal sphincter that I learned when I was potty training to open, up and close, and these muscles, if I have these types of stressors, may not want to open anymore and that leads to an increased burden of stress, which leads to more tightening of the pelvic floor muscles, which leads to increasing stress you can see where I'm going with this and becomes a cycle and I call it break the cycle.

Darren Brenner, MD:

But here's where Kate comes into our pyramid here, which is when you have all that constipation and you feel horrible, you don't want to eat and you may develop symptoms like our federal. Eat less and so, because you eat less, you lose weight and as you lose weight your GI tract slows down and you lose motility, which means when you eat you feel even worse. So you eat even less and then you lose even more weight and then you get to worse. So you eat even less and then you lose even more weight and then you get to a point where you don't have enough muscle mass to impact or to work the muscles in the pelvic floor. I see lots of patients who come in and they say I know my problem is my pelvic floor and I've been to physical therapy, but my physical therapist can't fix this. And I'll tell you in my academic program if your BMI is less than 16, my physical therapist won't touch you because there's not enough muscle down there to fix. So this becomes a cyclic spiraling process and the problem I think that we fall into is we don't understand how to explain this to patients, because we go directly to the weight and it's critical and we have to fix that. But here's what patients hear, no matter what you say, and it's critical and we have to fix that. But here's what patients hear, no matter what you say.

Darren Brenner, MD:

You think I have an eating disorder. No, I don't. What I'm saying is that weight restoration is key and you fall into this process of low weight, inability to eat, pelvic floor doesn't work. Stress making this all worse. And, from my standpoint, when we're looking at a cyclic process, I don't want to break the cycle at just one point. I want to blow up that cycle and I think the best way to do that is to engage all of us physician practitioners, behavioral therapists, psychologists and dietary experts because that's really the only way we're going to get them better. So I like to say, can stress play a role? At the beginning, yes, I think more so an irritable bowel and pelvic floor. But over time, constipation can lead to more stress, which leads down this pathway of doom, as I like to call it. But we can fix this problem.

Dr. Megan Riehl:

We can bust that cycle.

Kate Scarlata :

I think the notion of restricting food. Patients don't realize that that impacts the motility and is going to bring them down. Like your efforts are going backwards, you know you're not going in the right direction. That whole motility effect it's a muscle, it needs nutrients and fuel and that message hasn't gotten out to them strong enough. I don't think and I'm constantly saying this to patients you need the energy for your body to work. It's just so important.

Darren Brenner, MD:

Even there, when we talk to practitioners to put this in a little bit more technical terms, I tell my patients even if you can just eat a little bit, try and graze throughout the day, it's the gastrocolic reflex. Patients go to the bathroom, or I should say patients, individuals go to the bathroom first thing in the morning and after meals. When people come in they say I eat and I poop, that's completely normal because it's that reflex. That's that increase for the practitioners of high amplitude propagative contractions. And then we have medications that we use that activate GCC receptors, the secretogogs linacletide, placanetide. These are activating the same mechanisms that food does to help us go to the bathroom. So at the end of the day, having a bowel movement, food is key and essential.

Kate Scarlata :

Absolutely Good point.

Dr. Megan Riehl:

And the dream team approach of incorporating several different multidisciplinary specialists is so critical here because it is anxiety-provoking when you've gotten into the cycle and that's where you know, in addition to your treatment as the physician, Kate's treatment as the dietician, my treatment as the psychologist we're going to utilize cognitive behavioral therapies that are specific to those GI concerns that you have, the avoidant behaviors, the fear of reintroducing food. So there are treatment options out there to certainly break these cycles. It's just a matter of getting into the hands of that right team. And so if you haven't found that and Dr Brenner is explaining the cycle and you're listening and just nodding your head, going yes, yes, yes, yes, that's me Keep reaching out for those strategies and even in our book we give you a ton of resources to help create your own dream team.

Darren Brenner, MD:

Yeah, Megan, if I may. I'm sorry. If I can add one more point, I apologize, just for the practitioners and the patients alike. If you have this type of constipation, please, from the practitioner standpoint, be honest with your patients. Tell your patients you can't fix this alone. Patients don't expect the practitioner to be able to fix this problem with medicine. It doesn't work. So we have to be realistic in this process.

Dr. Megan Riehl:

Yeah, we have to all work together for the sake of the patient's well-being.

