A Doctor Visits the Doctor

Not a homeschooling post:)

If you have chronic, severe constipation, I encourage you to have hope.  When the probiotics, Miralax, Colace, Activia, extra psyllium, increased fruits and vegetables, whole grain cereals, and stimulant laxatives seem to be failing, keep looking.  When the doctors offer you nothing but increasing your Miralax or using more stimulant laxatives, bear with them.  Continue to be under their care, but keep looking.

In medical school, we are trained that nutritional intervention in most conditions is a non-player.  Diabetes.  Yes.  Heart disease.  Sure.  Acne.  Umm…no-oooo.  Ulcerative colitis or Crohn’s.  Umm…probably not.  Fibromyalgia.  Whatever.  Chronic fatigue syndrome.  Not likely.  Headaches.  Not unless they’re migraines triggered by red wine or MSG.  Joint pain.  Never heard of diet helping that, for crying out loud.

When patients come in touting this diet or that, we doctors graciously smile and nod as we would to a child. As we’d say to our children in a syrupy, soothing voice:  “That’s nice.  Yes, sweetie.  I know.  I’m so happy.”  Internally, we’re wondering when we can move on to the next question required in our medical history taking to meet CPT coding bullet points for insurances, Medicaid, and Medicare coverage.  So we don’t get accused of fraud.  Because most medical doctors aren’t intentionally fraudulent.  We do not have time to discuss diets that we were taught don’t work and can’t be broken down in such a way they can be actually scientifically studied.  And they don’t work.  Oh, maybe it worked for you.   But, “…that’s nice, sweetie.  I’m so glad it worked for you.  If it’s not hurting you, it sure can’t hurt to try.”  And off you both can go to the pertinent information necessary for this doctor’s visit.

For 37 years, I have dealt with symptoms such as hard stools, straining, lack of sensation to even have a bowel movement for weeks, digital disimpaction, and feeling of incomplete emptying after a bowel movement.  Different laxatives and over the counter medicines would work for a while, and then they would stop helping.  My doctors would ask, “So this has been chronic?”  “Yes.”  “Well, try eating more vegetables.”  Or more Metamucil.  Or Amitiza.  I never fretted too much about this problem as I had no discomfort with it, except when I had a bowel movement.  Which wasn’t too frequently anyway.  And if I just took Miralax, it would keep the discomfort from peristalsis at bay.  But, two bowel movements a month, and those only with stimulant laxatives, magnesium, and Miralax, cannot be healthy.  The bloating started.  Worries of colectomy for years of colonic inertia began setting in.  And I started Googling information.

There is a TON of GI information on-line.  Sifting through it is a tremendous challenge.  Time consuming.  Overwhelming.  Some of it sounds like PURE hocus-pocus.  Maybe it is.  Maybe it isn’t.  I don’t have time to read enough about all of it.  But, for myself, I settled on the Specific Carbohydrate Diet.  Much of the book made sense and seemed logical.  Then, I took it a step further and started on Gut and Psychology Syndrome diet.  Lots of it makes sense.  Some of it doesn’t.  There have been some great weeks and some terrible weeks.  But overall, since June 22, 2012, my GI tract is definitely moving in the right direction.  My husband, an orthopedic surgeon, cannot believe how GAPS has changed my GI tract.  I’m no longer “the butt” of jokes about anal-retentive women.  (I adore my husband.  And the feeling is mutual.)  Neither one of us “poo-poo” the role of diet in medical conditions anymore.

I cannot say what part of the GAPS diet is helping me.  And pure success (near-daily bowel movements) has only been in the last 6 weeks.  I would like to see 2-3 months of this kind of success before I get too excited.  I was going to wait until 2-3 months of success before writing about “success.”

But today I had my gastroenterology appointment.  In some ways, what a waste.  In other ways, a success.

