Wednesday, 16 March 2016

ClinicSpeak: constipation and MS

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.

28 comments:

  1. I was having constipation so I started having five fruit and veg portions made into a smoothie for breakfast each morning. For example banana, apple, Satsuma, some berries and watercress. This is helping and better to have in morning than later in the day as easier for body to digest.

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    1. I changed my diet saw improvement overnight. it won't work for everyone, but it's a start.

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  2. Replies
    1. What do your turds look like then? Pink and fluffy are they? Grow up and read a basic biology book. Every living animal has to excrete waste. Even George Osborne and Jeremy Hunt -
      who can even do it from both ends.

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    2. This comment has been removed by a blog administrator.

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    3. They're natural and normal, thanks.

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    4. Ah Anon at 12:56pm you do make me laugh.

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  3. Abdominal massage can help with constipation and pushing things along. Perhaps the hospital bladder and bowel team know this to demonstrate to us. Need to get the massage direction correct.

    Also perineal self acupressure can help constipation.

    https://link.springer.com/article/10.1007%2Fs11606-014-3084-6
    Effect of Perineal Self-Acupressure on Constipation: A Randomized Controlled Trial

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  4. Figs - fresh or dried - are delicious and really made a difference to my constipation.

    Another thing that helps is to use a low portable step to rest my feet on. Having your knees above your hips, while sitting on the loo, can make opening your bowels a lot easier.

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    Replies
    1. I like figs, even fig rolls yum.

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  5. I find there is a strong link between constipation and back ache. Even a little constipation can stiffen my whole body.

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    1. Speaking of strong links, I find constipation is almost always accompanied by frequent and incomplete urination. It's quite uncomfortable.

      I'm very glad this very important topic has been taken up. There is absolutely no emphasis on a high fiber diet in the MS field.

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    2. I noticed today when my bladder was full I was aching. Then I urinated and some of the aching went.
      May be it's similar to the bowels being full and aching in some ways?

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  6. I agree with the figs, lol. Tried it and it worked.

    And the diet and also putting one's knees higher up.

    All good advice.

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  7. Psyllium whole husk fiber has really changed my life. Not the products that contain processed psyllium because I've tried those too it is the whole husk psyllium that keeps things moving.

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    Replies
    1. I was told this would interfere with the absorption of meds. Thoughts Dr G?

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  8. I don't understand why would you name a poop scale after the University though?

    ReplyDelete
    Replies
    1. It's named after Bristol Palin, Sarah Palin's daughter.

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  9. How about magnesium and probiotics?

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  10. What about constipation and diaharea. Both within hours of each other,and a regular poo days later. Great information article. Time for a GI specialist?
    How does your body absorb meds during these episodes? Or not?

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    Replies
    1. Bowel and bladder team at hospital could help. I expect they come across this type of thing fairly often.

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  11. Excellent post Prof G and good on you for talking about what so few people will discuss (apart from mothers of newish babies who all seem to have obsessions about the contents of their little darlings' nappies!) Talking about bowel problems and MS seems to be avoided even more than bladder problems and MS is.

    A question - I was referred to the local continence nursing service and was advised by both them and the MS Nurse to increase my fibre intake as much as I could and to avoid any laxatives which worked by either stimulating or irritating the bowels, with them telling me that these would likely cause me a pain and discomfort, yet I note that you recommend such products. I already take fibre supplements, and drink heaps of water - where does one go from here? Should taking an occasional dose of Movicol be the next step when there aren't any leakage issues?

    Speaking of leakage issues - have people taking Fampridine reported that it helps with this problem? I found when I trialled Fampridine that it made constipation problems a whole heap worse.

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  12. Interesting, as Ampyra is Fampridine to help walking in ms patients. 2hrs on phone with their nurse about problem still did not solve questions, as more fiber would change how meds are absorbed.

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    1. Constipation is one of the potential side effects listed in the Patient Info Sheet for Amypyra/Fampyra/Fampridine.

      Like most side effects it does not necessarily affect all users, but it made my life almost unbearable for a few weeks. Thus it could almost be a good thing that Fampridine did not help with my walking, as it would have been a real struggle to keep taking it with the really bad constipation problems it caused for me.

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    2. Having diaharea instead.but also constipation. Viberzi now being tried, less generlac (lactolose) and stopped the metocloprimide, used to push things along. Two figs added, and now waiting for a gastrointrrologist

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  13. One dessert spoon of flax oil in a smoothie in the morning will do wonders. Psyllium works to really soften the stools. Beware taking 2 tablets of magnesium - you will spend afternoon in the loo. My doc won't prescribe senna stating it makes the bowl lazy. Try the natural remedies and add more fibre and water to diet. We already have enough bottles of chemicals to deal with.

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    1. Re "Beware taking 2 tablets of magnesium - you will spend afternoon in the loo" - this may apply for some but not others as different people respond to magnesium in varying degrees and the type of magnesium taken also affects it's impacts on the bowels. I take 300mg of mag citrate every day and it has no effect at all on my bowels - some days I wish it did!

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  14. I was reading on the NHS website:
    Constipation can increase your chances of developing a UTI. I didn't know this.

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