All things in moderation

Kathy KL Tsim 詹觀蘭

HK Pract 2016;38:1-2

Constipation itself is a symptom not a disease, but this one symptom alone can cause great psychological stress to the patient and, in the case of children, their parents. As any young parent would tell you, they start to worry if their young child has not passed stools for 1 to 2 days. With young infants, parents are used to a repetitive cycle of feeding and “pooing”. Needless to say, any variation in this pattern is distressing to all. However in reality we find that young infants suffer commonly from gastrointestinal symptoms.¹ Only a small percentage of these children would eventually require hospitalisation. As parents, does knowing this fact truly help to eliminate parental anxiety?

This worry of being constipated not only applies to parents of young children but to those at the other extreme of age. We as family physicians have great experience with elderly patients who comes in with frequent requests for laxatives.² Experience tells us that knowing facts does nothing to truly alleviate stress brought on by a common symptom.

Concerns brought on by the sense of being constipated might be one of the reasons why colonic irrigation/hydrotherapy has been so popular in many countries around the world. Its advocates indicate that it helps to detox and cleanse our body. They do have a point as studies have shown a positive association between constipation and an increased risk for colon cancer.^3,4 However whether colonic irrigation is the way to solve this issue is another matter. We are therefore grateful to have Dr Wong share with us his timely review on the management of adult constipation. It is indeed important for us to be on the same language level as our patients with regards to the actual definition of constipation, the various assessment pathways and available treatment modalities.

We must not miss the functional gastrointestinal disorders which can be associated with psychological and social factors in its development.⁵ We should also be aware of other important comorbidities, e.g. diabetes, as well as the fact that certain chronic illness e.g. Chronic Obstructive Pulmonary Disease (COPD) can be worsened by its presence.⁶

As mentioned before, it is very important for patients and clinicians to be on the same wavelength when we communicate about something as important as a symptom or an illness. This is even more so for us clinicians during our inter-professional exchanges. One such an example can be seen in the categorisation of the severity of COPD. There exists a heterogeneity in the assignment of patients with different COPD severity categories to different symptom scores. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013 classification of COPD, patients can be classified with either the Modified Medical Research Council Dyspnoea Scale (mMRC) score or the COPD Assessment Test (CAT). Completion of the multidimensional CAT may be difficult in our busy local primary care setting. The shorter unidimensional symptom scale mMRC is much simpler to apply and more practical. We obviously would like to know if these two tools can be used interchangeably. Dr Yeung’s article answers just this very important question.

One of the important causes of constipation is autonomic neuropathy which could be easily overlooked by family physicians when encountering diabetic patients. We need to remember this important and embarrassing condition in our encounters with diabetic patients. They might not automatically volunteer this distressing symptom.

Diabetic peripheral neuropathy is an important consequence of diabetes. As Dr Ip rightly pointed out in his article, some 50% of patients with long-standing diabetes develop peripheral neuropathy. Knowing how to manage this distressing complication will bring great relief to our patients. Like all illnesses, we need to know not only the pharmacological agents available but also the non-pharmacological interventions that are available to us to minimise this often disturbing symptom and to prevent it from interfering with our patients’ busy lives.

Dietary and lifestyle modification is a general important advice to give to all our patients. All too often patients would attend our clinics with a bottle of vitamins or supplements seeking our approval. One such vitamin which has been in the spotlight for the past few years is vitamin D. Research has shown that it is common for patients with multiple sclerosis to have low vitamin D level. It would appear that low levels of vitamin D in early disease is a risk factor for long term disease activity and progression.⁷ Study has hence advised the supplementation of this vitamin for patients with multiple sclerosis.⁸

Multiple sclerosis is not the only disease associated with hypovitaminosis D. Diabetes and cardiovascular diseases (CVD) have also been linked⁹, although evidence for vitamin D in reducing cardio-metabolic risk factors and improving vascular outcome is equivocal. Further large scale analysis is still warranted to determine its benefits, when to begin vitamin D therapy, as well as to determine the dose, route and duration of administration.¹⁰ Until then it might be best to recommend vitamin D maintenance for patients who suffer from cardiovascular diseases and those with diabetes, especially patients with peripherial neuropathy. So in conclusion, maybe a little sunshine is good for us. All things in moderation, I suppose.