A success because I am now acquainted with a gastroenterologist here.  So if my problem comes back despite this diet, I can go back to her.  Sometimes it isn’t until you’ve been to a doctor a few times that you really get their attention.  A success because she did a Chem 12, which will check out my liver, calcium, and renal function.  Which I know are okay–but it never hurts to check!  I love to get good grades on “tests.”  LOL!  And serological testing for celiac.  Which would most likely be negative as I’ve been off of gluten for 7 months now.  But she said that they can remain positive up to 2 years off of gluten.  So if it comes back positive–question answered.  If it comes back negative–keep on keepin’ on and who knows.  And finally, a positive visit because she said if my symptoms come back, she could set me up over the phone for a Sitz marker study, rectal manography testing, and perhaps a colonoscopy.  I wouldn’t have to drive the three hours again just for an office visit.

A waste because, although she knew I was a medical doctor, she continued to talk to me as if I were my mother.  With no understanding.  Explaining to me as if I didn’t already know about Sitz marker studies and rectal manography testing.  Explaining perhaps the extra fiber and vegetable intake of my diet was making a difference.  That I likely didn’t have FODMAP or SIBO because we should see diarrhea, not constipation.  And the thing is, I’m thinking that IBS, Crohn’s, and ulcerative colitis patients who are out there reading and learning know more than she does regarding FODMAP, SIBO, and dietary interventions for their illnesses.  I expect this from a primary care doctor or a non-gastroenterologist medical doctor.  I expect much more out of a gastroenterologist.  I asked her if she’d heard of the GAPS diet (in a VERY curious, polite, self-deprecating fashion).  No, she had not.  I explained it was similar to the Specific Carbohydrate Diet.  “Oh.  Those are all like the fructose intolerance, FODMAP, diets.”  I didn’t bother to explain anymore.  I chose to be a “silent genius” and not correct her.  She thought she knew, and she didn’t ask me any more questions or show any interest.  She was professional and kind enough.  I wasn’t there to educate her, unless of course she asked me about it.  And she didn’t.  I got what I expected from the visit.

But, I’m being a responsible physician-patient.  Not just treating myself.

I am hoping that dietary intervention will keep my GI tract healthy, and I’ll have no need of further testing.  Time will tell.  For now, I’ll encourage those with chronic constipation that the diet is helping me thus far after 6 months.

For further constipation related posts, please click on the GI Tracts Defying Gravity page.

15 thoughts on “A Doctor Visits the Doctor

  1. SCD Griddle

    Dear Homeschooling Doctor, I’m glad that your visit to a gastroent. was partly a success, but I’d like to comment on the “failure” part of your post.

    I have had similar experiences with my gastro doctor. I saw a gastroenterologist for a few years. She did help me get rid of a few nasty bouts of SIBO with antibiotics, but beyond that, she really did nothing besides order a few tests, give me some prescriptions (the medication DIDN’T HELP AT ALL) and give me vague advice. When I would ask her about my “condition”, she never gave me a satisfactory answer- until I pressed her on it about a year ago, when she mentioned that I could be celiac. Only when I asked her about eating a gluten-free diet did she say that it could help my symptoms. UGH.

    That’s when I decided that a lot of doctors don’t know anything.

    You struck the nail on the head when you wrote:
    “And the thing is, I’m thinking that IBS, Crohn’s, and ulcerative colitis patients who are out there reading and learning know more than she does regarding FODMAP, SIBO, and dietary interventions for their illnesses.”

    I’m all for being responsible (and continuing to go to useless medical appointments), but I refuse to go to another gastroenterologist unless they are referred to me by the SCD/GAPS/FODMAP community.

    That’s my rant for the evening!
    Theresa ~SCD Griddle

    Reply
  2. depresseddancer

    I understand that doctors must find it very frustrating to hear patients witter about xyz superfood and how it will cure all their ills, but I wish they’d be a bit more like you and listen.

    I underwent 7 years of invasive gynaecological treatments and investigations because of pelvic pain. In the end I started charting *everything* about my life and realised it wasn’t linked to menstrual cycles, gaining or losing weight, stress or activity levels.

    I wasn’t able to digest cows milk. I was vegetarian with a family history of osteoporosis buoying me to keep a good calcium intake. Between milk on my cereal, cheese sandwiches at lunch, butter in mashed potato, yoghurt-based snacks and the odd cheeky cake; I was poisoning myself at every meal.