Kate Scarlata :

IBS-C, or irritable bowel syndrome with constipation, is a common condition in which people experience constipation, along with other belly. Symptoms like pain, bloating and discomfort Sound familiar. Many people with IBS-C are willing to give up key parts of their lives in exchange for symptom relief. And because the causes of IBS-C may differ for each person, there is no one-size-fits-all treatment approach. If you're suffering from IBS-C, you may have to try a number of different medications before you find the right one for you. So don't be okay with just feeling okay. If you have IBS symptoms that continue to bother, you, talk to your healthcare provider to find out if your current medication is right for you or if it's time to try something different. The more you know about IBS-C, the better prepared you will be to speak with your doctor about the right treatment option for you.

Dr. Megan Riehl:

And as we shift to some other kind of potential factors when it comes to constipation, can you talk a little bit about intestinal methanogen overgrowth and its potential relationship to constipation? What is it, how do we test it, how do we treat it?

Darren Brenner, MD:

What is it? That's hard to define. I think we're in the fledgling stages of understanding these things and truly understanding our microbiomes. People come in every day. They're like, like I said earlier, can I just take a probiotic, fix my microbiome? I do personally think that the gut microbiome is the gatekeeper to everything, not just GI, allergy, immunology, pulmonary issues, rheumatologic issues. But the reality of the situation is I'm going to minimize, and I don't mean to. It's not as simplistic as the human genome where we can map it. The gut microbiome is different for everybody and it changes with very simple perturbations, like I said, just as simple as changing our diet. So I think we are really in the fledgling stages, we're at the base of the iceberg and understanding it. So I don't think we know it well enough to manipulate it.

Darren Brenner, MD:

But one thing that has been elucidated is this idea of emo, and I'm glad you bring this up, megan, because I think everybody just lumps this in to the SIBO category, and it's not. It's something completely different, which is why the acronym has changed. Remember, ladies and gentlemen, sibo is small intestinal bacterial overgrowth. Now I stress the small and the bacterial, because when we go to emo, those disappear. Emo is intestinal. Ie. It may not be in your small intestine, it may be in your colon.

Darren Brenner, MD:

Methanogenic these are not bacteria. They are archaea or primitive single-celled organisms that overgrow, and so you can find these things in the GI tract. And they are methanogens, meaning that they produce methane, and methane has been shown in clinical trials to slow gut motility. So I think about these as a potential trigger for slow transit constipation. But they're also associated with some of the abdominal symptoms you experience, like the bloating and the distension, and in many cases they are treated differently than SIBO. So people come and they say I've been treated for SIBO and SIBO, and SIBO and SIBO and it's not doing anything. And it may be because it is not, again, small bacteria but intestinal methanogens.

Darren Brenner, MD:

Now the best way to test for these right now is with breast tests, and you can use glucose and lactulose breast tests, and these are done in some clinical practice or academic center labs, but there are multiple proprietary institutions out there that you can get this kit and do it at home while you're watching TV on your couch. The accuracy of these tests, from my standpoint, still has yet to be elucidated, so I do like to tell everybody if you get a positive test for SIBO or emo. Don't put all of your eggs into this basket. Like I said before with the Venn diagram, do not focus solely on this. This may not be the only problem or even the problem that is causing your symptom profile and I mention that because I come to a lot. I see a lot of patients who come in. They're like I have constipation because I have intestinal methanogenic overgrowth, and then I do a couple of different tests and I say you may have intestinal methanogenic overgrowth and emo, but there are a few other things going on that we have to focus on as well.

Kate Scarlata :

That's right, like, is it the chicken or the egg? You know, like, what's causing this emo, a motility or something else, right?

Darren Brenner, MD:

Right. Where is it matters? Because when we think about treating and we treat primarily with antibiotics there's some herbal therapies that have some data, some studies we did recently in Northwestern for an herbal called the Atrantil, but the therapeutics and what you're going to be able to use to impact emo is probably going to be shown to be quite different than what we use for SIBO.

Kate Scarlata :

Can you just talk a little bit about Atrantil, because I get a lot of questions about that. In your study, did it reduce methane? I know there was a reduction in bloating, right, but did it reduce the actual methane levels as well?

Darren Brenner, MD:

Yeah, it's a really good question because that's what we're looking at. We're looking at symptoms and correlations to methane responses in two different fashions. One was did it just absolutely reduce methane? And two was did it lower it below the threshold of normalcy, ie 10 parts per million? Now I will say truth in advertising.

Darren Brenner, MD:

This is a small study. It's an open-label study. It had to be done in one year and it was done during COVID and so every patient who got a transult knew that they were getting a transult. So it wasn't compared to placebo. But I'm fine with that because I call this a case-based, real-world analysis of this type of therapeutic and that's what people are doing with probiotics every day.

