Motility, Constipation, & the Gut Microbiome: An Integrative Approach for Practitioners

By Shawn Manske, ND

Functional constipation (FC) is a common condition we see all too frequently in clinical practice. Characterized by infrequent bowel movements, difficult stool passage, and a sense of incomplete evacuation, FC is a serious and challenging health concern that affects an estimated 14% of the global population.¹ It also carries a hefty price tag, costing healthcare systems an estimated $7.4 billion annually.¹

Traditional treatment approaches often involve diet and lifestyle changes, and pharmaceutical interventions such as laxatives. But even when patients diligently comply with their practitioners’ recommendations, many continue to struggle.

So, what can you do to help your patients get things moving again? Understanding the critical role the gut microbiome plays in gastrointestinal motility and the pathogenesis of constipation is an important first step in implementing effective, microbiota-based therapeutic strategies for helping patients deal with FC.

The Gut Microbiome and Constipation

The gastrointestinal tract harbors a vast community of trillions of microorganisms, collectively known as the gut microbiome, which have co-evolved with humans in a mutually beneficial relationship.² This complex ecosystem plays a vital role in numerous physiological functions, including gastrointestinal function, metabolism, immune regulation, and nervous system interaction.² Disturbances in the composition and function of the gut microbial community, known as dysbiosis, have been increasingly implicated in the development of functional gastrointestinal disorders, including constipation.²

Research comparing the gut microbiomes of people with constipation to those with healthy digestion shows clear differences. Specifically, people with constipation tend to have:

• Fewer beneficial bacteria that produce lactate and butyrate – particularly Lactobacillus and Bifidobacterium species³
• Higher levels of methane-producing organisms (methanogens), which are linked to slower digestive transit time and constipation symptoms³
• Lower abundances of Bifidobacterium and Lactobacillus
• Increases in potentially pathogenic bacteria like Escherichia coli and Staphylococcus aureus²

Modern testing methods including 16S rRNA sequencing and shotgun metagenomics have supported these findings, revealing that constipated individuals generally have less diverse gut communities with specific decreases in important butyrate-producing bacteria like Faecalibacterium and Roseburia.² Additionally, machine-learning models have identified specific bacterial genera, such as inflammation-related Serratia, Dorea, and Aeromonas, as potential biomarkers for constipation.²

It’s important to recognize that defining a universally "healthy" gut microbiome remains a challenge, with significant inter-individual variations influenced by factors like genetics, diet, and lifestyle.¹ More clinically relevant is the idea of a healthy ”functional core” of microbes, which focuses on the core’s ability to maintain stability and resist perturbations rather than defining a healthy microbiome based solely on specific species. ¹

Furthermore, most research relies on fecal-derived microbiota samples, which may not fully represent the mucosa-associated microbiota that reside in closer contact with the host and may have a more direct impact on epithelial and mucosal function.² Studies suggest that the composition of colonic mucosal microbiota might be more closely correlated with constipation itself, while fecal microbiota may be more related to colonic transit time and methane production.¹

The Diet-Microbiome-Motility Connection

Dietary habits also strongly influence the gut microbiome and gut transit. Patients with constipation have been observed to consume fewer total calories and lower amounts of protein, fat, and fiber, which can ultimately affect the gut microbial composition and motility.² Whether these dietary habits are a cause or a consequence of constipation remains an area of ongoing research and an important clinical consideration.

Microbiome Mechanisms Affecting Gastrointestinal Motility

Understanding the many mechanisms by which the microbiome influences gut motility is essential for introducing targeted therapeutic approaches. These complex interactions between the microbiota, the enteric nervous system (ENS) and the central nervous system (CNS), the immune system, intestinal secretions, and microbial metabolites include:²

Neural Development and Signaling

• The gut microbiota, notably bacterial colonization, is essential for the normal development and maturation of the ENS.⁴
• Metabolic products from gut microbiota fermentation, such as short-chain fatty acids (SCFAs) and peptides, can stimulate the ENS and affect gut transit.⁵
• The gut’s neuroendocrine system interacts with the microbiota via serotonin (5-HT), produced in both the enteric and central nervous systems.  
• In the gut, 5-HT activates reflexes that stimulate secretion and motility and influences muscle contractions through signals sent via the vagus nerve.⁵

Short-chain fatty acids (SCFAs) Production

• SFCAs are metabolites of fermented dietary fiber and an important energy source for colonocytes.2 They help regulate the neurochemical makeup and activity of the enteric nervous system (ENS).
• SFCAs activate gut mucosal receptors, including G protein-coupled receptors (GPCRs) like GPR41 and GPR43 on enteroendocrine cells – promoting the release of glucagon-like peptide-1 (GLP-1) which helps regulate gut activity and communication with the brain.²
• SCFAs can also modulate 5-HT biosynthesis by regulating the expression of tryptophan hydroxylase¹ (TpH1) and serotonin-selective reuptake transporter (SERT) in intestinal epithelial cells, influencing colonic peristalsis.²
• SCFAs can also directly act on colonic and ileal smooth muscle; however, the effects of SCFAs on gut motility may be biphasic, with low concentrations promoting motility and excessive levels triggering dysmotility.²