    I stopped eating dairy, and the pain stopped within days, so did my problematic skin condition, my asthma got much better, I realised I didn’t have to have a bulbous pregnant looking stomach (it was normal for me!).

    That was 4 years ago. It was a tough change to make, but it’s made my world so much better. Initially I couldn’t balance my dietary needs with my life commitments, and had iron and calcium issues. I eventually began eating meat again and it’s helped a lot.

    The doctors can raise their eyebrows all they want, but if a food regime works for a patient, and they keep a balanced diet, then surely it’s a good thing!

    Reply
    1. thehomeschoolingdoctor Post author

      That is so fascinating! How great that eliminating dairy helped that much and that fast for those symptoms! Who ever would have guessed!? Ummm…not a medical doctor! We have so much to learn. How diligent did you have to be to figure that out? Did you have to do a severely restrictive elimination diet? How did you first see the connection? Do you remember? Is it all dairy? If you get casein, say in a non-milk based creamer, does it flare things back up? Sorry. I’m full of questions. But I am seeing so many complaints (that’s not an insult–that’s what we call it in medicine–a “complaint of…”) that have been eliminated by eliminating certain foods, but I am not hearing of medical doctors recommending eliminating the biggies–like dairy!!! My husband’s sinus issues and asthma issues are also flared by dairy–he’s a surgeon. Not one of our doctors/doctor-friends ever suggested eliminating dairy or any other food factor at his visits to their office. But now that I have more time to read since I’m not working (LOL), I’m fixing up the whole family–and he’s off dairy. Well, anyway, best wishes to you and your health!

      Reply
      1. depresseddancer

        It is amazing! I’m incredibly thankful!

        I didn’t try elimination. Partly because my body weight was already low – the trigger for me was catching a bug on holiday in Africa. It was supposed to be a relaxing holiday to fully heal from surgery, instead I was violently ill, and nothing I ate for 2 months afterwards stayed in me. I looked like a stick with a bulbous stomach! Elimination couldn’t fit around the schedule I had at the time – I thought prepping and carrying food was too time consuming (ahem!), I worried about my nutrition, and I’d also read internet wibbles about people becoming intolerant to things because they’d removed them from their diet.

        I became an obsessive charter, although I could have copy-pasted my entries most days, I ate, then I was ill. After a while I realised I couldn’t work out what I was eating on a diet of take away sandwiches, ready meals or pre-packaged food – they have so many ingredients you can’t know which is working for you. So I had to begin cooking. It was incredibly confusing, home-cooked vegetable soup with croutons was fine (yippee!), but then I had it with bread and was ill. It made no sense, it took a while to realise that if the bread didn’t have butter on then I was ok. There was other false starts too – for example some stocks contain milk powder, so a similar soup a week later made me ill. At least my reactions are easy to chart, because they happen about 30 minutes after consumption, I’ve heard of some wheat people having reactions hours later because of their gut motility.

        I had a head start because other members of my family are also lactose intolerant (but it’s usually happened after they’ve had a baby), some get spots and stomach pains, others get blistered lips and violent illness

        I can tolerate tiny amounts of dairy, unscientifically (or at least not charted!) it seems to be linked to fat content – a splash of low fat milk in coffee or a teaspoon of yoghurt are manageable if I don’t do it too often, but even a scraping of butter will make me very ill. Processed products like milk powder or cheese flavouring are an absolute nemesis.

        Oddly, I can have some dairy – sheep products cause a little swelling but no real problems (yum yum yum!) although aged cheese like Manchego is more likely to be an issue. Some reports say it has more lactose and caesin in, but in a more easily broken down form. I’m just grateful, I miss my cheese.

        I’m so glad it’s worked well for your husband, being a surgeon with a snotty sinus problem must be dreadful!

        PS If it’s relevant to your studies, lots of people on the dairyfree forum are also soya intolerant (like me) and can’t digest the ‘lacto-free’ milk (the US version was fine for me, the new UK version isn’t). I’m also collapsingly allergic to prawns. In fact, never invite me to dinner, I’m a nightmare to feed!

