“The Remains of the Day” or, why constipation is important to you… 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 2ndon • 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 multifocal 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!