The Gastrointestinal Tract And Parkinsons
As promised in a previous blog, I now return to the topic of the gastrointestinal tract and Parkinsons disease . As most of you know, GI symptoms are very common in PD. We will discuss what those symptoms are, why they occur, and the current research that links what is happening in the gut to theories as to why PD occurs at all. Many of you have suggested gut-related topics for this blog including a discussion of symptoms such as bloating and constipation, and a discussion of the use of probiotics in PD. I will address these issues as well. Submit additional topics that you would like to read about here.
GI symptoms can be among the most bothersome of the non-motor symptoms of PD. Constipation is the most common of these symptoms, affecting 80-90% of people with PD. APDA has a helpful brochure with practical tips to prevent and treat constipation in PD.
GI pathology in Parkinsons disease however, can involve the entire GI tract and includes sialorrhea and dysphagia . In addition, delayed gastric emptying, in which the digestive contents are held up in the stomach and do not move normally into the small intestine, can cause sensations of nausea and bloating.
The gut has its own nervous system
The gut as a biomarker
Entry to the brain
How do Lewy bodies propagate?
How To Deal With It
Like other symptoms of Parkinsons, constipation should also be treated properly. Because if not treated properly, it can lead to a number of other problems in patients. For example, it can cause abdominal pain, nausea, bloating, vomiting, and weight loss. In some patients it also lead to intestinal obstruction and bleeding.
So here are 4 ways that you can use to deal with constipation!
Bowel Management In Msa
This eight-page fact sheet addresses constipation specifically in Multiple System Atrophy, but the impairment of the autonomic nervous system is similar enough to Parkinsons disease as to be useful here. There is a nine-point list of contributors to constipation, other problems that can occur due to bowel problems, management tips, and medication options.
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Anatomy And Physiology Of The Colon And Defecation
The physiology of the colon is complex and modulated through several separate systems, including neural, endocrine, and luminal factors. The neural control can be separated into the intrinsic colonic nervous system and the extrinsic colonic nervous system. The intrinsic nervous system consists of nerve cell bodies and endings that are located between the circular and the longitudinal muscle coats.
The intrinsic nervous system of the colon consists of neurons, with cell bodies in the submucosal ganglia and the myenteric ganglia , which are interconnected through interneurons and act as single functional units. The classification of the intrinsic colonic neurons is very complex, as numerous neurotransmitters have been located and identified. However, the physiological role of each and the combination of these are not yet clear.
The extrinsic colonic nervous system innervates the gut, and presumably acts as a modulator of visceral activity through sympathetic and parasympathetic functions.
The parasympathetic innervation of the colon is divided into cranial and sacral divisions. The vagus nerve innervates the foregut and midgut and the pelvic nerves innervate the hindgut . Stimulation of parasympathetic fibres increases the overall activity of the gastrointestinal tract by promoting peristalsis, and increasing local blood flow and intestinal secretion, and this system is also an integral component of the defecation reflex.
A New Toilet Or An Alternative
If you have real difficulties getting to the toilet, it may be possible to get a grant to build a new one, perhaps downstairs. An occupational therapist can advise you on this.
Not all homes are suitable for building new toilets, so a commode might be needed. A commode is a moveable toilet that doesnt use running water. It looks like a chair, with a container underneath that can be removed and cleaned after someone has used it. They can be very discreet.
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Why Might Constipation Be A Parkinson’s Symptom
This 62-minute audio with slides is presented as an interview of two neurologists and explains how the gastrointestinal musculature is well enervated and, therefore, affected by the loss of dopamine and deposits of alpha synuclein, just as the brain is.; Management options are discussed, and recent research into the microbiome and the gut/brain connection in Parkinsons disease.;
What Causes Constipation In People With Parkinson’s Disease
In some people with Parkinson’s disease, constipation may occur due to the improper functioning of the autonomic nervous system. The autonomic nervous system is responsible for regulating smooth muscle activity. If this system is not working properly, the intestinal tract may operate slowly, causing constipation.
Also, medications used to treat Parkinson’s disease can cause constipation.
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Evaluation And Treatment Of Constipation In Neurological Diseases
In evaluation of the neurologically diseased patient with respect to gastrointestinal dysfunction, a combination of a carefully taken history , including actual medication, and physical examination including digital exploration, will be adequate in most cases. Patients may present with abdominal discomfort or pain, and investigations generally do not detect any abnormalities. Based on history alone, it may prove to be difficult to differentiate slow colonic transit time and outlet obstruction. Severe cases of constipation secondary to slow colonic transit, may present with decreased appetite and not uncommonly with nausea, but rarely with vomiting.
Stercoral diarrhoea is a bothersome symptom and though the impaction is evident to the physician, it may prove difficult to treat.
Patients, who have difficulty in evacuating the rectum, generally have outlet obstruction and neoplasia needs to be excluded.
In female patients with severe constipation and difficulty with defecation, it is important to exclude rectoceles, which are mostly asymptomatic but sometimes can cause incomplete emptying.
Further investigation with radiography or manometry depends on the situation. In cases with incomplete emptying, manometry with anal sphincter EMG should be conducted to establish the reason for the prolonged straining.
