I
have never liked to talk in detail about people's bowel movements.
Maybe it is because I was toilet trained by 12 months of age, or
maybe because we were a family of 8 with one toilet, and my mother
always had right of way. And we did not discuss such subjects as a
family – in fact my mother accused me of embarrassing the family
doctor by asking him what a bowel movement was! But for the sake of
my friends with Parkinson's I steeled myself to explore what is known
about constipation in Parkinson's disease. What I discovered, both
about bowel function and about Parkinson's disease, made the
exploration well worthwhile.
So
I will put a clothes pin on my nose and tell you all I have learned
about this shitty subject.
Constipation
is often the first sign of Parkinson's disease (PD), and a change in
bowel habits may closely precede the motor symptoms (that is the body
movement problems) of PD. Of course not everybody who is constipated
has Parkinson's disease. But PD is one explanation for a change in
bowel habits.
What
do we call constipation? For regular people it is not having a shit
as often as you feel you should. For the medical researcher, who
needs a more precise and objective definition, it is:
in
at least 12 weeks of the preceding 12 months:
1. 2 or fewer bowel movements per week, or
2. a frequent feeling of not having completed a bowel movement, or
3. frequently having to strain at stool, meaning you have to work hard
at it to get it to come out., or
4. feeling of obstruction at the level of the anus (butt hole), or
5. hard stools in more than 1 in 4 evacuations.
Depending
on what study you look at, it is estimated that between 20% and 80%
of patients with Parkinson's disease (PWP's) are constipated.
There
is a tremendous variation in the frequency with which normal
(non-Parkinson's) people have bowel movements. Some people it is
several times a day, for others only a few times a week. I saw in my
children when they were babies an incredible variation in their stool
frequency, from the one who was several times a day to the one for
whom it once or twice a week and you might have to stabilize the
perineum (put your hands around the anus to reinforce it ) to allow
them to pass the stool. It depends on diet, on the level of tension
in the home, on opportunity, and on toilet training and on genetics.
When I was in medical school and went to see my family for holidays I
might go the whole week without a bowel movement, then as soon as I
was in my apartment and relaxed I just went back to normal.
However
in Parkinson's disease it is a whole different ball game. PD is a
degenerative disease of the nerve cells, and it affects the nerve
cells in the bowel as well as those in the brain.
Here
was my first discovery to do with bowel function. (Rather, I did
not discover it, I just found out that it was known.) Some of the
cells which cause peristalsis in the bowel, have been killed by
apparently the same process that caused the Parkinson's disease.
Because of the loss of neurons around the bowel, peristalsis, which
moves the food around through the bowel and out the end, is
impaired.(3) Not only that, but the co-ordination that causes the
anal sphincter, the muscle around the anus which keeps it closed, to
relax when you push down, loses its co-ordination so you end up
pushing against a closed door.[1]
In
normal people who are not constipated, it takes about 20 hours for
waste material to pass through the colon or large bowel. Excess
fluid is removed and the stool becomes firm. But if it stays too
long it gets dry and hard, and it may not be easy for bowel
peristalsis to move it along. This situation is called impaction. and
may require medical intervention. If you have constipation and
abdominal pain, it could be due to fecal impaction and you should get
yourself to a doctor.
In
constipated people without Parkinson's disease it may take 60 hours
for stool to pass through the large bowel, but if they are treated
with laxatives the transit time returns to a normal time. However
with PWP's, almost whatever you do, you can't change the bowel
transit time.
What
should you do?[4] Once you are in trouble you should consult your
doctor. You may need an enema, a suppository, or even manual
disimpaction. If you are constipated and have abdominal pain you
need to see a doctor right away. Some of my Parkinson's friends have
had to go to the hospital on numerous occasions to be manually
disimpacted. That is to say: have the stool removed by hand. This is
painful and may require a general anaesthetic. The thing to do is to
prevent yourself from getting into that state.
1.
