Hi Carol,

> Regarding my original post asking if others have noticed a
worsening of
> symptoms if in a constipated state, it seems a little more
information
> from me would be  helpful.
> The doctors tell me Sinemet is not absorbed from the colon.  It is
> absorbed from the small intestine, they say.  So my contention is
that
> either they are wrong or there is some problem even  with the small
> intestine.

Yes, the L-dopa component of Sinemet (and other L-dopa medications)
is absorbed in the small intestine (the long, thin one), mainly in
its lower section, the ileum.

Two things can interfere with this, and cause fluctuations of dosage
effectiveness:
1. Medication not passing to the small intestine on time, and
2. Medication not being absorbed, or being inefficiently absorbed, in
the small intestine.

Complications of PD that can cause (1) include:
a. Slow or missing peristalsis (wave-like motions) in the oesophagus,
leading to possible projectile vomiting of the bolus (food ball).
b. Inefficient operation of the pylorus, the sphincter muscle that
controls the passing of food from the stomach to the duodenum

These factors can cause late absorption in the small intestine,
leading to prolongation of 'off' periods, and/or partial absorption
of the L-dopa by the stomach, delivering it to the liver, where it is
effectually lost to the brain.

Coupled with dehydration, they can cause 'pelletising' of food, which
can form a 'capsule' around tablets, rendering them ineffective, and
leading to the tablets being passed from the body.

Complications of PD that can cause (2) include:

a. Diarrhoea
b. Inefficient operation of the anal sphincter, at the lower end of
the rectum.
c. Constipation

Diarrhoea can cause the medication to pass from the body before
sufficient is absorbed.

'Freezing' of the anus can cause the faecal mass to compact, making
motions more difficult, and, coupled with dehydration, can cause
similar effects to constipation. Again, 'capture' of the tablet in
indigestible matter can lead to malabsorption.

The major factor in essential constipation is lack of sufficient
water in the body.
Water is extracted from the faecal matter in the rectum as a  part of
the natural water management cycle of the body.  But the process can
be interfered with by medications, such as codeine-based painkillers,
some mood control drugs, and some drugs used in controlling PD.

This results in the faeces becoming too dry and compacted, making the
mass difficult to pass.  Medications to aid elimination divide into
two classes: those which cause peristaltic (wave-like) motions in the
rectum, and those that cause the colon and rectum to 'sweat' water
from the bowel lining.

The former can be dangerous if the faecal mass is too large and/or
too hard, as they can cause further compaction, and possibly fissures
in the sphincter muscle, which closes off the anus. Any process that
causes matter to be passed to the rectum, without the anus relaxing,
can cause intense pain and is contraindicated.

The later may be dangerous if taken over a long period, as they can
lessen the 'natural' elimination process, and have been linked with
such disorders as ulcerative colitis, ileitis and bowel cancer.

In an emergency, a preparation that combines the two functions could
be the answer. But for regular use, and where complications may
arise, professional medical help should be sought.

Dehydration, a condition of loss of water and essential body salts,
is a particular problem for PWP's. They should drink approximately
two to three litres of water a day, depending on body weight and
diet. It has been said that if you feel thirsty, you are already
dehydrated.

The indications of dehydration can include:
Dry mouth
Decreased or absent urination
Sunken eyes
Wrinkled skin
Confusion
Lowered blood pressure, and
Coma

Possible complications can include:
Blood pressure drop
Shock
Even death, from severe, prolonged, untreated dehydration

The primary causes are:
1. Excessive sweating
2. Persistent vomiting
3. Diarrhoea
4. Over-exposure to heat
5. Illness with high fever
6. Use of diuretics ('water pills', frequently prescribed for high
blood pressure)
7. Chronic kidney disease

The relevance of these factors to PWP's is:
1. Intrinsic excessive sweating has been noted as a complication of
PD in some PWP's. In addition the inability of some PWP's to control
bedding and/or electric blankets can cause excessive sweating at
night.  Over-exercising of muscles caused by dyskinesia can cause
sweating, which can pass unnoticed if the affected muscle is covered,
and/or the humidity is low.

