Question of the Month Library

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Archive Date:  24/06/09

I note in your Question of the Month library that you describe how many capsules to take but you don’t mention how much fluid a person needs to consume while taking the capsules. Can you suggest an amount of liquid to drink while taking the capsules.

Thank you for writing to my website.

This really is a good question. A balance needs to be achieved between NOT drinking enough and drinking too much, especially too much water.

If you do not drink enough liquid, there is the possibility of becoming dehydrated. I have not yet seen this, even in people taking many capsules for bowel cleansing prior to bowel surgery or colonoscopy. Dehydration is really only likely to be an issue at very high doses and in at risk individuals such as the elderly. Fortunately, most people are able to drink plenty of liquid with their capsules and dehydration is a rare problem indeed.

It is, however, possible to drink too much water on its own. This can exacerbate the upper abdominal fullness and nausea that accompanies the ingestion of osmotically active agents of all types. Also, water on its own does not replace all the usual salts and minerals that are passed out with the liquid stools induced by the capsules. So I routinely advise people to drink something sweet or, preferably, savoury to add back some glucose or salt. Savoury broths and soups are excellent (and tasty) while there are some commercially available “power” drinks that have added glucose and salt which are also recommended.

As for the amount to drink, a good estimate is to drink 250ml of (non-alcoholic) liquid for every 5 capsules. However, Some people find this very difficult and, in my opinion, it isn’t necessary. So I do not recommend that 250ml be taken every 15 minutes but, rather, that the total volume be stretched out over a period of time longer than the taking of the capsules.

Say, for example, the dose is 20 capsules – 5 capsules each on four occasions over about 45 minutes. That means that the amount to drink will be 1 litre. Rather than drink the entire 1 litre over the 45 minute period dedicated to taking the capsules (5 every 15 minutes), I recommend that people take the correct amount of fluid (1 litre) over a 2 hour period or even longer. As long as you add back the right amount of liquid – and the right sort as well – it does not all need to be drunk in a short period of time. 

I do hope that this is helpful.

Michael Levitt


Archive Date:  28/04/09

A common recurring question to my website is whether taking Magnesium Sulfate Capsules interferes with the absorption of usual, daily medications that people are taking. 

As a powerful laxative, magnesium sulfate causes a speeding up of the transit time through the entire intestines. The biggest impact is upon transit through the large intestine where little if any drug absorption takes place. In other words, drug absorption is generally not affected by laxative use.

The strategy of once or twice-weekly capsule use means that, on the other 5 or 6 days of the week, this theoretical issue does not apply at all. Moreover, if you delay starting the capsules for about one hour after you have taken your usual medications (whether this is in the morning or at night), you will eliminate even this theoretical risk on the one or two days that you take the capsules.

In short, you need not be concerned about interference with absorption of your usual medications by using the capsule strategy I recommend but, to be as sure as you possibly can, delay taking the capsules for an hour after taking your medications.

I hope this helps.

Michael Levitt


Archive Date:  16/03/09

Dear Dr. Levitt,

I just want to say "thank You" for writing your book "The other Women's Movement". I just finished reading it and found it VERY informative. Only wished I could have read it two years ago when I started with bowel problems, including five days in hospital. I would also be grateful to hear your opinion on whether seeds and nuts are a problem with Diverticulosis. I'm confused. Thanking you again.

Thank you for your note to my website. I hope that the strategy outlined in my book helps you with your longstanding bowel problems.

There is much nonsense promulgated about the role of diet in the management of diverticular disease. In short, there is NO evidence that seeds, nuts, roughage or food of any specific type consistently aggravate diverticular disease to cause diverticulitis or bleeding. Any dietary restrictions that you have imposed should be on the basis of your own tried and tested experience. If there are foods that you KNOW aggravate the symptoms, then you are well within your rights to avoid those foods. But there is no reason to believe that diet will materially alter the natural history of this condition whatever you might have been told!

One important thing to be wary of is the fact that very many people have bowel symptoms - and very many people have proven diverticular disease. It doesn’t follow, however, that the bowel symptoms people have are actually caused by the diverticular disease that has been demonstrated on colonoscopy or CT scan or barium enema x-ray. Don’t be too sure that your bowel symptoms are due to diverticular disease – they might be a reflection of slow colonic transit (sluggish bowels, bloating and constipation) or irritable bowel syndrome (diarrhoea and urgency). The treatment of your symptoms would be much better directed at the slow transit constipation (magnesium sulfate capsules) or the irritable bowel syndrome (loperamide capsules).

I hope that this clarifies this for you. I hate to think how many Australians sift through their food every day trying to eliminate every little seed or pip or husk in the false belief that this will prevent complications of their diverticular disease.

