Constipation in ALS


Although we joke about constipation, it is a miserable experience and should never be taken lightly in the ALS patient. Loss of appetite from frequent constipation leads to weight loss, weakness and dehydration. Constipation can progress to blockage in the intestines and nausea, vomiting, and abdominal distension. (Vomiting is very dangerous for a person who cannot turn over when lying on his back because it causes choking.) One early sign of blockage is often overlooked. Repeated small very loose or liquid stools may be ignored or thought to be sufficient when they are actually the result of a large amount of hard stool blocking the bowel with only liquid stool being able to pass around it. The blockage can become so severe as to require hospitalization and possibly even surgery to correct.


What is constipation?

That may sound like a foolish question, but many people think of constipation as having infrequent, dry, hard bowel movements. It is actually defined simply as having stools that are hard to pass. Many people have only a couple of bowel movements a week, but if they do so without straining, they are not constipated.

Normally food is liquified in the stomach by digestive juices and moves through the small intestine in liquid form. Nutrients are absorbed in the small intestine. Waves of muscle contraction called peristalsis moves the remainder along into the large intestine. In the large intestine, water is reabsorbed from the left over waste product, leaving just fecal material (stool) which is moved along and passed out of the body in a bowel movement.

Anything that changes the speed with which foods move through the large intestine interferes with the re-absorption of water and causes problems. Rapid passage causes diarrhea, slowed passage allows too much water to be reabsorbed, leaving hard, dry stool that doesn't move easily through the bowel. Common causes in ALS patients include:

Because so many things contribute to constipation in the ALS patient, the solution may change over time.

How to Prevent or Treat Constipation

Reglan
Another medication sometimes ordered is Reglan. Reglan works primarily in the stomach to empty it faster in order to reduce nausea, vomiting, or esophageal reflux. It's value in treating constipation is minimal.

Enemas

Enemas are necessary for relief occasionally, but are the last resort as a routine method of bowel management. The repeated distension of the bowel will eventually cause loss of bowel tone which aggravates the problem. This "eventual" problem is not a concern for the ALS patient who does not plan on going on a vent, but should be considered when planning a bowel program for long term use.

Establishing a Bowel Routine
Very few people need to have a daily bowel movement. Every other day or third day is typical. Having a routine time when you can spend a longer period of time on the toilet is helpful. Although choosing a time is probably going to be more a matter of convenience for your caregiver, if you already have a certain time of day you are more likely to have a bowel movement, try to arrange for that time.
If having a bowel movement at a consistent time of day is important because you don't always have the necessary help to get to the toilet the rest of the day, you can encourage that schedule. Begin by using a stimulant laxative supposi tory to promote bowel movements on the scheduled day at the chosen time. After 2 weeks, use the suppository only if you can't have a bowel movement on your own. Within a month, you should be able to reduce reduce the stimulant laxative use to infrequent.
An unrushed and private bathroom trip is ideal, but safety and security need to be assured. Having some type of buzzer or doorbell type button (available from Radio Shack) to call for help works well. Arm rests and a seat belt might be necessary for safety. (The correct and safe angle for a seat belt is diagonal as they are in cars: The belt is around the hips and anchored lower. A belt anchored behind you at stomach level will allow you to slide down through it and end up tight around your chest.)
Sitting upright and as comfortably as possible is also important. A padded toilet seat can be a life saver!
Using a footstool will help put you in the most natural position for a bowel movement, a squatting position. It really does make a difference! Leaning forward over a pillow can help provide the necessary intra-abdominal pressure for pushing.
Drinking a cup of coffee or other hot beverage before or while in the bathroom will often help. Warm water through a feeding tube works as well.

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