Nausea Vomiting And Gastroparesis
Nausea and vomiting are reported by many Parkinsons patients, and may be the result of dopamine-based treatments aimed at alleviating motor symptoms.32 These symptoms can occur as the enteric nervous system of the GI tract, like the central nervous system, makes use of dopamine as a means of communication between neurons.33 Identical receptors for dopamine can be found in the GI tract as in the brain, and these play an important role in the movement of material through the intestinal tract.34 Nausea and vomiting can result from dopamine receptors within the gut interacting with Parkinsons treatments, such as levodopa, that are intended to act upon dopamine receptors in the brain. These symptoms can alleviate over time however, in cases of severe reaction to levodopa therapy, adjustments to treatment made in conjunction with a physician may be necessary. Such adjustments can include changes to dosage, or simply how such medication is taken, for example, by taking medication with a meal.21
What You Need To Know About Gastroparesis And Parkinsons
Gastrointestinal issues are some of the most common symptoms reported by people with Parkinsons. And while symptoms like constipation have gotten much attention, others, like gastroparesis, have not.
Gastroparesis, sometimes called delayed gastric emptying, impacts your stomach and, in turn, your overall digestion. It can cause nausea, vomiting, abdominal pain, blood sugar issues, malnutrition, and dehydration. For people with Parkinsons, gastroparesis can also interfere with the absorption of medications, especially carbidopa/levodopa, which can lead to more OFF times, fewer ON times, and a lower quality of life. Parkinsons can also increase your risk of developing gastroparesis so, its essential that you know the signs of gastroparesis, how to get an accurate diagnosis, and how to manage the condition if its one you experience. In this post, well share information that can help you do just that so you can live well today.
Q What Is Your Opinion Of A Ketogenic Diet With Pd
A. A ketogenic diet is a high fat, moderate protein, and very low carbohydrate diet that forces the body to burn fat as opposed to carbohydrates. It is used clinically to control seizures in children with very difficult-to-control epilepsy.
There have also been some studies to suggest that the ketogenic diet may have a neuroprotective effect, which led to the interest in studying the diet in PD. A recent study compared a low fat versus a ketogenic diet in PD. Interestingly, both diets resulted in improvement of motor scores, whereas the ketogenic diet showed improvement in non-motor scores as well.
It must be noted that the ketogenic diet is very restrictive and therefore very difficult to follow. In addition, it can pose health risks as well, especially to the elderly. It requires ingestion of high levels of fat which is linked to increased cholesterol and heart disease. It also requires a very limited ingestion of foods such as fruits and grains foods that provide nutrients and fiber. With such a limited array of permissible foods, there is a risk of nutrient deficiencies. Constipation, which is often a non-motor feature of PD can be exacerbated as well with a ketogenic diet. Because of the restrictive nature of the diet, it can lead to weight loss, an effect that is not typically desired in the PD population which can have difficulty maintaining weight.
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Pathophysiology Of Gi Dysfunction In Pd
Gastric motility and secretory functions are regulated by an extrinsic neuronal network composed of the sympathetic and parasympathetic systems, and an intrinsic neuronal semiautonomous network, the enteric nervous system . The ENS consists of myenteric plexus and submucous plexus . The myenteric plexus runs between circular and longitudinal muscle layers for the whole length of the gut and primarily provides motor innervation, whereas the submucous plexus plays a role in the control of secretion. The parasympathetic pathway is mainly driven by the vagus nerve, and by the sacral nerves for the distal part of the colon. The extrinsic system cooperates with the intrinsic network, and with the central nervous system. Intramural circuits of the ENS and efferent vagal nerves innervate motor neurons. Excitatory and inhibitory motor neurons drive the motility of the gastric smooth muscle. Interactions between the brainstem and ENS in the form of vago-vagal reflexes determine patterns of normal gastric motor activity .
When Parkinsons Interferes With Gastrointestinal Function
This 63-minute audio with slides by Dr. Peter A. LeWitt discusses the effect of Parkinsons disease on the gastrointestinal system, with particular focus on constipation. Improving GI function can have a positive impact on the consistency of benefit from Parkinsons disease medications. Highlights of recent research into Parkinsons disease originating in the GI tract, developing biomarkers for early diagnosis, and others.
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Parkinsons Disease And The Gut
In Part 1 of this 3-part blog I cover questions or concerns that many of my patients with Parkinsons disease have that center around the gut.
1. Gastrointestinal symptoms of Parkinsons disease
Up to 70% of patients with PD have gastrointestinal symptoms, often beginning years prior to the onset of motor symptoms, along the entire length of the gastrointestinal tract. I will describe the issues that can arise from top to bottom, so to speak.
Symptoms of the mouth and throat include the slowing down and reduction of the swallow response, resulting in drooling or repeated swallows being required in early stages of PD. As the disease progresses, swallowing difficulty may worsen, resulting in aspiration , which can be silent or associated with coughing, choking, or pneumonia. Dysphagia and aspiration should be evaluated by a swallow study, performed by a speech therapist. Treatment recommendations include chewing more slowly, clearing ones throat before taking another bite, eating while sitting up with the chin tucked, and changing the texture of the solids and liquids to be easier and safer to swallow.
