“The Remains of the Day” Interns 2008 or, why constipation is important to you…

“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

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 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

“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!