Table 1
Figure 1 outlines a possible strategy for management and drug treatment in constipated patients.
Figure 1
How Can It Affect People With Parkinsons
- Constipation can impact the absorption and effectiveness of levodopa .
- Constipation can disturb bladder function. An over-full bowel due to constipation can press on your bladder, reducing the amount of urine it can hold.
- Straining due to constipation can weaken your pelvic floor muscles. Pelvic floor muscle strength is important for both bladder and bowel control.
- Severe constipation is the most common cause of bowel incontinence. Bowel incontinence is the inability to control your bowel motions. It can range from soiling your underwear to the loss of a full bowel motion.
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A Constipation In Multiple Sclerosis
Bowel dysfunction in patients with multiple sclerosis is common. Constipation and faecal incontinence often coexist and occur in 39% to 73% of MS patients, depending on definitions and selection.
The pathophysiology of bowel dysfunction in MS is poorly understood. Symptoms of bowel dysfunction are not nearly as frequent as bladder dysfunction, indicating a more complex mechanism than the result of spinal lesions. Abnormalities of colonic activity and slow transit time have been demonstrated in patients with MS. A pathoanatomical explanation of slowed transit time is unidentified, and Clare Fowler has suggested, that the symptom of constipation could be a mechanism similar to that which causes fatigue in MS.
In respect to faecal incontinence, Nordenbo et al found a strong correlation between impaired rectal sensation and incontinence, and many patients may either clinically or manometrically have poor voluntary squeeze pressure, and may start the anorectal inhibitory reflex earlier than controls.
Patients with severe paraparesis may complain of difficulty in switching on the mechanism of defecation. Spasticity of the pelvic floor is associated with a failure of effacement of the puborectalis during attemps to empty the rectum, and patients may find digitation necessary to assist evacuation.
Do Abdominal Massage Therapy
Abdominal massage is becoming a very popular treatment option for people with constipation. It helps to activate normal motion of your bowels and relieve the symptoms of constipation.
A study published in the Journal of Clinical Nursing found abdominal massage an effective treatment approach for constipation. In this study, nine adults with constipation were participated in abdominal massage sessions. The participants found the massage pleasant and began to feel embraced and in safe hands. They described that not only their bowel habits were improved but also their agony was gone and they felt relieved.
Parkinsons patients are recommended to do abdominal massage therapy at least once a day, either yourself or with the help of your healthcare provider.
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How Might Parkinson’s Affect The Bowels
Bowel problems can occur in anyone, but some problems, especially reduced bowel movement or constipation, are particularly common in Parkinsons. This tends to be as a result of slowness of movement and muscle;rigidity, both of which are visible symptoms of the condition. But Parkinson’s also muscles we cannot see including the bowel muscles – which in turn causes a reduction or slowness of bowel movements.
Poor bowel function may be exacerbated if chewing and swallowing food is difficult, which is quite common in;Parkinsons. This may make it harder to eat a diet that is rich in fibre – for example fruit, vegetables and whole grains which helps form soft, bulky stools and aids bowel function.
Exercise is also thought to play a role in efficient bowel function, but if Parkinson’s makes activities more difficult, the bowel may be less stimulated and the intestines can become sluggish.
Constipation is thought to affect;up to 65% of people with Parkinson’s the bowel symptoms may predate the neurological ones . Tremor and a;fear of spilling drinks can mean some people unintentionally reduce their fluid intake;which can make stools hard and more difficult to pass. When stools remain unpassed for a long time, they become harder as the body absorbs more water from them. If stools build up in the rectum they can become impacted and block the rectum. They may also overflow as lumps of stool or watery mucus.
Diagnosis Of Constipation In Parkinsons Disease
Diagnosis of constipation may include:;
- medical history
- detailed description of symptoms
- physical examination.
Medical problems other than Parkinsons disease can also cause constipation. Your doctor may wish to do tests to rule out other possible causes. The tests depend on the medical condition under investigation.
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Bladder And Constipation Problems
Parkinsons commonly leads to problems with constipation and bladder control, including urinary urgency, frequency, retention and nocturia.
These problems add to the challenge of living with Parkinsons and can have a negative effect on a persons quality of life. It is important to seek help in managing these problems, as both issues can be effectively managed.
Bowel Issues In Parkinson’s
Recently, I was doing an interview about Parkinsons troublesome issues and I had to admit that by far my most troublesome and annoying problem is related to the effects of my gut. This is true for the majority of us living with this disease. Whether it be a direct or indirect consequence of our illness is irrelevant in my opinion when the effect is the same. Plus to be honest I am not sure anyone of us can tell the difference most of the time.
As I have re-discovered the agony of suffering from one of these ailments over the last several months when I had several bouts of ileus. In my opinion,;there is nothing worse than having stomach pain, bloating, nausea, indigestion, and gas to make life miserable.
Below are all the plausible GI symptoms all of us can experience throughout our journey with PD.1 The most common symptoms are those related to poor motility or dysmotility and can be compounded by the effect of the medication.
