Gastrointestinal symptoms in Parkinson's disease and their causes

There is hardly a Parkinson's patient who does not know them: The gastrointestinal complaints, i.e. those affecting the gastrointestinal tract. 

These include

• Dysphagia = swallowing disorders
• Sialorrhea = the involuntary discharge of saliva from the mouth
• Gastroparesis = Stomach paralysis or delayed emptying of the stomach
• Constipation = constipation

The symptoms appear years to decades before the onset of the motor symptoms.

Gastroparesis occurs in seventy to one hundred percent of patients. According to PD Dr. Lisa Klingelhöfer from the Clinic for Neurology at the University Hospital Dresden, a clear connection with the severity of the motor symptoms. The consequences are usually weight loss, malnutrition and dehydration. To make matters worse, in the case of disturbed peristalsis and absorption, a delayed or, in the worst case, no effect of the oral Parkinson's medication is to be expected.

The confirmation of the diagnosis of gastroparesis can be achieved, among other things, by a gastric emptying sintigraphy or a real-time visualization in the MRT.

If the diagnosis of gastroparesis is established, the following non-drug measures are recommended:

• frequent, small meals
• Avoid high-fat and high-fiber foods
• Increase fluid intake, especially during meals
• staying in an upright position or walking around one to two hours after a meal.

Possible medications include: prokinetics, domperidone, botulinum toxin injection or nizatidine. It is also recommended to switch to soluble levodopa or even switch completely to non-oral applications, for example pumps or patches. And as is often the case, that too Deep brain stimulation an option.

 Constipation has a similarly high frequency of symptoms as gastroparesis.

One differentiates

• Slow transient constipation, in which there is limited mobility
• Outlet constipation, which is a disorder of bowel emptying

High-fiber foods, plenty of fluids, and plenty of exercise are recommended as non-drug therapies.

 In terms of medication, the doctor will consider prokinetics, laxatives, enemas or, again, a botulinum toxin injection.

At the level of Parkinson's medication, the same applies as with gastroparesis, namely switching to soluble levodopa or completely to non-oral applications.

Although up to 87% of Parkinson's patients are affected by dysphagia (swallowing disorders), only 10% spontaneously report corresponding symptoms. More than a quarter have problems swallowing their tablets or capsules. You have to explicitly ask about it, stressed Prof. Dr. Carsten Buhmann from the Department of Neurology at the University Hospital Hamburg-Eppendorf. The swallowing disorder can also manifest itself very early, ie before the onset of the motor symptoms.

As a priority Therapy The treating doctor will consider a referral to a speech therapist, who will then train the patient in appropriate techniques to prevent swallowing disorders. If you have trouble swallowing your medication, you should take it with applesauce or something similar. But here too, you can consider changing the dosage form of Parkinson's medication.

So much for a summary of the congress report on the "German Congress for Parkinson's and Movement Disorders" by Dr Anja Braunwarth.

 I learned 2 things while writing this post:

• The possibilities of alleviating my gastrointestinal complaints are far from exhausted
• The link between GI symptoms and Parkinson's may be well known to most neurologists, but at least my personal experience shows that many doctors place Parkinson's at the bottom or not at all on the list of causes of the symptoms.

So starting in 2014 and in the context of a mesenteric vein thrombosis, I had severe gastrointestinal problems, with almost all of the symptoms mentioned above. The search for the cause lasted a full 6 years, employed 2 practicing internists, gave me an 8-day hospital stay in an internal medicine ward, 4 gastroscopy, a colonoscopy, numerous sonograms, an appointment with a nutritionist and a total of 15 kg weight loss. A food intake – even that Drink of completely normal water – caused me severe nausea in the immediate context.

only one Complex therapy in Bad Goeggingen (after 6 years!) brought salvation. After describing my symptoms, a drug mix consisting of Xadago (safinamide), entacapone and a neuro patch (rotigotine) was built around my daily levodopa dose, which, with a time delay of 2-3 days, has made my gastrointestinal symptoms almost completely disappear to date .

The prerequisite for this unusual success was the diagnosis of M. Parkinson in 2019 due to motor abnormalities (slowing down, lack of arm swinging, cog wheel phenomenon, swallowing difficulties) and the knowledge of the Bad Goegginger teams of neurologists about the connection between my Parkinson's disease and my gastrointestinal symptoms.

And finally ...
The interdisciplinary knowledge of Parkinson's symptoms still has room for improvement and the enlightened and well-informed patient is an important interface in the field of tension between diagnostics and therapy. Knowing what I know now, I could have saved myself six tough years.

Jürgen Zender, October 2022