Everybody Poops.. But it's Not Always Normal

The time has come to write about my hands down, all time favorite medical topic: POOPING.

While I love the enthusiasm of questions in emails or DMs regarding an individual’s bowel habits, most of you know I never give out specific medical advice over the internet. This has potential legal implications, it’s a disservice to the individual asking the question (so much more can be gleaned from seeing a doctor in person!), and quite frankly, I need to protect my own time and energy too.

All this being said, I LOVE sharing practical and general medical information from the perspective of a gastroenterologist-in-training with a love/respect for combining western and alternative medicine considerations. So here goes! I hope you find this fun & informative :-)

I mean, this e card is NOT wrong.

I mean, this e card is NOT wrong.

Why do we poop?

Feces, excrement, stool, doo-doo, crap, rocky mountain chocolate factory.. whatever you want to call it, poop is simply a collection of waste products that forms throughout the digestive process. Components include water, cells of the intestinal lining, bacteria, indigestible food product waste, etc. Along with urinating, sweating, and exhalation, pooping is a natural and necessary waste removal process to remain alive.

If you don’t get rid of the waste, this throws off homeostasis. In the worst case scenario, lack of pooping for an extended period of time would eventually lead to illness and death without intervention. All this to say- be proud of your body for pooping. It’s keeping you alive!

So.. what’s normal?

The American College of Gastroenterology (ACG) defines constipation based upon symptoms, which includes unsatisfactory defecation defined as either infrequent stools, difficult passage of stools or both. ACG defines diarrhea as having stools that would take shape of the container (like if you were providing a sample) thus often described as loose or watery. While some people think of diarrhea as increased frequency of stools, the consistency of the stool itself is key!

You may be asked to look at a Bristol stool chart to describe your poop’s consistency. Type 3 & 4 are considered ideal

You may be asked to look at a Bristol stool chart to describe your poop’s consistency. Type 3 & 4 are considered ideal

A common rule of thumb used: “normal” stool frequency can range from just three times per WEEK —> three times per DAY. That being said, if you are within this range but feel you are unsatisfactorily evacuating all your stool, or if you are having liquid or unformed stools, that’s a reason to seek medical advice. Additionally (and this is important) if you have any persistent change to the frequency or consistency of your stool, this is also a reason to seek expert medical care. Our bowel movements tell us a lot about our health and not just the GI system. Certain clues or accompanied symptoms may suggest a problem that needs further investigation.

Do NOT be embarrassed to speak to any medical provider about poop. It’s literally our job to talk about the most intimate, or seemingly embarrassing body functions. Even if it ends up being nothing, or a benign condition, this is YOUR body and you deserve to know if it’s working properly.

When should I REALLY be concerned?

Seek medical attention if you have abnormal bowel habits accompanied by:

  • bloody or black appearing stools

  • excessive mucus in stools

  • stools with significant undigested food

  • bulky, greasy, or very foul smelling stool

  • weight loss

  • fevers

  • new joint pains or rashes

  • significant abdominal cramping/pain

  • stool incontinence (not being able to control when you poop/seepage of poop/uncontrolled urgency)

I worry that with access to medical information, many people may write off their symptoms as normal, or “just IBS.” While this may be true, any of the above symptoms should be investigated further. Conditions such as inflammatory bowel disease, Celiac disease, pancreatic insufficiency (pancreas stops releasing enough enzymes to properly digest your food), SIBO (small intestinal bacterial overgrowth) or other infectious condition, or even colon or rectal cancer may be the underlying cause to any of the above symptoms. Those are either serious and/or potentially treatable conditions that warrant attention.

One of the best recommendations I have heard, is that when you go to a doctor’s appointment with your complaints, try asking this question: “What is the worst thing these symptoms could mean, even if it’s uncommon?” Healthcare providers are human, and when a complaint of “increased stool frequency” is addressed, it’s easy to get in a pattern of addressing more benign conditions. This question provides an open ended discussion regarding more rare or unlikely conditions that are also important to talk about.

I won’t go into treatment options for problems with bowel movements because it’s just so broad depending on the underlying cause or diagnosis. I’ll leave this part to the experts- you and your medical provider!

But can we talk about IBS?

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Ummm of course! In just over a year of GI fellowship I’ve already been dubbed the IBS doctor, as I’ve collected a number of patients that I see frequently in clinic for IBS-related symptoms. IBS stands for irritable bowel syndrome, with it’s diagnosis being defined by Rome criteria (see table). Basically, it’s abdominal pain that is related to bowel movements, and a change in frequency or consistency of stool. It can be either constipation or diarrhea, and the treatment/workup required will look differently based on this.

**A KEY point here, is that other conditions that can mimic as IBS should be appropriately ruled out. In my opinion, this step is often missed amongst physicians, due to the benign nature of symptoms and the bias placed on particularly young women who present with these complaints. I personally like to rule out certain conditions (if their symptoms warrant it) such as SIBO (this is a common one!), bile acid diarrhea, Celiac Disease, pancreatic insufficiency, or microscopic colitis. Not EVERY patient needs ALL of these tests to rule out mimickers, but it should be at least thought about, considered, and discussed with you at a doctor’s visit. Advocate for your health and ask about this before simply being given the diagnosis of IBS.

