Constipation as an early symptom in patients with mutliple sclerosis (MS).

SUMMARY

A group of 1256 MS patients, 361 males and 895 females, aged 479.3, with a duration of disease 9.54.2 years, were studied prospectively for a period of 10 years, in an attempt to evaluate the significance of constipation in their clinical course. Constipation and fatigue were early symptoms in the greatest proportion of the patients, with a prevalence of 88.6% and 67.5% respectively. A strong positive correlation of these symptoms was observed with the patients` Kurtzke EDSS stage (p>0,05). A subgroup of 240 of the above patients (55 males and 185 females) submitted to MITOXANTRONE therapy (80-100mg) for their disease. Following-up these patients for one year period, we observed an up to 45% amelioration of their clinical symptoms. It is worth mentioning that constipation was ameliorated up to 11%. It is concluded that constipation consists a hard managed early symptoms of MS.

INTRODUCTION

The development of constipation is naturally in people who either because of pain or weakness cannot be active. So, the appearance of constipation in M.S. patients in large proportions is not surprising. This may also be related to the clinical condition of the patient. We know however that defecation a disturbance of which is constipation is somehow regulated by the central nervous system 2. As it is known the central nervous system (CNS) is disturbed in various levels of its, in MS. It is possible then that CNS disturbances due to demyelinization foci in MS in the points where defecation is regulated, to produce constipation 3. It is possible that this happens similarly with the case of easy fatigue, before MS clinically presents itself. Based on the observation we made on our MS patients in a period of ten years we investigate the possibility that constipation exists as a symptom prior to the clinical appearance of MS.

METHODS AND MATERIAL

A group of 1256 patients(361 males and 895 females) with "clinical definitive" MS according to the criteria of Poser et al 5 aged 479.3 years and a duration of disease 9.54.2 years. Our attempt was to evaluate the significance of constipation as an early symptom in their clinical course. An extensive medical history report was taken from each of the patients for up to 5 years prior to the onset of the disease especially concerning the early presence of constipation and fatigue. The patient examinations were based on the Kurtzke Disability Status Scale 4 ranges from 0 (normal neurological examination) to 10 (death due to MS). The patients that presented constipation as an early symptom were split into 3 groups (Mild, medium-intensity, and severe) and the results were compared with those of Kurtzke Disability Status Scale (DSS). A subgroup of 240 from the above patients (55 males and 125 females) who received one treatment of MITOXANTRONE (80-100 mg) for a year were examined also with the same criteria, i.e. which was the change in the severity of the constipation symptom.

RESULTS AND CONCLUSIONS

After extensive research of the medical history of all 1256 patients, it was found that 1113 of those had a light to severe form of constipation 3-5 years prior to the clinical appearance and diagnosis of MS. This condition deteriorated after the outbreak of the illness. 143 patients were added to those who had presented constipation raising the percentage from 88.6% to 95.4%. It is also characteristic that constipation got worse with the development of the disease in many of the 1113 patients. Tables 1 and 2 analytically present the results. Early fatigue, known as an early symptom of MS, was found in 6,7% of the patients. For the same time period constipation was present. It is worth mentioning that of the 847 patients with the early fatigue, 768 (90.6%) also presented constipation. Thirty six more were added after the development of the disease, i.e about 48% of what was left of the team. The intensity of constipation as an early symptom compared to the severity of the patient clinical status measured on the Kurtzke DSS 4 after the development of the disease, was found to have a significant correlation (p<0.05) as shown in table 1. In the subgroup of the MS patients who received one treatment of MITOXANTRONE for a year there was an improvement at the rate of 45% based on the KDSS. Conversely the improvement in constipation was only 11% and it was particularly evident in young patients. In two patients constipation got worse. Exacerbation of constipation was observed in MS relapses and in infectious episodes. Constipation is a disorder of colonic mobility caused by defecation disturbances. In the defecation process the CNS is involved having a multilevel function. This function is possible to be disturbed as happens in this case, in the levels above the anospinal centres fig.1 e.g. paracentral lobes, in lesions inside the anospinal centre (S3-S4) as well as in the pyramidal area in between. In all these functional points disturbances could possibly appear due to demyelination in MS resulting in the appearance of constipation 1,2. It is not worthy according to our results that constipation could appear in a large numbers of prospective MS patients prior to the onset of the disease. It presents itself at a time when the patients have no pain nor activity deficit. Consequently it is an early symptom just like early fatigue, occurring due to the sensitivity in immunological disturbances inside the CNS. The fact that there was improvement after immunosuppressive treatment lends support to that view. Consequently, in cases where there is chronic constipation accompanied by another suspicious MS symptom such as fatigue, vertigo, sensory disorders one must think of and diagnostically investigate the possibility of MS. Therefore, the sooner the diagnosis is made the earlier the treatment will be given

REFERENCES

1.BROSER F. Topische und klinische Diagnostik neurologischer Krankheiten, Urban und Scharzenberg, Muenchen-Berlin-Wien, 1975

2.JOHNSON LR et al, Physiology of the gastrointestinal tract, Raven press, New York, 1986

3.HINDS JP. Eidelman BH Wald A, Prevalence of bowel dysfuction in mutliple sclerosis, Gasrtoenterology;98:1538-1542,1990

4.MAUCH E,KORNHUBER HH,KRAPF H,FETZER U, LAUFEN H, Treatmentof Multiple Sclerosis with MITOXANTRONE, Eur Arch Phychiatry clin Neurosci 242:96-102,1992

5.POSER CM,PATY DN, SCHEINBERG L,Mc DONALD WI, DAVIS FA, EBERS GC,JOHNSON KP, SIBLEN WA,SILBERBERG DH,TOURTELLOTTE WW, New diagnostic criteria for Multiple sclerosis guidelines for research protocols, Ann Neurol 13:227-231, 1983

CAPTIONS

Table 1:The relationship between the symptoms of constipation and the score of the clinical symptoms after the clinical manifestation

Table 2:The relationship of the constipation before and after the clinical manifestation of MS.

Figure 1:Brain and spinal cord showing nerves controlling bladder function. Paracentral lobes (1), anospinal centre (2).

Reprented from 8th World Congress of the INTERNATIONAL GASTRO-SURGICAL CLUB, Strasburg, France, April 15-18 1998, Editors H.Bismuth, J.P.Galmiche, M.Huguier, D.Jaeck, Monduzzi Edotore, International proceedings Division.