I experience severe constipation with abdominal pain and inability to pass gas. Please help.

Hello,

Welcome to icliniq.com.

I can imagine how much you have been upset about your health. Constipation and left side lower abdominal pain with no alarming features (such as ongoing bleeding, weight loss, reduced appetite, and normal colonoscopy) make me think that you have irritable bowel syndrome IBS-C constipation-predominant. I assume you have heard this term before.

So in IBS-C, it is not uncommon to have constipation, lower abdominal pain, plus association with stomach-related symptoms such as burping, belching, early stomach fullness after meals, upper abdominal pain.

Your previous history of gut infection requiring hospital admission can be a provoking factor in IBS development. Studies show that most patients with IBS have prior gastrointestinal infections. This is medically termed as post infections IBS. I want you to understand two things about your problem. First is IBS will remain with you for life, but symptoms can be well controlled so that it does not affect your quality of life.

The second is IBS is a harmless condition. In the long term would not cause you to develop complications such as narrowing of bowel or cancers. So do not get tensed thinking that it will cause you some serious damage.

The treatment is multidirectional, starting from some symptomatic treatment and later on escalating therapies based on the improvement of your symptoms.

1. Take tablet Xifaxan (Rifaximin) 200 mg thrice daily for three weeks. This is an antibiotic with a good safety profile and used to correct abnormal gas-producing microorganisms (microbiota).
2. Avoid FODMAPs diets.
3. Take tablet Levosupiride 75 mg twice daily half an hour before meals for two weeks.
4. Do not use Ispagol or increased fiber in diets since they are notorious for increasing gas and bloating. You can take, however, if it does not trouble you. Or use Polyethylene glycol (Miralax) 17 gram twice daily to help your constipation.

Please update me about your symptoms next week as I can reassess your symptoms and adjust medications accordingly. I do not suggest any investigation for now since you already had some. I want you to upload the tests you had already as I review them before embarking on any further tests.

I hope this helps.

Hello,

Welcome back to icliniq.com.

Hyoscyamine is a muscle relaxant of gut smooth muscles and can cause constipation. You should not be taking this. I have reviewed your lab test as well as USG (ultrasound) abdomen. They all are perfectly fine (attachment removed to protect patient identity).

You should start the regimen as I mentioned above and let us see in one to two weeks. I expect that it would take three to four weeks even to affect your gut and before you, and I know an improvement in your symptoms. So I want, and I know that you will adhere to the above treatment regimen for the said duration.

Hello,

Welcome back to icliniq.com.

This joint pain and stiffness of the joints seems new. Can you tell me more about this? For how long you have developed this? And which joints are involved? Are these small joints of hands and wrists, or large joints like knee, hip, elbow, and shoulder? How long the stiffness lasts?

Hello,

Welcome back to icliniq.com.

No, the Prednisone is not necessary at the moment, may we get some more blood tests, and see if you need it later in time? Actually, there are certain conditions with abdominal symptoms with large joint pains namely celiac disease, vitamin D deficiency, food allergies, and rarely Crohn's disease with arthritis; but remember all are treatable things.

Last time I did not suggest any investigations since it was of short duration and negative blood tests for celiac disease, and thyroid, probably more favoring diagnosis of acute gastroenteritis. However, if you were able to take medications then, we would have a good idea, since in case if it were resolved, the diagnosis of acute gastroenteritis and post-infection IBS could have been made.

Hello,

Welcome back to icliniq.com.

The HbA1c, lipid profile, and insulin, are all normal. The fasting blood sugar that you uploaded earlier was high i.e. 109, normal should be less than 100. But remember they are just blood tests, their value depends upon the machine, and the machine can have an error at times. Given your Hb1Ac normal, suggests that you do not have diabetes. You should the other blood tests as suggested including the hydrogen breath test HBT. For bloating, I want you to get the HBT before starting you on any treatment otherwise the results will be masked and erratic.

Hope this helps.

Hello,

Welcome back to icliniq.com.

I can understand, you must be upset about your persistent health condition.

I have reviewed your reports, and they mostly fall within normal ranges, except for low folate and low ferritin, both of which indicate vitamin deficiencies. However, they can be easily supplemented. You can take any over-the-counter multivitamin available in your country. Please remember, that they are micronutrients, and their supplements will not harm you, but your symptoms do not seem to be related to these nutrient deficiencies.

Secondly, the gastric emptying studies also show borderline impairment. Considering your previous history and current conditions, I believe this is chronic idiopathic constipation (CIC), where bowel movements are typically slow without any clear cause. Since your anal rectal manometry and gastric emptying study, both came back normal, this further supports the diagnosis.

For now, I suggest taking medication to improve your bowel movements and address your gas, bloating, and pain. Slow bowel movements can exacerbate gas and bloating issues. Here is the regimen:

1. Tablet Prucalopride 2 mg once daily.
2. Ispagol husk 2 tablespoons dissolved in water or 0.123 ounces daily.
3. Tablet Domperidone 10 mg twice daily, half an hour before meals.

Since I suspect you have chronic idiopathic constipation, it is likely to persist, but it is not a serious condition that will cause long-term trouble if you continue with the medications. The prevalence of this condition is increasing, and I regularly see patients with similar issues in my office.

Let me know if you have any concerns or questions.

Regards.

Hello,

Welcome back to icliniq.com.

Well, a CT (computed tomography) scan can detect strictures or narrowing in the small or large bowel. Yes, oral contrast can provide a clearer view inside the bowel lumen, but it is mostly administered when there is suspicion of narrowing or a leak. In cases of obstruction or narrowing, individuals typically experience severe pain, accompanied by absolute constipation. In your case, it is relative constipation, meaning you are able to pass stools, although less frequently than normal. You have never experienced absolute constipation, which would suggest a narrowing or obstruction. Perhaps this was the reason why the clinician did not initially opt for oral contrast.

Secondly, vitamin B12 deficiency can provide a clue to pernicious anemia or atrophic or autoimmune gastritis. However, vitamin B12 deficiency can be a common finding and may occur in various other conditions. If you are concerned about autoimmune gastritis, there is a blood test called anti-parietal cell antibodies, which can provide us with a clue. Linaclotide and Prucalopride, which I have recommended, have a similar mode of action. Many of my patients are taking Prucalopride with almost no side effects. Yes, these medications can cause diarrhea and severe crampy abdominal pain. We can titrate the doses to find what best suits you. The medication is available in 1 mg, 2 mg, and 4 mg doses, taken once daily. You can start with 1 mg daily and see if it improves your symptoms.

Lastly, undergoing a barium follow-through can provide a clear picture of small bowel or large bowel disease. In your case, for the diagnosis of CIC, I suggest getting a colonic transit study. In this study, you are asked to take barium tracers orally, and after 120 hours, an X-ray of the abdomen is performed to locate the tracers in your gut. A normal human being can pass all tracers before this time, while a person with CIC would not be able to pass them all. The other medicines that I have prescribed need to be taken along with Prucalopride.

I hope your queries are resolved, and any further queries are welcome.

Thank you.