Constipation refers to the difficult or infrequent passage of feces or a subjective feeling of incomplete evacuation. There is no general agreement in medicine as to the proper frequency for bowel movements, which observes an apparently normal range that can fluctuate between 2 to 3 per day to one bowel movement 2 or 3 times per week (Berkow 1992). This is contrary to the accepted tradition in herbal medicine, which indicates that every person should evacuate the bowels at least once daily. Nonetheless, an occasional alteration in normal bowel habits is not necessarily pathogenic, and care should be taken not to worry the patient if this happens. This can happen if for example the patient experienced some change in dietary or sleeping habits, during travel or lack of exercise, or when having just overcome a bout of diarrhea.

The Chinese perspective on the function of the Large Intestine is that it is related to the emotion or feeling of “letting go.” Thus where constipation becomes a cause for excess worry, it soon becomes part of a vicious cycle relationship that can end up making things worse. Ultimate success in constipation comes with being gentle, freeing and relaxing the mind so the bowels open and empty in turn. Excessive reliance upon laxatives and enemas can disturb the delicate bowel ecology and contribute to a loss of the colonic haustra. Patients that habitually use anthraquinone laxatives such as Rhamnus or Rheum sometimes exhibit melanosis coli, or deposits of brown pigment in the mucosa seen upon endoscopy and colonic biopsy that can interfere with normal bowel function.

The clue to understanding the nature of constipation is by understanding the dynamics of feces formation and what constitutes its make-up. As reviewed in the previous section on physiology, the bulk of feces is formed by the bacterial fermentation of indigestible fibers such that the feces is upwards of 80% by volume bacteria. Thus the bowel ecology is of prime importance when discussing the issue of constipation, and obviously becomes important when constipation is associated with diet or the use of medications such as antibiotics that adversely effect this ecology.

The most obvious manifestation of constipation is fecal impaction, common in the elderly and in the bedridden, in those who have received barium enemas, taken antibiotics or opiods such as morphine that inhibit peristalsis. Other medications that can promote constipation include aluminum hydroxide, bismuth salts, iron salts, cholestyramine, anticholinergics, ganglionic blockers, several different tranquilizers and sedatives, and following general anesthesia. Sometimes constipation is caused by the use of hydrophilic bowel laxatives, such as psyllium, in which the patient doesn’t drink enough water, rendering the fiber into a sticky mass that is difficult to evacuate. In fecal impaction the patient often complains of rectal pain and tenesmus, and when after a period of time the patient finally evacuates the bowels, the consistency of the bowel movement is a hard, dry marble-like mass, often evacuated with much watery mucus. Sometimes the bowel movement may vary in color and shape, the first portion appearing as a dark hard mass that causes much pain to evacuate, but then followed with watery feces at the end, almost like diarrhea.

There are a great many potential causes of constipation, besides the medications mentioned, and the most common cause is usually ascribed to a low fiber diet and a lack of exercise. As mentioned, the elderly are particularly susceptible to constipation, primarily due to an overall weakening and diminishment of digestive secretions, and a loss of colonic reflexes. Other causes include inflammatory abdominal conditions such as peritonitis and diverticulitis, bowel infections, traumatic conditions (e.g. head injuries, spinal fractures, spinal cord injury), hypothyroidism, hypercalcemia, uremia, porphyria, Parkinson’s disease, cerebral thrombosis, or a local tumor. (Berkow 1992).

The determination of the cause of chronic constipation may include rectal and sigmoidoscopic examinations, barium enemas, as well as a full physical examination, including an assessment of thyroid function. (Berkow 1992).

Medical Treatment

The medical treatment of uncomplicated constipation relies upon the usage of vegetable fibers, usually in the form of hydrophilic bulk laxatives such as psyllium, bran or methylcellulose. Occasionally laxatives will be recommended such as Cascara, phenolphthalein, bisacodyl, castor oil, which all act to irritate the intestinal mucosa, increasing peristalsis and intraluminal fluid volume. It has been noted however that these agents may promote dependence, and can cause serious fluid and electrolyte disturbances. Laxatives however are contraindicated in acute abdominal pain related to inflammatory bowel disorders, intestinal obstruction, GI bleeding, and fecal impactions. (Berkow 1992)

Some laxatives that work by virtue of changing the osmostic gradient of the bowel, containing poorly absorbed polyvalent ions such as magnesium, phosphate, ulfate, lactulose, and sorbitol, increasing intraluminal osmotic pressure and drawing water into the intestine. Others such as mineral oil soften the fecal matter but may decrease the absorption of fat-soluble vitamins. Detergent laxatives such as docusate are used both internally and as a suppository to soften stools, breaking down surface barriers and allowing water to enter the fecal mass to soften and increase its bulk. Docusate is contraindicated with mineral oil. In cases of fecal impaction the treatment may consist of warm water or oil enemas. (Berkow 1992)

Holistic Treatment

Constipation is an exceptionally common problem in the West, and for the most part, can be seen to be a symptom of an improper diet, usually one low in fiber, high in foods that are sticky and difficult to digest (e.g. flour, dairy), and also due to a lack of exercise. Together, diet and exercise are key in the treatment and prevention of constipation. Although herbal laxatives can be used with a great deal of symptomatic success, their chronic usage should be avoided because they create dependence. Only once the underlying causes of constipation have been ascertained should treatment be initiated. Both Ayurvedic and Chinese medicine account for the fact that constipation can be caused by too much dryness, either because of an excess of heat or an excess of cold in the system, or because the digestion is weak causing mucoid accumulations, congestion and dampness. The following is an overview of the different treatments used in chronic constipation:

