Chronic constipation
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Chronic Constipation. No organ in the body is so misunderstood, so slandered and maltreated as the colon! Sir Arthur Hurst, 1935 Besides death, constipation is the big fear in hospitals Robert McCrumm Dr Stephen Bridger. Myths?. Simple Usually an underlying cause

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Chronic Constipation

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Chronic constipation

Chronic Constipation

No organ in the body is so misunderstood, so slandered and maltreated as the colon!

Sir Arthur Hurst, 1935

Besides death, constipation is the big fear in hospitals

Robert McCrumm

Dr Stephen Bridger


Myths

Myths?

  • Simple

  • Usually an underlying cause

  • Primary constipation uncommon

  • Not a ‘real disease’

  • Minimal impact on QOL

  • Caused by poor diet, poor lifestyle

  • Improved by Diet, fluids, exercise

  • Wide variety of effective laxatives

  • Treatment unrewarding


Definition

Patient Definition:

Hard Stools

Infrequent stools (<3 per week)

Excessive straining

Sense of incomplete bowel emptying

Excessive, unsuccessful time spent on toilet

Definition

  • Rome 3

  • Must include at least 2 of the following

  • At least 25% of bowel movements associated with

    • Straining

    • Lumpy or hard stools

    • Incomplete bowel evacuation

    • Anorectal obstruction

    • Need for manual manoeuvres

    • < 3 bowel movements per week

  • Loose stools rarely present without the use of laxatives

  • Insufficient criteria for IBS


  • Chronic constipation

    Used in Clinical Trials

    Correlates with symptoms of straining and difficult evacuation

    Also correlates with colonic transit (Type 1 or Type 7 stool is correlated with slow or rapidcolonic transit Degen LP, Phillips SF. How well does stool form reflect colonic transit? Gut 1996;39:109-113.

    Majority of “constipated”

    patients have stools that are Type 1-3

    University of Bristol, Scand J Gastroenterol, 1997


    Other symptoms and consequences of constipation

    Nausea +/- vomiting

    Abdominal and Rectal pain

    Flatulence

    Loss of appetite

    Lethargy

    Depression

    Nausea and reduced appetite  weight loss

    Behavioral disturbances in dementia  increased use of psychotropic medications

    Extra staff time needed for increased toileting needs

    Overall increased number of medications in the regime

    Other Symptoms and Consequences of Constipation


    Quality of life

    Quality of Life

    Impact as severe as Diabetes, IHD, Rheumatoid Arthritis

    Social and mental health particulary affected

    Estimates that > 13 million work days lost to constipation in USA/year

    Systematic review: impact of constipation on quality of life in adults

    Belsey et al Alim, Ther & Pharm 2010


    Epidemiology

    Epidemiology

    • North American prevalence 2 – 27%!

    • Using Rome 2, about 63 million Americans with chronic constipation

    • Women, non-whites, >60’s, low income, little exercise, poor education

    • >65’s, 26% men, 34% women


    Costs

    Costs


    Economic costs

    Economic Costs

    • UK National study, 2 x nos of GP visits for pts between 65 – 74 yrs, 5 x nos of visits for pts > 75

    • about 2.5 million Americans undergo Ixs for Constipation annually at a cost of $2700/pt (based on 1994 paper!)…85% of those pts will be prescribed long term laxatives

    • In 1994, In US, about 90,000 pt hospitalised for constipation

    • In 2004 (Levy et al), $660 million OTC Laxatives sold (US)


    Management

    Management


    Chronic constipation

    NEJM


    Case 1

    Case 1

    • 42 yr old Staff Nurse

    • Childhood abdominal pain + constipation

    • ‘life-long laxative use’

    • Liquid paraffin, glycerine supps, senna+++, unsuccessful trials of movicol

    • Wide variety of other symptoms: intermittent nausea, bloating, headaches etc

    • Occupational health issues


    Case 1 ixs

    Case 1 Ixs

    • FBC, Renal, Calcium, TFTs normal

    • Colonoscopy normal

    • Gut transit, normal…less than 5 days

    • Manometry normal

    • Pelvic US and laparoscopy (under genie) normal


    Case 1 mx

    Case 1 Mx

    • Inpatient admissions

    • Enemas

    • Biofeedback

    • Escalating doses of movicol

    • Bisacodyl

    • Picolax

    • Dietician


    Case 11

    Case 1

    • What Next?


