“The Remains of the Day” or, why

constipation

to you… is important

Interns 2008

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 2 nd 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

The learning bit…

“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 25% after – 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

“please review Mr Strain,BNO 4/7”

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

The Call to Stool!

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!