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] ************************************