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Michael Okun Indu Subramanian Jonny Acheson

 

5 reasons to consider seeing a gastroenterology (GI) doc if you have Parkinson's disease

One important life lesson for navigating the healthcare system is knowing “who should be in the room?” When it comes to Parkinson’s disease, we frequently overlook “available” expertise, which if properly deployed, can help to tackle challenging PD symptoms. In this month’s blog, we will delve into 5 reasons why you should consider consulting a gastroenterologist (GI) doc as part of your care team.

I am struggling with constipation with my Parkinson’s.

I am not sure my Parkinson’s medications are

absorbing properly.

Constipation is one of the most common and disabling symptoms in Parkinson’s disease. Constipation can be treated by your family practice doctor, your internist, your physician’s assistant, your nurse practitioner, your nurse or your neurologist. It may be surprising for you to learn that despite all of these “experts” trialing constipation formulas— including medications and other concoctions— that in some cases all the potential solutions fall short. A GI doctor can provide a a deeper knowledge of this topic— and also can employ more aggressive strategies to “get you moving.”

We wrote about some of the most common constipation treatments on the blogin November of 2012.

General Treatment Tips for Parkinson’s Constipation

  • Daily vigorous exercise as is possible

  • Drinking 6-8 glasses of water a day

More severe cases are characterized by the following and we offer a few considerations:

  • Constipation is an alteration in stool frequency, consistency, and/or passage of stool

  • The normal pattern of bowel movements can and will vary

  • A stool-voiding pattern of every day or every other day is optimalCauses

Diet – Fiber-rich foods:  bran, whole-grain breads – oat, rye, fruits, vegetables (leave peel on), whole-grain cereals, oatmeal, pasta, nuts, popcorn and brown rice.

Watch out for these medications that may result in constipation-  narcotics, sedatives, antacids, antispasmodics, iron supplements

Daily recommended fiber intake:  20 – 30 grams

A NATURAL RECIPE SOME FOLKS LIKE TO USE FOR CONSTIPATION:

Miller’s (unprocessed wheat) Bran*        1 cup

Applesauce                                      ½ cup

Prune Juice                                      ½ cup

Mix and refrigerate.

Take 1 – 2 tablespoons daily for one week 

*Miller’s Bran is unprocessed wheat bran

Sprinkle bran on food to supplement fiber intake

Medications for constipation:

Bulk producing:  Metamucil, Fibercom or Citrucel. Mix 1-2 Tablespoons in juice or water and take by mouth 1 to 2 times daily. This adds consistency or bulk to the stool and facilitates water retention in stool – must take adequate fluids by mouth to avoid causing constipation.

**Some docs avoid metamucil or psyllium as they slow the gut transit.

Stool Softeners:  Colace. Softens stool by facilitating the admixture of fat and water (detergent activity). Do not use with mineral oil. Take 1 tablet by mouth 1 to 2 times daily.

Combinations:  Pericolace. Mild stool softener and laxative combined. Take by mouth 1 to 2 times daily.

Irritant/Stimulant:  Products containing Senna. Laxative with direct action on the intestinal mucosa and the nervous plexus of the bowel.

Suppositories:  Glycerin, Dulcolax. Inserted rectally every other day or when needed. Stimulates the rectum and assists with evacuation.

There are drugs for constipation that your doc can prescribe. One example that has been tried for Parkinson is Amitiza.  

Reference for the Amitiza Parkinson study:

Ondo WG, Kenney C, Sullivan K, Davidson A, Hunter C, Jahan I, McCombs A, Miller A, Zesiewicz TA. Placebo-controlled trial of lubiprostone for constipation associated with Parkinson disease. Neurology. 2012 May 22;78(21):1650-4. doi: 10.1212/WNL.0b013e3182574f28. Epub 2012 May 9. PMID: 22573627.

I am worried my Parkinson’s medications are not

absorbing?

This is a common complaint among persons with Parkinson’s. Either the medication is not absorbing or the medication is not consistently absorbing. The quickest fix is to recommend to the person with Parkinson’s to take the medication— and to wait 30-60 minutes before eating (to allow medication to absorb). If this does not work, or there is still a question, we usually order a gastric emptying study and refer to a GI doctor. A gastric emptying study uses a dye swallowed into your stomach— the radiologist takes pictures to see how long it will take for the dye to exit the stomach. If it doesn’t exit, or is slow to exit, a GI doc may recommend safe medications to help the issue. Note that the drug metoclopramide (commonly used to treat this) is not appropriate in Parkinson’s since it blocks dopamine— and may thus make your symptoms worse.

