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

Hello,

Welcome to icliniq.com.

I understand your concern about your health. Constipation and left-sided 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 an association with stomach-related symptoms such as burping, belching, early stomach fullness after meals, and 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 a history of gastrointestinal infections. This is medically termed "post-infectious IBS." I want you to understand two things about your problem. First, IBS will remain with you for life, but symptoms can be well-controlled so that they do not affect your quality of life.

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

The treatment is multidirectional, starting with symptomatic treatment and later escalating therapies based on symptom improvement.

• Take tablet Xifaxan (Rifaximin) 200 mg thrice daily for three weeks. This antibiotic has a good safety profile and is used to correct abnormal gas-producing microorganisms (microbiota).

• Avoid FODMAP diets.

• Take the tablet Levosupiride 75 mg twice daily, half an hour before meals, for two weeks.

• Do not use Isabgol or increase fiber intake, as it is notorious for causing gas and bloating. You can take it, however, if it does not trouble you. Or use Polyethylene glycol (Miralax) 17 grams twice daily to help with your constipation.

• Please update me on your symptoms next week so I can reassess and adjust medications accordingly.

• I do not suggest any investigation for now since you already have some. I want you to upload the tests you have already so I can review them before embarking on any further tests.

I hope this helps answer your query.

Thank you.

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 laboratory test results and the USG (ultrasound) abdomen.

They 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 it will take 3 to 4 weeks to affect your gut, and before you know it, you'll see an improvement in your symptoms. So I want to, and I know that you will adhere to the above treatment regimen for the said duration.

I hope this helps answer your query.

Thank you.

Hello,

Welcome back to icliniq.com.

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

Kindly revert to assist further.

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 them later? 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 conditions.

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

I hope this helps answer your query.

Thank you.

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, that is, 109; the normal level should be less than 100. But remember, they are just blood tests; their value depends on the machine, and the machine can sometimes have errors. Given that your HbA1c is normal, it suggests you do not have diabetes.

You should undergo 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.

I hope this helps answer your query.

Thank you.

Hello,

Welcome back to icliniq.com.

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

I have reviewed your reports (attachments removed to protect the patient’s identity), 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:

• Tablet Prucalopride 2 mg once daily.

• Ispagol husk: 2 tablespoons dissolved in water or 0.123 ounces daily.

• 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.

Thank you.

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 of the bowel lumen, but it is most often 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 suggest pernicious anemia, atrophic gastritis, 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, a blood test for anti-parietal cell antibodies can provide 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 the best fit for 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, a barium follow-through can provide a clear picture of small- 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, whereas a person with CIC would not. 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.