For more on management of constipation, please see Part 2 of this blog.
- Green leafy vegetables
Diet Tips For Parkinsons & Gastroparesis
Gastroparesis is a common non-motor symptom of Parkinsons. Also known as slow stomach emptying, gastroparesis slows the movement of food from your stomach to your small intestine. It can greatly impact your quality of life, nutrient intake and the effectiveness of levodopa . Diet advice from a Dietitian will benefit you if you have slow stomach emptying.
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Gastroparesis In Advanced Parkinson Disease
Adolfo Ramirez-Zamora, MD: There are some challenges as well when theres absence. We dont have a biomarker that tells us where the disease is, where we are in the disease progression, or something we can monitor. We rely on interviews with patients and collateral information about how theyre doing with their quality of life. How much attention do you pay to the concern about gastroparesis? There has been some discussion in recent years about how if somebody is having prominent fluctuations, is it just because the problem is in the gut? Do we need to treat H pylori, do we need to give you probiotics, do we need to give you high doses of vitamins, or do we need to do a study to see if your gastrointestinal tract is moving too slowly, and maybe all your pills are sitting in the stomach for a few hours? Do you incorporate that in your practice, Ari?
Adolfo Ramirez-Zamora, MD: Those are great points. Im glad you brought up some of the newer devices because its a hot topic lately. Theres a lot of interest in developing new technologies that will keep track of everything we do, including motor fluctuations or changes in Parkinson symptoms.
Thank you all for watching this Neurology Live® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletter to receive upcoming Peer Exchanges and other great content right in your in-box. Thank you so much.
Transcript Edited for Clarity
Highlights From The Episode
It was a very informative conversation, and we encourage you to watch the full episode , but for your convenience weve listed the topics and questions from the episode below with timestamps, so you can skip to what interests you most:
03:41 Dr. Keshavarzians presentation
28:15 Diarrhea in Parkinsons disease
34:04 How many years does constipation show up before a diagnosis of Parkinsons? How many years may you develop small intestinal bacterial overgrowth before a diagnosis of Parkinsons?
40:07 What are your thoughts on the use of probiotics in someone with Parkinsons?
44:20 Use of prebiotics in someone with Parkinsons
48:59 Pelvic floor physiotherapy
But there were many more questions that came in that we didnt have time to answer during the live broadcast. Today we present some of those additional questions and their answers.
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Q What Medication Can Work For Bloating
A. The first thing to determine is why you are having this symptom. There are many causes of bloating some are related to PD and some are not. It is important to always keep in mind that a person with PD can also have another unrelated disease, so a thorough investigation of every symptom is necessary.
However, there are at least two common causes of bloating that are related to PD gastroparesis, also known as delayed gastric emptying, and constipation. Gastroparesis is treated with lifestyle changes which include eating small frequent meals, drinking fluids during meals, avoiding fat, and taking a walk after eating. In some cases, a medication called prucalopride can be tried to enhance the motility of the gut. Constipation is also treated with lifestyle changes including eating meals at the same time of day, adding fiber to the diet, and eliminating medications that can contribute to constipation. There are many medications on the market both over-the-counter and by prescription that can be very effective to counteract constipation. Many people need to be on a daily medication to keep constipation in check. These medications include: docusate , senna , and polyethylene glycol .
Considering Gi And Non
GI symptoms have a significant influence on the quality of life of those living with Parkinsons, and can reduce the effectiveness of medications such as levodopa. As an example, drooling and difficulty swallowing can result in difficulty taking oral prescriptions. Similarly, gastroparesis can result in changes in response to levodopa treatment by affecting absorption of the drug into the blood stream, and, therefore, into the brain.20,29,39-41 The result of this can be more severe motor-fluctuations in patients, as is also seen in those with other GI conditions that can decrease levodopa absorption, such as small intestinal bacterial overgrowth, or infection with Helicobacter pylori.42 The significance of this is that through appropriate treatment of non-motor and GI symptoms of Parkinsons disease, there is potential for patients to also experience improvement in their response to treatment for motor-symptoms, for a broad improvement in quality of life.
Daniel Levy, PhD, Health Researcher & Writer
First published in the Inside Tract® newsletter issue 211 2019
We thank Maria Marano, Information and Referral Associate, and Julie Wysocki, Director, Research Program, with Parkinson Canada for reviewing this article.
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Conclusions And Future Prospect
Gastroparesis is a frequent disorder in PD patients, and may lead to impaired quality of life, weight loss, and malnutrition. It may also impact drug absorption, and worsen the course of PD.
