Articles

Constipation

Introduction

Constipation is a common problem in clinical practice. It does not, however, have one consistently used definition. Because of the wide range of normal bowel habits, constipation is difficult to define precisely. Stool frequency is most often used to describe constipation, and has been defined as less than three stools per week. Frequency alone, however, is not sufficient criterion to describe constipation, as patients often complain not only about frequency, but also about stool size or consistency, straining, lower abdominal pain or fullness, and a sense of incomplete evacuation.

While constipation may be caused by numerous reasons, probably the most common reason, particularly in the United States, is due to lack of fiber in the diet. Often, cases are self-treated by the patient without consultation or advice from a health care practitioner. The large dollar volume spent each year on laxatives, advertising attention received, and shelf space allotted in retail stores is evidence that constipation is a common occurrence. Another reason for frequent laxative use may be misconceptions concerning normal bowel habits. Some people believe that if they do not have a daily bowel movement, that it is detrimental to their health because toxins will accumulate.

Pathophysiologically, constipation generally results from disordered colonic transit or anorectal function as a result of a primary motility disturbance, certain drugs, or in association with a large number of systemic diseases that affect the gastrointestinal tract. (1) It is therefore, not a disease, but a symptom of some underlying problem. Approaches to treatment of constipation should begin with attempts to determine its cause. Disorders of the GI tract (irritable bowel syndrome or diverticulitis), metabolic disorders (diabetes), or endocrine disorders (hypothyroidism) may be involved. (2)

Constipation is a frequent problem in the elderly, and may be caused by a lack of fiber in the diet or decreased fluid intake. Other factors to consider may include lack of physical activity or diminished abdominal muscle wall strength. However, the frequency of bowel movements is not decreased with normal aging. (3) Abdominal surgery, hospitalization, stress and anxiety, or chronic illnesses that lead to physical or mental impairment and result in physical immobility or inactivity may exacerbate constipation.

In a patient presenting with recent onset of constipation, the possibility of an obstructing lesion of the colon should be sought. Such an obstruction may be due to colonic neoplasm, strictures due to colonic ischemia, diverticular disease, irritable bowel syndrome, foreign bodies, or anal strictures. Hemorrhoids, anal fissures, or ulcerative proctitis may all result in painful defecation and inhibit the desire to evacuate.

Neurologic disorders of the GI tract may also cause constipation. Hirschsprung’s disease, also called aganglionosis, is characterized by a congenital absence of neurons to terminal segments of the bowel. Most cases are diagnosed by six months of age; however, mild cases may not be detected until adulthood. In addition to peripheral neurologic disorders, central nervous system disorders may be responsible for constipation. The CNS plays an important part in GI regulation, rather through reflexes, or coordination of other organs. It also modifies GI function in response to conscious effort or emotional stimuli. In patients with multiple sclerosis, constipation may be associated with neurogenic dysfunction of other organs. Similarly, CNS lesions caused by Parkinsonism or cerebrovascular accident may cause constipation.

Disruption of parasympathetic innervation to the colon as a result of injury or lesions of the lumbosacral spine or sacral nerves may produce constipation with hypomotility, colonic dilatation, decreased rectal tone and sensation, and impaired defecation. (4) Constipation is a frequent problem during pregnancy, possibly resulting from complex factors that include depressed gut motility, increased fluid absorption from the colon, decreased physical activity, and dietary changes. (5)

Endocrine disorders such as diabetes, hypothyroidism, and panhypopituitarism may result in inhibited bowel function. Collagen vascular diseases may be associated with constipation, as progressive systemic sclerosis causes delayed intestinal transit resulting from atrophy and fibrosis of colonic smooth muscle.

The term psychogenic constipation has variable acceptance by clinicians, due at least in part, to the lack of objective evidence for its existence. However, it is generally accepted that when evaluating patients with constipation, careful assessment should be made for evidence of anxiety, emotional distress, or affective disorders and the use of mood altering drugs.

Drugs that may lead to constipation include opiates, various agents with anticholinergic properties, such as antidepressants and antipsychotics, antacids containing calcium or aluminum, iron supplements, sucralfate, and calcium channel blockers. Generally, the constipating effects of these drugs are dose related, with larger doses causing constipation more frequently. Opiates have effects on all segments of the bowel, but particularly the colon. The major mechanism of opiate action has been proposed to be prolongation of intestinal transit time by causing spastic, nonpropulsive contractions. (6) , (7)

In the large majority of patients with severe constipation, no obvious cause can be identified.