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Stay Away From Red Meat
Parkinsons patients are recommended to stay away from red meat while constipated. This is because red meat contains proteins and unhealthy fats that are difficult for the body to digest quickly. Red meat is also rich in iron, which is hard on the digestive tract and so can easily contribute to the constipation problem.
B Constipation In Spine And Spinal Cord Disorders And Cauda Equina
An important and time consuming problem in caring for patients with spinal cord injury is constipation, and the presence of this is well documented. It is known that the mechanism of constipation in spinal cord injured patients is prolonged colonic transit time, but the pathophysiological background for this is still not known.
In the patient with spinal cord injury, the extrinsic neural control is lost, and patients with spinal cord lesions demonstrate disordered sympathic function. The nature of this abnormality depends on the level and the degree of the lesion, and is often clinically evident in relation to gastrointestinal function. Impairment is generally most pronounced in patients with quadriplegia with a complete transection above the sympatic outflow.
In high cord transection with intact isolated cord below the lesion, resting colon activity is reduced compared with normal controls, whereas patients with low cord lesions show a significant increased colonic activity. It has been concluded from these findings, that an inhibitory centre in the lumbar outflow exists, and that in patients with low cord injury, this outflow is inhibited, resulting in increased sigmoid activity.
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Toilet Habits And Constipation In Parkinsons Disease
Suggestions for good toilet habits include:
- Go to the toilet as soon as you feel the urge to pass a bowel motion. Hanging on can contribute to constipation.
- Use the correct posture on the toilet to help you pass a bowel motion place your elbows on your knees, bulge out your stomach, straighten your spine and put your feet on a footstool.
- Avoid holding your breath and dont strain when you are on the toilet. Allow yourself plenty of time.
- Use a warm washcloth pressed against your back passage or gently massage with one or two fingers to help to relax the muscles.
- Talk to your doctor or pharmacist about medicines to help soften your bowel motions.
How Can I Help Myself
It is easy to become obsessed with bowel activity, but it is not necessary to have a bowel movement every day it can be quite normal for some people to empty their bowels only three or four times a week. What is important is that passing stools does not cause pain or unnecessary strain. Focus on what is normal and healthy for you and remember that bowel activity is affected by food and exercise, so will vary according to what you are eating and doing.
Remember that learning to manage your bowels will take time and patience, so dont expect to solve problems overnight. It may take a few weeks to adjust diet etc, so be patient. There are also plenty of ways you can help yourself.
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How Is Constipation Treated
The treatment of constipation typically begins with optimization of fiber and fluid intake. While fiber may be increased through changes in diet, it can be challenging to get people to change their long-standing dietary habits. For many people, the addition of bulking agents such as psyllium or methylcellulose is an inexpensive and simple way to increase fiber. Polyethylene glycol, guar gum and lactulose are other choices that have less texture though may be more expensive than bulking agents. For an occasional patient stimulant laxatives or prescription medication is necessary to control symptoms of constipation.
Neil R. Greenspan, MD, FACG Gastroenterology Associates Providence, RI
What’s Going On In My Gut
In this 30-minute talk Leslie Cloud, MD, MSc explains the underlying causes, lifestyle tips, and treatment options for drooling, swallowing issues, nausea, slow stomach emptying, constipation, difficulty defecating.; She alto explained the complex interplay between Parkinson’s motor medications and GI symptoms before answering questions.
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Addressing Practical Aspects Of Eating And Drinking
Some people with Parkinsons have problems chewing and swallowing. This can make it difficult to eat a diet with plenty of fibre. A speech and language therapist can give advice about this. Ask your GP, specialist;or Parkinsons nurse for a referral.; ; If it takes a long time to eat and your meal goes cold, eat smaller portions and go back for seconds that have been kept warm. You can also get special plates that keep your meals hot the Disabled Living Foundation has more information.;
An occupational therapist will also be able to give you some tips and practical advice.;
Treatment For Constipation In Parkinsons Disease
Your doctor may suggest various treatments to help combat constipation, including:;
- dietary changes, including more fibre rather than refined or highly processed foods, and water
- moderate exercise
- good toilet habits
- avoidance of unnecessary medicines that contain substances known to cause constipation
- laxatives, particularly agents that bulk and lubricate the stools
- treatment for any other medical problem that may be contributing to your constipation, such as haemorrhoids .
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Dietary Fibre For Constipation In Parkinsons Disease
Be guided by your doctor, but general suggestions include:;
- Choose easy-to-eat fibrous foods such as soft fruits. Consider mashing or pureeing fruits to make them easier to eat. Make sure to include the skin, where most of the fibre is found.
- Eat at least two pieces of fruit and five serves of vegetables every day.
- Eat homemade vegetable soups.
- Sprinkle a tablespoon of bran, psyllium husks or chia seeds on your breakfast cereal or add the bran to baked products such as cakes. However, avoid bran if you have swallowing problems.
- Fibre supplements may be helpful, but you must drink enough fluids for these to work properly. Avoid fibre supplements if you have problems swallowing.
- Dont increase dietary fibre too quickly or youll risk bloating and abdominal cramps. If discomfort occurs, cut back your fibre intake, increase your fluid intake, apply a hot water bottle to your abdomen and see your doctor.