Darren Brenner, MD:

We use the NIH PROMIS scales as our threshold to determine who responded, and we wanted to, because if we're truly treating intestinal methanogenic overgrowth or emo, we don't expect it to improve some of the other PROMIS items like reflux or dysphagia. And it didn't like reflux or dysphagia and it didn't. What the patients responded to was we saw significant improvements in bloating and abdominal distension and discomfort and a very close trend. It didn't meet statistical significance but it was close for constipation the cardinal symptoms of emo. We also looked at adequate relief. We know this is a validated endpoint. The vast majority of our patients had irritable bowel syndrome, were positive for methane and more than 50% of patients endorsed adequate relief at the end of a month of treatment compared to how they were at baseline.

Darren Brenner, MD:

The next thing is the safety profile. We had really no serious severe adverse events whatsoever. The interesting part was we saw really no changes in methane no absolute changes over time, and certainly there were only about three or four patients that dropped below the 10 part per million threshold. Now, the vast majority of patients that we enrolled weren't very high above that threshold. The price per million was in the probably 10 to 20 range, so there could have been a floor effect. But it also begs the question with this therapeutic, which does contain some bark Peppermint oil. I think many of our practitioners and listeners are familiar with what peppermint oil can do. So some things we don't know a lot about, some things we do, but very natural interventions these are the things that we're trying in these patients. Awesome.

Dr. Megan Riehl:

All right. So you mentioned this. You're starting to talk a little bit more about the potential things that patients can try to help with their constipation, and one thing that we frequently hear is fiber. So do you have a go-to fiber supplement as a gastroenterologist that you feel comfortable recommending to your patients, or do you just send the patients to one of your fabulous dietitians and have them help with fiber intake? What's your approach?

Darren Brenner, MD:

So my dietitians are fabulous, but if I sent everybody who needed fiber for constipation to them, woe to the patients who really need to see them. So, yes, I do have a go-to and I think in GI there are two schools of thought people who believe in fiber and people who don't, at least based on studies that came out of the University of Michigan, where you practice, looking at what practitioners, specifically gastroenterologists, recommend as first and second line interventions. So I will give all of these synonyms for the one I use Plantago ovato, isfagula in my world. Ground up corn husk, okay. Psyllium soluble, minimally fermentable, gel-forming fiber. I think this is the best. This is my go-to and this is the one that I recommend, based on clinical literature and clinical experience, for patients with chronic constipation and irritable bowel syndrome or constipation.

Darren Brenner, MD:

Now, the vast majority of the people that I see do come in with a complaint of bloating and distention and I don't minimize that even this one has the potential to cause this. So I always start with the old, start slow and low and titrate from there. I do not try to pound 20 to 30 grams of fiber, as recommended by everybody, into somebody on the first day. They will blow up like a balloon and want to kill you. I've had this experience. I have tried the different fibers and supplements at DDW and then laid on the floor miserable, because I'm not afraid to share the fact that for 20 years I have suffered from post-infectious irritable bowel syndrome. So I am not only a patient, I'm also a client and if I use fiber, this is the one I use. I think it is the most effective with the least likelihood to give gas and bloating. And again, I start very slow, a couple tablespoons a day with meals and I work my way up from there.

Dr. Megan Riehl:

Perfect. So take heed, so that you too are not on the floor low and slow and work your way up to the proper daily dose. And then when do you escalate from some of these? Because that's over-the-counter, right, we can get over-the-counter supplements and medications when do you escalate to something like some of the prescriptions you've mentioned earlier?

Darren Brenner, MD:

Yeah, you know I'm a big fan of over-the-counters. When we published our systematic review a couple years ago on all the over-the-counter therapies, I'm a big fan of PEG 3350. Everybody starts there. So if they don't want fiber or they fail fiber, everybody starts there. Now when I say I'll fail fiber, I'm also talking about Kate's dietetic interventions. So I talk about kiwis, mangoes, prunes, with everybody that walks in the door. I know our dieticians are big fans of chia seeds as well. So I do like people to go healthy and natural first.

Darren Brenner, MD:

When people fail PEG, that's when, in many cases, I will start thinking about the prescription therapeutics. That does not mean that I'm anti-Sena or bisacodyl. I use these more as rescues. I'm not adverse to magnesium. A lot of my patients have already come in and failed magnesium because it's a natural supplement and they've tried it. But where I really start to differentiate is with the severity of the abdominal symptoms the pain, the bloating, the discomfort. Prevention none of the over-the-counter therapies have ever been shown to improve abdominal symptoms and in fact in the clinical trials some have been shown to worsen them. So when somebody walks in the door and says my predominant symptom is pain, discomfort and bloating, yeah, I can get my bowels under better control, the frequency, texture, straining and complete evacuation with the over-the-counter. That's when I go to the prescriptions, because the data is much more robust for helping those abdominal symptoms.