Statistic

National Digestive Diseases Information Clearing House, 1999.

    Prevalence of Constipation: 4.4 million people (1983-87) Mortality: 29 deaths (1982-85) Hospitalizations : 100,000 (1983-87) Physician office visits: 2 million (1985) Prescriptions: 1 million (1985) Disability: 13,000 people (1983-87)

National Health Interview Survey, 1996.

    About 3 million people in the United States have frequent constipation. Those reporting constipation most often are women and adults age 65 and over. Pregnant women also complain of constipation, and it is a common problem following childbirth or surgery. Constipation is the most common gastrointestinal complaint in the United States, resulting in about 2 million annual visits to the doctor. Most people treat themselves without seeking medical help, as is evident from the $725 million Americans spend on laxatives each year.

Signs and Symptoms

[span class=alert]The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.[/span]

Constipation may actually be a symptom of an underlying disease or problem and is difficult to precisely define. All possible causes of constipation need to be evaluated.

Some, or all, of the characteristics enumerated below may be present in the patient complaining of constipation:

General

    Defecation less than three times per week Feelings of incomplete evacuation Feelings of abdominal bloating or fullness Hard stools Excessive straining Stools of insufficient size Difficulty or pain on passing stool

Treatment Options

Conventional

Since constipation may vary from a minor discomfort in an otherwise healthy adult, to a symptom of colon cancer or other serious disease, treatment must be individualized and is highly dependent upon the severity and duration of constipation, as well as the possible contributing factors.

Initial therapy is usually dietary, with an emphasis on increasing daily fiber intake. Although it has not been proven that constipated individuals consume less dietary fiber than non-constipated individuals, it has been shown that most patients respond well to an increase in dietary fiber to between 20 and 30 grams daily. Fiber supplementation may decrease colonic transit time, as well as increase the weight of stool and the frequency of defecation. Fiber supplementation is inappropriate for patients with megacolon, megarectum, or colonic obstruction. Dietary sources of fiber include fruits, vegetables, and cereals. Bran is very high in fiber and often added to foods to increase the fiber content.

Medicinal products such as psyllium, methylcellulose, or polycarbophil have properties similar to dietary fiber and may be taken as tablets, powders, or granules.

Other lifestyle changes may be suggested as well. Moderate increases in physical activity, such as walking, are helpful. Increased fluid intake generally helps, although there is little objective evidence of benefit.

Emollient laxatives, such as the docusate salts, result in a softening of the stool within one to three days. They work as surfactants, facilitating mixing of aqueous and fatty material within the intestinal tract to soften stool. Emollients are generally used to prevent, rather than treat constipation, particularly if a patient has a condition where straining should be avoided.

Mineral oil is a lubricant that coats stool to allow easier passage. Mineral oil may be given orally or rectally in a dose of 15-45ml. It softens stool by inhibiting colonic absorption of water, increasing stool weight, and decreasing colon transit time. It has been associated with many more adverse effects than the docusates; however, routine use should be avoided.

Stimulant laxatives, including the diphenylmethyl derivatives such as bisacodyl and anthraquinone derivatives, including cascara sagrada, sennosides, and casanthrol, generally have strong effects that forcefully stimulate the bowel to evacuate, and generally produce results between 6-12 hours. The effective dose seems to vary among individuals, with some patients reporting no effect, while others report severe cramping and fluid evacuation when given the same dose. These products are not recommended for daily use. Their use is acceptable intermittently, or for bowel evacuation prior to diagnostic procedure. Phenolphthalein was removed from laxative products during 1997 and 1998 because of concerns about carcinogenicity. (8)

One potential problem with stimulant laxatives is that they evacuate the bowel so completely that bowel movements may not occur normally until a few days later. Thus when a patient attempts to defecate on the following day with negative results, they assume they are constipated again and may take another dose of stimulant laxative.

