All Your Poop Questions, Answered
Written by: the Editors of goop
Updated: November 14, 2022
We know that our gut is intricately related to our health on many levels. We know that what goes on in the bathroom can be symptomatic of larger issues—like food intolerances or irritable bowel syndrome. We know that everyone poops. And yet we often shy away from conversations about digestion and bowel movements. So: We asked gastroenterologist Dr. S. Radi Shamsi all the shit we needed to know.
A Q&A with S. Radi Shamsi, MD
Having a bowel movement anywhere between three times a day and once every three days is fine. But it also depends on whether the person is comfortable with that. Someone might be going every day and still feel backed up and constipated. On the other hand, somebody else might be going two or three times a day, which is still in the realm of normal, and they may feel that it’s too much for them and be uncomfortable with it.
The consistency of the stool is also important. You may be going more than once a day and still be constipated because the stools are hard to pass and it hurts. Or you might go two or three days without a bowel movement, then suddenly have massive, explosive diarrhea where you go a lot.
Food intolerances, such as lactose intolerance, are a major reason for bloating, gas, and diarrhea.
The next most common cause is irritable bowel syndrome, where bloating, gas, and diarrhea are due to the bacterial population in the bowel called the microbiome. People with IBS may have too much bacteria that creates excess gas. And depending on the kind of gas that’s produced—too much methane, hydrogen, or hydrogen sulfide gases—as well as the balance of these gases, this determines whether stools are loose or firm. Other factors could be insufficient pancreatic enzymes, gluten intolerance, or celiac disease.
Food also affects the quality of stool. When you go to a gastroenterologist, they’ll talk to you about eating a high-fiber diet. Eating lots of vegetables and fibrous foods can bring people who have either too much diarrhea or too much constipation to the middle, which can balance things out. However, too much fiber can create bulky stools and a lot of bowel activity, which some people don’t like. Raw foods also tend to cause more bloat.
Traditionally, fiber has been the main supplement recommended to make people regular. I usually suggest psyllium husks to fluff up the stool and create easier, more frequent bowel movements. Many people are now using probiotics for this purpose. And although we find that probiotics can help about 20 to 30 percent of patients, they can sometimes make things worse and are not always a cure-all. Whether probiotics help depends on the person. It’s safe to give probiotics a try, unless you have an immune deficiency, in which case you should avoid them.
Many people use magnesium in the form of magnesium citrate or magnesium oxide. In fact, magnesium citrate is used for colonoscopy prep because magnesium acts as an osmotic and causes stool evacuation. If you don’t have kidney or cardiac problems, magnesium can be safely used in low doses.
I also see people in my practice who are using laxatives long-term. There are mixed thoughts about herbal laxatives, specifically those in the form of senna and cascara, which are the main component of a lot of cleanses that people may have heard of. Long-term use of senna and cascara can cause discoloration of the colon, which is called melanosis coli. In years past, we thought that this was a bad thing and that melanosis coli could cause a cathartic colon, meaning a colon that has become dependent on laxatives. We’re not sure about this anymore.
At this time, we don’t know if melanosis coli is a bad thing or just a meaningless darkening of the colon. Either way, many experts believe that these types of laxatives are not good long-term solutions for constipation. Products that we’ve found do help our patients include Swiss Kris or Dr. Schulze’s colonic formulas.
It should be noted that laxative abuse is a big issue, especially among people with eating disorders, and chronic laxative abuse can be harmful to the colon. But episodically using some form of laxative may be helpful for certain people.
The most famous is red beets. Often, people think that they have blood in their stool, and then they’ll come in, and we’ll test their stool and find out that there’s no blood. When I ask, “Did you have a beet salad two or three days ago?” They’ll realize that they forgot, and everything is okay. Seaweed is a surprising new thing—people are eating a ton of seaweed snacks, which can cause fluorescent-green poop.
