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“The Remains of the Day”

“The Remains of the Day”. or, why constipation is important to you…. Interns 2008. outline. Case studies Types of constipation Assessment Treatment The importance of PR!. Mrs BM. 84 yr old, Lives alone, care package 2X week

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“The Remains of the Day”

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  1. “The Remains of the Day” or, why constipation is important to you… Interns 2008

  2. outline • Case studies • Types of constipation • Assessment • Treatment • The importance of PR!

  3. Mrs BM • 84 yr old, Lives alone, care package 2X week • Presents on Christmas Eve - daughter found her confused + cooking breakfast at 4pm • “difficult historian” • no complaints, wants to “leave this airport.” • Hx HTN, OA, T2DM, mild cognitive impairment • Meds: • Paracetamol • Gliclizide MR 30mg od • Perindopril plus 5/1.25mg • Diltiazem CD 180mg od

  4. Mrs BM… • o/e • Confused, looks dehydrated, Bsl 7.3 • AMTS 7/10 • Afebrile, p=90, bp 120/70 • cvs, resp, cns, abdo exam nad • msu: +WCC, glu+

  5. Mrs BM… • ED Assessment: • Likely UTI + Acopia • Plan: • Admit Medics • MSU,bloods • Trimethoprim

  6. Mrs BM… • MSU- no bacteria, no growth • Bloods: Na 134, Ur 18, Cr 89, FBC nad • Refuses to eat or drink • Feels nauseous – given dolesetron by 2nd-on • Commenced on iv fluids

  7. Mrs BM… • Next medical review on 27/12 • Still confused ++ • Picking at bottom (dirty fingernail sign!) • Still not eating • 3x dolesetron given for nausea • incontinent • No BM since admission? How many days prior? • Abdo soft, but distended • PR – empty rectum but “ballooned”

  8. Mrs BM… • Further hx: • GP had commenced Diltiazem CD 2weeks prior for HTN • Very hot over Christmas – decreased oral intake

  9. Mrs BM • Dolesetron and diltiazem ceased • Given aperients (more on this later) • Large BM x3 • Improvement in continence • Improvement in mental function • Stint on 3K: • d/c home with previous level of care

  10. What have we learned so far? • Constipation can cause delirium • Constipation can cause urinary incontinence • “poo on fingers” often means constipation • Ca+ blockers can cause constipation • Dehydration can cause constipation! • PR PR PR PR PR

  11. Mr PR • 59 year old Professor of engineering • Admitted for R total hip joint replacement • PMx- OA R hip, L knee, ex-smoker 10yrs • Meds – aspirin only – withheld at present • Pre-op bloods normal – FBC, UE

  12. Mr PR…. • Post-operatively: • Pain: PCA and then tramadol and oxcodone SR 20mg bd • Nurse prescribed C+S given daily • Refuses to use bed pan. • Refuses to use commode by bed – 4 bedded room.

  13. Mr PR… • Day 4 post op – no BM yet • Grumpy+++ • Refuses PR intervention – undignified! • Finally on day 5 – small BM • Abdo discomfort continues • PR- still evidence of loading • Aperients increased to regular

  14. Mr PR… • Transfer to rehab -periodic constipation continues • RMO decides to investigate further: • Ca 3.28! • PTH elevated • Confirmed primary hyperparathyroidism

  15. What have we learned so far? • Always co-prescribe aperients with opiates • Hospitals are undignified! – this can cause constipation • If constipation persists – always investigate! • PR PR PR PR PR

  16. Mr BO… • 74 yr old, lives “with mates”. • Presents with fall and prolonged lie • PMx: • ETOH: cirrhosis, portal HTN • T2DM – poor control • Smoker +++ • Meds: • Propranolol 40mg • Thiamine

  17. Mr BO… • No fractures • Mildly elevated CK – treated with iv fluids, IDC inserted to monitor output • Probable LRTI – commenced on oral abs

  18. Mr BO… • Difficult to manage – always wanting a smoke, noisy friends • No BM for 4/7 then some watery diarrhoea, further BNO 2/7 then more diarrhoea • Needing supervision to mobilise – falls risk • Found next to bed on the floor, unable to stand up

  19. Mr BO… • RMO called to examine: • No obvious injury • Decreased power both lower legs • Hypo reflexic • Odd pattern of decreased sensation to soft touch • PR: • No anal tone • Soft faeces loading rectum

  20. Mr BO… • Repeat Abdo USS – confirmed likely multi-focal HCC • Rapid deterioration on the ward - transferred to hospice soon thereafter

  21. What have we learned so far? • Watery diarrhoea after a period of NBO often indicates overflow diarrhoea • Constipation can indicate other problems.. • PR PR PR PR PR PR

  22. The learning bit…

  23. “Normal” bowel habit • Varies from person to person • Most people empty their bowels between 3 times a day and 3 times a week

  24. Constipation(2+ for at least 3months during the last year) • Straining in 25% of movements • Feeling of incomplete evacuation after 25% • Sense of anorectal obstruction / blockade in 25% • Manual manoeuvres to help in 25% • Hard or lumpy stools in 25% • Stools less frequent than 3 per week

  25. Subtypes • IDIOPATHIC • Slow Transit Constipation • Pelvic Floor Dysfunction • Combination Syndromes • Normal Colonic Transit Constipation • SECONDARY • Primary Diseases of the Colon / Rectum • Irritable Bowel Syndrome • Peripheral Neurogenic • Central Neurogenic • Non-Neurogenic • Drugs