Kate Scarlata :

Awesome. I don't want to get totally into brands, but is there one that's more? First line.

Darren Brenner, MD:

Yeah, for the prescriptions, Kate, it comes down to my four Cs, but I'll focus on the first two, which are cost and coverage. In many cases, unfortunately, in 2024, and I think all of us practitioners hate this what we prescribed is dictated by what insurance gets as their initial tiers, and that's what we have to give these individuals, and the differences can be hundreds, if thousands, of dollars, and so we're a little bit restricted in that process. So, realistically, that's my go-to.

Kate Scarlata :

Yep, that makes a lot of sense. I know I just switched insurance so I'm hearing you. It's like a whole new world. I'm trying to figure out what's covered and what isn't. I don't think I'm going to let go of the milk dud analogy earlier. I keep thinking that was one of my favorite candies growing up. So, yes, if you are experiencing poops that look like milk duds and you have constipation, as Dr. Brenner has explained very beautifully, there are some diet and lifestyle interventions that I often will use with my patients, so in individuals that I consult with. So I'm just going to briefly run through some of these as a review.

Kate Scarlata :

Green kiwi fruit is my go-to and I tell people to buy it in bulk. Wash it, chop it up, keep it in your freezer. It's a great. You can just throw it into a smoothie. It's two green kiwi fruit that have the best sort of efficacy. You can keep the skin on in a smoothie. You're not even going to see it or taste it and it's fine. It's extra fiber for you.

Kate Scarlata :

Mango has excess fructose, which is very osmotic. So Dr. Brenner mentioned that Sorbitol-containing foods like prunes or apricots peaches those also have a lot of osmotic effects, pulling water into the gut, that may soften up your stool. I am also a huge psyllium husk fan so I add it to my smoothie and I just go titrate slow. I get Kate Farms (note: should be Kate Naturals). It's a powdered psyllium husk and about a teaspoon is four grams of fiber. I think that's a great starting point for most people and then you can titrate that up to kind of see where you are. But, as Dr. Brenner mentioned, it's soluble, which tends to be a more tolerable type of fiber. It's not adding a lot of bulk to the stool. We already have a lot of bulk to pass. It's low fermentable, which is great, and then that viscous property is great because it sops up extra fluid softening stool. It's low fermentable, so it stays intact in the colon to do the job that it does. So that is absolutely my favorite favorite.

Kate Scarlata :

The other idea is a squatty potty. If you talk to any GI dietitian they all have them, including me. I have a streamlined one that's kind of see-through, very, very posh. But we talk about the proper poop position in our book on actually page 329, so that you can kind of see you want to raise those knees above your hips, open up that rectal canal angle and let things flow a little bit more easily into the porcelain throne. I love that.

Kate Scarlata :

Always make sure, as Dr. Brenner mentioned, fiber should be titrated up slowly. Let your body adapt. There's a big ecosystem going on, trillions of microbes in the colon and they're going to love that fiber you're upping in your diet. So just go slow. Lots of fluids to have your body adjust. And then exercise is another really good thing. So keep your body moving. I think a good long walk a lot of people will be like, oh, come home and be ready to hit the toilet. So I think that's important. And another really important point that Dr. Brenner mentioned was eating regularly. So we do have that gastro colic reflex after we eat. That stimulates colonic motility. So if you're skipping to avoid symptoms, you're not going to take advantage of that gastro colic reflex. So eating regular meals is key. So that's my little spiel, Dr. Riehl. Hey, is the Squatty Potty like a real thing?

Dr. Megan Riehl:

I saw it on Shark Tank and he said you know, yes, I endorse this thing. So it was actually from Dr. Brenner where I was able to really, you know, remind our patients of the value and importance of our posture and our behavior as well, on the porcelain throne. So thank you, Dr. Brenner. A couple other words about, as you mentioned, we go back to that cycle that people get into and recognizing that stress can be a big factor and sometimes the stress is completely related to just your bathroom habits, and so if you're somebody that does, you're afraid to go to the bathroom at work because you're like, ah, people are going to wonder what I'm doing in there and we have Poo-Pourri now, like so it's so important to not miss your body's cues that it's time to go, and when you do, you start to really impact that brain-gut connection where the brain is saying like, hey, we got to go, I got signals from down below and you're not going, so now I'm going to have more clenching, spasming, anxiety, pain.