Bile Acid Signaling

• Bile acids act as signaling molecules, activating the G protein-coupled bile acid receptor¹ (TGR5), which is expressed in various GI tract tissues, including gastric smooth muscle, enteric neurons, and enteroendocrine cells.
• Activation of TGR5 leads to distinct effects on GI motility. In the stomach, TGR5 activation causes muscle relaxation by inhibiting the RhoA/Rho kinase pathway, thereby delaying gastric emptying.⁵
• In the colon, TGR5 activation stimulates peristalsis and accelerates colonic transit. This is mediated through the release of neurotransmitters such as 5-hydroxytryptamine (5-HT) and calcitonin gene-related peptide (CGRP) from enterochromaffin cells and intrinsic primary afferent neurons. These neurotransmitters activate the peristaltic reflex, promoting coordinated muscle contractions.⁶
• Additionally, the gut microbiota metabolizes primary bile acids into secondary bile acids, such as deoxycholic acid (DCA) and lithocholic acid (LCA), which have distinct effects on GI motility.⁶
• Secondary bile acids like DCA and LCA activate TGR5 receptors in the colon, leading to enhanced peristaltic contractions and accelerated colonic transit.⁶

Microbial Gas Production

• Gases such as methane, produced by gut microbiota, can act as a neuromuscular transmitter affecting gut motility.² Methane has been shown to slow intestinal transit time and affect small intestinal contractile activity in animal models.⁴
• Conversely, hydrogen gas has been reported to increase contractility and decrease colonic transit time in some studies.² The balance between hydrogen and methane production by different microbial groups can influence gut motility.²
• Hydrogen sulfide (H2S) gas, produced by Desulfovibrionaceae, can inhibit colonic motility and promote inflammation.⁷

Intestinal Secretions 

• While healthy motility is essential to effective defecation, so are intestinal secretions. The gut microbiota can affect the transport of fluid and electrolytes into the intestine.²
• Constipation-induced dysbiosis can lead to an increased water-retaining capacity of the colon and reduced fecal water content.4 Microbial mediators, such as SCFAs, can influence the 5-HT-mediated secretion of intestinal fluid and electrolytes by acting as ligands of 5-HT receptors (5-HT3R and 5-HT4R).²

Four Microbiome-focused Interventions for Functional Constipation

Knowing that the gut microbiome plays a significant role in constipation, targeting the microbiota with therapeutic strategies has become a promising approach to improving motility and healthy elimination. Here are several evidence-based approaches to consider in your practice. 

1. Botanical Support for Microbial Balance

   Addressing microbial balance with botanicals offers a unique approach to support those experiencing constipation and other digestive concerns. Biocidin Botanicals' foundational formula, Biocidin®, offers a powerful combination of 18 botanicals and essential oils that can reduce unwanted and opportunistic pathogenic microorganisms, break apart biofilms (protective scaffolding that microorganisms create and hide within), modulate immune responses, and reduce oxidative stress.
   
   

   Collectively, these actions allow beneficial bacterial species to grow and thrive, thus creating a more balanced microbiome, which may positively influence intestinal motility and effective elimination of digestive waste. For many patients, addressing underlying dysbiosis is a crucial first step before other motility-focused interventions can reach their full potential.

2. Probiotic Supplementation

   Supplemental probiotics offer another strategy to balance the microbiome and support GI motility. These are live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. Probiotics help to crowd out pathogenic or opportunistic microbes while encouraging the growth of resident beneficial microorganisms. They also affect immune activity in the gut and benefit oxidative and inflammatory balance.
   
   

   Numerous studies have investigated the efficacy of probiotics in treating functional constipation. A systematic review and meta-analysis of randomized controlled trials demonstrated that probiotics significantly increased stool frequency, improved stool consistency, and reduced symptoms of functional constipation compared to placebo.

   Biocidin Botanical’s Proflora® 4R offers a combination of clinically researched spore-based probiotics, along with quercetin, marshmallow, and aloe vera to help soothe the lining of the GI tract while supporting intestinal barrier integrity. Together, these actions – along with the probiotics – may help regulate motility and encourage healthy bowel function. This multifaceted approach addresses not only the microbial component of constipation but also the mucosal health that supports proper gut function.

3. Supporting Liver and Gallbladder Function

   Supporting the liver and gallbladder, especially the healthy production and flow of bile, can not only encourage healthier food digestion and nutrient absorption, but may also help to promote GI motility and reduce the likelihood of developing constipation.
   
   

   Bile, which contains bile acids, as discussed previously, can be metabolized into secondary bile acids by the microbiome and enhance peristalsis. This can reduce the chances of stagnation in the bowels. Additionally, bile helps to lubricate the intestines and allows for easier passage of stool for elimination.