1. Restore the bowel ecology

  • Live culture foods, e.g. pickles, fermented vegetables, kefir
  • Probiotics: e.g. lactobacilli, bifidobacterium
  • Prebiotics: e.g. fructo-oligosaccharides, inulin (e.g. found in Elecampane (Inula helenium) and Dandelion (Taraxacum officinale root)
  • increase fiber intake, with preference to non-grain fibers, e.g. leafy-green vegetables, unpeeled root vegetables, etc.
  • avoid dairy, flour, sugar which impair gastric motility and increase the growth and development of organisms that are antagonistic to the “friendly bacteria,” e.g. Candida

2. Promote proper digestion

  • bitters to stimulate appetite and digestive secretions e.g. Barberry (Berberis vulgaris), Oregon Grape (Mahonia repens), Artichoke (Cynara scolymus), Yellow Gentian (Gentiana lutea), etc. These remedies are particularly appropriate when there is excess heat in the system, which dries out the stool. Chinese patent remedies include Wei Re Xin Huo Ling, 3-5 pills bid-tid, and Lung Tan Xie Gan Wan, 6 pills bid-tid
  • aromatic carminatives, to enkindle proper digestion and relieve flatulence and spasm, e.g. Calamus (Acorus calamus), Hingu (Ferula asa foetida), Cardamom (Elettaria cardamomum), Caraway (Carum carvi), Fennel (Foeniculum vulgare), Ginger (Zingiber officinalis), Spearmint (Mentha spp), Bitter Orange (Citrus aurantium), etc.
  • pungent-tasting stimulants to remove mucoid accumulations with e.g. Ginger (Zingiber officinale), Pippali (Piper longum), Cardamom (Eletarria cardamomum), etc. The Ayurvedic remedies Trikatu, 1-2 g bid-tid, and Hingvastak, 2-3 g bid-tid are particularly useful here, the latter also when there is tenesmus and flatulence
  • full spectrum digestive enzymes, long term in elderly patients, 2-3 caps with meals
  • rejuvenatives, for use in cases of digestive weakness and fatigue (Spleen qi-ojas deficiency), e.g. Ginseng (Panax ginseng), Huang Qi(Astragalus membranaceus), Dan Shen (Codonopsis pilosula), Atractylodes (Atractylodes alba), etc. Useful Chinese patent remedies include Fu Zi Li Zhong Wan (“Aconite Compound”),8-13 pills tid; Xiang Sha Liu Jun Wan (“Six Gentelmen pills”), 8 pills bid; and Bhu Zhong Yi Qi Wan (“Central Qi pills ”), 8 pills tid

3. Promote proper liver function

  • cholagogues, taken before meals e.g. Oregon Grape (Mahonia repens), Barberry (Berberis vulgaris), Black Radish (Raphnus sativa)semen, Dandelion (Taraxacum officinale) radix, Yellow Dock (Rumex crispus) as tinctures, 2-3 mL before meals, as powders, 2-3 g before meals; several of these remedies also act against pathogenic bacteria and fungi
  • avoid drugs and alcohol, which impair liver function
  • hepatic trophorestoratives, to support hepatic function, e.g. Milk Thistle (Silybum marianum), Wu Wei Zi (Schizandra sinensis), Chai Hu (Buplerum chinense), Amalaki (Emblica officinalis); Hsiao Yao Wan 8 pills tid; Chandraprabha vati (2 pills bid)

4. Restore tone to bowel

  • bowel tonics, e.g. aged Cascara (Rhamnus purshiana bark), taken with aromatic carminatives, e.g. Ginger (Zingiber officinale rhizome), as powder 2-3 g before meals
  • Triphala, 3-5 g before meals, taken with equal parts Turkey Rhubarb (Rheum palmatum) or Trivrit (Operculina turpethum) for particularly recalcitrant cases

In some cases the issue of constipation, especially in the elderly, the problem may relate to an inherent dryness of the bowel:

5. Lubricate the bowel

  • increase oil consumption in diet, e.g. olive, sesame, coconut oils
  • warm water enemas or oil enemas, 60-120 mL performed on an empty stomach, first thing in the morning; NOTE: this may cause dependence and should not be relied upon
  • Yin-nourishing herbs, e.g. Run Chang Wan, 4 pills tid. The following is a particularly useful formula I have developed using Chinese herbs for bowel dryness:
  • Paeonia lactiflora(Bai shao) 3 parts
  • Morus alba (Sang shen) 3 parts
  • Polygonum multiflorum(He shou wu) 3 parts
  • Prunus persica(Xing ren) 2 parts
  • Ophiopogon japonicus(Mai men dong) 2 parts
  • Rehmannia glutinosa(Shu di huang) 2 parts
  • Glycyrrhiza glabra(Gan cao) 1 part

Mix all the above, to make 16 parts. Make as a strong decoction, boiling for several hours, until the final volume equals that of the original weight of the herb. Strain well and when cool mix with equal parts unpasteurized honey. Dose is 15-45 mL, 2-3 times daily with warm water, before meals.