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Constipation - Update

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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  1. Constipation - Update GS Duthie

  2. Assessment • Constipation • Infrequent • Hard • Difficult Evac • Abdominal Pain • ( important for surgical options ) • Not resolved by colectomy

  3. Assessment • Previous History • Medical (surgery/gynae) • Social • Current Treatment • 2 week diary (or more) • Dietary assessment

  4. Assessment • Exclude organic causes • History • Examination • PR / Sigmoidoscopy • Radiology • Endoscopic

  5. Assessment • Large Bowel Transit • Pellets • One day / Three day • Scintigraphic • Oro-Caecal Transit • Breath test • Scintigraphic • Proctography • Radiol • MRI • Scintigraphic

  6. Assessment • Doctor • Nurse Practitioner • Physiologist • Multi disciplinary meeting ? • ? Psychology

  7. Diagnosis • Transit Slow / No Obstruction • Treat for Transit • Transit Slow / Obstructive • Treat for Obstruction then Transit • Transit Normal / Obstructive • Treat for Obstruction

  8. Diagnosis • Transit Normal / No Obstruction • Reassess • ? IBS • Somatisation • Psychology / Psychiatry • Remember the Childrens Act

  9. 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

  10. 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

  11. Slow Transit • Dietary Manipulation • CUT Fibre Intake • Laxative Therapy • High Doses • Poly-pharmacy • Rectal Irrigation

  12. Slow Transit • ACE • Neuromodulation • (funding issues) • Stoma – Ileostomy • Especially if considering colectomy • Colectomy + IRA (2 years)

  13. Obstructive Causes • Anismus / Spastic Pelvic Floor • Failure of Pelvic Floor (physics) • Rectoceles • Intussussception

  14. Anismus • No “surgical” option • Stomas Bad • Laxatives (PEG) • Biofeedback • Consider Neuromodulation • Beware test “enthusiasm” • Funding

  15. Failure of Pelvic Support • Almost impossible to resolve • ? Urinary symptoms • Multidisciplinary Approach • Physiotherapy • Sacro-colpo-rectopexy • (Rectopexy) • Neuromodulation (funding) • Express Procedure

  16. Rectoceles • (? Biofeedback) • Irrigation • Repair • Surgical / Gynae (USS sphincter) • ?STARR • Medium / Long term results • ? logic

  17. Intussussception • (?biofeedback) • Irrigation • Rectopexy (poor longterm results) • STARR • Repeatability • Longevity

  18. Solitary Rectal Ulcer • Is a Pathological diagnosis • Refer for Specialist Assessment

  19. Megarectum / Colon • Refer for Specialist Assessment

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