Posted by: Thixia | July 4, 2008

MS and the Bowel 4 of 6

 

 

 

Managing severe constipation

 

The five general measures can help many people, but if you have severe constipation, you will need professional advice. There are several treatments to try – in sequence and then in combination. It can be a case of trial and error, and testing things in a systematic way by trying or adding one thing at a time to see what works. It is likely that, over time, you will need further professional advice to reassess how you manage.

 

Treatments for severe constipation

 

Any person with MS who has apparent constipation (pain on or difficulty with defecation, bowels open less than twice a week) should be offered advice on fluid intake and dietary changes that might help, and then be considered for oral laxatives.

 

A general aim of a number of treatments is to try to reduce ‘transit time’ (the time waste spends in the gut) and keep stool soft. Other treatments are focused more towards stimulating the bowel to act. Note that nearly all laxatives become less effective over time, so keep to a minimum that works for you. If you can find two or three that work, you can rotate them. If you take treatments and/or adopt techniques to help, do so with advice from a health professional.

 

 

Bulking agents

 

These act by increasing the mass of the stools that then stretch the bowel wall to help stimulate waves of contraction in the colon. (If you stretch the bowel, it stimulates pressure and contraction.) Bulky, softer stools can also be easier and more comfortable to pass. If the gut is slow, however, bulking agents might not be suitable (see the point about fibre). For example, if there is hard stool around the rectum, a stool softener (see below) might be the right treatment to try instead. A number of bulking agents are the undigestible parts of plants, like husks or stalks. Bulking agents include natural bran, sterculia (e.g. Normacol), ispaghula husk (e.g. Fybogel or Manevac) and methylcellulose (e.g. Celevac).

 

Stool softeners

 

As the name says, these try to keep the waste soft, adding a softener such as an oily substance to the stool. Stool softeners work in a similar way to bulking agents, but they do not increase bulk in the same way. They help stools to retain moisture and stay soft and bulky as they pass through the colon, and you may not get as much bloating as with a bulking agent. Stool softeners include castor oil and sodium docusate (e.g. Dioctyl).

 

Osmotic laxatives

 

These try to stop the bowel from drawing out the fluid from the stools and keep fluid in the bowel. (The colon acts osmotically; that is, drawing out fluid from the stools through the walls of the colon.) Again, the aim is for stools to stay soft and bulky. Osmotic laxatives include lactulose, and polyethylene glycol (e.g. Movicol). If you take too much, however, they can produce liquid stool.

 

Stimulant laxatives

 

These contain medications to stimulate the pressure waves in the colon to ‘get the gut going’. They are sometimes described as harsh, but they can be reliable and effective, providing you take the right dose. A professional can help you ‘titrate’ or vary the dose so the stools do not become liquid and cause excessive urgency. They can cause cramping if, for example, you have a build-up of hard stool. Stimulant laxatives include senna, and bisacodyl (e.g. Dulco-Lax).

 

Suppositories and enemas

 

These stimulate the wall of the rectum to push stool out, or distend the rectum to get a reflex action. They can be useful to expel the contents of the rectum. They are given either as a suppository (a firm jelly-like preparation that is inserted into the rectum) or as an enema (a fluid that is inserted into the rectum). One advantage they have is that you can predict your bowel movements. They may also help stimulate the bowel ‘further up’.

 

Glycerine suppositories are medication-free. They have a mildly irritating action that promotes emptying of the bowels. Other suppositories contain a stimulant medication. Similarly, an enema might be medication-free (e.g. water enema) or contain stimulant.

 

The experiences of people with spinal cord injury suggest that it is best to begin with a glycerine suppository and only progress if necessary to other treatments such as a bisacodyl suppository, sodium citrate micro-enema and ultimately a phosphate enema. For example, some people with MS use glycerine suppositories on a regular basis. Again, seek professional advice.

 

If a person with MS has apparent constipation (pain on or difficulty with passing stools, their bowels open less than twice a week) despite treatment with oral laxatives, they should be considered for the routine use of suppositories or enemas.

 

Digitation: Some people with MS are taught a method of using their finger (a ‘digit’) to help the stool out. ‘Digital stimulation’ massages the anal sphincter muscles to get the rectum and anus to respond and expel stool. ‘Manual evacuation’ is like hooking the stool from within the rectum. Do take advice from a health professional before you try either of these techniques.

 

 Further tests and treatments for managing severe constipation

 

A gastroenterologist can carry out different tests to establish which aspects of bowel function may be causing problems, and where there is good function, too. They can measure transit time through the gut (using radio opaque markers), use x-rays to help analyse the way the rectum and anus are working (defaecography), make measurements of ‘squeezing pressures’ of sphincter muscles (anorectal manometry) or use a very small telescope to inspect the lining of the bowel (endoscopy). Tests can help a specialist advise on overall management. Other treatments to consider with a health professional include the following:

 

Irrigation: Washing out the bowel may help to stimulate it. This is not the same procedure, however, as colonic irrigation.

 

Abdominal massage: You can be taught how to apply firm massage to your abdomen in the direction of the flow of the colon for several minutes.

 

Complementary therapies: Some people report benefits from therapies such as reflexology, acupuncture and hypnotherapy, although there is no evidence to support their use and such treatments can prove expensive.

 

Biofeedback: This is a way of trying to ‘retrain’ the bowel. A course of biofeedback sessions may help people become more aware when their rectum is full, for example. There is limited research in MS, but one study suggests biofeedback may benefit people with MS who have minimal disability and a non-progressive disease course. Continence advisers are likely to know where biofeedback sessions might be held locally.

 

Surgery: This is a rare last resort for constipation when doctors can identify a problem that can be corrected by surgery. Surgery requires careful evaluation – it can make matters worse. Colostomy (diversion of the large bowel to an artificial opening in the abdominal wall), or ileostomy (diversion of the small bowel to an artificial opening in the abdominal wall) may improve the quality of life for people with severe disability. An antegrade continence enema (ACE, also known as the ‘Malone operation’) allows irrigation of the bowel and has been successful in some people with MS. In rare instances, it is possible that chronic straining can result in a blockage of the bowel, when it ‘turns in on itself’. So-called ‘intussusception’ or rectal prolapse might be the problem in people who have severe difficulty emptying their bowels and a continuous sensation of incomplete evacuation. Surgery can correct this and ‘straighten out’ the bowel.

 

 

 

Compliments of:MS Society, UK

 

Bowel,constipation,bladder,coping, Diarrhoea,exercises,sphincter exercises,constipated,bowel incontinence,

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