Constipation update
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Constipation - Update. GS Duthie. Assessment. Constipation Infrequent Hard Difficult Evac Abdominal Pain ( important for surgical options ) Not resolved by colectomy. Assessment. Previous History Medical (surgery/gynae) Social Current Treatment 2 week diary (or more)

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Constipation - Update

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Constipation update

Constipation - Update

GS Duthie


Assessment

Assessment

  • Constipation

    • Infrequent

    • Hard

    • Difficult Evac

  • Abdominal Pain

    • ( important for surgical options )

    • Not resolved by colectomy


Assessment1

Assessment

  • Previous History

    • Medical (surgery/gynae)

    • Social

  • Current Treatment

  • 2 week diary (or more)

  • Dietary assessment


Assessment2

Assessment

  • Exclude organic causes

  • History

  • Examination

  • PR / Sigmoidoscopy

  • Radiology

  • Endoscopic


Assessment3

Assessment

  • Large Bowel Transit

    • Pellets

      • One day / Three day

    • Scintigraphic

  • Oro-Caecal Transit

    • Breath test

    • Scintigraphic

  • Proctography

    • Radiol

    • MRI

    • Scintigraphic


Assessment4

Assessment

  • Doctor

  • Nurse Practitioner

  • Physiologist

  • Multi disciplinary meeting ?

  • ? Psychology


Diagnosis

Diagnosis

  • Transit Slow / No Obstruction

    • Treat for Transit

  • Transit Slow / Obstructive

    • Treat for Obstruction then Transit

  • Transit Normal / Obstructive

    • Treat for Obstruction


Diagnosis1

Diagnosis

  • Transit Normal / No Obstruction

    • Reassess

    • ? IBS

    • Somatisation

    • Psychology / Psychiatry

  • Remember the Childrens Act


Treatment

Treatment

  • Treat based on QoL

  • Agree acceptable Outcome

  • Use Minimal Acceptable Treatment

  • Surgery is LAST Option

  • Stomas often give poor results

  • Reassess transit after treating obstruction

  • Reconsider psychological assessment


Assessment 2

Assessment 2

  • Physiological Assessment

    • Early if ? Megarectum/Colon

      • Recto-anal reflex

      • May help define Obstruction

  • Late if ? Surgery

    • Anal Ultrasound

      • Remember Diarrhoea/Sphincter Injury

      • Don’t Mix Well


Slow transit

Slow Transit

  • Dietary Manipulation

    • CUT Fibre Intake

  • Laxative Therapy

    • High Doses

    • Poly-pharmacy

  • Rectal Irrigation


Slow transit1

Slow Transit

  • ACE

  • Neuromodulation

    • (funding issues)

  • Stoma – Ileostomy

    • Especially if considering colectomy

  • Colectomy + IRA (2 years)


Obstructive causes

Obstructive Causes

  • Anismus / Spastic Pelvic Floor

  • Failure of Pelvic Floor (physics)

  • Rectoceles

  • Intussussception


Anismus

Anismus

  • No “surgical” option

  • Stomas Bad

  • Laxatives (PEG)

  • Biofeedback

  • Consider Neuromodulation

    • Beware test “enthusiasm”

    • Funding


Failure of pelvic support

Failure of Pelvic Support

  • Almost impossible to resolve

    • ? Urinary symptoms

    • Multidisciplinary Approach

  • Physiotherapy

  • Sacro-colpo-rectopexy

    • (Rectopexy)

  • Neuromodulation (funding)

  • Express Procedure


Rectoceles

Rectoceles

  • (? Biofeedback)

  • Irrigation

  • Repair

  • Surgical / Gynae (USS sphincter)

  • ?STARR

    • Medium / Long term results

    • ? logic


Intussussception

Intussussception

  • (?biofeedback)

  • Irrigation

  • Rectopexy (poor longterm results)

  • STARR

    • Repeatability

    • Longevity


Solitary rectal ulcer

Solitary Rectal Ulcer

  • Is a Pathological diagnosis

  • Refer for Specialist Assessment


Megarectum colon

Megarectum / Colon

  • Refer for Specialist Assessment


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