“The Remains of the Day” Interns 2008 or, why constipation is important to you…
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Transcript of “The Remains of the Day” Interns 2008 or, why constipation is important to you…
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“The Remains of the Day”
Interns 2008
or, why constipation is important
to you…
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outline
• Case studies
• Types of constipation
• Assessment
• Treatment
• The importance of PR!
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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
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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+
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Mrs BM…
• ED Assessment:– Likely UTI + Acopia
• Plan:– Admit Medics– MSU,bloods– Trimethoprim
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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 2nd-on
• Commenced on iv fluids
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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”
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Mrs BM…
• Further hx:– GP had commenced Diltiazem CD 2weeks
prior for HTN– Very hot over Christmas – decreased oral
intake
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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
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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
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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
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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.
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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
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Mr PR…
• Transfer to rehab -periodic constipation continues
• RMO decides to investigate further:– Ca 3.28!– PTH elevated– Confirmed primary hyperparathyroidism
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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
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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
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Mr BO…
• No fractures
• Mildly elevated CK – treated with iv fluids, IDC inserted to monitor output
• Probable LRTI – commenced on oral abs
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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
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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
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Mr BO…
• Repeat Abdo USS – confirmed likely multi-focal HCC
• Rapid deterioration on the ward - transferred to hospice soon thereafter
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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
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“Normal” bowel habit
• Varies from person to person
• Most people empty their bowels between 3 times a day and 3 times a week
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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
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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
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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
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Idiopathic…
• Combination syndromes
• Normal Colonic Transit Constipation– Misperception of bowel habit– Often psychosocial stresses
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Secondary
• Primary diseases of colon/rectum• Benign stricture, malignancy, proctitis, anal
fissure
• IBS
• DRUGS
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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
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DRUGS ASSOCIATED WITH CONSTIPATION
• ANALGESICS
– Opiates!!! (this includes tramadol)• ANTICHOLINERGICS
– Antispasmodics, antidepressants, antipsychotics
• CATION-CONTAINING
– Iron supplements, antacids, • NEURALLY ACTIVE
– Ca+blockers, 5HT3 antagonists
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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
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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
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ALARM…..
• Haematochezia• Weight loss • Family history of CRC or IBD• Anemia• Positive FOBT• Acute onset of constipation in elderly
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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
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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
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Treatment
• Good habits
• Pelvic floor exercises
• Diet
• Remove ppt factors
• aperients
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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
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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
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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
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Aperients
• BULK FORMING
• STOOL SOFTENERS
• OSMOTIC
• STIMULANT
• SUPPOSITORIES & ENEMAS
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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
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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)
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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!
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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
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“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
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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.
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Oh, and PR!