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Symptom Management in Multiple Sclerosis by Randall T. Schapiro, M.D.
Chapter 11 - Bowel Symptoms
As with the urinary tract, many people with MS have some degree of bowel complications at some point during the course of the disease. These difficulties may be effectively managed with medications and other treatments.
The Gastrointestinal Tract and Its Control
The gastrointestinal (G1) tract is a hollow, muscular tube that extends from the mouth to the anus and is responsible for the digestion and absorption of food followed by elimination of the waste products of the digestion process.
TABLE 11-1. Bowel Management
- Eat a high-fiber diet of balanced meals
- Drink 8 to 12 cups of fluid daily
- Establish a bowel program
- Medications
The stomach primarily acts as a storage chamber and is the first site of major digestive processes. It slowly passes food to the small intestine, which in turn sends it to the large intestine by a propulsive movement.
The large intestine is approximately five feet long and is divided into four sections: the ascending, transverse, descending, and sigmoid colon. In the sigmoid colon, stool is concentrated into a solid mass by the absorption of much of the fluid that is present in other areas of the tract. The reflex process that leads to a bowel movement (defecation) occurs when stool moves from the sigmoid colon into the rectum, the last four to six inches of the tract.
The rectum usually remains empty until just before and during defecation, when stool enters it either as a result of a mass propulsive movement or by voluntary contraction of the abdominal muscles. In a manner similar to what happens when the bladder initiates urination, filling of the rectum with stool causes nerve endings in the rectal wall to transmit a message of fullness to an area of the spinal cord that is involved in bowel function. As stool leaves the rectum, it passes through the anal canal, which contains the internal and external sphincter muscles.
The sphincters, which are ling-shaped muscles that control the opening and closing of the passageway from the rectum, normally are contracted to prevent leakage. The internal sphincter is under the control of the spinal cord; its relaxation is what is termed an involuntary reflex because it is not under conscious control, and its relaxation depends only on stretching of the rectal wall by stool. In contrast, the external sphincter is under the joint control of the spinal cord and the brain, so that a bowel movement may be consciously delayed by constricting the anus if the time is not appropriate for a bowel movement. The most common bowel problems associated with MS are constipation, diarrhea, and incontinence.
Constipation
Constipation is defined as the infrequent or difficult elimination of stool. It is by far the most common bowel problem associated with MS and may result from one or several problems that are direct or indirect consequences of the disease.
Demyelination in the brain and/or spinal cord may interfere with the nerve transmission that is necessary for normal defecation, in a manner similar to that described in Chapter 1 0. A slower than normal passage of stool through the bowel results in more water being removed from it than is normal, which results in hard, constipating stool.
A person with MS may limit fluid intake because of bladder difficulties. If fluid intake is insufficient to allow the body to meet its basic needs, more water will be absorbed as the stool passes through the colon, which also produces hard, compacted stool that is difficult to pass.
Weakness, spasticity, or fatigue may significantly limit physical activity, which in turn slows bowel activity and the movement of stool through the GI tract; again, excessive amounts of water will be absorbed from the stool, causing it to harden and become difficult to pass.
Some of the medications taken for other problems such as bladder frequency or depression also may slow the bowel.
The Development of Good Bowel Habits
DIETARY MANAGEMENT
Good eating habits are important to achieving good bowel control. It is important to have a routine and to eat balanced meals at regular times and in a relaxed atmosphere.
The intake of adequate amounts of liquid (8 to 12 cups daily) and the addition of fiber to the diet generally alleviates constipation. Dietary fiber is that portion of plant materials which is resistant to digestion; its addition to the diet aids in the formation of softer stool and decreases the amount of time required for stool to pass through the intestinal tract. A high-fiber diet includes raw fruits and vegetables, nuts and seeds, and whole grain breads and cereals such as commeal, cracked and whole wheat, barley, graham, wild and brown rice, and bran (one of the most concentrated sources of dietary fiber).
To increase the amount of fiber in your diet, your daily intake should include:
one serving of fruit (with the skin left on) or vegetable, served cooked, raw, or dried;
one half to one serving of whole wheat or rye bread, or fruit juice; and
one serving of bran (one tablespoon), bran cereal, shredded wheat, nuts or seeds; raw bran may be eaten plain; mixed with cereal, applesauce, soups, yogurt, or casseroles; or added to flour in cooking or baking.
Incorporating bran and other high-fiber foods into the diet too quickly may produce gas, distention, and occasionally diarrhea. These effects may be eliminated or lessened substantially if high-fiber foods are incorporated in small amounts and then gradually increased.
ESTABLISHING A BOWEL PROGRAM
Because decreased sensation in the rectal area in MS may decrease perception of the need to have a bowel movement, stool may remain in the rectum and become hard and constipating. Although this and other factors may lead to constipation becoming a significant problem, it is manageable with a commitment to following an established elimination schedule, timing of meals. fluid intake, and the use of medications if necessary.
The first step in establishing a bowel program is to select the time that is most convenient to have a bowel movement. Although this may vary depending on your job commitments, family routines, and other daily activities, the most effective time to have a bowel movement is shortly after a meal because there normally is a greater movement of contents through the bowel at that time. With this in mind, 15 to 30 minutes of uninterrupted time in which to have a bowel movement should be scheduled.
After a convenient time has been selected, it is important to adhere to this routine on a daily basis, whether or not there is an urge to defecate. Drinking a cup of warm liquid, such as coffee, tea, or water, frequently facilitates the process. Although this schedule initially may produce little result, it is imperative that the routine be adhered to if a successful bowel program is to be established.