Saline cathartics are composed of relatively poorly absorbed ions such as magnesium, sulfate, phosphate, and citrate, which produce their effects, primarily by osmotic action, to retain fluid in the GI tract. Magnesium has been shown to stimulate the secretion of cholecystokinin, a hormone that causes stimulation of bowel motility and fluid secretion. (9) These agents may be given orally or rectally and usually produce results within a few hours after oral doses, and in an hour or less after rectal administration. Some agents include milk of magnesia, citrate of magnesia, sodium phosphate solution, and Epsom salts. Such agents may be used occasionally to treat constipation, but should not be used on a routine basis.

Castor oil has a strong purgative action, and works by conversion in the GI tract to ricinoleic acid. It stimulates secretory processes, decreases glucose absorption, and promotes intestinal motility, primarily within the small intestine. It usually results in bowel movements within three hours and is not recommended for routine treatment of constipation.

Glycerin is usually administered as a suppository and exerts its effect by osmotic action in the rectum. Onset is generally less than 30 minutes and is considered safe, although it may occasionally cause rectal irritation.

Tap water enemas may be used to treat simple constipation. The administration of 200ml often results in a bowel movement within one-half hour. Soapsuds are no longer recommended due to the possibility of proctitis or colitis.

Nutritional Supplementation


Lactobacillus acidophilus

Frequently, individuals with either constipation or diarrhea have disordered gastrointestinal bacterial microflora. (10) An important part of normalizing both the functional activity and bowel microflora consists of ingesting large doses of beneficial bacteria such as Lactobacillus acidophilus. Many practitioners suggest that patients consume from 10 to 15 billion cfu (colony forming units) twice daily with meals until normal intestinal activity resumes.


Flaxseed

Flaxseed oil acts as a lubricant in the gastrointestinal tract. Although flaxseed oil is not regarded as a primary therapeutic modality for constipation, its lubricating properties may help facilitate bowel movements. Since the diets of most people are deficient in omega-3 fatty acids, taking one tablespoonful of flaxseed oil daily may help to alleviate constipation and also improve overall health.


Fiber

Constipation is a major complaint of older adults and studies indicate that increasing the intake of dietary fiber can often help patients improve their bowel movement regularity. (11) Chronic constipation is also relatively common in children and a lack of fiber may play an important role in the etiology of chronic idiopathic constipation in children. (12)

Herbal Supplementation


Aloe Vera

Aloe, a genus with over 150 species, is mostly native to East and South Africa. Aloe is a succulent plant that has been used medicinally for centuries. Records of its use date back to 1750 BC. The plant has a variety of uses, including topically in wounds, burns, rashes, and internally as a laxative and cathartic. The mucilaginous gel from the aloe leaf is an effective wound healing agent and is now found in many commercial skin-care products, shampoos, and conditioners. (13) The bitter, yellow latex from the plant contains the bowel stimulant hydroxyanthracene derivatives, used commercially as a laxative.

It has long been recognized that the latex from aloe is an anthranoid stimulant laxative. Studies have reported the effects of aloe as a laxative, with the 1,8-dihydroxyanthracene derivatives (aloe-emodin, aloins). (14)


Cascara Sagrada

Northern California Native Americans introduced this herb, which they called sacred bark, to sixteenth-century Spanish explorers. Being much milder in its laxative action than the herb buckthorn, cascara became popular in Europe as a treatment for constipation and has been part of the U.S. Pharmacopoeia since 1890. (15) Cascara traditionally has been used to treat a sluggish gallbladder, digestive problems, hemorrhoids, skin problems, intestinal parasites, jaundice, and colitis. (16)

Anthranoid laxatives, or stimulant laxatives, are widely used in nonprescription products and dietary supplements. They are carried unabsorbed to the large bowel, where metabolism to the active aglycone form takes place. (17) The aglycones exert their laxative effect by damaging epithelial cells, which leads directly and indirectly to changes in absorption, secretion, and motility.


