Constipation: treatment in primary care, when to refer

and novel therapies....

Lee DvorkinConsultant General , Colorectal & Laparoscopic

Surgeon

Spire Roding Hospital

Department of Surgery – North Middlesex University Hospital

The next 20-30 mins• An overview

• Primary care management• cIBS• Faecal impaction

• When to refer

• Novel therapies

Constipation

• 2nd most common GI symptom

• 3% of population (2 - 34%)

• 1% have intractable symptoms

• Often in combination with FI

Epidemiology and Cost

• Constipation is more common in – Women (X3)– > 65 years– Non-whites– Poor socio-economic background

• Most common treatment is laxatives– 3 million people (USA) – > $725 million

Constipation

• A subjective term reported by patients when their bowel habit is perceived to be abnormal

• Wide variety of symptoms

• Objective criteria now exist• Rome II (Thompson et al., 1999)

Rome II Criteria• At least 12 weeks in the preceding 12 months, of 2 or more

of the following

– straining in > 25 % defaecations

– hard stools in >25 % defaecations

– incomplete evacuation in >25 % defaecations

– anorectal obstruction / blockage in >25 % defaecations

– digitation >25 % defaecations

– <3 defaecations / week

Specialists

Primary care

~75%non-consulters

~70% female

~30%male

~25%consulters

Constipation: Aetiology

Aetiology

Structural Functional

Secondary (systemic)Drugs and Diet

EndocrineMetabolic

Neurological

Primary (bowel problem)

Colon or rectum

“Primary” Constipation

• Structural

Cancer Strictures Megacolon/rectum

Hirschsprung’s Idiopathic

Outlet obstruction Anal stenosis Rectocele Prolapse

Functional

c- IBS Colonic inertiaIatrogenic (post pelvic surgery) Evacuatory dysfunctionRectal hyposensitivityAnismusProctalgia fugax ‘anal fixators’

Treatment: functional constipation

Vast majority don’t need referral or Ix unless no response to simple measures

Treatment focussed on underlying cause.... – Combination of softener and stimulant– High fibre for slow transit– Suppositories for evacuatory dysfunction– Colonic Irrigation– Bowel retraining / Biofeedback– Novel therapies including surgery

cIBS treatment

• Stress relief

• Hypnosis/Yoga

• Mebeverine 135mg tds before meals

• Laxatives (avoid lactulose)

• Antidepressants (avoid constipating ones)

• Diet-wheat exclusion, reduce fibre

Faecal Impaction

• PR

• Elderly, immobile patients

• No red flag symptoms

• Treat with enemas then reassess

Bowel-retraining programme

• Package of care

• Psychosocial counselling

• Optimisation of medication / diet/laxatives

• Pelvic floor co-ordination exercises

• ‘Biofeedback’ techniques

Pelvic floor co-ordination exercises

• Posture

• Diaphragmatic breathing

• Abdominal bracing exercises

• Balloon expulsion

• Splinting

‘Biofeedback’

• Physiological parameter (sphincter pressure) displayed on a screen visible to the patient

• Patients are re-educated, and learn how to co-ordinate the activity of the pelvic floor and anal sphincters

Novel therapies

Colectomy/Proctocolectomy for constipation

• Poor results

• High complication rates

• Rectal and small bowel dysmotility reduces effectiveness of colectomy

• Even stoma unsatisfactory but good results in selected few

ACE

• Good results esp. with neurological disease

• Intubate stoma with water or osmotic laxative

• High stoma complication rate

Prucalopride

• NICE approved

• Women only

• Failed 2 different laxatives after 6 months

• If no response after 4 weeks unlikely to work

• Selective serotonin agonists leads to colonic motility (1-2mg od)

Sacral Nerve Stimulation• Stimulation of S3

• “neuromodulation” effect on ascending pathways, local autonomic system

– Locally (sphincter pressures, rectal sensation)

– Distant (gut motility)

• 2 stage procedure

– Trial period 3 weeks

– Permanent implant

Indications• Constipation

– not NICE approved

– Largest study to date, Kamm et al 2010, Gut.

– Sig improvement in no of defecations, straining, incomplete emptying and abdo pain

– Used in both slow transit and obst defecation

– Difficult to achieve complete resolution of symptoms

SNS: Problems• Expensive

– Test box £200, Lead £2000, Battery £8000

• Post operative problems– Infection, nerve damage, battery lasts 6-8 years

• Loss of efficacy over time– Requires regular “re-programming”

• Pregnancy– Must be switched off during pregnancy – c-section to avoid lead displacement

Posterior Tibial Nerve Stimulation

• 2003 used for FI

• Neuromodulation of sacral plexus via the posterior tibial nerve

• Achieved by – Percutaneous

– transcutaneous

PTNS- Indications

• Just FI, so far

• Studies in constipated patients awaited

PTNS

• Cheap equipment costs– Needles £200– Pads £3– Stimulator boxes £80

Conclusions

• Simple therapies often effective

• Tailor treatment to underlying pathophysiology

• Refer to exclude underlying disease or if simple measures ineffective

• Avoid surgery!