#T4TD Intermittent diarrhoea?

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Did you know constipation with intermittent diarrhoea may mean you have faecal impaction? 

The majority of people with MS who have bowel problems suffer from constipation. This occurs because the MS bowel is sluggish due to reduced motility. This can be made worse by anticholinergic drugs that are used for treating urinary frequency and urgency. 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 another cause of this problem 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 again and the cycle repeats itself. 

To manage MS-related constipation  you really need to:

  1. Optimise your diet by eating lots of fibre.
  2. Don’t dehydrate yourself. Drink plenty of water and don’t equate caffeine and alcoholic beverages as hydrating. Both caffeine and alcohol cause the kidney to make more urine (diuresis) and are in fact dehydrating.
  3. Try and eliminate concomitant medication that exacerbates constipation (anticholinergics and opioids).
  4. Exercise regularly; the anticipation of exercise and exercise stimulates a defaecation reflex.
  5. 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).
  6. 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. 

#T4TD = Thought for the Day

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About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

14 comments

    • No, you can examine the abdomen and often palpate (feel) a distended colon with hard faeces. If you a rectal examination the rectum is often empty as the impaction occurs higher up.

    • Yes, magnesium sulphate or Epsom salts can be used, but you need to go very slowly with the dose as it can cause severe abdominal cramps. I prefer using polyethylene glycol (Movicol) and titrate up the dose slowly.

  • So I’ve had bowel issues with my MS for some years. I have a good diet and apply all the suggestions in your post. I now use Navarna Smart system. Irrigation system. It’s really liberated my life. I can even go swimming now, Once Covid is under control I can return to the pool. It’s electronic so is not difficult to use. At least now I know I won’t get caught short.

  • When I am jogging I have bowel incontinence and have to wear a diaper. I do not have problems any other time. Any suggestions? I love running and do not want to give it up.

    • You need to see a pelvic floor specialist. There are many causes for this including a prolapse. It is treatable.

      • I thought this was one of my first MS signs. Is it unrelated?

        I did see a pelvic floor expert for almost a year, but it did not help.

        • It could be MS-related, but also incidental and unrelated. You need to have a full pelvic floor assessment including neurophysiological assessments to see if this is neurogenic or mechanical. It is important to know that there are potential treatments for both.

  • “5.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).

    Prof G the point above implies that you would end up taking Senna plus bulking agents plus liquefying agents all in one go eventually
    Is that what you mean?
    Would you not just use Senna to clear everything then either use a bulking agent like fibrogel or a liquefying agent like movicol?

    • In some people senna is enough, others need senna plus a bulking agent and others need all three. If you are eating a high fibre diet you may simply get away with senna or another prokinetic agent and a liquefying agent. At the end of the day is trial and error and working out the correct combination. Does this makes sense?

  • It does it just seems difficult to find the ideal balance
    I know you don’t give specific advice but after successfully using movicol for years I became more constipated than usual and was prescribed dulcolax on an ongoing basis by my GP with no end date suggested despite the usual no more than 7-days advice on the box
    After just one tablet dulcolax worked far too violently so I’ve been advised to try Senna on an ongoing basis
    After the dulcolax fiasco I have reverted back to movicol to see what happens as I’m scared to try Senna and I’m dubious as to whether people do take Senna on a daily basis. Will your bowel not become too dependent?

    Ps I think your thought of the day blog entries are a really good idea

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