How constipated are you? Get it sorted. #ClinicSpeak #MSResearch #MSBlog
"Did you know that the fourth commonest cause of unplanned hospital admissions from pwMS is chronic constipation with faecal impaction. Constipation is a big problem in pwMS. The cause is multifactorial and related to many factors; poor diet, medication, lack of exercise, dehydration and slow bowel movements due to MS. The management of constipation requires a systematic approach to make sure all the issues are addressed. Reaching for the laxatives is not necessarily the right thing to do. You need to have your diet reviewed to make sure you are getting enough fibre and drinking enough water. Exercise is also good for constipation; exercise or the anticipation of exercise simulates the colic or defecation reflex. Many of the symptomatic drugs we use to treat MS symptoms can make constipation worse, in particular anticholinergic and spasticity drugs. Once we have corrected as many as these problems as possible we may have to start a laxative. I typically start off by increasing your fibre intake and using a mild laxative to stimulate the bowel, i.e. prokinetic agents. I typically start with senna and if that fails I might try prucalopride an agent that works via stimulating the nervous system in the bowels. If prokinetic agents fail I would add in laxatives to retain fluid in the bowel, lactulose or polyethylene glycol (movicol). Often when you over do it on the laxatives you get diarrhoea and if you have faecal urgency it can cause urgency incontinence. You then stop your laxatives and get constipated again. This typically starts a stop-start cycle of using laxatives; this is not ideal in the long-run and lot of my patients become fixated with their bowel habits. Therefore it is better to gradually titrate-up your laxatives until you find the right combination and dose that works for you."
"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 will 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 the one complication of bowel dysfunction we need to prevent."
"Faecal urgency, and urgency incontinence, is problem that also 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 glycerine 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 lowered my threshold for referring patients for assessment to use this system; mainly because of the psychological benefits patients derive from it and the improvement in their QoL."
"A 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 early with effective DMTs. Preventing disability, i.e bowel dysfunction, is better that treating it."
Choung et al. Chronic constipation and co-morbidities: A prospective population-based nested case-control study. United European Gastroenterol J. 2016 Feb;4(1):142-51.
BACKGROUND: Chronic constipation (CC) is common in the community but surprisingly little is known about relevant gastro-intestinal (GI) and non-GI co-morbidities.
OBJECTIVE: The purpose of this study was to assess the epidemiology of CC and in particular provide new insights into the co-morbidities linked to this condition.
METHODS: In a prospective, population-based nested case-control study, a cohort of randomly selected community residents (n = 8006) were mailed a validated self-report gastrointestinal symptom questionnaire. CC was defined according to Rome III criteria. Medical records of each case and control were abstracted to identify potential CC comorbidities.
RESULTS: Altogether 3831 (48%) subjects returned questionnaires; 307 met criteria for CC. Age-adjusted prevalence in females was 8.7 (95% confidence interval (CI) 7.1-10.3) and 5.1 (3.6-6.7) in males, per 100 persons. CC was not associated with most GI pathology, but the odds for constipation were increased in subjects with anal surgery relative to those without (odds ratio (OR) = 3.3, 95% CI 1.2-9.1). In those with constipation vs those without, neurological diseases including Parkinson's disease (OR = 6.5, 95% CI 2.9-14.4) and multiple sclerosis (OR = 5.5, 95% CI 1.9-15.8) showed significantly increased odds for chronic constipation, adjusting for age and gender. In addition, modestly increased odds for chronic constipation in those with angina (OR = 1.4, 95% CI 1.1-1.9) and myocardial infarction (OR = 1.5, 95% CI 1.0-2.4) were observed.
CONCLUSIONS: Neurological and cardiovascular diseases are linked to constipation but in the community constipation is unlikely to account for most lower GI pathology.