Psyllium Seed

An estimated 4 million Americans use psyllium products daily. (18) Psyllium is rich in dietary fiber, which is the most satisfactory prophylactic and treatment for functional constipation. (19) Dietary fiber increases the mass of stools, their water content, and the rate of colonic transit. Psyllium has traditionally been used as a bulk-forming laxative; however, recent research points to other uses including hypercholesterolemia, irritable bowel syndrome, and ulcerative colitis. (20) , (21) In February, 1998, the FDA gave permission to allow food manufactures to make a health claim on the packaging of food products regarding psyllium. The claim reads: "Eating soluble fiber from foods such as psyllium as part of a diet low in saturated fat and cholesterol may reduce the risk of heart disease." These findings make psyllium a potential agent for reducing the risks of cardiovascular diseases.

Laxative: The powdered husks of ripe seeds of various plantago species are commonly used as bulk mucilaginous laxatives. The water-soluble psyllium fibers consist mainly of indigestible mucilaginous polysaccharides. Taken with plenty of fluids, psyllium leads to an increase in the fecal mass; the stool becomes softer and peristalsis is stimulated. (22) This eventually causes a reduction of intraluminal rectosigmoid pressure. Psyllium fibers bind bile acids, which causes increased bile acid excretion. (23) This causes an increased hepatic synthesis of bile acids and a certain reduction in blood cholesterol levels.

There have been various clinical studies reporting the effectiveness of psyllium in treating constipation. One study compared psyllium to docusate sodium in treating constipation, reporting psyllium as the superior laxative. (24) A 1998 study reported psyllium produced a higher percentage of normal, well-formed stools and fewer hard stools than other laxatives, mainly lactulose. (25) Incidences of soiling, diarrhea, and abdominal pain were lower in the group receiving psyllium. It was concluded that overall, psyllium was an effective treatment for simple constipation, and was associated with better stool consistency and a lower incidence of adverse events compared with lactulose.

Ulcerative colitis and IBS: Psyllium has been reported effective in supporting the management of irritable bowel syndrome (IBS) and ulcerative colitis. (26) , (27) , (28) One report, an open label, parallel-group, multicenter, randomized clinical trial, was conducted on patients with ulcerative colitis who were in remission. (29) The patients received oral treatment with psyllium seeds (10 gm twice a day), mesalamine (500mg three times a day), and psyllium seeds plus mesalamine at the same doses. The primary efficacy outcome was maintenance of remission for 12 months. The authors concluded that psyllium seeds may be as effective as mesalamine in maintaining remission in ulcerative colitis. In IBS, psyllium has been reported to increase bowel movements, appearing to be a major reason for the therapeutic success of ispaghula in IBS. (30)

Homeopathic

Graphites

Typical Dosage: 6X or 6C, 30X or 30CNo urge to defecate; Large stools that are painful to pass; Itching and burning of the anus after evacuation; Constipation during menstrual periods

Hydrastis canaensis

Typical Dosage: 6X or 6C, 30X or 30CNo urge to defecate; Sinking feeling in the upper abdomen; Constipation during pregnancy or after childbirth

Nux vomica

Typical Dosage: 6X or 6C, 30X or 30CSedentary individuals; Urge to defecate but unable to do so; When stool occurs there is a feeling of incomplete stool

Plumbum metallicum

Typical Dosage: 6X or 6C, 30X or 30CAbdominal cramping and pain; Stool is passed with great difficulty and is dry and hard

Veratrum album

Typical Dosage: 6X or 6C, 30X or 30CMuch straining in an effort to evacuate the bowels often breaking out in a sweat

Acupuncture & Acupressure

Gao, et al. treated 40 cases of constipation with otopuncture. Bilateral lung-related otopoints were selected for this treatment. The otoneedles were used to puncture the ear cartilage without piercing through it and then covered the needle handles with adhesive plaster. The results showed that the treatment had a total effectiveness rate of 95%. (31)

Li treated 34 cases of paralytic intestinal obstruction after surgery with acupuncture. The acupoints selected for this treatment were Zu San Li (He-Sea Point, St 36), Shang Ju Xu (St 37), and Xia Ju Xu (St 39). Needles were rapidly inserted, maneuvered using the lifting-thrusting-twirling-reducing method, and were retained for 30 minutes. The treatment was conducted once or twice a day. The results illustrated that after 8 sessions of treatment, 22 cases were resolved, and the remaining 12 cases had improved. (32)

