Monday, 8 September 2014

ClinicSpeak: rectal dysfunction

MS is many diseases in one: the problem of faecal incontinence. #ClinicSpeak #MSBlog #MSResearch

"This weekend was an emotional roller-coaster ride. Saturday started with a gut wrenching memorial service for Max Faulkner, aged 20. Yes, our Max, the political voice, from this blog. We have lost someone who had so much potential. This was followed by a trip with my oldest daughter to Edinburgh; she starts University next week. When you first child is fully fledged you realise how short life really is."

"My daughter was very upset by an incident on the plane flying up to Edinburgh. An elderly man didn't quite make it the toilet and had an episode of faecal incontinence on the plane. It was obviously very embarrassing for all concerned, but the indignity of the event is what got to her most. She felt very sorry for the him and the distress it caused him. She was very surprised when I told her that in my profession I look after many patients to whom this happens to frequently and that the psychological effects of the being incontinent in public can be so devastating that some of them refuse to go out in public again.”

"The following study shows that in MSers fecal incontinence is a problem and is not necessarily linked to disability. Why? The reason is that a strategically place lesion in spinal cord and impact on bowel function without causing other disabilities. I have several patients who have had spinal cord relapses that leave them with faecal urgency and episodes of faecal incontinence, but very little other disability."

"This abstract highlights the problem of bowel dysfunction that is common in MS. The management aim in patients with faecal incompetence is for them to have a regular bowel action, either daily or at least every 2 days. The main problem in MS is bowel hypomotility (slow or sluggish movements); MS-related constipation therefore needs to be treated with so called prokinetic agents, i.e. drugs that increase the muscular action of the bowel. The most common prokinetic agent I prescribe is senna. If the latter fails we try prucalopride and agent that works via stimualting the nervous system in the bowels.  Prokinetic agents often need to be taken with bulking (fibre) and loosening (liquid) agents. Loosening agents keep liquid in the bowel, for example lactulose or polyethyelene glycol (Movicol). It is important to realise that dehydrating yourself to control your bladder problems can make constipation worse; therefore you need to drink adequate quantities of water throughout the day. Similarly drugs to help your bladder dysfunction, pain and spasticity may make constipation worse. Therefore if you are constipated your medications need to be reviewed . Some MSers become so constipated that they become faecally impacted and go onto develop intermittent overflow diarrhoea; i.e. the bacteria in the bowel liquefies the stool above the impaction and the liquid overflows past the impaction. A typical history is periods of constipation, punctuated by episodes of diarrhoea. Faecal impaction is a serious problem and often warrants admission to hospital to treat. This is one of the complications of bowel dysfunction we need to prevent."


"Faecal urgency, and urgency incontinence, is problem that needs attention; if you have to go you have to go. This is best treated by developing a bowel routine and trying to evacuate your bowels at a regular time of day, typically in the morning. This can be aided by using something to stimulate the bowels. I typically use start by prescribing glycrine suppositories or mini-enemas. If the latter fails I may elect to use transanal irrigation. Trans-anal irrigation sounds terrible, but in MSers who need it often makes a massive difference to the quality of their lives and gives them some control back to tackle a problem that often leaves them stranded at home. The commercial rectal irrigation system we use most is the Peristeen system. In recent years I have therefore lowered my threshold for referring patients for assessment to use this system; mainly because of the psychological benefits patients derive from it."

"The biggest problem with poor rectal compliance* and faecal urgency is the odd occasion when you have diarrhoea. With diarrhoea, whatever the cause, your rectum fills multiple times during the day and hence you are more likely to be incontinent. In this situation some gastroenterologists recommend using  a rectal plug in combination with incontinence pads."

"Bowel dysfunction is one of the many symptomatic problems that may be avoided by preventing or delaying the development of disability. Preventing bowel dysfunction is another reason to actively manage your MS with DMTs. Preventing disability, i.e bowel dysfunction, is better that treating it."

"For those of you with Bowel problems you can download the Wexner Incontinence Score from our SlideShare site to assess whether or not you have a problem. If you do don't suffer in silence discuss it with you MS team and get help."


*Rectal compliance is the term we use to refer to how much distention the rectum can tolerate before it triggers the uncontrollable urge to open your bowels or in people with no sensation the reflex contractions that empty the bowel.

Preziosi et al. Autonomic rectal dysfunction in patients with multiple sclerosis and bowel symptoms is secondary to spinal cord disease. Dis Colon Rectum. 2014 Apr;57(4):514-21. doi: 10.1097/DCR.0000000000000048.

BACKGROUND: Most patients with multiple sclerosis report bowel symptoms, but the underlying pathophysiology is unclear.

OBJECTIVE: We hypothesize that rectal dysfunction in multiple sclerosis is secondary to involvement of the spinal cord by the disease and that this can be measured by assessing rectal compliance.

DESIGN: This was a case-control study.

SETTINGS: The study took place in a neurogastroenterology clinic and tertiary referral center.

PATIENTS: Forty-five patients with multiple sclerosis, 19 with a spinal cord injury above T5, and 25 normal control subjects were included in this study. Patients with multiple sclerosis were subdivided into 2 groups according to the Expanded Disability Status Scale, below 5 (multiple sclerosis minor disability, n = 25) or above 5 (multiple sclerosis major disability, n = 20), as a reflection of spinal cord involvement.

MAIN OUTCOME MEASURES: Rectal compliance, Wexner constipation, and Wexner incontinence scores were measured.

RESULTS: Data are presented as mean and SD. Expanded Disability Status Scale correlated with rectal compliance but not with Wexner constipation or Wexner incontinence scores. Post hoc analysis showed no significant difference in Wexner constipation and Wexner incontinence between the 2 multiple sclerosis groups.

LIMITATIONS: Limitations to this study include the lack of an asymptomatic group with multiple sclerosis and the small sample size to evaluate bowel symptoms.

CONCLUSIONS: Rectal compliance correlates with disability, and observed alterations in the rectal properties are secondary to spinal cord involvement. Our findings suggest that, in patients with neurologic impairment, rectal compliance is a surrogate of reflex activity of the spinal cord regulating rectal function and both a potential predictor of outcome and target for treatment. Multiple sclerosis patient subgroups had similar symptom burden, arguing that bowel dysfunction is multifactorial.

3 comments:

  1. Thank you for writing this. Others can rarely understand the misery of bad bowels. I ended up having an ileostomy due to the extreme slowness of my gut. I'm very happy with it, but recovery seemed to take a very long time.

    ReplyDelete
  2. Whole psyllium husk has changed my life.

    http://en.m.wikipedia.org/wiki/Psyllium_seed_husks

    ReplyDelete
  3. Tried psyllium, senna, prucalopride, linseeds, movicol, fruit, veg & much more besides, combinations of everything, and always pint after pint of water. Believe me, I was desperate before I resorted to surgery. But I hope others will find a combo that works for them before they reach that stage. If they don't, having a stoma is not as awful as some would have you believe (eg: my mum), but it's by no means an easy ride.

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