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

2. outline Case studies Types of constipation Assessment Treatment The importance of PR!

3. 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

4. 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+

5. Mrs BM… ED Assessment: –Likely UTI + Acopia Plan: –Admit Medics –MSU,bloods –Trimethoprim

6. 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

7. 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”

9. Mrs BM… Further hx: –GP had commenced Diltiazem CD 2weeks prior for HTN –Very hot over Christmas – decreased oral intake

10. 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

11. 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

12. 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

13. 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.

14. 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

15. Mr PR… Transfer to rehab -periodic constipation continues RMO decides to investigate further: –Ca 3.28! –PTH elevated –Confirmed primary hyperparathyroidism

16. 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

17. 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

18. Mr BO… No fractures Mildly elevated CK – treated with iv fluids, IDC inserted to monitor output Probable LRTI – commenced on oral abs

19. 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

20. 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

22. Mr BO… Repeat Abdo USS – confirmed likely multi- focal HCC Rapid deterioration on the ward - transferred to hospice soon thereafter

23. 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

24. The learning bit…

25. “Normal” bowel habit Varies from person to person Most people empty their bowels between 3 times a day and 3 times a week

27. 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

28. 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

29. 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

30. Idiopathic… Combination syndromes Normal Colonic Transit Constipation –Misperception of bowel habit –Often psychosocial stresses

31. Secondary Primary diseases of colon/rectum Benign stricture, malignancy, proctitis, anal fissure IBS DRUGS

32. 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

33. DRUGS ASSOCIATED WITH CONSTIPATION ANALGESICS –Opiates!!! (this includes tramadol) ANTICHOLINERGICS –Antispasmodics, antidepressants, antipsychotics CATION-CONTAINING –Iron supplements, antacids, NEURALLY ACTIVE –Ca+blockers, 5HT3 antagonists

34. 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

35. “please review Mr Strain,BNO 4/7”

36. 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

37. ALARM….. Haematochezia Weight loss Family history of CRC or IBD Anemia Positive FOBT Acute onset of constipation in elderly

39. 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

40. 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

41. Treatment Good habits Pelvic floor exercises Diet Remove ppt factors aperients

42. The Call to Stool!

43. 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

44. 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

45. 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

46. Aperients BULK FORMING STOOL SOFTENERS OSMOTIC STIMULANT SUPPOSITORIES & ENEMAS

47. 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

48. 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)

49. 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!

50. 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

51. “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

52. 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.

53. Oh, and PR!