      2. thehomeschoolingdoctor Post author

        Lots to chew on there! I’d love to see a list of all the known components of milk. Then see a list of the components in the various products (milk, cream, yogurt, hard cheese, soft cheese). Including fat, sugars, and protein. Ghee is supposed to be only milk-fat, but my daughter still had her typical dairy reaction to it. There is so much to learn. I find dairy interesting because it seems to give our family fits. And it’s so pervasive in our foods. And it seems like we should have great research on it because it has been around so long, consumed so much, and causes issues in many people. And that information may be out there–I just need more time to look up everything! Regardless, I am now utterly convinced that food causes/hugely contributes to many, many health issues. I’m glad I know and can make changes, but they are very difficult to implement. Especially for the kids. If we never left the house, it’d be helpful…However, we are healthier, and I’d like to get the word out to other people. It’s worth a try!

  3. thehomeschoolingdoctor Post author

    Yep. I hear ya! I’m still mocking some of her suggestions…but if I were having a massive GI bleed–I suppose I’d let her get in there and cauterize it–and she’d get me taken care of! But this more chronic, low-grade type of stuff, medicine really needs to step back and do some listening and learning.

    Reply
  4. Michelle

    I have a very lazy colon due to years of laxative abuse. Do you think that the gaps diet will help me I want to give it a try where can I get the a copy of the diet.

    Reply
    1. thehomeschoolingdoctor Post author

      That is a very good question. Makes me think a couple of things (or more). Which came first? The constipation or the too much laxative use? How much laxative use is implied by “abuse”–a normal dose every few days, a low dose every day, a high dose several times a week? Which laxatives were used? Stimulants or Miralax or docusate? Was the purpose for constipation or ED? When I went through pharmacy school, it was pretty accepted that stimulant laxative overuse contributed to colonic inertia. By the time I was winding down from medicine to stay home with my kids, that had become controversial. I would say, if someone has normal function before the laxatives, the years of use was detrimental. If someone had constipation before, well, he/she was just doing what had to be done and added fuel to a fire. But removing all factors that can affect bowel motility may get that person back on track. Things that need looked at include: getting good whole nutrition IN, taking OUT processed negative stuff (sugar, preservatives, grains), and identification of food intolerances you likely have NO idea you have (or maybe you’re more aware of that than I was!). This is where GAPS and GAPS introduction helped me immensely. This medical doctor wrote a book: http://www.amazon.com/Gut-Psychology-Syndrome-Natasha-Campbell-McBride/dp/0954852001. GAPS is not end all be all, and you have to sort through it based on your reactions. Also, people have issues with FODMAPS, candida, and intrinsic probiotic issues and addressing some or all of these helps their constipation. GAPS helps to address these issues, althought not head on, and it may take a year or more. Versus tackling FODMAPS head on or candida head on. Am I making any sense? I will try to write more constipation articles. That really is one of the reasons I started this blog. For me, with GAPS diet, elimination of dairy and eggs (eliminating eggs is SO hard for me), and some magnesium, I have daily bowel movements. I HAVE NEVER HAD THAT.

      Reply
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  8. pana303

    Hi Terri,

    I am so glad my internet search for chronic constipation landed me here. I, too, am a doctor (in one of the non-clinical specialities). My constipation woes started in my early twenties. I am in my late fifties now and find that my gut has become more and more resistant to laxatives.

    During my college days, not having time to pamper my fussy and obstinate colon and nervous about taking laxatives that would make me run out in the middle of a class, I used to administer myself a tap water enema every single morning so that my belly looked flat and my acne did not flare up. I did this for three to four years and stopped when I started retaining the enema water. Then came the herbal medicines which worked for a while and then became less effective. Over the years, I have tried many different kinds of laxatives, all of which work well for some time and then become ineffective. I am at a point where I have exhausted all my resources and am now trying to make my gut move without any herbal or allopathic medicines.

    Growing up in an era without the internet, I was deprived of the opportunities to research extensively my chronic ailment, or have mutual exchange of knowledge with fellow sufferers, as I am able to do so now.

