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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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Presentation Transcript
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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