Otopoint plastering therapy
Yuan treated 35 cases of constipation with auricular-plaster therapy. Selected for treatment were otopoints related to the following areas: the lung, the large intestine, the lower section of the rectum, endocrine, sympathetic nerves, and the brain. A viccaria seed was pressed against the auricular-point and covered with adhesive plasters, then press the auricular-point for 10 minutes every 2 hours. The treatment was repeated every 3 days, and one course of treatment lasted for 15 days. The results indicated that 20 cases were resolved, and the remaining 15 cases improved. (33)

Min treated 52 cases of constipation with auricular-plaster therapy. Acupoints were selected for treatment as follows: for patients with excessive heat in the large intestine, otopoints related to the large intestine, lower section of the rectum, abdomen, and feet were treated; for patients with liver-qi stagnation, otopoints related to the liver, stomach, brain, and large intestine were treated; and for patients with qi and blood deficiencies, otopoints related to the spleen, lung, tri-jiao, and large intestine were treated. Oil rapeseeds were (Semen Brassicae Oleiferae) adhered onto a small piece of adhesive plaster, which was then placed on the selected otopoints. The plaster was gently pressed for 1-2 minutes. The patients were instructed to press the treated otopoints 5-6 times a day, 1-2 minutes each time. One course of treatment required applying the plaster 4 times. The study results showed that the treatment had a total effectiveness rate of 85%. (34)

Combined Otopoint plastering Therapy with Herbs
Huang et al. treated 53 cases of constipation in the elderly with herbs and otopoint plastering therapy. The treatment selected otopoints related to the large intestine, small intestine, spleen, stomach, and endocrine as the principal points for treatment. Supplemental treatments were applied to otopoints related to sympathetic nerves, under the cortex, Shenmen (H 7), and tri-jiao. Vaccaria seeds (Semen Vaccariae) were adhered onto a small piece of adhesive plaster, which was then placed on the mentioned otopoints, and the course of treatment lasted a month. In addition, the patients took Ma Zi Ren Wan 6 g, 1-2 times a day. The results of the study showed that 12 cases were resolved, 24 cases had shown great improvement, another 12 cases had improved somewhat, and the remaining 5 cases did not respond to the treatment, with a total effectiveness rate of treatment being 90%. (35)

Guo et al. treated 31 cases of constipation with herbs and acupuncture. Patients with damp-heat in the large intestine were administered modified Ma Zi Ren Wan; patients with liver-spleen incoordination were administered modified Long Dan Xie Gan Tang; and patients with qi and blood deficiencies were administered Bu Zhong Yi Qi Tang and modified Si Wu Tang. All of the patients received the acupuncture treatment at acupoints Da Chang Shu (UB 25), Tian Shu (St 25), and Shang Ju Xu (St 37). In addition, patients suffering from excessive syndromes received acupuncture treatment at acupoints He Gu (LI 4), Quchi (LI 11), Fen Lung (St 40), Zu San Li (St 36), Zhi Gou (SJ 6), and Xing Jian (Liv 2), and patients suffering from deficiency syndromes received acupuncture treatment at acupoints Pi Shu (UB 20), Wei Shu (UB 21), Zu San Li (St 36), Tai Bai (Sp 3), and Tai Heng (Sp 15). The results of the treatment showed that 24 cases were resolved, another 5 cases had shown great improvement, and the remaining 2 cases had improved. (36)

Aromatherapy

Constipation Formula

  • Mix In Suitable Container; Label. Massage A Small Amount To The Lower Abdomen And Sacral Area On A Daily Basis.
  • Rosemary Essential Oil - 7 Drops
  • Fennel Essential Oil - 5 Drops
  • Carrier Oil Of Choice - 30ml

Caution: Essential Oil therapies should not be used during pregnancy or lactation and should always be used under the direction of an experienced aromatherapist.

Traditional Chinese Medicine

Constipation

Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.

Clinical Lab Assessment

Some of the following laboratory testing can provide information necessary for diagnosis and treatment. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.

Thyroid Profile

Constipation is a well-known symptom of hypothyroidism. (37)

Organic Acids

Certain biochemical intermediates reflect sufficiency of nutrient cofactors (vitamins of the B complex, magnesium, some amino acids, and many others) that are important in carbohydrate, neurotransmitter and fatty acid metabolism, among other vital functions. Organic acids analysis is a useful method for measurement of biochemical intermediates in urine. Stress response can deplete enzymes dependent on these cofactors for synthesis. Chronic stress may also interfere with proper digestion and result in increased allergic response (38) and imbalanced gastrointestinal flora. A subset of organic acids, the dysbiosis markers, may provide useful information regarding gastrointestinal pathogens that can contribute to immune compromise.