MEDICATIONS
Medications may be needed if constipation cannot be corrected by changing the diet, increasing fluid intake, and/or establishing a routine. To determine the most appropriate medication, the reason for the constipation must be determined because it may be caused by lack of bulk, hard stools, or difficulty in expelling stool.
Bulk formers may be prescribed if the cause of constipation is inadequate bulk in the diet and stool. These agents add substance to the stool by increasing its bulk and water content. In order to be effective, bulk formers should be taken with one or two glasses of liquid; this combination distends the GI tract, which in turn increases the passage of stool through it. Defecation usually occurs within 12 to 24 hours, although in some cases it may be delayed for up to three days.
TABLE 11-2. Medications for the Management of Constipation
Medication
Bulk formers
Stool softeners
Laxative (oral stimulant)
Suppositories and other rectal stimulants
Therevac mini-enemas
Enemas
Indications for Use:
inadequate bulk in the diet and stool
hard stool causes constipation
difficulty expelling stool
In combination with other medicationsrectal stimulants if necessary
When lubricating stimulation is helpful
For occasional use only, to avoid dependency
Daily use of bulk formers is necessary for maximal effectiveness. They are not habit-forming, so frequent use is not a problem.
Common bulk formers include:
Metamucil, taken in a dose of one to two teaspoons daily mixed in a glass of water or juice and followed by an extra glass of fluid. This may be increased to one teaspoon taken two or three times per day if necessary;
Perdiem fiber (brown container), taken in a dose of one to two rounded teaspoons daily; it should be placed in the mouth (not chewed) and swallowed with at least eight (preferably more) ounces of cool beverage;
FiberCon, two tablets, one to four times a day; each dose should be followed by eight ounces of liquid;
Citrucel, one tablespoon, one to three times daily, mixed in eight ounces of juice or water;
Fiberall, available in chewable tablets, wafers, or powder, may be taken one to three times a day with eight ounces of liquid.
STOOL SOFTENERS
If the cause of constipation is hard stool, stool softeners are used to draw increased amounts of water from body tissues into the bowel, thereby decreasing hardness and facilitating elimination. Consistent use is recommended to obtain maximal benefit; as with bulk formers, stool softeners are not habit-forming. They include:
Colace (also known as DSS); take one pill every morning and evening;
Surfak; take one pill every morning; and
Chronulac syrup; take one ounce every evening, increasing to one ounce each morning and evening if necessary.
LAXATIVES (ORAL STIMULANTS)
If difficulty in expelling stool is the cause of constipation, it may be corrected with laxatives, also referred to as oral stimulants.
Laxatives provide a chemical irritant to the bowel. Although a number of over-the-counter laxatives are available, care should be taken to avoid the use of harsh laxatives, which may be highly habit-forming. The same results may be obtained by using the following milder laxatives, which are less harmful to the bowel and induce bowel movements gently, usually overnight or within 8 to 12 hours:
Pericolace; take one or two capsules at bedtime; increase to two capsules twice a day if necessary;
Perdiem (yellow container, not to be confused with the bulk former Perdiem Plain), which contains the bulk former found in Perdiem Plain plus a mild stimulant or laxative effect; take one or two teaspoons once a day, placed in the mouth and swallowed with at least eight ounces of cool liquid, preferably more; and
Milk of Magnesia; take one ounce at bedtime every other day.
SUPPOSITORIES AND OTHER RECTAL STIMULANTS
Rectal stimulants provide both chemical stimulation and localized mechanical stimulation combined with lubrication to promote stool elimination. They may be used either occasionally when necessary or on a routine daily or every-other-day basis in conjunction with other medications already listed. Suppositories generally act within 15 minutes to an hour. They include:
Glycerin suppositories, which contain no medication and provide rectal stimulation and lubrication for easier passage of stool. Glycerin suppositories are milder and less habit-forming than Dulcolax and are used to help develop a bowel routine;
Dulcolax suppositories, which contain a medication that is absorbed by the lining of the large bowel and stimulates a strong wavelike movement of the rectal muscles that facilitates elimination; and
Therevac mini-enemas, which are not traditional enemas but rather lubricating stimulants in a easy-to-administer shell. This preparation is a clean way of administering a helpful medication to stimulate a bowel movement.
Enemas may be considered an occasional treatment for constipation, but the frequent use of enemas should be avoided because the bowel may become dependent on them when they are used routinely.
In summary, many medications are available without a prescription for the treatment of constipation, but their indiscriminate use should be avoided. A professional should be consulted to determine which medication or combination of medications is best suited to a specific problem. In attempting to control constipation, it may be necessary to begin a bowel program that includes a number of medications. This may seem rather overwhelming in the beginning, but some medications may be eliminated as a routine is established and bowel movements become more regular. Consistency is the key to regulating constipation.
Diarrhea and Incontinence
Diarrhea is much less common than constipation in people with MS. It may, however, be a significant problem because there may not be adequate warning of an impending attack and incontinence may therefore occur. The probable cause of such diarrhea is a reflex-like activity that results from the short-circuiting in MS, causing frequent emptying even though the bowel is not full.
The key to controlling diarrhea is to make the stool bulkier without producing constipation. Bulk formers such as Metamucil or Perdiem Plus may be helpful because they absorb water and therefore make the stool firmer. When it is used to treat diarrhea, a bulk former should be taken no more than once a day, and it should not be followed by the recommended extra fluid that is needed when a bulk former is used to treat constipation. In extreme cases, medications that slow the movement of the bowel muscles, such as Kaopectate, Imodium, or Lomotil, may be needed to control diarrhea.
Other causes of diarrhea must be considered. A loose stool in a person with MS most often is caused by something other than MS!
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