Chronic Constipation No organ in the body is so misunderstood, so slandered and maltreated as the colon! Sir Arthur Hurst, 1935 Besides death, constipation is the big fear in hospitals Robert McCrumm Dr Stephen Bridger Myths? • • • • • • • • • Simple Usually an underlying cause Primary constipation uncommon Not a ‘real disease’ Minimal impact on QOL Caused by poor diet, poor lifestyle Improved by Diet, fluids, exercise Wide variety of effective laxatives Treatment unrewarding Definition • Patient Definition: • Hard Stools • Infrequent stools (<3 per week) • Excessive straining • Sense of incomplete bowel emptying • Excessive, unsuccessful time spent on toilet Rome 3 Must include at least 2 of the following (1) At least 25% of bowel movements associated with Straining Lumpy or hard stools Incomplete bowel evacuation Anorectal obstruction Need for manual manoeuvres < 3 bowel movements per week (2) Loose stools rarely present without the use of laxatives (3) Insufficient criteria for IBS Used in Clinical Trials Correlates with symptoms of straining and difficult evacuation Also correlates with colonic transit (Type 1 or Type 7 stool is correlated with slow or rapid colonic transit Degen LP, Phillips SF. How well does stool form reflect colonic transit? Gut 1996;39:109-113. Majority of “constipated” patients have stools that are Type 1-3 University of Bristol, Scand J Gastroenterol, 1997 Other Symptoms and Consequences of Constipation Nausea +/- vomiting Abdominal and Rectal pain Nausea and reduced appetite  weight loss Flatulence Behavioral disturbances in Loss of appetite dementia  increased use of Lethargy Depression psychotropic medications Extra staff time needed for increased toileting needs Overall increased number of medications in the regime Quality of Life Impact as severe as Diabetes, IHD, Rheumatoid Arthritis Social and mental health particulary affected Estimates that > 13 million work days lost to constipation in USA/year Systematic review: impact of constipation on quality of life in adults Belsey et al Alim, Ther & Pharm 2010 Epidemiology • North American prevalence 2 – 27%! • Using Rome 2, about 63 million Americans with chronic constipation • Women, non-whites, >60’s, low income, little exercise, poor education • >65’s, 26% men, 34% women Costs Economic Costs • UK National study, 2 x nos of GP visits for pts between 65 – 74 yrs, 5 x nos of visits for pts > 75 • about 2.5 million Americans undergo Ixs for Constipation annually at a cost of $2700/pt (based on 1994 paper!)…85% of those pts will be prescribed long term laxatives • In 1994, In US, about 90,000 pt hospitalised for constipation • In 2004 (Levy et al), $660 million OTC Laxatives sold (US) Management NEJM Case 1 • • • • 42 yr old Staff Nurse Childhood abdominal pain + constipation ‘life-long laxative use’ Liquid paraffin, glycerine supps, senna+++, unsuccessful trials of movicol • Wide variety of other symptoms: intermittent nausea, bloating, headaches etc • Occupational health issues Case 1 Ixs • • • • • FBC, Renal, Calcium, TFTs normal Colonoscopy normal Gut transit, normal…less than 5 days Manometry normal Pelvic US and laparoscopy (under genie) normal Case 1 Mx • • • • • • • Inpatient admissions Enemas Biofeedback Escalating doses of movicol Bisacodyl Picolax Dietician Case 1 • What Next? Case 1 Subtotal colectomy and ileo-rectal anastomosis Stormy post operative course, leak, septic shock, ITU, Inotropes Indications for Surgery • 4 Major Criteria – The patient has chronic, severe, and disabling symptoms from constipation that are unresponsive to medical therapy. – The patient has slow colonic transit of the inertia pattern. – The patient does not have intestinal pseudo obstruction, as demonstrated by radiologic or manometric studies. – The patient does not have abdominal pain as a prominent symptom. • The outcome of surgical treatment was illustrated in a study that included 74 patients with severe, refractory slow-transit constipation who underwent colectomy and ileorectostomy • Postoperative complications included small bowel obstruction (9 percent) and prolonged ileus (12 percent). • Most patients were satisfied with the results of surgery (97 percent) and reported a good or improved quality of life (90 percent) during a mean follow-up period of 56 months. Case 2 • 66 yr old Outpt Nurse • Admitted with intractable nausea, poor appetite, bloating, LIF and RIF discomforts • Diagnosed with IBS in 1967 • Longstanding constipation, Bowels open once per week, increasingly struggling… Case 2 • • • • • • • • • • • • • Tonsillectomy and adenoidectomy 1946 IBS 1967 Ovarian Cystectomy 1972 Hysterectomy (for fibroids) 1975 BSO for ovarian cancer 1978 Anterior and post vaginal repair 1997 Cholecystectomy 1987 GORD 1988 Hypertension Coccyectomy and fusion of L4/5/S1 2000 Ig A nephropathy 2004 Laparatomy for omental infarction 2008 Laparatomy for division of adhesions April 2010 Case 2 DAY 2 DAY 4 DAY 6 Case 2 • OGD/Colon/Abdo CT/Brain MRI/Shape study/FBC/Ca/LFTs/TFTs/Igs/AIP etc • • Diagnoses: • ‘Chronic intestinal Dysmotility’, – Slow transit constipation, – Abdo/pelvic adhesions Case 2 • Drugs were rationalised (Calcium antagonists + Amitripyline stopped) • Unsuccessful trials of senna, lactulose, bisacodyl • Some success with 4 sachets of movicol/day + sodium docusate • Trials of maxolon, misoprostol… Case 2 • What next? Case 2 • Prucalopride 1 mg od for a month • Headaches, increasing nausea • Didn’t work • Awaiting review by London Specialist • Pt desperate for surgery Case 3 • Complex • 69 year old woman • Abdo pain, colicky, poorly localised, LIF and back discomforts radiating to her groin • Wind and bloating • BO 2x per week with 4 sachets of movicol per day • Known Diverticulosis, Colonoscopy a year ago • PMH: Mastectomy 10 yrs ago, • FH: 2 rels with bowel cancer (70’s),+ cousin with UC Case 3 • • • • Previously investigated at St Mary’s Slow motility Features of “chronic intestinal Pseudo-obstruction” Diagnosis of a rare neuromuscular disorder of the small and large bowel…”alpha-epitope deficiency in the inner circular layer of intestinal smooth muscle” • Associated detrusor muscle dysfunction …need to selfcatheterise 4 x per day…recurrent UTIs • Her previous GI symptoms had improved with tegaserod (Zelmac)…subsequently withdrawn Case 3 • What next? Case 3 • Prucalopride 1 mg od June 2010 • Now taking 2mg od • Much better: reduced abdo pain, Much less wind and bloating, Bowels open once daily…still taking movicol but only 2 sachets 2x or 3x per week • Negatives: “My GP won’t prescribe it”. She’s happy to pay £90 per month Any Questions?