Intermittent diarrhoea in MS
Did you know constipation with intermittent diarrhoea may mean you have faecal impaction? This Newsletter gives advice on how to manage this problem.
Did you know constipation with intermittent diarrhoea may mean you have faecal impaction?
The majority of people with MS have bowel problems, in particular constipation. This occurs because the MS bowel is sluggish due to reduced motility. This can be made worse by anticholinergics that are used for treating urinary frequency and urgency and other medication for example tricyclic antidepressants (e.g. amitriptyline) and opioids (e.g. codeine, morphine, oxycodone, etc.). Over time pwMS may impact their bowels with faeces, which can form a faecolith (faecal stone). Above the hard and impacted faeces or faecolith, the gut bacteria overgrow and liquefy the stool, which is then able to bypass the impaction and cause diarrhoea.
So if you suffer from chronic constipation and intermittent diarrhoea you need to contact your HCP for help. Please note there are other causes of intermittent diarrhoea that need to be excluded as well. The latter include things such as irritable bowel syndrome, inflammatory bowel disease, celiac disease, bile acid malabsorption, diverticular disease, bowel cancer, parasitic and other infections, chronic pancreatitis, hyperthyroidism, etc.
Please note a common cause of intermittent diarrhoea in pwMS is cyclical use of laxatives, i.e. you get constipated and then you use laxatives to treat your constipation. The laxatives then cause diarrhoea so you stop taking them. You then become constipated and the cycle repeats itself.
To manage MS-related constipation you really need to:
Optimise your diet by eating lots of fibre.
Don’t dehydrate yourself. Drink plenty of water and don’t think caffeine and alcoholic beverages are hydrating. Both caffeine and alcohol cause the kidney to make more urine (diuresis) and are in fact dehydrating.
Try and eliminate concomitant medication that exacerbates constipation (anticholinergics and opioids).
Exercise regularly; the anticipation of exercise and exercise stimulates a defaecation reflex.
If you need to use laxatives start with a prokinetic agent that stimulates the bowel to move, for example, senna, and then add in bulking (e.g. psyllium husks or other fibre substitutes) followed by liquifying agents (lactulose or polyethylene glycol).
Don’t suppress the need to go to the toilet; a lot of people with chronic constipation have learnt bad habits, for example, they don’t like using toilets that are unfamiliar to them.
Try and develop a daily bowel routine, for example, by having a bowel movement at a particular time of the day. The best time to do this is in the morning. This may require you to do things to stimulate a bowel movement, for example, eating breakfast, consuming a caffeine-containing drink, anal stimulation (anal plug), glycerine suppositories, mini-enemas and if necessary using an anal irrigation system. I am aware that these sound quite extreme, but they not only prevent faecal impaction they may also give you the confidence to face the day, by avoiding the threat of faecal urgency and urgency incontinence.
For more information please read my MS-Selfie Newsletter Faecal Incontinence from the 4-Aug-2021.
I would be interested to hear if any of you have developed strategies for dealing with chronic MS-related constipation and intermittent diarrhoea that you can share with us.
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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust. The advice is intended as general advice and should not be interpreted as being personal clinical advice. If you have problems please tell your own healthcare professional who will be able to help you.
My partner has a very unpleasant experience. Initially (20 year ago) he was getting constipation, had many problems and tried different treatments including movicol, but that did not work well for him. Someone in health food shop recommended magnesium which he started taking, this made a huge difference and he was fine for a number of years, went every night at the same time. Then he started getting the impaction and dealt with by 'digging for cold' as one of mother-in-law's carers called it :-). Now he does self- irrigation. The pattern is, he has a couple of days where the digging thing works. Then the next day it will be a 'bad one' where he gets loads of black sludge (from the iron tablets he has to take) - then he will irrigate to make sure he's clear. Perched on the toilet for nearly an hour. Left side is weak but he is still able to clean himself up. He's had various tests, I think his bowel muscles don't work properly because of the MS so they have weakened. Are there exercises for the bowel muscles??? Very helpful reading what other people are doing. I like the imodium/ducolax idea, but I don't think he would try that. A bidet would be nice! But they're too low, he wouldn't be able to get off it. Fabulous blog!
The biggest impact on my life with MS is my bowel! The problems began around the beginning of the century, 5 years after diagnosis in 1995, so I’ve been living with this and trying various things for over 20 years. You name a laxative and I’ve probably tried it! I started with the obvious, more fibre/water to no great effect. After 10 years a visit to a continence nurse convinced me that I needed laxatives. I monitored my fluid intake and discovered I was drinking 4 L of water daily and I was still constipated! Her suggestion was to use Movicol which to begin with was brilliant.
However after two weeks using daily I began to lose control of my bowel. I described my motions as cream cheese. It was unbearable, I couldn’t go out because I had lost all control. I went back to the continence nurse who told me I needed to balance the Movicol with Imodium. That apparently is what all ‘her’ ladies with MS do.
Telling someone who has been constipated for 10 years to use something that will bung them up seemed ridiculous to me so I went to see a GP. Together we came up with another option which was to use Docusate (brings water into the bowel)and Dulcolax (stimulator) in combination.
This worked to begin with however I started to get the diarrhoea effect again so I stopped using docusate and began to take one Dulcolax at night. This is still my routine to this day and 80% of the time it works.
In 2018 I went on a big trip to South Africa and I was worried about being constipated on that 3 1/2 week holiday. I didn’t need to worry because I discovered something, sitting in a car driving on bumpy gravel roads meant that I had no problems with my bowel. Since coming home I bought a vibrating pad off Facebook marketplace for eight quid and if I get constipated I sit on that for five minutes and it sorts me out!
I do still get occasional bouts of diarrhoea where I have urgency and need to be near at loo I’m beginning to learn the signals that this might be about to happen. What I have learnt is I probably only need six Dulcolax each week, so I miss out Sunday night.
Sorry for the long post…20 years worth of bowel trouble! One tip…get a bidet … mine is invaluable!