IBS is a frustrating condition for both the patient and the provider. It’s causes are complex and difficult to tease out and treat sometimes. Patients often don’t feel heard or validated, and providers often feel helpless in their treatment options. The best management in my opinion is frequent visits and both parties being open minded in management. Teamwork makes the (IBS) dreamwork :-)

What lifestyle changes/ supplements should I try for better pooping?

If you are confident that you do not have any alarming features, or are patiently waiting for an appointment and want to do some safe trial and error, there a few things to consider. A few things I recommend trying: a deep investigation of your diet, regular exercise (especially anything that gets you upright and moving, or yoga!), stress reduction (easier said than done, I’m sorry) and improved sleep hygiene. Things I recommend against: coffee enemas (or really any “professional” bowel cleanses I see on groupon), detox teas, supplements with no proven benefit but heavily pushed on social media, and fasting. Fasting may be useful for some people in very specific situations, but dealing with bowel movement issues isn’t one of them. We want to be sure you can eat AND poop normally. Lack of food is not the answer.

I HIGHLY encourage anyone with problematic pooping to keep a food diary. What you put into your digestive system can OBVIOUSLY affect it, and if you ever encounter a doctor who dismisses a discussion regarding what you eat— find. a. new. doctor. Tracking what foods you eat and patterns of your bowel movements can be incredibly useful. Common conditions such as lactose intolerance, or less common things like fructose intolerance or Celiac disease, can be really subtle. But keeping a close trend of diarrhea or constipation as it relates to certain foods can be diagnostic, and make a big difference in how you feel. Once you do get to a physician or dietitian, this can be incredibly helpful for them in guiding diagnosis, treatment, or management. Do it!

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With the exception of dairy, I recommend against blindly removing complete food groups to assess if your symptoms will abate. Because dairy is such a common culprit given the prevalence of lactose intolerance for many adults across the world, this one may be worth a trial if you’ve noticed any digestive distress associated to consuming it. I would also recommend paying attention to/removing caffeine from your diet, especially if you have increased frequency or soft consistency. Caffeine is known to initiate bowel movements and some individuals are highly sensitive to it! On the other hand, coffee can be a healthy tool for those with constipation. Further nuances such as complete removal of gluten (without diagnosis of Celiac Disease), groups of plant products (such as removing fruit, nightshade vegetables, or tubers) is likely more suitable to be trialed under the care of a doctor or dietitian. This may cause more harm than good, and in the case of Celiac disease, removal of gluten makes it actually difficult to diagnose since your body no longer has exposure.

Aside from nutrition, regular exercise can be a very useful tool in helping especially with constipation. Poop moves through our colon with the assistance of gravity, plus the added assistance of abdominal contraction/torso movement can help in moving stool along. You can imagine that the more sedentary you are, the more likely stool will just sit stagnant. Get up and move! For most cases of diarrhea, exercise is unlikely going to make it worse, so don’t be afraid of that :-)

While I highly encourage incorporating increased fiber from food products, this can be a challenge for many. There is no shame in using a fiber supplement while learning to enjoy high fiber foods (or if supplementation is more affordable.) If focusing on fiber increase from diet, aim for a variety of fruits, vegetables, bran and/or grains. Also, keep in mind that fiber isn’t very helpful in the absence of water. Stay hydrated! Incorporation of regular water consumption is sometimes the only thing a person needs to improve constipation. A combination of soluble and insoluble fiber is ideal for health in general, thus don’t try to overcomplicate it. Insoluble fiber in particular helps bulken the stool, so its role is typically more helpful in easing constipation. Soluble fiber can help slow digestion and promote better absorption. Both types of fibers are found in most plants, but keep in mind how certain foods specifically affect your digestion (as it’s often individualized how people respond, and quantity of fiber required is different for everyone.) Plants high in fiber also serve as great prebiotics to gut bacteria, so it’s win-win. Speaking of prebiotics; while I don’t discourage the use of PRObiotics, the evidence is still not strong enough for me to recommend it for regulating bowel movements. Verdict is still out on that one.

Conclusions?

Your pooping habits really tell you a lot about your health. Even if you’ve had digestive issues “forever” doesn’t mean it’s normal, and doesn’t mean you have to just deal with them. Never hesitate to get checked out, advocate for your own health, and think outside the box. Your daily lifestyle choices can play a major role in digestion and shouldn’t be underestimated. We all deserve to have good, satisfying, healthy poops :-)

Was this helpful? Are you more comfortable about talking about your poops? Is this also one of your favorite topics? Let me know. Love hearing from you!

Love,

Shanny DO

Disclaimer: The information on this blog is not intended to replace or be construed for medical advice nor be a substitute for professional medical expertise or treatment.