Pepto-Bismol also changes the color of stool, to black. Black stool that’s sticky and tarlike is an indicator of the upper gastrointestinal area bleeding, because as blood is digested, it comes out black. But some people may forget that they took Pepto-Bismol, see the black stool, and worry about an ulcer. The way to differentiate is: If you take Pepto-Bismol and then have hard, black, pebble stools, it’s probably just the Pepto-Bismol, but if you take a bunch of aspirin and then have a stomachache along with tarry black stool that smells, it’s probably an ulcer bleeding. In that case, you should see a doctor about the blood. Iron supplements can also cause black stools, but these will appear black and grainy instead of black and sticky.
If you have pain in the upper right side of your abdomen, like a gallstone attack, and have pale, white, or manila-envelope-colored stool, this could mean that your bile ducts are plugged, and you should see a doctor. Grey stool is an indicator of a pancreatic issue. If your urine is dark and your stool is light, this could mean a pancreatic issue or a bile duct issue.
Red stool can be indicative of a hemorrhoid, fissure, or deeper diseases in the gastrointestinal area, such as ulcerative colitis, Crohn’s disease, polyps in the colon, or cancers. Red stool needs to be investigated with a colonoscopy.
It depends on whether we’re taking about pain inside the anal canal or pain at the exit hole (the anus). When passing a large stool, you can have pain with some blood if the anal canal is torn. This is called an anal fissure. Hemorrhoids (swollen veins on the anus) can also cause bleeding in constipated patients. But if there’s a cut feeling that’s felt only during the evacuation, then that’s likely an anal fissure.
Hemorrhoids and fissures can be treated with creams and by sitting in a warm bath. On rare occasions, patients with anal fissures end up seeing rectal surgeons if the initial treatments at home don’t help. Sometimes patients with severe hemorrhoids may seek treatment, such as infrared coagulation (infrared light that coagulates the affected blood vessels) or banding (putting tight bands around the swollen veins). Colorectal surgeons may also use a treatment called sclerotherapy, which involves injecting the veins of the hemorrhoid with a medicine that causes clotting. This treatment requires multiple visits, and I find that it is less successful than infrared coagulation or banding. If all of these treatments fail, you may need surgical hemorrhoid therapy. Treating fissures surgically is much more challenging.
There are other, more serious things that can cause abdominal pain, such as bowel obstruction from surgeries (this requires an emergency room visit), large intestinal growths, or colon cancer. If you haven’t had a colonoscopy and experience changes in your regular stool pattern along with abdominal pain, you should get an exam right away.
It is normal to have to work a little to get started. Giving a gentle push is a reflexive mechanism that relaxes the anus, allowing it to open and the rectum to squeeze so that you can push out the stool. A little gentle push at the beginning is okay, but not a prolonged strain.
If you have to work really hard and strain while sitting on the toilet for a long period of time, that’s not good. You can get hemorrhoids or fissures from this. I’ve even had patients get hernias from trying to push something out.
There’s a condition called anorectal dyssynergia that is quite a common cause of constipation and is often overlooked. It includes the word “dyssynergia” because there is an absence of synergy between the anus and the rectum. This means that when the rectum squeezes to get stool out, the anus shuts itself closed instead of opening. So people end up sitting there straining but may actually be doing the opposite of the action desired by tightening their anus. There’s a test for this called the anal rectal manometry, as well as biofeedback exercises that can be done along with patient homework that allows you to relearn the mechanism of both relaxation and squeezing.
Another important factor is body position. Simply having a little step stool beneath your feet that lifts your legs into a squatting position can straighten the angle of the anal rectal turn, which can ease the evacuation of stool. Leaning forward also helps.
This is a big area of debate among myself, many of my colleagues, and the practitioners who do these cleanses. I don’t have any data that colon cleanses, flushes, or things like that are beneficial. I also don’t have data that they’re harmful. In Western medicine, at least, it is not advised that colon cleanses in of themselves have any particularly helpful benefit.
S. Radi Shamsi, MD, is the founder of the Los Angeles Gastroenterology Clinic in Santa Monica. He’s a graduate of University of California, Los Angeles, and the University of California, Irvine, College of Medicine. He also spent three additional years at the Keck School of Medicine of the University of Southern California, where he focused on gastroenterology and hepatology. For more information, visit lagidoc.com.
This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.