I hope this brief explanation is of some assistance. Good luck with your treatment.

Best wishes.

Michael Levitt



 Archive Date:  18/02/09

"I have purchased the Magnesium Sulfate capsules, and I tried taking the 15 calpsule dosage, which had no effect at all. This may be because I have a stubborn problem. I have been diagnosed with a lazy bowel, and am reliant on laxatives. I have been taking laxatives every night for the past 5 and a 1/2 years. I also take more than the recommended dosage as over time I've had to increase my dosage. When I heard about your product I knew I had to give it a go, however I am not sure how many capsules to take the next time as obviously 15 isn't enough for me. I'd really appreciate your advice. Thank you."

This is a common problem – I would actually like to use your question on my “Question of the month” section if you are happy for me to do so.

The fact of the matter is that you do need to take more than 15 capsules. At least at the outset, it might take many more capsules to do the job particularly if you have a very sluggish bowel (I don’t use the word lazy as it suggests that you aren’t trying hard enough when I suspect that you have been trying very hard for a long time).
Take 15 capsules last thing one night (5 every 15 minutes) and another 15 capsules first thing next morning (also 5 every 15 minutes). If there is no convincing response by midday, take yet another 15 capsules ((5 every 15 minutes) and this is likely to sort you out. It is OK to take even more and it is essential to clean out thoroughly. But only do this once every week and you can wean yourself off your usual laxatives over time. Try the following schedule:
The first thing to do is to select one day of the week to be the day that you clean yourself out completely with capsules. Once this day is decided you take the following steps:
1)      The night BEFORE, last thing, you take 15 capsules (5 every 15 minutes) but you do not take your usual laxatives.
2)      The next morning, you take another 15 capsules (5 every 15 minutes) – if there is no convincing response by midday, you take another 15 capsules (5 every 15 minutes). It  really is essential that you clean out completely on this day, even if you must take every capsule in the bottle.
3)      That night AND the following night you omit your usual laxatives.
4)      The next night you can take your usual laxatives if you feel the need. The same goes for the next few nights although I often recommend that you try to take your usual  laxatives only twice during the week.
If we assign a day to these instructions (and you can choose any day that suits you so this is just a guide), it will look like this:
Sat night – no usual laxatives, 15 capsules
Sun morning – 15 or more capsules according to response
Sun night – no usual laxatives
Mon night – no usual laxatives
Tues night – usual laxatives if required
Wed night – no usual laxatives
Thurs night – usual laxatives if required
Fri night – no usual laxatives
I hope this schedule helps you get going. This is covered in the book referred to on my website which I really think will help you.
Please let me know how you get on.


Archive Date:  19/01/09

“Could you explain the basic difference between Irritable Bowel Syndrome and Inflammatory Bowel Disease (just in layman terms)? Is there any role of surgery in the management of Irritable Bowel Syndrome apart from using anxiolytics or reassurance? Can MgSO4 be useful in either of the cases (IBD or IBS)?”

IBD stands for Inflammatory Bowel Disease which usually means either Ulcerative Colitis or Crohn’s Disease. Both of these are true inflammatory diseases characterized by inflammation and ulceration of the bowel wall lining. We don’t know exactly what causes these diseases, they often require powerful anti-inflammatory and anti-immune system medications (salicylates, cortisone, azathioprine, infliximab and others) to bring them under control and many patients do come to surgery for their IBD. In almost every case, patients will be managed by a Specialist Gastroenterologist with or without the input, when required, of a Surgeon.

IBS stands for Irritable Bowel Syndrome and describes a group of conditions where there is disordered activity of the intestinal muscular tube. Frustratingly, there is nothing abnormal to see on colonoscopy or barium x-ray examination.

IBS can manifest as excessive intestinal activity with urgency and diarrhoea, intestinal under-activity with bloating and constipation or uncoordinated intestinal activity with abdominal pain and variable diarrhoea and constipation - as well as other rarer variants. The treatment depends upon the principal clinical problem - laxatives if the bowel is under-active (magnesium sulfate capsules are ideal) and anti-diarrhoeal medication if the bowel is over-active. Surgery has an extremely limited role in IBS and this is confined to cases of severe constipation only. This sort of surgery should only be performed after detailed consideration of the clinical issues and thorough assessment of the nature and extent of the constipation.

I hope this is of some assistance. Please don’t hesitate to correspond with me if there is more you think I can explain.