Allergy and Food Sensitivity Response Assessment

The severity of allergic response correlates with an increase in stress levels. (39) Allergies may have considerable impact on inflammatory processes. Direct correlation of impaired digestion or food allergic response is controversial, though some case studies manifest improvements on food elimination diets. Allergy has long been recognized as a source of constipation. (40)

Clinical Notes

Water: A lack of water often contributes to constipation. Published studies have reported that increasing fluid intake to 1.5 to 2.0 liters per day can help to improve bowel regularity. (41) Many health professionals recommend that constipated patients try to drink 8 eight-ounce glasses of water per day.

References

  1. Friedman LS, Isselbacher KJ. Diarrhea and Constipation. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:242-244.
  2. Longe RL, DiPiro JT. Diarrhea and Constipation. In: DiPiro JT, et al, eds. Pharmacotherapy, A Pathophysiologic Approach, 4th ed. Stamford, CT: Appleton & Lange; 1999:606-612.
  3. View Abstract: Romero Y, Fleming KC, Phillips SF. Constipation and fecal incontinence in the elderly population. Mayo Clin Proc. 1996;71:81-92.
  4. Friedman LS, Isselbacher KJ. Diarrhea and Constipation. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:242-244.
  5. View Abstract: Clausen MR, Mortensen PB. Lactulose, disaccharides and colonic flora. Clinical consequences. Drugs. 1997;53:930-942.
  6. View Abstract: Clausen MR, Mortensen PB. Lactulose, disaccharides and colonic flora. Clinical consequences. Drugs. 1997;53:930-942.
  7. View Abstract: Sandgren JE, McPhee MS, Greenberger NJ. Narcotic bowel syndrome treated with clonidine. Ann Intern Med. 1984;101:331-334.
  8. Pray WS. Constipation. In: Nonprescription Product Therapeutics. Philadelphia: Lippincott, Williams, & Wilkins; 1999:146.
  9. Longe RL, DiPiro JT. Diarrhea and Constipation. In: DiPiro JT, et al, eds. Pharmacotherapy, A Pathophysiologic Approach, 4th ed. Stamford, CT: Appleton & Lange; 1999:606-612.
  10. View Abstract: Dunne C. Adaptation of bacteria to the intestinal niche: probiotics and gut disorder. Inflamm Bowel Dis. May2001;7(2):136-45.
  11. View Abstract: Rodrigues-Fisher L, et al. Dietary fiber nursing intervention: prevention of constipation in older adults. Clin Nurs Res. Nov1993;2(4):464-77.
  12. View Abstract: Roma E, et al. Diet and chronic constipation in children: the role of fiber. J Pediatr Gastroenterol Nutr. Feb1999;28(2):169-74.
  13. Salcido R. Complementary and alternative medicine in wound healing. Adv Wound Care. Nov1999;12(9):438.
  14. View Abstract: Ishii Y, et al. Studies of aloe. III. Mechanism of cathartic effect. (2). Chem Pharm Bull (Tokyo). Jan1990;38(1):197-200.
  15. Leung A, et al. Encylopedia of Common Natural Ingredients Used in Foods, Drugs, and Cosmetics. New York: Wiley-Interscience Publication; 1996:128-130.
  16. Newall CA, et al. Herbal Medicines: A Guide for Health Care Professionals. London: The Pharmaceutical Press; 1996:62.
  17. View Abstract: De Witte P, et al. The metabolism of anthranoid laxatives. Hepatogastroenterology. Dec1990;37(6):601-5.
  18. View Abstract: Freeman GL. Psyllium hypersensitivity. Ann Allergy. Dec1994;73(6):490-2.
  19. View Abstract: Wong PW, et al. How to deal with chronic constipation. A stepwise method of establishing and treating the source of the problem.Postgrad Med. Nov1999;106(6):199-200, 203-4, 207-10.
  20. View Abstract: Tomas-Ridocci M, et al. The efficacy of Plantago ovata as a regulator of intestinal transit. A double-blind study compared to placebo. Rev Esp Enferm Dig. Jul1992;82(1):17-22.
