Other Digestive Disorders

Achalasia / Acid Reflux / Dyspepsia / Mid Gut Disorders / Bad Bowels

Bad Bowels: Constipation / Diarrhea

Slow transit constipation, and colonic inertia are extensively covered under our diabetic section. Even if you are not diabetic, this information will be of help to you since the disordered nerve-gut problem in diabetics is similar. The diagnosis and treatment of these problems too is very similar.

When Your Bowels are Misbehaving.

Diarrhea / Constipation--What to do, How to Cope.

Perhaps not a topic for casual conversation, yet when your bowels are misbehaving, you can be stuck in the bathroom for the entire day, all the while putting your upper digestive system into a fit of increased symptoms.

Trying to keep the digestive tract copasetic may seem like a daunting task.

Here are some tips and practical suggestions. What may work for one does not work for others. Use these suggestions as an approach to try various tactics. Review these ideas with your doctor and devise a systematic plan.

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Coping with Diarrhea:

I. Review all medications, vitamins and supplements with your doctor or dietitian.

• Many medications and vitamin supplements can alter bowel habits.

II. Small bowel bacterial overgrowth is a very common problem for individuals with gastrointestinal motility disorders, and for individuals who are on acid-suppressing medication for treating esophageal reflux. Fiber foods feed the problem. If you bloat badly, especially after eating whole grain cereals, ask your doctor to test you for this problem (or it can be safely treated with antibiotics without bothering to test). One new antibiotic ideally suited for treating SBBO (because it stays in the intestinal tract and is not readily absorbed into the body) is Rifaximin. SBBO usually causes diarrhea, but if excess methane is produced by bacteria in the small gut, then constipation can present as the overriding problem.

III. Enteral feedings can cause diarrhea. Explore this problem carefully with your dietitian. Things to consider when trouble shooting:

• Many liquid medications that you place in your enteral tube may have a high sorbitol concentration. Sorbitol is a sugar and an effective laxative.

• Fiber in the enteral formula may be “feeding” a bacterial overgrowth.

• Some calcium and iron supplements may be at fault.

• Position of the feeding tube inside the intestine, (feeding into the ileum instead of jejunum).

• Calorie-dense formulas given too rapidly.

• Bacterial contamination of the formula solution.

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When diarrhea persists without explanation, then other remedies can be tried. A new natural product available over the counter has been found in clinical trials to be very effective for treating chronic diarrhea from a variety of causes. It is a natural yeast (not all types of yeast are bad) that acts as a probiotic and helps to stabilize the lining of the digestive tract. Called Florastor, it is widely available, safe and effective.

Medications commonly used for threating pain and discomfort from irritable bowel syndrome may also be of help for treating diarrhea. This class of medications -- called antispasmodics / anticholinergics help to relax smooth muscle and have been used for decades in the treatment of spastic bladder and bowel conditions. The anticholinergic effects helps to slow transit along the entire length of the digestive tract and alliviate diarrhea. This class of durgs however may not provide much relief for the symptom of bloating. You may ask your physician for a short-term perscription to see if one of these mediations helps releive your symptom of diarrhea:

• Bentyl (dicyclomine)
• Levbid, Levsin (hyoscyamine)
• Buscopan (butylscopolmine)

For those suffering from abdominal pain along with diarrhea, or constipation, relief may be found through the addition of another drug called:

• Modulon® (trimebutine maleate), 

licensed by Axcan Pharma (a Canadian phamaceutical company) the drug has been available since the late 1960's. Classified as an antispasmodic it also helps to regulate lower bowel motility. 

Another drug used for the treatment of diarrhea predominating IBS was Lotronex®, (alosatron). Lotronex proved to be a very potent 5HT3 antagonist, which resulted in deleterious side-effects of ischemic colitis. This rare, but very serious side-effect was found associated with a number of deaths. Lotronex has since been placed under a special access program by the US Food and drug administration. However, there is another option form this same pharmocological class of drugs -- Zofran®. Zofran (ondansetron) too is a 5HT3 antagonist, but not nearly as potent in binding to the 5HT3 receptors.

Also, this category of drugs all possess anti-nauseant effects. Many people suffering from lower bowel IBS-D (diarrhea predominate IBS) symptoms also have trouble with upper digestive symptoms like nausea. Therefore relief for diarrhea and nausea can be effectively achieved with Zofran. Unfortunately, zofran is a very expensive medication -- but if your life has been reduce to being confined to your home due to uncontrollable diarrhea -- then the cost of the medication -- if it brings symptom relief -- is of great value.

Dietary manipulation can also prove to be highly effective at controlling problems of rapid transit diarrhea. By manipulating the body's normal physiological response to fats when present in the small intestine, it is possible to trigger the "ileal break" and slow small bowel transit thus halting diarrhea.

To use this dietary technique requires obtaining pure oleic acid (olive oil is primarily oleic acid, but contains other acids as well, therefore will not work) from a food chemical supply house. For more details on how to use this dietary method, please see our patient educational booklet titled: "Gas, Bloating and Belching".

Cholestyramine is also another safe medication that can help reduce diarrhea, especially resulting after removal of the gall bladder. This medication binds bile salts. It can interfere with the absorption of some vitamins and medications, so check with your doctor.

Finally, Caltrate, which is a calcium supplement can also effectively help control diarrhea.

Intolerance to dietary sugars can also be another cause of diarrhea. Having chronic upper digestive problems makes it very difficult to sort out contributing factors to digestive distress and problems like diarrhea. Post-surgical gastroparesis, and/or vagal nerve damage, creates increased problems of lactose intolerance. Other sugars, too, like fructose, sucrose and sorbitol can cause persistent diarrhea.

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What About Constipation?

Constipation is a very common problem for individuals suffering from upper gut motility problems; or constipation may present in a severe form and represent a more generalized gut dysmotility affecting the whole gastrointestinal tract. Many of the medications discussed in this newsletter for treating the pain of gastroparesis the TCA medications, SSRIs, all the anti-cholenergic (anti-spasmodic medications) and many others also cause problems with constipation.

For treating constipation, numerous over-the-counter and alternative remedies are available; yet many people are still suffering.

Sorting out what is clinically effective for most is the trick. Suggestions are:

• Polyethylene glycol, or PEG (Miralax), seems to be better tolerated and slightly more effective than lactulose. Combined with prescription medications like Tegaserod, this is an effective approach for severe constipation.

• For less severe problems, dietary means can work well. As mentioned, foods high in sorbitol act as a laxative.

• A natural product called Fruit-eze available only from a single supplier: www.fruit-eze.com, or by calling:1-888-regular. Using a blending of natural fruit sugars, Fruit-eze provides a very gentle laxative action.

• Adequate hydration is key for everyone.

• Fiber is usually not well tolerated by patients with motility problems.

• Stool softeners and lubricant laxatives (like heavy mineral oil provided you don't have severe nocturnal reflux problems) are all good choices.

For those on enteral tube feedings, ensuring adequate hydration is essential to avoid hard stools. Your dietitian should map out for you the additional water required over and above your enteral feeding formula.

Getting into a walking regimen, if your upper digestive symptoms will permit, also is very helpful.