Dr. Megan Riehl:

So it's so important that we listen to those cues. And the other side of this is really about balance that you know if you're having constipation, balance in life in general which is good for all of us, whether you have constipation or not is so key, and so that comes in the form of self-care and so practicing relaxation. And you can really up this by doing gut-directed relaxation or gut-directed hypnotherapy, which is actually an evidence-based behavioral therapy to help with the management of constipation, even if you don't have access to a GI psychologist to guide you through this. The world of digital behavioral therapeutics is evolving, and so there's an app that you can download now the Nerva app. That's a gut-directed hypnotherapy app that provides you with a behavioral strategy to really address the restoration between the brain and the gut that can become so dysregulated with our gut health and, you know, for a variety of reasons, as we've hit on, whether it be our nutrition, our stress, the mechanics of our toileting and our motility. So there's lots to consider here and finding that balance through both movement and relaxation.

Dr. Megan Riehl:

You guys have all heard me already talk about the benefits of diaphragmatic breathing, but that's a beautiful strategy that can help to quickly break that stress cycle, while you then can employ a variety of other techniques and strategies. So we just want to be mindful that constipation is not a one thing is going to fix it all a lot of times, and so we hope that our guest today, Dr. Brenner, gave you lots to consider and maybe ponder while you're on that porcelain throne, but don't ponder for too long. A lot of times, with constipation, people are sitting on the toilet for far too long, and maybe, Dr. Brenner, how long should somebody sit on the toilet before they decide you know what, now's not the time and they get up and go?

Darren Brenner, MD:

I usually tell people five to 10 minutes and override your brain. You can override, lift your legs and walk away, and I want you to do that. And a lot of times people have a lot of difficulty and, Megan, that's where you can come in and help assist some of these people. It's getting over that perseverative piece and overriding that urge, knowing that you will try again later and hopefully have more success at that point. Perfect.

Dr. Megan Riehl:

All right. Well, we have learned. I have learned so much from you today, and I hope our listeners have too, and as we wrap up this episode, we like to ask all of our guests the following question okay, what is something that you, Dr. Darren Brenner, prioritize when it comes to your own overall health and wellness? What do you do?

Darren Brenner, MD:

That's a great question. I will honestly and wholeheartedly admit that I spend all day recommending to all of my patients that they eat these very healthy, balanced diets. And I know the two of you have broken bread with me in the past and I'm probably anything, but I love my food. I love my junk food. There's the live to eat and eat to live, and I live to eat. So I focus on the exercise aspect.

Darren Brenner, MD:

As Kate mentioned, people tell me all the time I just can't find the time to exercise. Please, please, please, please, please, please, please, please, please, please, please, please, make the time 30 minutes an hour. Just get up and go for a walk. I will do my workout, if I have to, at midnight and then go to bed. But it's amazing how much the exercise can help, just not in the gut motility per se, as you mentioned, but also on the psyche side and the way you feel. I wake up every morning the next day feeling much better if I worked out than if I hadn't, and I think that alone can be a major contributor overall to not only your gut health but just your health in general.

Dr. Megan Riehl:

So this man is one of the busiest. We were lucky to grab time from him. But I think it just begs to kind of show the benefit that, even if you are living a very, very busy lifestyle, prioritizing your own time for self-care and moving your body, it's going to give you the endorphins, it's going to help you be more productive in your day-to-day work life, school life, mom, dad life. Thank you for elucidating the benefits of that.

Kate Scarlata :

Yes, I love that I'm all about the exercise too, but I'm going to work on. I think we're going to have a little nutrition consult the next time I see you what we call a gentle diet cleanup.

Darren Brenner, MD:

Which is funny, Kate, because I'm going to call you out here, because the next time you see me, we're sharing a dinner at Fogo do Chão. All you can eat Brazilian steakhouse.

Kate Scarlata :

I know I have to. Really I'll have to clean up my act that evening. That is so funny, it's true. Oh my goodness, this was phenomenal and so helpful on so many levels. You've covered everything I think about constipation and more. So thank you so much for coming on, Dr. Brenner. We appreciate your time, especially knowing how busy you are, and keep making the GI space a better place to work in. Keep doing that wonderful research. It's making a difference in the lives of people living with GI conditions. So thank you, it is my pleasure.

Darren Brenner, MD:

Thank you for having me. I really do appreciate it.

Dr. Megan Riehl:

Thank you for joining us as we grow this gut health community. We hope you enjoyed this episode and don't forget to subscribe, rate and leave us a comment. You can also follow us on social media at the Gut Health Podcast, where we'd love for you to share your thoughts, questions and experiences. Thanks for tuning in, friends.

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Kate Scarlata

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Megan Riehl

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