2. Vomiting as a result of nausea promoted by medications should not
pass untreated. Additionally, poor digestion resulting in ineffective
peristalsis can cause expulsion of the  food bolus, which in turn can
trigger vomiting episodes.

3. Diarrhoea can rob the body of quite large quantities of water.
Contrarily, this can in turn cause dehydration leading to
constipation.

4. Over-exposure to heat can arise as a result of a PWP having a
lowered perception of temperature change, and, in extreme cases, can
result from an inability to move away from heat sources, coupled
perhaps with an inability to convey discomfort.

5. In sub-tropical areas of the world, insect-borne diseases such a
malaria can cause excessive sweating. Even in temperate climates,
diseases with similar effects can be found. In Australia, for
example, two diseases that use mosquitoes and water-fowl as vectors
are Murray Valley encephalitis and Ross River fever.  These are not
endemic, but residents in certain areas should be aware of the
possible complications.

6. PWP's with hypertension, and their treating physicians, should be
aware of the possible implications of diuretics, and adjust the PWP's
diet and water intake accordingly.

7. Similar warnings apply to chronic kidney disease and other
disorders of the urinary system.

A good indicator of body water balance is the colour of the urine.
Except for the first discharge in the morning, the urine should
generally be relatively clear.  Any discolouration, in the absence of
any other factor, would suggest incipient dehydration.  Intense
discolouration, especially if coupled with very low volume and/or
brown staining is usually a sign of severe dehydration.

Factors that can cause discolouration unassociated with dehydration
can include colouring caused by medications, such as Vitamin B
preparations (this is usually a bright straw colour). Unusual colours
such as blue or green tones can be attributable to colouring
substances in medication.  In general lemon colours may indicate the
need to increase water intake, while orange to brown colouring
indicates the need for immediate action, especially if coupled with
an offensive smell and/or cloudiness.

Care-givers need to be aware of the very real possibility that a PWP
may not be able to control their own water intake.  General feelings
of lethargy, nausea, and/or depression may cause a lowered
inclination to drink; in addition, a 'fugue' state may prevent the
PWP from realising their dehydration.

I am considering the effects of dehydration in relation to other
bio-chemical processes, as they may affect PD, such as lipid-water
bonding, and substance transport, and will write here if I come to
any viable conclusions.

> I mentioned the water cleanup, not because it caused the problem;
but
> because the doctors and nurses couldn't believe that the patient
they
> were seeing had been able-bodied just two or three days before.

Even health professionals can be unaware of the proliferation of
complications from PD, which are, at the same time, very apparent to
the CG.

> But he'd been put on Golytely (cute name).  This is a product that
is
> normally used before an x-ray or surgery to cleanse the intestinal
> tract.  And the normal amount to drink is a gallon.  (It comes as
> a powder in a gallon jug and you add the water.)   But we varied
the
> amount as needed, usually two to four cups per day.

An old remedy, Epsom Salts (magnesium sulphate) can be effective in
chronic cases, especially if taken with a large glass of water.  Once
the system is stabilised, just one third of a teaspoon, dissolved in
a little hot water, then diluted with cool water, drunk in the
morning, can be beneficial.  This can be flavoured to mask the
slightly bitter taste.

For those 'health fiends' out there who will insist that all that is
needed is to eat lots of fruit and vegetables, and  get an adequate
dietary fibre intake, let me say that this can be counter-productive
if the bodily water content is low.  The two need to be considered
together.  Incidentally, drinks such as alcohol, especially beer, and
caffeinated drinks such as kola, coffee and black tea are
counterproductive, as they are themselves diuretic, and should not be
counted in the daily required intake. Herbal teas are alright,
provided that they contain no caffeine, and little if any tannin.

Of course PWP's should discuss any change in their regimen with their
treating physician, while emphasising the need to consider
Parkinsonian symptomatology in any diagnosis.

I hope this posting may be of some assistance in helping to
understand some of the bio-chemical and bio-mechanical processes
involved in the treatment of PD.

Jim

************************************
James F. Slattery, JP, MACS
JandA Computing Consultancy
E-mail: [log in to unmask]
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