    Case 12

    Case 1

    Subtotal colectomy and ileo-rectal anastomosis

    Stormy post operative course, leak, septic shock, ITU, Inotropes


    Indications for surgery

    Indications for Surgery

    • 4 Major Criteria

      • The patient has chronic, severe, and disabling symptoms from constipation that are unresponsive to medical therapy.

      • The patient has slow colonic transit of the inertia pattern.

      • The patient does not have intestinal pseudo obstruction, as demonstrated by radiologic or manometric studies.

      • The patient does not have abdominal pain as a prominent symptom.

    • The outcome of surgical treatment was illustrated in a study that included 74 patients with severe, refractory slow-transit constipation who underwent colectomy and ileorectostomy

    • Postoperative complications included small bowel obstruction (9 percent) and prolonged ileus (12 percent).

    • Most patients were satisfied with the results of surgery (97 percent) and reported a good or improved quality of life (90 percent) during a mean follow-up period of 56 months.


    Case 2

    Case 2

    • 66 yr old Outpt Nurse

    • Admitted with intractable nausea, poor appetite, bloating, LIF and RIF discomforts

    • Diagnosed with IBS in 1967

    • Longstanding constipation, Bowels open once per week, increasingly struggling…


    Case 21

    Case 2

    • Tonsillectomy and adenoidectomy 1946

    • IBS 1967

    • Ovarian Cystectomy 1972

    • Hysterectomy (for fibroids) 1975

    • BSO for ovarian cancer 1978

    • Anterior and post vaginal repair 1997

    • Cholecystectomy 1987

    • GORD 1988

    • Hypertension

    • Coccyectomy and fusion of L4/5/S1 2000

    • Ig A nephropathy 2004

    • Laparatomy for omental infarction 2008

    • Laparatomy for division of adhesions April 2010


    Case 22

    Case 2

    DAY 4

    DAY 6

    DAY 2


    Case 23

    Case 2

    • OGD/Colon/Abdo CT/Brain MRI/Shape study/FBC/Ca/LFTs/TFTs/Igs/AIP etc

    • Diagnoses:

    • ‘Chronic intestinal Dysmotility’,

      • Slow transit constipation,

      • Abdo/pelvic adhesions


    Case 24

    Case 2

    • Drugs were rationalised (Calcium antagonists + Amitripyline stopped)

    • Unsuccessful trials of senna, lactulose, bisacodyl

    • Some success with 4 sachets of movicol/day + sodium docusate

    • Trials of maxolon, misoprostol…


    Case 25

    Case 2

    • What next?


    Case 26

    Case 2

    • Prucalopride 1 mg od for a month

    • Headaches, increasing nausea

    • Didn’t work

    • Awaiting review by London Specialist

    • Pt desperate for surgery


    Case 3

    Case 3

    • Complex

    • 69 year old woman

    • Abdo pain, colicky, poorly localised, LIF and back discomforts radiating to her groin

    • Wind and bloating

    • BO 2x per week with 4 sachets of movicol per day

    • Known Diverticulosis, Colonoscopy a year ago

    • PMH: Mastectomy 10 yrs ago,

    • FH: 2 rels with bowel cancer (70’s),+ cousin with UC


    Case 31

    Case 3

    • Previously investigated at St Mary’s

    • Slow motility

    • Features of “chronic intestinal Pseudo-obstruction”

    • Diagnosis of a rare neuromuscular disorder of the small and large bowel…”alpha-epitope deficiency in the inner circular layer of intestinal smooth muscle”

    • Associated detrusor muscle dysfunction …need to self-catheterise 4 x per day…recurrent UTIs

    • Her previous GI symptoms had improved with tegaserod (Zelmac)…subsequently withdrawn


    Case 32

    Case 3

    • What next?


    Case 33

    Case 3

    • Prucalopride 1 mg od June 2010

    • Now taking 2mg od

    • Much better: reduced abdo pain, Much less wind and bloating, Bowels open once daily…still taking movicol but only 2 sachets 2x or 3x per week

    • Negatives: “My GP won’t prescribe it”. She’s happy to pay £90 per month


    Any questions

    Any Questions?


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