    I had my first colonoscopy at age 50, as routinely recommended, and the GI md found nothing exceptional, noting only in passing that the colon was long and tortuous. That was an AHA! moment for me. I believe that is the root of my chronic constipation. However, I do not know which came first, the constipation or the long colon. Maybe, both contributed a little bit to each other. My experience with my GI doctor was similar to yours. I got my 15 minutes with him during which he recommended that I continue to take metamucil or isabgol (psyllium husk) which I had already been doing, drink enough fluids and eat well. That is it! Anyone with constipation for 30+ years knows this basic drill.

    I am menopausal now, but the post above brought back memories of my own menstrual cycle days. I, too, remember that on the first and, sometimes, the second day, my constipation stayed away and my stool would be somewhat loose and diarrhea-like. I used to atribute this to the fact that, as I also had dysmenorrhea simultaneously, the excessive uterine contractions somehow worked their magic on my rectum and made me go. As I am typing this, it occured to me, could the excessive release of prostaglandins (which contract the smooth muscle of the uterus) also have had an effect on the smooth muscle of the intestine, increasing its motility? In the pre-internet era, I would just have been left wondering. With search engines on the scene now, I immediately typed the words ‘prostaglandins and constipation’ in the search bar and came across an article that says, women with chronic constipation due to slow transit have abnormal muscle tissue levels of prostaglandin and cyclooxygenase enzymes due to overexpression of nuclear progesterone receptors that may be responsible for the condition. Here’s the link: http://www.modernmedicine.com/modern-medicine/news/modernmedicine/welcome-modernmedicine/chronic-constipation-women-linked-prostag?page=full. There are some other similar articles too down the list of search items that show up.

    Here’s some more food for thought I found in this article:(http://www.ncbi.nlm.nih.gov/books/NBK53473/)
    “Findings in patients with constipation are just the opposite of those in IBS-D patients. The contractile response to ACh in circular muscle strips from idiopathic chronic constipation patients is significantly less than that in normal strips from patients with normal colon transit [289]. Interestingly, the muscle strips from constipated patients also show smaller contractile responses to electrical field stimulation (EFS). EFS induces in vitro contractions by releasing ACh from the cholinergic motor neurons. These findings suggest that the impaired colonic motor function in constipated patients is due to a reduction in the expression of ChAT, synthesis or release of ACh, or a defect in excitation-contraction coupling in circular smooth muscle cells. A decrease in the evoked release of 3Hcholine confirms the defect in the activity of cholinergic neurons in constipated patients [290].

    An impairment in excitation-contraction coupling in smooth muscle cells follows from the finding that the contractile response to edrophonium chloride—a short acting choline esterase inhibitor—is significantly lower in slow-transit constipation patients than in healthy controls [291]. ACh accumulation at the neuromuscular junction acts directly on muscarinic M3 receptors to stimulate smooth muscle contractions. Smooth muscle dysfunction in idiopathic chronic constipation patients is evident from the inability of cathodal current to generate spikes, which suggests impairment of Cav1.2b (L-type) calcium channels [292].

    Constipated patients also display subclinical autonomic and sensory neuropathy [293, 294]. These observations may explain the hyposensitivity to colorectal distension in some constipated patients.”

    For now, lately I have been taking 3 tsp of psyllium husk (Isabgol), found in Indian stores, with a full glass and a half of warm water at bedtime. I have also started a probiotic capsule with 10 billion beneficial microbiota, which I cannot tolerate everyday, so I take it as and when my belly indicates it will be able to tolerate it. I also take a kefir drink a few times a week. From not passing stools at all for 5-6 days and having only minimal evacuation thereafter for a day, I have gone to partial evacuation everyday or every other day with these additions. I feel encouraged with this little success but, like you, always worry, “will I go tomorrow?” By no means do I feel normal with this minor success, as the probiotics give me major stomach rumblings and bloating. But I have been going partially almost everyday. Yay! What more can I ask for?

    I have imposed on your time more than I should have, but I am so happy that I have found a fellow sufferer who is also a doctor like me and can analyze the problem medically.

