Gastrointestinal (GI)
The complex and integrated functions of the gastrointestinal system require input from the peripheral nerves that innervate the GI tract. These peripheral nerves are ultimately regulated by the brain and spinal cord. Thus, neurologic illnesses that disrupt the normal functioning of the central nervous system, such as multiple sclerosis, can lead to significant gastrointestinal problems.
At UPMC, we have begun to provide a coordinated approach between our neurogastroenterologists at the Center for Neurogastroenterology and neurologists at the Center for Neuroimmunology to best provide care for MS patients suffering from these varied GI symptoms. This collaborative approach allows us to optimize patient care and also serves as a ready platform for clinical research that can advance our understanding and improve treatment options.
Nearly two-thirds of MS patients have at least one GI symptom that persists for 6 months or more. Some of the most common problems are: 1) Dysphagia, 2) Heartburn, 3) Nausea, 4) Dyspepsia, 5) Diarrhea, 6) Constipation, and 7) Fecal Incontinence. Below, you will find a brief overview of these six GI symptoms and some remedies that can be tried at home even before seeing your physician. However, as always, tell your doctors about new symptoms and any new treatments you are using.
Dysphagia
Dysphagia refers to problems swallowing. Such problems are distressing and, in severe forms, can lead to unintended inhalation of secretions or ingested food (“aspiration”) or chronic weight loss from inability to eat. Tell your physician about these symptoms, as significant problems can develop if the issue is not recognized. Your physician may order testing of swallowing function and refer you to see someone in Speech Pathology, a medical field that focuses not only on disorders of speech but also on swallowing.
Dietary habits:
Many patients find that they choke or sputter when ingesting thin liquids (water-like consistency). Slowly drinking thicker, shake-like consistency liquids may help. Taking small bites of food and chewing extensively before swallowing can help as well.
Speech Pathology:
Practitioners in this field of medicine can help identify specific problems, recommend dietary changes, and help with physical therapies and exercises to improve swallowing function.
Heartburn
Heartburn is a burning sensation typically located in the low to mid chest and accompanied by either sour taste in the mouth, regurgitation, or abdominal discomfort. Patients with MS can suffer from heartburn at rates that appear to be comparable to the general population (about 10-15%). Please talk to your PCP about medication for heartburn.
Lifestyle interventions:
Some foods and habits can predispose to acid reflux, such as smoking cigarettes, consuming alcohol, and eating chocolate, caffeine, or spicy foods. Heartburn also tends to be worse in those that have gained a significant amount of weight.
Other interventions include raising the head of the bed up a few inches (using wood blocks), such that at night, even while lying flat relative to the bed, gravity favors the retention of material in the stomach and minimizes reflux.
Nausea
Nausea is an unpleasant feeling, typically localizable to the upper abdomen, that often precedes vomiting. However, several people have nausea without actually vomiting, and these patients tend to have a poor appetite and may even lose weight because of avoiding food. For unclear reasons, about 10% of MS patients feel persistently nauseated. It is a symptom that should be mentioned to your doctors, who may consider further testing looking for an underlying cause or a change of medications (nausea is often a side effect of medications).
Constipation
Hard and/or infrequent bowel movements that are difficult to pass define constipation. While impaired mobility of any cause is a known contributor to constipation, MS patients who lack any significant mobility impairment still frequently experience constipation. Up to ~40% of all MS patients experience constipation at some point in their illness. Some people can be severely constipated and experience bloating and abdominal pain.
If stools are only slightly hard and there is no significant chronic bloating or abdominal pain:
Make dietary changes that include:
Fiber – Adding fiber in the diet or using fiber supplements can be helpful. Fiber is not significantly digested and binds water, therefore, softens stools if they are hard.
Dietary laxatives – Many fruits have naturally occurring sugars that can act as mild laxatives, such as apples, pears, and prunes. If constipation is not severe, then adding these foods to the diet can improve constipation.
If stools are very infrequent (1-2 per week) and there tends to be bloating and abdominal discomfort, use over-the-counter laxatives:
Osmotic laxatives: There are many options, including milk of magnesia, Magnesium Citrate, and PEG-3350 (Miralax). Lactulose tends to cause bloating (it is fermented by colon bacteria) and is generally not a good first choice.
Stimulant laxatives: These include senna products (Sennakot) and bisacodyl (Dulcolax).
Diarrhea
Very loose or watery bowel movements and/or a significant increase in the frequency of bowel movements defines diarrhea. There are many potential causes of diarrhea, including intestinal infection, medication side effects, or potentially a consequence of MS disease itself, although by far more MS patients suffer from constipation. Without any other symptoms such as fever, chills, abdominal pain, nausea, vomiting, or blood in the stool, diarrhea is more likely to be of a benign cause. Yet, it should be mentioned to your physician if it persists, as this may warrant further testing to rule out more subtle forms of intestinal infection.
Dietary changes:
Fiber – If stools are of only slightly loose or muddy consistency and not of profound volume, then bulking stools by increasing dietary fiber or using fiber supplements can be helpful. Fiber is not significantly digested and tends to “bind water,” therefore leading to more formed stools if they were loose.
Anti-diarrheal medications: There are several over-the-counter preparations to help directly counteract diarrhea and firm up stool, such as Kaopectate and Peptobismol. Other medications work to slow down the contractions of the colon, such as Imodium. In general, these medications are safe, but you should notify your physician if the diarrhea is persistent enough to need these medications longer than 2 weeks.
Fecal incontinence
Fecal incontinence refers to impairment in the ability to retain fecal material in the rectum. It can range in severity from occasional staining of material in undergarments (“fecal soiling”) to persistent and unwanted passage of fully formed stool. While fecal incontinence is seen in up to 5-8% of both men and women over the age of 50 and tends to increase with age, many patients with MS of any age (~15-20%) can experience these issues. This is likely due to MS-related impairments in both rectal and anal sensation, as well as impaired motor function of pelvic floor muscles and the anal sphincter. Many MS patients suffer from impaired mobility, and this in and of itself can be a factor to fecal incontinence due to not having sufficient time to find a commode.
Physical therapy can potentially improve some of the pelvic muscle strength needed to support fecal (and urinary) continence mechanisms.
Referral to GI specialists may be necessary.
Reference:
1. Levinthal, DJ, Rahman A, Nusrat S, O’Leary M, Heyman R, Bielefeldt K (2013) Adding to the Burden: Gastrointestinal Symptoms and Syndromes in Multiple Sclerosis. Multiple Sclerosis International vol 2013: 319201.