Michael Levit


Archive Date:  11/12/08

"Would Magnesium Sulfate capsules be useful for the treatment of wind? I am 58, and have 'bouts' of wind which last for a week or two at a time. I can't pinpoint anything dietary that affects this and I eat a fairly healthy diet. Along with the wind, I am somewhat constipated, particularly during these bouts, but not overly so. Could you let me know if Magnesium Sulfate capsules are likely to be useful in this situation?"

Thanks for writing to my website.

I suppose the first thing to say is that "wind" means different things to different people. Many people - more often men than women - produce and pass large amounts of wind per rectum (called flatus in medical circles) every day of their lives. Apart from the social consequences of all this gas-passing, these people do not feel unwell in the least. In truth, they are not unwell and the gas they are producing is the end result of normal physiology. Bacteria which normally and quite safely reside in our large intestine act on undigested fibre and other sugars passing into the large intestine after a meal. The gas builds up then passes through.

This is totally normal, occasionally embarrassing, often not just a little offensive. To change this situation - if you really are very embarrassed by the situation - you might try to reduce dietary fibre intake. Watch out for so-called "sugar-free" sweeteners and chewing gums and other sweets which contain, amongst others, the agents mannitol or sorbitol. These are sugars (hence their sweet taste) but they can cause excessive gas. Likewise, the laxatives lactulose and sorbitol are famous for the amounts of gas with which they are associated.

Occasionally, excessive gas is attributed to some form of malabsorption or other. One example which is commonly blamed for gas (but which is rarely proven) is lactose intolerance. You say that there are no specific foods that seem to cause your wind problems - dairy products (lactose intolerance), wheat products (coeliac disease), diabetic sweeteners, sugar-based laxatives and excessive dietary fibre are the commonest mechanisms by which the things we eat really do give us excessive gas. The fact remains, however, that all these food intolerances are generally associated with loose and frequent stools whereas you clearly describe a propensity towards constipation. Like you, I don't think that dairy or wheat products or other food intolerance or malabsorption is your problem at all.

I think that a complaint of "wind" can often be the inability to pass the wind that is being formed within the large intestine rather than the production and passage of too much. This can result in uncomfortable abdominal bloating. Since this is a common symptom in patients with constipation - and since you clearly describe a tendency towards constipation - I am certain that the first steps in your treatment should be directed at this particular issue. Put vey simply, I recommend:

1) Do NOT overdo dietary fibre. Fibre is unlikely to speed up your bowels sufficiently to help and, even if it did, the amount of extra gas you would produce would be a huge disincentive. So, do not take fibre supplements and do not heap excessive fibre into breakfast cereals, home-made breads, lunch-time sandwiches or even dinner-time plates. Fruit and vegetables, cereals and nuts are all potential offenders so beware of the excessively "healthy" diet which would probably exacerbate your symptoms considerably.

2) Definitely DO give weekly magnesium sulfate capsules a go. A thorough clean-out once every week with these exceptionally easy-to-take and non-habit-forming capsules (you must take enough to clean out thoroughly) represents an effective and sustainable strategy for the long term.

I hope this helps. Please keep in touch.

Michael Levitt


Archive Date:  14/11/08 

Thanks for all the correspondence and feedback. I have had dozens of inquiries, comments and questions. I have tried to respond to them all but I apologise if I haven’t been able to deal with every question.

A recurring theme amongst correspondents has been about the management of their constipation during pregnancy. Needless to say, since problems with sluggish bowels are so common amongst women, many women encounter particular problems with their bowels when they become pregnant. Not only can hormonal changes alter colonic function, the expanding uterus fills the pelvis and compresses the rectum altering rectal sensation and modifying the usual sensation of urge.

Like all medicines, laxatives also need to be used with care and common sense during pregnancy. And just like the use of laxatives in general, the basic theme of a vigorous, weekly clean-out with a non habit forming agent is both appropriate and effective during pregnancy.
There is little objective, scientific evidence of the use of laxatives during pregnancy. Magnesium salts are particularly appropriate during pregnancy and I strongly recommend magnesium sulfate capsules in this setting.  Only about 4% of the dose of magnesium is actually absorbed into the bloodstream which makes it very unlikely that magnesium will accumulate in the bloodstream.  Even more, during pregnancy, there is enhanced excretion of magnesium from the kidneys which makes toxicity from magnesium even less likely.

Obviously, you should consult your Obstetrician, General Practitioner or Midwife about any medication you wish to take during pregnancy. But while traditional strategies for treating constipation continue to insist that you take something every day, my experience has been that once-a-week magnesium sulfate capsules are frequently well tolerated, highly effective and very safe in pregnant women.

I’d be happy to hear from anyone about their experience with constipation during pregnancy.

Michael Levitt

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