I’m working with a patient, and her only complaint is constipation and bloating. She’s eating a Paleo-type diet that includes some grains such as quinoa but is entirely gluten free. She drinks eight ounces of water every hour pretty religiously, gets good sleep, has good energy, clear skin, exercises daily. She’s very resistant to gut testing because she thinks there’s no way that’s the problem. She has her own theory on what’s going on. She has always had very hypermobile joints and lax ligaments and puts herself somewhere on the spectrum of hypermobility syndrome and believes this is the root cause of her constipation. Magnesium, Iberogast, and coffee do not help with symptoms. Tomato is the only thing that seems to induce a bowel movement. Otherwise, she will have hard, small movements for about two days, then a pretty normal one on the third day. What would you do next? Would you continue to advocate for SIBO gut testing? Are there any other interventions you would try in the meantime?

Dr. Amy Nett:  This is a tricky one because I don’t know how you cannot do gut testing when her complaints are constipation and bloating! So, yeah, I would absolutely advocate for SIBO and stool testing. I think that’s where you have to start and look for small intestinal bacterial overgrowth. Particularly, you’re going to be thinking about methane overproduction. It’s really, I think, where you have to start, and it’s going to have to be a conversation with her about just ruling it out. Say, “You know what? Fine. Let’s just do one stool test.” Just do the Doctor’s Data test. If she’s incredibly resistant, just do a one-day. Something is better than nothing. If you can’t get the three-day, which is definitely best for a parasite, at least get a one-day collection. Get some idea as to what the makeup of the microbiome is, get some markers of inflammation, and get a SIBO breath test. I feel like that’s the bare minimum, that you have to communicate to her why that’s important. It’s entirely unclear to me why someone with constipation and bloating would not think that there’s any possibility of a microbial imbalance. It sounds like it’s going to be a tricky conversation.

You could also think about HPA axis testing. Is it a stress issue? I think I’ve mentioned before there are always those vagal nerve exercises. It sounds like she’s… I want to say a little bit compulsive, without putting the negative connotation on that, but if she drinks eight ounces of water every hour, that sounds like she’s somebody who can follow a schedule, so maybe she would be open to doing the gargling and singing at the top of her lungs and doing the vagal exercises to encourage motility.

Then Liz is following up. “Do you think there’s any validity in her theory of being so hypermobile that her gut isn’t able to contract enough to lead to a bowel movement?” Not in my experience. I haven’t seen that. When I hear “hypermobile,” what I actually think of is chronic inflammatory response syndrome. There’s a relationship between CIRS, which is the biotoxin-related illness, and hypermobility. Some of my patients with hypermobility, I will start to think that if we don’t improve their symptoms with gut treatment, then I’ll go down that CIRS pathway a little bit more quickly than I might with someone who doesn’t have hypermobility, but my patients, by and large, who have hypermobility issues don’t have constipation. I’m not entirely sure why hypermobility would limit smooth muscle contraction. That’s not entirely clear to me. So, Liz, it sounds like you have your hands full with trying to convey some options.

In terms of interventions, have you tried FiberMend? I really like that one from Thorne. It has the PHGG, some psyllium, a few other prebiotics, I think, and it has some prune powder in there to help. It can help normalize with the fiber in there, a little bit of bulking, but it also has the PHGG and prebiotics, so it can help strengthen the microbiome and maybe improve the makeup of the microbiome. Also see, if she’s doing something like that, does it increase bloating? Ask her what’s triggering the bloating. Is it FODMAPs? Is it resistant starch? Maybe you can make a connection between what worsens some of her GI symptoms. Maybe that would also be a lead-in to like, “Oh, FODMAPs worsen your symptoms. That’s weird because, you know, FODMAPs trigger people with SIBO, so maybe we should think about doing SIBO testing.”

I don’t know. It’s a tricky one, but if you can, push through and try to see if you can get her to do some gut testing. HPA testing would be a second option, just to think about cortisol, stress, and how that’s affecting it. Everything else is going to be kind of further out. I mean, it’s hard for me imagine that she’s saying, “Well, I have hypermobility, and it is what it is.” I don’t know if that’s what she’s saying. “Well, I just am hypermobile, and therefore I’m going to have these constipation issues.” I don’t know. I wouldn’t be happy with that. Hopefully you can get her down the path of gut testing. Keep us posted.