“the remains of the day” interns 2008 or, why constipation is important to you…
TRANSCRIPT
“The Remains of the Day”
Interns 2008
or, why constipation is important
to you…
outline
• Case studies
• Types of constipation
• Assessment
• Treatment
• The importance of PR!
Mrs BM• 84 yr old, Lives alone, care package 2X week• Presents on Christmas Eve - daughter found her
confused + cooking breakfast at 4pm• “difficult historian”
– no complaints, wants to “leave this airport.”
• Hx HTN, OA, T2DM, mild cognitive impairment• Meds:
– Paracetamol– Gliclizide MR 30mg od– Perindopril plus 5/1.25mg– Diltiazem CD 180mg od
Mrs BM…
• o/e– Confused, looks dehydrated, Bsl 7.3– AMTS 7/10– Afebrile, p=90, bp 120/70– cvs, resp, cns, abdo exam nad– msu: +WCC, glu+
Mrs BM…
• ED Assessment:– Likely UTI + Acopia
• Plan:– Admit Medics– MSU,bloods– Trimethoprim
Mrs BM…
• MSU- no bacteria, no growth
• Bloods: Na 134, Ur 18, Cr 89, FBC nad
• Refuses to eat or drink
• Feels nauseous – given dolesetron by 2nd-on
• Commenced on iv fluids
Mrs BM…
• Next medical review on 27/12– Still confused ++– Picking at bottom (dirty fingernail sign!)– Still not eating– 3x dolesetron given for nausea– incontinent
• No BM since admission? How many days prior?• Abdo soft, but distended• PR – empty rectum but “ballooned”
Mrs BM…
• Further hx:– GP had commenced Diltiazem CD 2weeks
prior for HTN– Very hot over Christmas – decreased oral
intake
Mrs BM
• Dolesetron and diltiazem ceased
• Given aperients (more on this later)
• Large BM x3
• Improvement in continence
• Improvement in mental function
• Stint on 3K:– d/c home with previous level of care
What have we learned so far?
• Constipation can cause delirium
• Constipation can cause urinary incontinence
• “poo on fingers” often means constipation
• Ca+ blockers can cause constipation
• Dehydration can cause constipation!
• PR PR PR PR PR
Mr PR
• 59 year old Professor of engineering
• Admitted for R total hip joint replacement
• PMx- OA R hip, L knee, ex-smoker 10yrs
• Meds – aspirin only – withheld at present
• Pre-op bloods normal – FBC, UE
Mr PR….
• Post-operatively:– Pain: PCA and then tramadol and oxcodone
SR 20mg bd– Nurse prescribed C+S given daily– Refuses to use bed pan. – Refuses to use commode by bed – 4 bedded
room.
Mr PR…
• Day 4 post op – no BM yet
• Grumpy+++
• Refuses PR intervention – undignified!
• Finally on day 5 – small BM
• Abdo discomfort continues
• PR- still evidence of loading
• Aperients increased to regular
Mr PR…
• Transfer to rehab -periodic constipation continues
• RMO decides to investigate further:– Ca 3.28!– PTH elevated– Confirmed primary hyperparathyroidism
What have we learned so far?
• Always co-prescribe aperients with opiates
• Hospitals are undignified! – this can cause constipation
• If constipation persists – always investigate!
• PR PR PR PR PR
Mr BO…
• 74 yr old, lives “with mates”.• Presents with fall and prolonged lie• PMx:
– ETOH: cirrhosis, portal HTN– T2DM – poor control– Smoker +++
• Meds:– Propranolol 40mg– Thiamine
Mr BO…
• No fractures
• Mildly elevated CK – treated with iv fluids, IDC inserted to monitor output
• Probable LRTI – commenced on oral abs
Mr BO…
• Difficult to manage – always wanting a smoke, noisy friends
• No BM for 4/7 then some watery diarrhoea, further BNO 2/7 then more diarrhoea
• Needing supervision to mobilise – falls risk
• Found next to bed on the floor, unable to stand up
Mr BO…
• RMO called to examine:– No obvious injury– Decreased power both lower legs– Hypo reflexic – Odd pattern of decreased sensation to soft
touch– PR:
• No anal tone• Soft faeces loading rectum
Mr BO…
• Repeat Abdo USS – confirmed likely multi-focal HCC
• Rapid deterioration on the ward - transferred to hospice soon thereafter
What have we learned so far?
• Watery diarrhoea after a period of NBO often indicates overflow diarrhoea
• Constipation can indicate other problems..
