Bowel Function & Management following Treatment for Colorectal Cancer

1. Bowel Function & Management following Treatment for Colorectal Cancer Maria Stapleton RGON, BN, PGCert STN, PG Dip (Nursing) Clinical Nurse Specialist-Lead: Colorectal Care and Stomal Therapy

2. MidCentral District HealthBoard Palmerston North New Zealand

3. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER • Case study • Anatomy and Physiology • Assessment • Management • The challenges • Summary

4. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERA STUDY CASE Phase 1. (Nearly 12 months) Awareness of the signs symptoms and the recognition of the need to seek medical help, subsequent referral, testing and diagnosis. • 50yr old, married, female “Kim”. • Several months of rectal bleeding and pain. • Slim, otherwise healthy, no family history. • Colonoscopy – near obstruction with a moderately differentiated adenocarcinoma of the upper rectum and histology showed T3 Nx M0.

5. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERA STUDY CASE Phase 2. Treatment (12 months) The timely implementation of the most appropriate treatment. • Kim was immediately admitted and had the formation of a loop ilesotomy – near obstruction. • Neo adjuvant chemotherapy and radiotherapy. • 6 months later an anterior resection – her ileostomy remained. • Adjuvant chemotherapy. • 6 months later reversal of stoma.

6. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERA STUDY CASE Phase 3. Surveillance and survivorship. (5yrs – lifetime??) • Completion colonoscopy, • 3 monthly CEA • CT scan at 3 Months Survivorship. Coping with the after-math.

7. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERA CASE STUDY “Patients and family/whanau balance these ‘hellish’ times against ‘hopes’ around the patients future recovery, when they can re-establish a new life with plans for the future. But the possibility of re-occurrence of cancer means the latter, future-orientated state remains linked or tainted by the former.” (Waitemata District Health Board, Colorectal Cancer Service Improvement Project)

8. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERANATOMY AND PHYSIOLOGY

9. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERANATOMY AND PHYSIOLOGY Internal sphincter relaxation when the rectum is full

10. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERANATOMY AND PHYSIOLOGY External sphincter squeezes retracting stool

11. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERTHE TREATMENT Surgery remains the main treatment for colorectal cancer. • Chemotherapy, radiotherapy or both are also used in conjunction with surgery, or some cases are the sole most appropriate treatment. It is not surprising, therefore, that treatment of colorectal cancer changes the way in which the bowel functions.

12. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER: SURGERY Transverse colectomy Right hemicolectomy Left hemicolectomy Anterior Resection Colorectal Surgery (Young, 2007)

13. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERTHE AFFECTS. Treatment can result in in: • Reduction in colon available to absorb fluids from the fecal matter, inhibiting the formation of a soft formed bowel motion. • Reduction in rectal storage capacity. • Thickening and scarring of the remaining colon. • Changes to the colon mucosa and flora.

14. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERTHE AFFECTS. • Sphincter and nerve damage which leads to diminished control of the bowel motion. • The motility of the colon may be increased or in some cases decreased, disrupting the timely passing of a bowel motion. • Pelvic floor weakness. • Post treatment exhaustion, disempowering the person leaving them vulnerable and with a sense of lack of control.

15. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERASSESSMENT • Surgical Consultant • GP • Physiotherapist. • Stomal Therapy Nurse (for those who have had an ileostomy). • Clinical Nurse Specialist - Colorectal Care (if they have had appropriate training). • Clinical Nurse Specialist – Continence.

16. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERASSESSMENT When? (3mths, 6mths, year). • Bowel function is at its worst immediately after bowel surgery (or closure of a temporary ileostomy). • Bowel function improves during the first few months and can continue to do so for up to two years. • Bowel function will not be the same as previous bowel habit - a ‘new normal’ will develop.

17. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERPROIR TO ASSESSMENT The Bowel Diary. Present pattern of defection – using Bristol stool chart • 2-3 days of tracking bowel pattern • Frequency and consistency • Events that trigger motion • Awareness of sensation

18. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCERPROIR TO ASSESSMENT

19. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:ASSESSMENT Full assessment of problem must allow both patient and family • Opportunity • Time • Privacy to express and explore fears and frustrations related to bowel function

20. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:ASSESSMENT - SUBJECTIVE • Previous bowel habits. • How long since treatment. • What type of treatment. • Medications and herbal or alternative treatments. • Other medical conditions. • Diet and types of fluids. • History of present bowel function – dairy using Bristol Stool chart and notebook (prior to appointment is ideal) • Any interventions trialed/advise given. • Expectations

21. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:ASSESSMENT - PHYSICAL EXAMINATION • Focused examination – abdomen. • Quality of bowel sounds. • Tenderness. • Masses, gas and fluid distention. • Digital rectal examination • Detects fecal impaction. • Evaluates tone and strength of anal sphincter. • Anal gaping. • Condition of peri - anal skin. • Cognitive assessment may be appropriate. • Fecal specimen. • Plain film abdominal x-ray.

22. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:EFFECTS OF BOWEL MANAGEMENT CHALLENGES. • Peri - anal skin breakdown. • UTI. • Lowered self esteem. • Loss of personal dignity, embarrassment, shame. • Lowered Quality of life. • Increased financial burden. • Increased health care costs, nursing time, supplies laundry.

23. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:COMMON PROBLEMS • Loose bowel motions. • Frequent bowel motions. • Urgency or incontinence of bowel motion. • Difficulty in complete evacuation • Waiting • Straining • Occasionally constipation.

24. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:MANAGEMENT • TIME: • Give time to develop a new normal – everyone is different • DIET: • Is it appropriate – may need dietician referral. • BULK UP THE BOWEL MOTION – easier to hold onto. • Diet • Add fibre supplements • SLOW DOWN COLONIC TRANSIT TIME • Soluble fibre turns into a gel during digestion eg metamucil – bulks up and slows down transit. • Loperamide / immodium. Codiene Phosphate.

25. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:MANAGEMENT • Pelvic floor exercises. • Bowel re training. • Ongoing support and assessment

26. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:PRACTICE GOOD TOILETING HABITS

27. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:MANAGEMENT OF THE PERI-ANAL SKIN • Keeping the area clean. • Warm water and baking soda. • Baby wipes • Unscented toilet paper. • Protecting the area. • Thick commercial barrier cream. • If the skin is damaged. • May need antifungal or prescribed creams.

28. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:AIM OF MANAGEMENT CONTROL OF MOTION: allowing defecation at a socially appropriate time.

29. BOWEL FUNCTION & MANAGEMENT FOLLOWINGTREATMENT FOR COLORECTAL CANCER:SUMMARY • Colon cancer alters the bowel motion. • Ongoing assessment and management needs to be linked to the package of care available in phase three. • Who is responsible for this needs to be clearly identified. • Ongoing development of Health professionals with the appropriate level of skills, who can be easily identified and accessed, is vital to the full and complete recovery for those with Colorectal cancer.