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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.

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Constipation

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  1. Constipation Assessment

  2. Constipation • More common in people >65 • 26% men 34% women complain of constipation • Related to low food intake, not fibre or fluid

  3. Assessment • Goals of assessment: make a diagnosis with a view to safely manage symptoms • History • Examination • Investigations

  4. Differential diagnosis • Due to disease of anus/rectum/colon • Due to systemic disease • No structural or systemic disease • Due to medication, immobility, environment

  5. History • 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

  6. More History Past history Medication: laxatives now and past, analgesics, anticholinergics (include antidepressants, antipsychotics, antispasmodics, antihistamines) antihypertensives, anti-cancer drugs

  7. What if limited history from patient? • Caregivers • Relatives • Notes • Bowel record

  8. Bowel record • Frequency • Consistency • Associated symptoms • Bristol stool charts

  9. Examination 1 • Abdominal examination appearance tenderness masses bowel sounds

  10. 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

  11. Investigations • Bloods (which?) • Plain abdominal x-ray • Colonoscopy, CT abdo, other?

  12. Assessment of constipation • History • Examination • Investigations With a view to making a diagnosis in order to safely manage symptoms

  13. Older people and illness I • More illnesses • More functional impairment • More medication • Frail elderly have less reserve • Non-specific presentation of illness

  14. Older people and illness 2 • More detective work required • Small changes can make a big difference • Very rewarding

  15. 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?

  16. Afternoon tea

  17. Mrs A aged 82 • 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

  18. More history • Medications: diltiazem, celiprolol, quinapril, alendronate, inhalers, paracetamol • Social: Lived with husband, independent simple ADL’s, low walking frame

  19. Examination • Distended abdomen • Percussible bladder • Dilated anus • Perineum distended • Rectum full of hard faeces

  20. Case continued • Bloods normal • AXR some dilated bowel loops, faeces++ Diagnosis: faecal impaction • IDC inserted • Rx enemas, Coloxyl/senna, Movicol

  21. 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?

  22. Case continued 2 • Repeat AXR: still faeces ++ sigmoid • Gastro review ? flexi sig or colonoscopy • Declined, suggested high enema with Foley • Good result, mass resolved

  23. Case continued • Loose stools 1-2/day, weary of movicol • What next?

  24. Encouraged self management • To keep bowel diary • MMSE 27/30

  25. 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

  26. Outcome • 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

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