   Liver GB+™ is a botanical-focused formula consisting of artichoke extract, Siliphos® milk thistle phytosome, TUDCA, turmeric extract, tangerine peel extract, and bupleurum extract – all of which support the production and flow of bile while also protecting the liver. For patients with constipation who also show signs of suboptimal liver function or bile flow, this approach may provide benefits beyond what traditional laxatives or fiber supplements can offer.

4. Targeted Support for Motility

   A number of botanicals are known to have direct influence on the GI system and have been used throughout history to support those with GI concerns. Biocidin Botanicals' newest formula was developed to address those with motility concerns utilizing these ancient herbs alongside a novel, patented formula that is backed by clinical research.
   
   

   Motility Assist™ is formulated around Digexin®, an award-winning blend of two botanicals, ashwagandha and okra. In a 60-day randomized controlled trial with 135 participants, Digexin significantly improved GI transit time, bowel function, and markers of inflammation, while also enhancing mood and sleep. A 14-day pilot study of Digexin supported these benefits, showing rapid symptom relief and improved well-being.

   Motility Assist also includes Triphala, a traditional Ayurvedic formula used for thousands of years for its digestive benefits, as well as fennel and ginger extracts. Fennel seed extract has long been revered for its GI-focused benefits – notably relieving flatulence. Preclinical studies suggest it also benefits GI motility. Ginger is well known to ease nausea and vomiting and has been suggested as a prokinetic agent that improves GI motility.

   This combination of traditional wisdom and modern research provides practitioners with a powerful tool to address constipation through multiple complementary mechanisms, working with the body's natural processes rather than simply forcing evacuation.

Creating a More Comprehensive Approach 

The gut microbiome plays a pivotal role in modulating gastrointestinal motility and contributing to the pathophysiology of functional constipation. By understanding the complex interplay between the microbiome and gut function, integrative medicine practitioners can leverage microbiota-based therapies, including botanicals and probiotics, along with diet and lifestyle modifications, as valuable tools in a comprehensive and personalized approach to managing this common but challenging condition. 

As you work with patients struggling with constipation, consider how these microbiome-focused approaches might complement your existing protocols. For many individuals, addressing the underlying microbial imbalances may be the missing piece that finally brings relief after years of struggling with conventional treatments alone. 

Continued research will further refine our understanding and optimize the clinical application of these promising interventions. In the meantime, these evidence-based strategies offer new avenues of support for the many patients seeking natural solutions for this common but challenging condition

References: 

1. Erhardt R, Harnett JE, Steels E, Steadman KJ. Functional constipation and the effect of prebiotics on the gut microbiota: a review. Br J Nutr. 2023 Sep 28;130(6):1015-1023. doi: 10.1017/S0007114522003853. Epub 2022 Dec 2. PMID: 36458339; PMCID: PMC10442792. 
2. Pan, R.; Wang, L.; Xu, X.; Chen, Y.; Wang, H.; Wang, G.; Zhao, J.; Chen, W. Crosstalk between the Gut Microbiome and Colonic Motility in Chronic Constipation: Potential Mechanisms and Microbiota Modulation. Nutrients 2022, 14, 3704. https://doi.org/10.3390/ nu14183704 
3. Li Y, Zhang XH, Wang ZK. Microbiota treatment of functional constipation: Current status and future prospects. World J Hepatol. 2024 May 27;16(5):776-783. doi: 10.4254/wjh.v16.i5.776. PMID: 38818289; PMCID: PMC11135260. 
4. Dimidi E, Christodoulides S, Scott SM, Whelan K. Mechanisms of Action of Probiotics and the Gastrointestinal Microbiota on Gut Motility and Constipation. Adv Nutr. 2017 May 15;8(3):484-494. doi: 10.3945/an.116.014407. PMID: 28507013; PMCID: PMC5421123. 
5. Bunnett NW. Neuro-humoral signalling by bile acids and the TGR5 receptor in the gastrointestinal tract. J Physiol. 2014 Jul 15;592(14):2943-50. doi: 10.1113/jphysiol.2014.271155. Epub 2014 Mar 10. PMID: 24614746; PMCID: PMC4214650. 
6. Alemi F, Poole DP, Chiu J, Schoonjans K, Cattaruzza F, Grider JR, Bunnett NW, Corvera CU. The receptor TGR5 mediates the prokinetic actions of intestinal bile acids and is required for normal defecation in mice. Gastroenterology. 2013 Jan;144(1):145-54. doi: 10.1053/j.gastro.2012.09.055. Epub 2012 Oct 3. PMID: 23041323; PMCID: PMC6054127. 
7. Ma W, Drew DA, Staller K. The Gut Microbiome and Colonic Motility Disorders: A Practical Framework for the Gastroenterologist. Curr Gastroenterol Rep. 2022 Oct;24(10):115-126. doi: 10.1007/s11894-022-00847-4. Epub 2022 Aug 9. PMID: 35943661; PMCID: PMC10039988.