I am hearing a lot about small intestinal bacterial

overgrowth syndrome (SIBO). Do I need to be

worried about this with my Parkinson’s?

If you have persistent bloating, abdominal pain, diarrhea or have been losing weight, these are all potential symptoms of the small intestinal bacterial overgrowth syndrome (SIBO). The problem with diagnosing this syndrome is that all of these symptoms may commonly occur in Parkinson’s— and a number of other non-Parkinson related disorders.

SIBO in simple terminology is an increased amount of bacteria (referred to as bacterial density) which is larger than 100,000 colony-forming units per millimeter. It has also, alternatively, been defined as abnormal “types of bacteria” in a part of the gastrointestinal tract called the small intestine (the tube right after the stomach).

To make the diagnosis and to receive treatment for this syndrome, it is recommended that you see a GI doctor. The tests the GI doctor may perform to diagnose this syndrome are:

  • Microbial investigation of jejunal aspirate culture (JAC); the jejunum is part of the small intestine. This test is considered the best available and some refer to it as the gold standard.

  • Lactulose hydrogen breath test (LBT).

  • Glucose hydrogen breath test (GBT).

My friends and even some of my doctors are

encouraging me to take a probiotic with my

Parkinson’s?

It seems like a good idea to take a probiotic, however in reality, probiotics could make things worse, better or may not change a thing. It is likely that before we can consistently see success with probiotics, we will need to understand what your individual microbiome looks like prior to consideration of selecting a probiotic . We do not recommend probiotics at this time for Parkinson’s disease.

There is a very expensive microbiome analysis

available for my Parkinson’s. Should I buy this test and

change my diet based on the results?

  • The microbiome has been defined as “all microbes (bacteria, fungi, viruses, genes) that live in the GI tract.

  • The microbiome can change under different conditions (eating, drinking, etc.).

  • We do not know what is normal microbiome— additionally what is a “normal microbiome” for one person may be different for another.

  • We do not know the short and long term affects of changing the microbiome.

In short, you may spend a lot of money on a microbiome analysis— the hard truth is that the experts have no idea yet what to do with the information. You may consider a clinical trial which investigates collection of microbiome and how drugs (probiotics) affect it.

We recommend, if you are worried about small bacterial overgrowth or microbiome related issues, you speak to a GI expert for advice and potential treatment (if indicated).

Selected References:

Fasano A, Visanji NP, Liu LW, Lang AE, Pfeiffer RF. Gastrointestinal dysfunction in Parkinson's disease. Lancet Neurol. 2015 Jun;14(6):625-39. doi: 10.1016/S1474-4422(15)00007-1. PMID: 25987282.

Boulos C, Yaghi N, El Hayeck R, Heraoui GN, Fakhoury-Sayegh N. Nutritional Risk Factors, Microbiota and Parkinson's Disease: What Is the Current Evidence? Nutrients. 2019 Aug 14;11(8):1896. doi: 10.3390/nu11081896. PMID: 31416163; PMCID: PMC6722832.

Wang Q, Luo Y, Ray Chaudhuri K, Reynolds R, Tan EK, Pettersson S. The role of gut dysbiosis in Parkinson's disease: mechanistic insights and therapeutic options. Brain. 2021 Oct 22;144(9):2571-2593. doi: 10.1093/brain/awab156. PMID: 33856024.

Barboza JL, Okun MS, Moshiree B. The treatment of gastroparesis, constipation and small intestinal bacterial overgrowth syndrome in patients with Parkinson's disease. Expert Opin Pharmacother. 2015;16(16):2449-64. doi: 10.1517/14656566.2015.1086747. Epub 2015 Sep 16. PMID: 26374094.

To read more books and articles by Michael S. Okun MD check on Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #Livingwith Parkinson’s #EndingPD #Parkinsonsecrets #LessonsFromTheBedside

He also serves as the Medical Advisor for the Parkinson’s Foundation.

To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance.

Michael Okun