B Y

T I M O T H Y O L A D O S U

ABNORMALITIES OF FECAL ELIMINATION

OUTLINE

• Introduction

• Constipation • Causes

• Clinical manifestations

• Diagnostic findings

• Management

• Drugs used in constipation

• Complications

• Diarrhea • Causes

• Clinical manifestations

• Diagnostic findings

• Management

• Complications

• Fecal incontinence • Causes

• Clinical manifestations

• Diagnostic findings

• Management

INTRODUCTION

• Changes in patterns of fecal elimination are

symptoms of functional disorders or disease states in

the GIT

• The most common changes seen are;

• Constipation

• Diarrhea, and

• Fecal incontinence

CONSTIPATION

• It is a term used to describe;

• An abnormal infrequency or irregularity of defecation

• Abnormal hardening of stools that makes their passage

difficult and sometimes painful

• A decrease in stool volume

• Retention of stool in the rectum for a prolonged period of

time

• Any variation from normal habits may be seen as a

problem

CAUSES

• Constipation can be caused by; • Certain medications (e.g. tranquilizers, anticholinergics,

antidepressants, antihypertensives, opioids, antacids with aluminium, iron)

• Rectal or anal disorders (e.g. hemorrhoids, fissures) • Obstruction (e.g. cancer of the bowel)

• Endocrine disorders (e.g. hypothyroidism, pheochromocytoma)

• Lead poisoning

• Connective tissue disorders (e.g. scleroderma, lupus erythematosus)

• Metabolic, neurologic, and neuromuscular conditions (e.g. diabetes mellitus, Hirschsprung’s disease, Parkinson’s disease, multiple sclerosis)

• Opoids analgesics • Diseases of the colon (e.g. irritable bowel syndrome, diverticular

disease)

• Acute abdomen (e.g. appendicitis)

• Other causes include;

• Weakness

• Immobility

• Debility

• Fatigue

• Inability to increase intra-abdominal pressure(as seen in

emphysema)

• Ignoring the urge to defeacate

• Dietary habits (low consumption of fiber and inadequate

fluid intake)

• Lack of regular exercise

• A stress-filled life

CLINICAL MANIFESTATIONS

• Abdominal distention

• Borborygmus (intestinal rumbling)

• Pain

• Pressure

• Decreased appetite

• Headache

• Fatigue

• Indigestion

• Sensation of incomplete emptying

• Straining at stool

• Elimination of small-volume, hard, dry stool

DIAGNOSTIC FINDINGS

• Patient history

• Physical examination

• Barium enema

• Stool testing for occult blood

• Sigmoidoscopy

• Anorectal manometry

• Defecography and bowel transit studies

MANAGEMENT

• Treatment is aimed at the underlying cause

• Inclusion of fiber in the diet with an increase in fluid

intake

• Routine exercise to strengthen abdominal muscles

• Discontinuity of laxative abuse

DRUGS USED FOR CONSTIPATION DRUG CATEGORY AND EXAMPLES MECHANISM OF ACTION NURSING CONSIDERATIONS

CHEMICAL STIMULANTS

bisacodyl (Dulcolax)

cascara (generic)

castor oil (Neoloid)

senna (Senokot

Directly stimulate the nerve

plexus in the intestinal wall,

causing increased movement

and stimulation of local

reflexes. Lead to intestinal

evacuation

Prior to administration assess client’s abdomen for

tenderness, rigidity, and bowel sounds.

Ask when client had last bowel movement.

Repeated use in the older adult may cause

orthostatic hypotension and weakness from

electrolyte loss.

Encourage client to maintain adequate fluid intake.

After administration assess client for:

-Bowel activity and stool consistency

- Bowel sounds

- Serum electrolytes for clients with repeated use

BULK FORMING AGENTS

magnesiumsulfate (Epsom salts)

magnesiumcitrate (Citrate of

Magnesium)

magnesiumhydroxide (Milk of

Magnesia)

polycarbophil (FiberCon)

psyllium (Metamucil

Increase intestinal motility by

increasing fluids in intestinal

contents. This in turn enlarges

bulk, stimulates local stretch

receptors, and activates bowel

reflex activity

Prior to administration assess client’s abdomen for

tenderness, rigidity, and bowel sounds.

Ask when client had last bowel movement.

Magnesium products may cause ECG changes with

prolonged use.

After administration assess the client for:

-Amount, color, and consistency of stool

-Daily pattern of bowel activity

- Bowel sounds

- BUN, serum creatinine, and magnesium levels for

clients with repeated or chronic use

HYPEROSMOTIC

AGENTS

Lactulose (Chronulac)

polyethylene glycol

(PEG)

glycerin (Fleet Babylax

Similar action as bulk-forming

agents; pulling water into intestine

results in distention and peristalsis,

leading to evacuation. The action

of these drugs is limited to only the

large intestine.

Assess for chronic constipation.

After use, assess for abdominal

bloating and potential electrolyte

imbalance.

