Transcript Constipation

Constipation
Assessment
Constipation
• More common in people >65
• 26% men 34% women complain of
constipation
• Related to low food intake, not fibre or fluid
Assessment
• Goals of assessment: make a diagnosis
with a view to safely manage symptoms
• History
• Examination
• Investigations
Differential diagnosis
• Due to disease of anus/rectum/colon
• Due to systemic disease
• No structural or systemic disease
• Due to medication, immobility, environment
History
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Duration
Bowel motions/week, consistency
Straining/symptoms of rectal outlet delay
Urine and faecal incontinence
Abdo pain (?relieved by evacuation)
Red flags: weight loss, rectal pain/bleeding
Mood, cognition, diet
More History
Past history
Medication: laxatives now and past,
analgesics, anticholinergics (include
antidepressants, antipsychotics,
antispasmodics, antihistamines)
antihypertensives, anti-cancer drugs
What if limited history from patient?
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Caregivers
Relatives
Notes
Bowel record
Bowel record
• Frequency
• Consistency
• Associated symptoms
• Bristol stool charts
Examination 1
• Abdominal examination
appearance
tenderness
masses
bowel sounds
Examination 2
• Rectal examination
Appearance of perineum
Appearance of anus
Perianal sensation
Anal wink
Anal tone
Pain or tenderness
Contents of rectum
Wall smoothness, ?masses
Investigations
• Bloods (which?)
• Plain abdominal x-ray
• Colonoscopy, CT abdo, other?
Assessment of constipation
• History
• Examination
• Investigations
With a view to making a diagnosis in order
to safely manage symptoms
Older people and illness I
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More illnesses
More functional impairment
More medication
Frail elderly have less reserve
Non-specific presentation of illness
Older people and illness 2
• More detective work required
• Small changes can make a big difference
• Very rewarding
80 year old frail rest home resident
• Reports constipation over several months
• Bowel motions less often, some hard
stools
• Abdominal and rectal exam normal
• No medication
• What next?
Afternoon tea
Mrs A aged 82
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Constipation 5 months
Urinary & faecal incontinence 3 months
Weight loss 20kg
No PR bleeding
• Past Hx: COPD, hypertension, osteoporosis,
type 2 diabetes, forgetful last 1 year
More history
• Medications:
diltiazem, celiprolol, quinapril,
alendronate, inhalers, paracetamol
• Social:
Lived with husband, independent simple
ADL’s, low walking frame
Examination
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Distended abdomen
Percussible bladder
Dilated anus
Perineum distended
Rectum full of hard faeces
Case continued
• Bloods normal
• AXR some dilated bowel loops, faeces++
Diagnosis: faecal impaction
• IDC inserted
• Rx enemas, Coloxyl/senna, Movicol
Transfer to OPH
• Loose stools 1-2 daily, IDC still
• Abdomen soft, non-tender, bs normal
• PR hard faecal mass at finger tip
Rx more enemas and movicol
• Loose stools 1-2 daily
• What next?
Case continued 2
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Repeat AXR: still faeces ++ sigmoid
Gastro review ? flexi sig or colonoscopy
Declined, suggested high enema with Foley
Good result, mass resolved
Case continued
• Loose stools 1-2/day, weary of movicol
• What next?
• Encouraged self management
• To keep bowel diary
• MMSE 27/30
Case continued
• Unable to keep bowel diary
• ACE-R 74/100 (fluency 1/14 suggests
impaired executive function)
• Discharged home once daily formed stool
on Movicol 1 sachet daily with
Coloxyl/senna if no motion that day
• Husband to keep bowel diary, Mrs A to use
commode
Outcome
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6 months later, doing well at home
Bowels fine
10kg weight gain with food supplements
Husband’s heart condition a problem,
planning to move to retirement unit