Constipation: treatment in primary care, when to refer and novel therapies....

1. Constipation: treatment in primary care, when to refer and novel therapies.... Lee Dvorkin Consultant General , Colorectal & Laparoscopic Surgeon Spire Roding Hospital Department of Surgery – North Middlesex University Hospital

2. The next 20-30 mins • An overview • Primary care management • cIBS • Faecal impaction • When to refer • Novel therapies

3. Constipation • 2nd most common GI symptom • 3% of population (2 - 34%) • 1% have intractable symptoms • Often in combination with FI

4. Epidemiology and Cost • Constipation is more common in • Women (X3) • > 65 years • Non-whites • Poor socio-economic background • Most common treatment is laxatives • 3 million people (USA) • > $725 million

5. Constipation • A subjective term reported by patients when their bowel habit is perceived to be abnormal • Wide variety of symptoms • Objective criteria now exist • Rome II (Thompson et al., 1999)

6. Rome II Criteria • At least 12 weeks in the preceding 12 months, of 2 or more of the following • straining in > 25 % defaecations • hard stools in >25 % defaecations • incomplete evacuation in >25 % defaecations • anorectal obstruction / blockage in >25 % defaecations • digitation >25 % defaecations • <3 defaecations / week

7. Specialists ~25% consulters Primary care ~75% non-consulters ~70% female ~30% male

8. Constipation: Aetiology Aetiology Primary (bowel problem) Secondary (systemic) Drugs and Diet Endocrine MetabolicNeurological Structural Functional Colon or rectum

9. “Primary” Constipation • Functional • c- IBS • Colonic inertia • Iatrogenic (post pelvic surgery) • Evacuatory dysfunction • Rectal hyposensitivity • Anismus • Proctalgia fugax • ‘anal fixators’ • Structural • Cancer • Strictures • Megacolon/rectum • Hirschsprung’s • Idiopathic • Outlet obstruction • Anal stenosis • Rectocele • Prolapse

10. Treatment: functional constipation Vast majority don’t need referral or Ix unless no response to simple measures Treatment focussed on underlying cause.... • Combination of softener and stimulant • High fibre for slow transit • Suppositories for evacuatory dysfunction • Colonic Irrigation • Bowel retraining / Biofeedback • Novel therapies including surgery

11. cIBS treatment • Stress relief • Hypnosis/Yoga • Mebeverine 135mg tds before meals • Laxatives (avoid lactulose) • Antidepressants (avoid constipating ones) • Diet-wheat exclusion, reduce fibre

12. Faecal Impaction • PR • Elderly, immobile patients • No red flag symptoms • Treat with enemas then reassess

13. Bowel-retraining programme • Package of care • Psychosocial counselling • Optimisation of medication / diet/laxatives • Pelvic floor co-ordination exercises • ‘Biofeedback’ techniques

14. Pelvic floor co-ordination exercises • Posture • Diaphragmatic breathing • Abdominal bracing exercises • Balloon expulsion • Splinting

15. ‘Biofeedback’ • Physiological parameter (sphincter pressure) displayed on a screen visible to the patient • Patients are re-educated, and learn how to co-ordinate the activity of the pelvic floor and anal sphincters

16. Novel therapies

17. Colectomy/Proctocolectomy for constipation • Poor results • High complication rates • Rectal and small bowel dysmotility reduces effectiveness of colectomy • Even stoma unsatisfactory but good results in selected few

18. ACE • Good results esp. with neurological disease • Intubate stoma with water or osmotic laxative • High stoma complication rate

19. Prucalopride • NICE approved • Women only • Failed 2 different laxatives after 6 months • If no response after 4 weeks unlikely to work • Selective serotonin agonists leads to colonic motility (1-2mg od)

20. Sacral Nerve Stimulation • Stimulation of S3 • “neuromodulation” effect on ascending pathways, local autonomic system • Locally (sphincter pressures, rectal sensation) • Distant (gut motility) • 2 stage procedure • Trial period 3 weeks • Permanent implant

21. Indications • Constipation • not NICE approved • Largest study to date, Kamm et al 2010, Gut. • Sig improvement in no of defecations, straining, incomplete emptying and abdo pain • Used in both slow transit and obst defecation • Difficult to achieve complete resolution of symptoms

22. SNS: Problems • Expensive • Test box £200, Lead £2000, Battery £8000 • Post operative problems • Infection, nerve damage, battery lasts 6-8 years • Loss of efficacy over time • Requires regular “re-programming” • Pregnancy • Must be switched off during pregnancy • c-section to avoid lead displacement

23. Posterior Tibial Nerve Stimulation • 2003 used for FI • Neuromodulation of sacral plexus via the posterior tibial nerve • Achieved by • Percutaneous • transcutaneous

24. PTNS- Indications • Just FI, so far • Studies in constipated patients awaited

25. PTNS • Cheap equipment costs • Needles £200 • Pads £3 • Stimulator boxes £80

26. Conclusions • Simple therapies often effective • Tailor treatment to underlying pathophysiology • Refer to exclude underlying disease or if simple measures ineffective • Avoid surgery!