Possible rectal irritation if given by

the PR route.

EMOLLIENTS AND

LUBRICANTS

docusate (Colace)

glycerin (Sani-Supp)

mineral oil (Agoral

Plain)

Lubricants ease defecation

without stimulating movement in

the GI tract. Products form a

slippery coat on intestinal

contents, decreasing the loss of

water out of the contents and

preventing the contents from

becoming hard or impacted.

Clients with lower GI surgery such

as hemorrhoidectomy or those for

whom straining could be

harmful (such as in heart

dysrhythmias) benefit from

lubricants.

Prior to administration assess client’s

abdomen for tenderness, rigidity,

and bowel sounds.

Ask when client had last bowel

movement.

Encourage client to maintain

adequate fluid intake.

Monitor bowel function to evaluate

drug effectiveness

COMPLICATIONS

• Hypertension

• Fecal impaction

• Hemorrhoids

• Fissures

• megacolon

DIARRHEA

• Diarrhea can be defined as; • Increased frequency of bowel movements (more than 3

times per day)

• Increased amount of stool (more than 200g/day)

• Altered consistency (looseness) of stool

• It is usually associated with urgency, perianal discomfort, incontinence, or a combination of these

• Diarrhea can be acute or chronic;

• Acute diarrhea is most often associated with infection and is usually self-limiting

• Chronic diarrhea persists for a longer period of time and may return sporadically

CAUSES

• The most common cause is infection by bacterial, parasitic or viral agents

• Lactose intolerance

• Food allergies or intolerance

• Uremia

• Intestinal diseases e.g. diverticulitis, ulcerative colitis, malabsorption, intestinal obstruction

• Rapid addition of fiber to diet

• Consumption of highly spiced or seasoned food

• Overuse of laxatives

• Adverse effect of drugs esp antibiotics

• Concentrated tube-feeding formulas

• Irritable bowel syndrome

• Immunoglobulin A deficiency

• Overeating

• Metabolic disorders & diseases e.g. cystic fibrosis, pancreatic insufficiency, inflammatory bowel diseases

CLINICAL MANIFESTATIONS

• Increased frequency and fluid content of stool

• Abdominal cramps

• Distention

• Intestinal rumbling (borborygmus)

• Anorexia

• Thirst

• Ineffectual straining (tenesmus)

• Fluid and electrolyte imbalances

• dehydration

DIAGNOSTIC FINDINGS

• Detailed history

• Complete blood count

• Urinalysis

• Stool examination for infectious or parasitic

organisms, bacterial, toxins, blood, fat & electrolytes

• Endoscopy

• Barium enema

MANAGEMENT

• Primary management is directed at; • Controlling symptoms • Preventing complications • Eliminating or treating the underlying disease

• Medications such as antibiotics, anti-inflammatory agents may reduce the severity

• Administration of an antidiarrheal agent, such as diphenoxylate hydrochloride with atropine sulfate (Lomotil), loperamide hydrochloride (Imodium), or a combination product such as kaolin and pectin (Kaopectate)

• Fluid and electrolyte replacement by either the oral or intravenous (IV) route

• Dietary adjustments, which may involve eliminating foods that cause diarrhea

• Total parenteral nutrition (TPN) if diarrhea is severe and prolonged and if the introduction of oral fluid and food results in another episode of diarrhea

COMPLICATIONS

• Muscle weakness

• Paresthesia

• Hypotension

• Anorexia

• Cardiac dysrhythmias (due to loss of potassium)

• Urinary output of less than 30mL/hour

FECAL INCONTINENCE

• Is the involuntary passage of stool from the rectum

• The following factors influence it;

• Ability of the rectum to sense & accommodate stool

• Amount & consistency of stool

• Integrity of the anal sphincters & musculature

• Rectal motility

CAUSES

• Trauma (post rectal surgeries)

• Neurologic disorder (e.g. stroke, multiple sclerosis, diabetic neuropathy, dementia)

• Inflammation

• Infection

• Radiation treatment

• Fecal impaction

• Pelvic floor relaxation

• Laxative abuse

• Medications

• Advancing age (i.e. weakness or loss of anal or rectal muscle tone)

CLINICAL MANIFESTATIONS

• Minor soiling

• Occasional urgency and loss of control

• Complete incontinence

• Poor control of flatus

• Diarrhea

DIAGNOSTIC FINDINGS

• Detailed history

• Rectal examination

• Flexible sigmoidoscopy to rule out tumors,

inflammation or fissures

• X-ray studies

• Barium enema

• CT scans

• Anorectal manometry

MANAGEMENT

• Fecal incontinence is frequently a symptom of fecal

impaction, once the impaction is removed & the

rectum is cleansed, normal function resume

• If fecal incontinence is related to diarrhea, the

incontinence may disappear when that process is

successfully treated

• Surgical procedures include;

• Surgical reconstruction

• Sphincter repair

• Fecal diversion