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. Historically, it was believed that the GI problems seen in MS patients were restricted to impairments in swallowing and defecation, which both require coordinated activity in skeletal muscles. However, newer research has shown that many patients with MS suffer from gastrointestinal symptoms that would not appear to be linked with impairments in skeletal muscle function.
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. Dysphagia, particularly during the initial phases of swallowing while material is moved from the mouth to the back of the throat (“oropharyngeal phase”), is common in the MS population, with about 20% of patients reporting symptoms. Dysphagia presumably occurs because of a direct MS impairment in the refined coordination of muscles required for an efficient swallow. 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 more thick, shake-like consistency liquids may help. Taking small bites of food and chewing extensively before swallowing can help as well.
Head position:
In general, bending one’s head forward closes the entrance to the airway and opens the opening to the food pipe “esophagus”. Swallowing in this “chin-tuck” position should favor the passage of food and/or drink without choking. One should avoid eating or drinking while lying down or reclining.
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%). Heartburn is classically felt as being worse after meals or while lying flat. Heartburn can arise from anatomical defects or impairment in the neural control of the muscle barrier between the esophagus (“food pipe”) and the stomach. Most of the symptoms of heartburn are due to the presence of acidic material from the stomach refluxing up into the esophagus and irritating the esophageal lining. Therefore, therapies that either reduce acid and/or minimize reflux are the most helpful.
Antacids:
There are numerous products available to neutralize acid and provide quick heartburn relief. These include calcium carbonate (TUMS), milk of magnesia/Maalox, and Gaviscon, which are available in pill and/or liquid forms. If these remedies help, then acid reflux is likely and other systemic medications may be necessary.
Acid suppression:
These medications stop stomach acid from being produced, rather than neutralize existing acid. The most commonly available over-the-counter medications include: ranitidine (Zantac), famotidine (Pepcid), and omeprazole (Prilosec). These medications suppress acid production for most of the day. Omeprazole is best taken 30 minutes prior a meal, and many patients take ranitidine or famotidine at night to prevent nighttime 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). For example, the new MS disease modifying agent Tecfidera (dimethyl fumerate) often leads to nausea, particularly when the medication is started. At home, there are a few options for nausea relief.
Herbal remedies:
Concentrated ginger has long been used as a medicinal approach to relieve nausea. Ginger is widely available in an extract (pill or capsule) or as a tea. Some people have relief with peppermint oil extract (pill or capsule) or peppermint sucking candies.
Medications:
If you have a history of motion sickness, or if vertigo, dizziness/imbalance, or ringing in the ears (“tinnitus”) accompanies your nausea, then nausea may be due to a vestibular (or “inner ear”) problem. In this case, over-the-counter medications that target the inner ear can help relieve nausea (as well as vertigo, imbalance, and tinnitus). These medications include: Dimenhydrinate (Dramamine) and meclizine (Antivert).
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. Most constipation is due to impairment in the transit of material through the colon (“slow transit constipation”), but in some instances, constipation occurs due to impaired coordination of the anal sphincter muscles and the rectum (“dyssynergic defecation”). If constipation is not improved with dietary approaches or over-the-counter medications, then you should certainly see your doctor for further evaluation.
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).
Dyspepsia
Dyspepsia is the collective medical term for upper abdominal pain, bloating, and easy sense of fullness that tend to be worse after eating. Some people also feel nauseated in this context. There are innumerable potential causes of dyspeptic symptoms, and you should notify your doctor if there is a sudden development of these symptoms. It would appear that up to 25-30% of all MS patients suffer from dyspepsia, a rate that is about twice that of the general population. If the symptoms are persistent, then a referral to a gastroenterologist may be warranted to look for structural problems with the stomach (such as an ulcer) or irritation of the stomach lining (gastritis).
Herbal remedies:
Iberogast is a liquid mix of herbal extracts with high-quality medical evidence supporting its use for alleviating many dyspeptic symptoms. It is generally taken in 20 drops mixed in a drink twice or three times daily. It is mostly available via online purchase (Amazon.com).
Trial of acid suppression:
In some individuals, dyspeptic symptoms diminish with lower stomach acid levels. Therefore, over-the-counter medications to try include: ranitidine (Zantac), famotidine (Pepcid), and omeprazole (Prilosec).
Dietary changes:
Avoiding fried, fatty, or spicy foods can improve symptoms. In general, eating smaller, more frequent meals (“grazing” or “snacking”) rather than relying on 3 larger meals per day can improve dyspepsia.
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. In some circumstances, in the context of chronic constipation, stool output can abruptly shift to become liquidy as a consequence of a fecal impaction, during which time the only material that can pass by the blockage is liquid (“overflow diarrhea”).
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.
Avoid “non-absorbable” sugars – Many naturally occurring sugars can have mild laxative effects. These include sugars ending in “-ol” (sorbitol, xylitol, mannitol) or “-ose” (lactulose, fructose). Many of these sugars are commonly found in apples, pears, and prunes. Other artificial sweeteners such as Splenda (sucralose) and Truvia (erythritol) can similarly lead to diarrhea if used frequently.
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.
In general, the single factor that improves fecal incontinence is improving stool form. Liquid stools pose the most challenge to continence mechanisms, and bulking stool and reducing stool frequency often is very helpful. Bulking stool tends to provide a sense of rectal filling, giving enough time to get to the restroom and evacuate stool. Physical therapy can potentially improve some of the pelvic muscle strength needed to support fecal (and urinary) continence mechanisms.
Yet, many patients suffer from both fecal incontinence and constipation, which is challenging to treat. The general concept here is that, if the rectum is empty, then there is nothing that could “leak”. The use of a “planned evacuation” strategy using rectal suppositories to induce a bowel movement within a short time frame (waiting near the commode) should provide several hours or even a day or two without rectal filling and the possibility of fecal incontinence. The goal is to avoid incontinence while having frequent enough bowel movements to avoid chronic bloating and abdominal discomfort from constipation.
These concepts lead to the following general recommendations for fecal incontinence:
Underlying pattern is generally looser stool with liquidy/muddy fecal incontinence: Bulk stools with fiber and/or low daily dose of an anti-diarrheal agent
Underlying pattern is generally harder stool with fecal incontinence of any consistency: “Timed evacuation” strategy using rectal suppositories — glycerin (Fleet’s) or bisacodyl (Dulcolax) — on a regular basis ranging from every day to every 3rd day
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.