Much progress has been made in recent years in understanding the pathophysiology of digestive involvement in PD, with a growing role of -synuclein deposits in the ENS and demonstration of its spreading through the vagus nerve, which interacts with the substantia nigra, and impacts gastric motility. New techniques are being developed to obtain adequate endoscopic biopsy samples from the neuromuscular layers of the stomach and the duodenum. These samples could help evaluate the pathological status of the ENS. Evaluation of pyloric dysfunction with specific endoscopic technique also appears as a promising strategy. Correlation between histological findings, new endoscopic technique evaluations, and treatment outcome could help personalize therapeutic strategy.
Controlling Blood Glucose Levels
If you have gastroparesis and diabetes, you will need to control your blood glucose levels, especially hyperglycemia. Hyperglycemia may further delay the emptying of food from your stomach. Your doctor will work with you to make sure your blood glucose levels are not too high or too low and dont keep going up or down. Your doctor may recommend
- taking insulin more often, or changing the type of insulin you take
- taking insulin after, instead of before, meals
- checking your blood glucose levels often after you eat, and taking insulin when you need it
Your doctor will give you specific instructions for taking insulin based on your needs and the severity of your gastroparesis.
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How Is Gastroparesis Linked To Parkinsons
Although researchers are exploring possible connections between Parkinsons and gastroparesis, no definitive conclusions about the underlying disease process or prevalence among people with Parkinsons have been reached. However, researchers believe gastroparesis is underreported and undertreated in the Parkinsons community.
Some research into the pathophysiology of delayed gastric emptying shows an association with mechanisms caused by neuromuscular dysfunction and suggests that gastroparesis in Parkinsons is caused by disturbances in either the vagus nerve or in the myenteric plexus, which is part of the enteric nervous system . Researchers continue to explore the pathophysiology of digestive complications in Parkinsons, looking especially at the role of alpha-synuclein deposits in the ENS and how these may spread through the vagus nerve, which interacts with the substantia nigra.
Other research suggests that some Parkinsons medications, including anticholinergic medications and levodopa, may delay gastric emptying, which may help explain why it is more common among people who have been living with Parkinsons for many years and why it often worsens as Parkinsons progresses.
Management Of Dysphagia And Gastroparesis In Parkinsons Disease In Real
- 1Chulalongkorn Centre of Excellence for Parkinsons Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- 2Academy of Science, Royal Society of Thailand, Bangkok, Thailand
- 3Division of Neurology, Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- 4Department of Basic and Clinical Neurosciences, The Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology & Neuroscience, Parkinsons Foundation Centre of Excellence, Kings College London, London, United Kingdom
- 5National Institute of Mental Health and Neurosciences, Bengaluru, India
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How Do Doctors Treat Gastroparesis
How doctors treat gastroparesis depends on the cause, how severe your symptoms and complications are, and how well you respond to different treatments. Sometimes, treating the cause may stop gastroparesis. If diabetes is causing your gastroparesis, your health care professional will work with you to help control your blood glucose levels. When the cause of your gastroparesis is not known, your doctor will provide treatments to help relieve your symptoms and treat complications.
Q Are There Vitamins Or Herbs That Help The Pd Gut
A. Many people ask if there is a particular supplement, vitamin, or food that people with PD should take to improve their gut health and it is hard to find evidence for a specific supplement. However, as Dr. Keshavarzian said, a great diet for the PD gut is the Mediterranean diet. This diet emphasizes whole grains, vegetables, nuts, legumes, and berries. Fish is the preferred protein and olive oil is the preferred fat. So it seems that a combination of healthy, plant-based eating does more for PD than any one element of that diet.
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Q Please Discuss Fecal Matter Transplants In People With Pd
A. Fecal transplantation is a technique in which fecal matter from a healthy person is delivered to the gut of a person with a disease, with the goal of restoring a healthier microbiome . Only case reports and very small studies have been reported so far in the literature about whether this helps people with PD, but this may be an area worth exploring. There are a few additional studies underway which you can read about here:
We await the results of this research to assess whether fecal transplantation will prove to be useful for patients with PD.
Why Do I Get Constipated
We are still learning about constipation in PD and why it happens. Here is what we know:
Parkinsons Disease
The same changes that occur in brain cells in Parkinsons disease may also occur in nerve cells in the spinal cord and the intestinal wall. These changes may slow down the muscles that push food through the intestines.
Medications
Medications used to treat PD in particular, the class called anticholinergics and the medication amantadine, used to treat dyskinesia are known for causing constipation. If you are on these medications, your healthcare provider may be able to reduce your dose or switch you to a different one. But for some people, the benefits of the medication outweigh the possibility of constipation.
Because people with Parkinsons disease experience difficulty with their movement, they often become less active. People with PD who increase their movement experience better overall functioning, which includes their digestive system.
Many people with Parkinsons disease limit their fluids to avoid making frequent trips to the bathroom. When a person drinks less liquid, the gut may not have the lubrication it needs to have a bowel movement, which contributes to constipation.
Genetic Predisposition
It is possible to have a family predisposition to constipation. Ask family members what solutions work for them. Your body may respond to the same strategies.
Individual Body Chemistry
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