Fluids: The first thing is to make sure you are getting lots of
fluid. For example, make sure you take a full glass of water with
each dose of medicine. Unless there is a medical reason you cannot
drink large volumes, you should aim for 8 glasses of water or other
fluids per day.
2.
Fibre: Next, increase the amount of fibre in your diet. The current
recommendation() is 20 to 35 grams per day [b]. This is really a lot
– you have to take the high fibre option for every thing you eat.
Lets
look at how I did today:
| Meal | Food | fibre |
| Breakfast | ||
| All bran 1 cup | 6 grams | |
| 1 c milk | 0 | |
| apple | 1.8 | |
| orange | 1 | |
| raisins | 0.2 | |
| tea | 0 | |
| Lunch | lasagne | .5 |
| salad | .5 | |
| Dinner | Bread, whole wheat 2 slices | 6 |
| Tomato and lettuce | .2 | |
| Ice cream pie | 0 | |
| Chicken | 0 | |
| Nuts, 50 g | 8 g | |
| total | 24.2 grams |
So
even though I chose as many high fibre options as I could, I only got
to 24 gram, the lower part of the target range.
Note
that “all bran” cereal has psyllium added to artificially
increase the fibre content (like Metamucil), and that the whole wheat
bread and the nuts are the major contributors to the total. It takes
real dedication to get the fibre up into this range.
4.
Exercise: Get some exercise every day. This will help to keep
things moving.
5.
Laxatives: It is not recommended to take irritant laxatives such
as senna every day. However you can add an osmotic laxative, such as
polyethylene glycol (PEG) 3350. (Magnalax and others) An osmotic
laxative remains in the bowel and is not absorbed from the digestive
tract, and helps the stool to retain water by its osmotic pressure.
Lactulose is also an osmotic laxative. PEG by itself has been shown
to help with constipation in the elderly in general [4], and in
Parkinson's patients although it does not normalize the colonic
transit time it has been shown to reduce fecal impaction by keeping
the stool soft. It can be taken up to twice a day.
If
that is not enough Magnesium or milk of magnesia may be added.
(Discuss this with your doctor first – if you have other medical
problems like kidney disease this could be dangerous.) Magnesium can
be titrated to give the required stool frequency.
If there is still a problem then more draconian measures such as suppositories or enemas . may be needed. These should be discussed with your doctor.
Around
Christmas this year my husband decided to please our youngest by
buying white bread instead of brown bread. It took a few weeks for
me to develop severe constipation, with hard stool which really
required pushing to get it out in spite of the fact that I had been
taking a stool softener (ducosate 100 mg twice daily) all along.
I
realized that I had to find a protocol that I could follow regularly
to keep me out of trouble. I have added daily polyethylene glycol
(PEG) to my regular medications. One dose every day at bedtime.
(To cover the chemical taste I mix it with hot milk and Ovaltine or
Horlicks (delicious)). Even that is not enough to keep me going,
though there is no more hard stool. Now on the instruction of my
doctor I am taking a magnesium tablet (each has about 100 mg
elemental magnesium) every day, and that keeps me going. (Actually
she told me to take three, but if I take the three I feel like I need
to spend the whole day on the toilet.)
No
doubt things may get trickier as time goes by. I will have to deal
with that then.
Ah!
Now I can take that clothes peg off my nose. I just have to figure a
way to get everyone around me to stop talking about their shit!
Next:
the gastrointestinal theory of Parkinson's disease.
References:
1.
Kim, JS, et al, Anorectal dysfunction in Parkinson's disease, J Neuro
Sci 310(2011)
144
2.
uptodate
2015
3.Cersosino
M G et al, Pathological correlates of gastrointestinal dysfunction
in Parkinson's disease, Neurobiology of Disease 46:559, 2012
4.
Cosgrave,M, et al, 'Management of faecal incontinence and
constipation in adults with neurological disorders, the Cochrane
library, 2014, #1