• PR PR PR PR PR PR
“Normal” bowel habit
• Varies from person to person
• Most people empty their bowels between 3 times a day and 3 times a week
Constipation (2+ for at least 3months during the last year)
– Straining in 25% of movements
– Feeling of incomplete evacuation after 25%
– Sense of anorectal obstruction / blockade in 25%
– Manual manoeuvres to help in 25%
– Hard or lumpy stools in 25%
– Stools less frequent than 3 per week
Subtypes• IDIOPATHIC
• Slow Transit Constipation• Pelvic Floor Dysfunction• Combination Syndromes• Normal Colonic Transit Constipation
• SECONDARY• Primary Diseases of the Colon / Rectum• Irritable Bowel Syndrome• Peripheral Neurogenic• Central Neurogenic • Non-Neurogenic • Drugs
Idiopathic…• Slow transit constipation
– Slower than normal movement from proximal to distal colon and rectum
– Colonic inertia vs uncoordinated motor activity?– ? enteric nerve plexus dysfunction
• Pelvic floor dysfunction– Functional defect in coordinated evacuation -
difficulty evacuating contents from rectum– Probably acquired / learned dysfunction rather
than organic / neurogenic
Idiopathic…
• Combination syndromes
• Normal Colonic Transit Constipation– Misperception of bowel habit– Often psychosocial stresses
Secondary
• Primary diseases of colon/rectum• Benign stricture, malignancy, proctitis, anal
fissure
• IBS
• DRUGS
SECONDARY …
• Peripheral neurogenic – Hirschsprung’s, autonomic neuropathy, Diabetes,
pseudo-obstruction
• Central neurogenic – Parkinson’s, multiple sclerosis, spinal cord injury
• Non-neurogenic– Hypothyroidism, hypercalcaemia,
panhypopituitarism, pregnancy, anorexia nervosa, systemic sclerosis
DRUGS ASSOCIATED WITH CONSTIPATION
• ANALGESICS
– Opiates!!! (this includes tramadol)• ANTICHOLINERGICS
– Antispasmodics, antidepressants, antipsychotics
• CATION-CONTAINING
– Iron supplements, antacids, • NEURALLY ACTIVE
– Ca+blockers, 5HT3 antagonists
Hospital causing constipation
• Decreased exercise/mobility• Hospital food (Not eating enough fibre)• Not drinking enough fluid• Lack of privacy• Limited toilet access• Depression / grief / anxiety
HISTORY• SYMPTOMS (Nature / Onset / Duration)
• Frequency• hard stools?• satisfaction• Straining/extra help required?• Bloating, pain, malaise
• BOWEL PATTERN (Usual and current)
• BOWEL REGIME (Usual and current)• Aperients/PR intervention/ frequency, dose
• IDENTIFICATION OF CONTRIBUTING FACTORS
ALARM…..
• Haematochezia• Weight loss • Family history of CRC or IBD• Anemia• Positive FOBT• Acute onset of constipation in elderly
EXAMINATION
• PERINEAL / ANAL EXAMINATION• Perianal skin, anal reflex, squeeze,
simulated evacuation, mucosal prolapse
• PR!!!!!!!!!!!!!!• Sphincter tone (resting, squeezing),
masses, tenderness, expel finger• PV
• Rectocele• ABDOMINAL EXAMINATION
INVESTIGATIONS
• BLOOD TESTS– FBP, TSH, Calcium, Glucose, Creatinine
• RADIOGRAPHY– Abdo XR– RPH imaging guidelines: DO A PR FIRST– only use to: diagnose constipation or ? obstruction
• ENDOSCOPY• Flexible sigmoidoscopy, colonoscopy
• SPECIALISED TESTS• Colonic transit (radiopaque marker) studies, barium defecography,
anorectal manometry, balloon expulsion test
Treatment
• Good habits
• Pelvic floor exercises
• Diet
• Remove ppt factors
• aperients
DIET
• INSOLUBLE FIBRE• Speeds up bowel motions• eg. Multigrain wheat, corn and rice cereals,
bran, fibrous vegetables, skins of fruits and vegetables
• SOLUBLE FIBRE• Turns into gel and firms up loose stools• eg. Oats, barley, rye, legumes, peeled fruits
and vegetables
Fibre supplements
• Ispaghula (Fybogel)
• Psyllium (Metamucil)
• Guar gum (Benefibre)
• Sterculia (Normafibe)
• Methylcellulose
• Recommended dietary fibre = 20 – 35 g/day
• Water intake must be increased according to manufacturers instructions when taking fibre supplements
MEDICATIONS
• Appropriate use of aperients• Only commence if simple measures (fibre / fluid /
exercise / review of medications) not adequately controlling constipation
• Only take for short periods of time
Aperients
• BULK FORMING
• STOOL SOFTENERS
• OSMOTIC
• STIMULANT
• SUPPOSITORIES & ENEMAS
BULK FORMING
• Add bulk to the stool• Absorb water and increase faecal mass• Soften stool and increase frequency
• Ispaghula (Fybogel)• Psyllium (Metamucil)• Guar gum (Benefibre)• Sterculia (Normafibe)• Methylcellulose• Calcium polycarbophil
• Not helpful in opioid induced, may worsen incipient constipation
STOOL SOFTENERS
• Soften the stool
• Lower surface tension of stool allowing water to more easily enter stool
• Few side effects
• Less effective than laxatives
• Eg.• Docusate sodium (Coloxyl)
OSMOTIC
• Attract water into the bowel • Osmosis keeps water within intestinal lumen• Improve stool consistency and frequency
• Lactulose (Actilax, Duphalac, Genlac, Lac-dol)• Sorbitol (Sorbilax)• Polyethylene glycol (Movicol, Golytely, Glycoprep)• Glycerol (Glycerol / Glycerin suppositories)• Magnesium sulfate (Epsom salts)
• Lactulose can take up to 3 days• Can get bloating, colic, wind!
STIMULANT
• Increase intestinal motor activity• Alter mucosal electrolyte,fluid transport
• Bisacodyl (Bisalax, Durolax)• Senna• Castor oil• Cascara
• 6-12 hour latency• Good in opioid with stool softener• Excessive use may cause hypokalemia,
protein losing enteropathy, salt overload
“PR intervention”
• Always with oral aperient
• Faecal impaction/cord compression/neurogenic
• PR!– soft poo + “lax” rectum= bisacodyl– hard poo = glycerine– If palpable in abdo = glycerine, then
phosphate. May need to repeat
Summary
• PR!• Constipation can indicate an underlying
problem – rule this out.• Opioids are not the only offending drug• The elderly can develop delirium with just
constipation.• Hospitals are bad for your bowels.• Never prescribe PR intervention without
oral.
Oh, and PR!