    Reply
    1. thehomeschoolingdoctor Post author

      Hi, “Pana!” So good to hear from you! I had read the one article (the first), and actually have it sitting in my comment bin from someone else who sent it to me many months ago to constantly remind me I needed to really explore this issue. Maybe it’s time “to move on it,” eh!? I had not read the second article. But, hey, good to know we wouldn’t get diarrhea from muscarinic poisoning!? 😉

      Have you, by chance, had any children? This is completely stupid, maybe nothing. But I’ve had to be induced 3/4 times (the last was post-dates). With prostaglandin (Cervidil), bam, I took off. I don’t know. Probably a nothing. (Also, pregnancy always exceptionally worsened things.) But I definitely plan on exploring the progesterone/estrogen/prostaglandin effects more and more. Just finished (although will keep using many techniques) trialing mind-body stuff, which should help with vagal tone and acetylcholine/parasympathetic tone/parasympathetic production.

      Yes! I agree. The progress I have made is not what is normal, but for me, I’m like you–“What more can I ask for?” Sure, I’ll keep learning, but the desperation is gone now that I know my colon most likely will remain intact.

      Oh, and lastly, I have also planned, at some point, to read up on the long, tortuous colons, but they seem to be commonly found in people with constipation. I’ve read it was more as a result of the constipation. But I haven’t read enough to make up my mind. I didn’t seem to have that on my colonoscopy.

      Would appreciate and enjoy further information you may have/find! Take GREAT care! And thanks for reaching out!

      Terri

      Reply
      1. pana303

        Hi Terri,

        “Have you, by chance, had any children?” Yes, Terri, I have, without any complications. I recently got my annual physical done and got the lab results today. I have mild hyperkalemia, it says. The nurse asked me, “Due you eat a lot of green leafy vegetables or bananas or oranges?” No, nothing excessive, was my response. However, I connected the dots immediately, suspecting that poor intestinal elimination might be the culprit. Again, an internet search confirmed my suspicion when a reliable article source mentioned this : “Constipation as a cause of elevated K: enteral elimination of potassium can be decreased and therefore lead to hyperkalemia, which again might lead to reduced bowel movements.” Sadly, my internist did not think of this even though I was in tears while talking about the severity of my constipation to her. I have been trying to avoid taking any osmotic or irritant laxatives (except the bulk forming psyllium husk which only helps to keep everything soft until it moves out – does not really initiate bowel movements for me), have done so for a month or so, but will have to take some for a few days – to relieve hyperkalemia, hah! Did you know chronic constipation can also lead to high cholesterol levels? Since my last post, the little success I had proudly mentioned has vanished again. I should have knocked on wood when I mentioned it. 🙂 Will keep you posted as and when I come across interesting articles as I work toward my Ph.D. in constipation. Lol.

      2. thehomeschoolingdoctor Post author

        Gee! I hadn’t really heard of that either, constipation leading to high potassium levels; the kidneys are the power-house so of course that’s what we all think of! However, the gut does get rid of potassium too. I found the article you were referring to, I think. Tucked that one away for reference. I tried looking for an article for the higher cholesterol with constipation as a direct source, but I couldn’t find one. In my mind, I’m coming up with speculative reasons that could happen. But, boy, it is important to keep stuff moving for so many reasons! SO MANY!

        Like you, I avoid stimulants and endeavor to keep things soft so they can move when my gut does decide to move along. I just don’t think most doctors get the gravity of the situation when people like us say we have “constipation.” Most people don’t. Then wonder how I can write about it. 🙂 I do exactly what you do; just try to keep things soft until something, sometime makes the gut move. And it seems like knocking on wood is always necessary! 🙂 My husband says, “If you only understood exactly the changes that happen JUST as you try something new that works [because things so often work at first then stop], then you could fix your problem!” That has taken me to mind-body, which I’ll keep trying for several months and see what happens. “=_

        Thanks for the knowledge passing on. You make sure the potassium comes down; you now. Just to make sure nothing is being missed…

        Terri

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