  21. View Abstract: Mac Mahon M, et al. Ispaghula husk in the treatment of hypercholesterolaemia: a double-blind controlled study. J Cardiovasc Risk. Jun1998;5(3):167-72.
  22. View Abstract: Dettmar PW, et al. A multi-centre, general practice comparison of ispaghula husk with lactulose and other laxatives in the treatment of simple constipation. Curr Med Res Opin. 1998;14(4):227-33.
  23. View Abstract: Trautwein EA, et al. Increased fecal bile acid excretion and changes in the circulating bile acid pool are involved in the hypocholesterolemic and gallstone-preventive actions of psyllium in hamsters. J Nutr. Apr1999;129(4):896-902.
  24. View Abstract: McRorie JW, et al. Psyllium is superior to docusate sodium for treatment of chronic constipation. Aliment Pharmacol Ther. May1998;12(5):491-7.
  25. View Abstract: Dettmar PW, et al. A multi-centre, general practice comparison of ispaghula husk with lactulose and other laxatives in the treatment of simple constipation. Curr Med Res Opin. 1998;14(4):227-33.
  26. View Abstract: Hotz J, et al. Effectiveness of plantago seed husks in comparison with wheat brain on stool frequency and manifestations of irritable colon syndrome with constipation. Med Klin. Dec1994;89(12):645-51.
  27. View Abstract: Chapman ND, et al. A comparison of mebeverine with high-fibre dietary advice and mebeverine plus ispaghula in the treatment of irritable bowel syndrome: an open, prospectively randomised, parallel group study. Br J Clin Pract. Nov1990;44(11):461-6.
  28. View Abstract: Fernandez-Banares F, et al. Randomized clinical trial of Plantago ovata seeds (dietary fiber) as compared with mesalamine in maintaining remission in ulcerative colitis. Spanish Group for the Study of Crohn's Disease and Ulcerative Colitis (GETECCU). Am J Gastroenterol. Feb1999;94(2):427-33.
  29. View Abstract: Hallert C, et al. Ispaghula husk may relieve gastrointestinal symptoms in ulcerative colitis in remission. Scand J Gastroenterol. Jul1991;26(7):747-50.
  30. View Abstract: Jalihal A, et al. Ispaghula therapy in irritable bowel syndrome: improvement in overall well-being is related to reduction in bowel dissatisfaction. J Gastroenterol Hepatol. Sep1990;5(5):507-13.
  31. Gao Gui Rong, et al. 40 cases of constipation treated with otopuncture. Shaanxi Journal of Traditional Chinese Medicine. 2000;21(6):270.
  32. Li Jing Ming. 34 cases of paralytic intestinal obstruction after surgery treated with acupuncture. Journal of New TCM. 1999;31(5):23.
  33. Yuan Hai Yan. 35 cases of constipation treated with otopoint plastering therapy. Journal of Chinese Acupuncture. 1999;19(1):18.
  34. Min Xue Jin. 52 cases of constipation treated otopoint pressure therapy. Journal of TCM Research. 1999;15(1):18-19.
  35. Huang De Bao, et al. 53 cases of senile constipation treated with herbs and otopoint pressure therapy. Chinese Journal of Convalescence. 1989;4(4):183.
  36. Guo Chun Yan, et al. Treating constipation with Chinese herbs and acupuncture. Journal of Clinical Acpuncture. 1999;15(11):12-13.
  37. Gay LP. Gastrointestinal Allergy. J Missouri Med Assoc. 1932:29:7-10.
  38. View Abstract: Santos J, et al. Release of mast cell mediators into the jejunum by cold pain stress in humans. Gastroenterology. Apr1998;114(4):640-8.
  39. View Abstract: Santos J, et al. Release of mast cell mediators into the jejunum by cold pain stress in humans. Gastroenterology. Apr1998;114(4):640-8.
  40. Gay LP. Gastrointestinal Allergy. J Missouri Med Assoc. 1932:29:7-10.
  41. View Abstract: Anti M, et al. Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology. May1998;45(21):727-32.