  26. Idiopathic… • Slow transit constipation • Slower than normal movement from proximal to distal colon and rectum • Colonic inertia vs uncoordinated motor activity? • ? enteric nerve plexus dysfunction • Pelvic floor dysfunction • Functional defect in coordinated evacuation -difficulty evacuating contents from rectum • Probably acquired / learned dysfunction rather than organic / neurogenic

  27. Idiopathic… • Combination syndromes • Normal Colonic Transit Constipation • Misperception of bowel habit • Often psychosocial stresses

  28. Secondary • Primary diseases of colon/rectum • Benign stricture, malignancy, proctitis, anal fissure • IBS • DRUGS

  29. SECONDARY … • Peripheral neurogenic • Hirschsprung’s, autonomic neuropathy, Diabetes, pseudo-obstruction • Central neurogenic • Parkinson’s, multiple sclerosis, spinal cord injury • Non-neurogenic • Hypothyroidism,hypercalcaemia, panhypopituitarism, pregnancy, anorexia nervosa, systemic sclerosis

  30. DRUGS ASSOCIATED WITH CONSTIPATION • ANALGESICS • Opiates!!! (this includes tramadol) • ANTICHOLINERGICS • Antispasmodics, antidepressants, antipsychotics • CATION-CONTAINING • Iron supplements, antacids, • NEURALLY ACTIVE • Ca+blockers, 5HT3 antagonists

  31. Hospital causing constipation • Decreased exercise/mobility • Hospital food (Not eating enough fibre) • Not drinking enough fluid • Lack of privacy • Limited toilet access • Depression / grief / anxiety

  32. “please review Mr Strain,BNO 4/7”

  33. HISTORY • SYMPTOMS (Nature / Onset / Duration) • Frequency • hard stools? • satisfaction • Straining/extra help required? • Bloating, pain, malaise • BOWEL PATTERN (Usual and current) • BOWEL REGIME (Usual and current) • Aperients/PR intervention/ frequency, dose • IDENTIFICATION OF CONTRIBUTING FACTORS

  34. ALARM….. • Haematochezia • Weight loss • Family history of CRC or IBD • Anemia • Positive FOBT • Acute onset of constipation in elderly

  35. EXAMINATION • PERINEAL / ANAL EXAMINATION • Perianal skin, anal reflex, squeeze, simulated evacuation, mucosal prolapse • PR!!!!!!!!!!!!!! • Sphincter tone (resting, squeezing), masses, tenderness, expel finger • PV • Rectocele • ABDOMINAL EXAMINATION

  36. INVESTIGATIONS • BLOOD TESTS • FBP, TSH, Calcium, Glucose, Creatinine • RADIOGRAPHY • Abdo XR • RPH imaging guidelines: DO A PR FIRST • only use to: diagnose constipation or ? obstruction • ENDOSCOPY • Flexible sigmoidoscopy, colonoscopy • SPECIALISED TESTS • Colonic transit (radiopaque marker) studies, barium defecography, anorectal manometry, balloon expulsion test

  37. Treatment • Good habits • Pelvic floor exercises • Diet • Remove ppt factors • aperients

  38. The Call to Stool!

  39. DIET • INSOLUBLE FIBRE • Speeds up bowel motions • eg. Multigrain wheat, corn and rice cereals, bran, fibrous vegetables, skins of fruits and vegetables • SOLUBLE FIBRE • Turns into gel and firms up loose stools • eg. Oats, barley, rye, legumes, peeled fruits and vegetables

  40. Fibre supplements • Ispaghula (Fybogel) • Psyllium (Metamucil) • Guar gum (Benefibre) • Sterculia (Normafibe) • Methylcellulose • Recommended dietary fibre = 20 – 35 g/day • Water intake must be increased according to manufacturers instructions when taking fibre supplements

  41. MEDICATIONS • Appropriate use of aperients • Only commence if simple measures (fibre / fluid / exercise / review of medications) not adequately controlling constipation • Only take for short periods of time

  42. Aperients • BULK FORMING • STOOL SOFTENERS • OSMOTIC • STIMULANT • SUPPOSITORIES & ENEMAS

  43. BULK FORMING • Add bulk to the stool • Absorb water and increase faecal mass • Soften stool and increase frequency • Ispaghula (Fybogel) • Psyllium (Metamucil) • Guar gum (Benefibre) • Sterculia (Normafibe) • Methylcellulose • Calcium polycarbophil • Not helpful in opioid induced, may worsen incipient constipation

  44. STOOL SOFTENERS • Soften the stool • Lower surface tension of stool allowing water to more easily enter stool • Few side effects • Less effective than laxatives • Eg. • Docusate sodium (Coloxyl)

  45. OSMOTIC • Attract water into the bowel • Osmosis keeps water within intestinal lumen • Improve stool consistency and frequency • Lactulose (Actilax, Duphalac, Genlac, Lac-dol) • Sorbitol (Sorbilax) • Polyethylene glycol (Movicol, Golytely, Glycoprep) • Glycerol (Glycerol / Glycerin suppositories) • Magnesium sulfate (Epsom salts) • Lactulose can take up to 3 days • Can get bloating, colic, wind!

  46. STIMULANT • Increase intestinal motor activity • Alter mucosal electrolyte,fluid transport • Bisacodyl (Bisalax, Durolax) • Senna • Castor oil • Cascara • 6-12 hour latency • Good in opioid with stool softener • Excessive use may cause hypokalemia, protein losing enteropathy, salt overload

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