Constipation Flashcards
What does constipation mean
Stools passed irregularly or with difficulty
Categories of constipation
Abnormal peristalsis
Hard faeces
Bowel obstruction
Patient not pushing
Main causes of abnormal peristalsis
IBS Medications such opiates, CCBs and iron supplements Hypothyroidism Hypercalcaemia Hypokalaemia MS Diabetic neuropathy
Main causes of hard faeces
Lack of fibre
Dehydration
Main cause of bowel obstruction leading to constipation
Adenocarcinoma
Sigmoid volvulus
Pelvic masses such as uterine fibroids or ovarian cancer
Colonic stricture from Crohns, radiotherapy, diverticular disease
Main causes of patient not being able to push in consitpation
Anal fissure
Haemorrhoids
Pelvic floor dysfunction
What must always remember about constipation for people whove been in hopsital for a while
Discomfort from going so mental
What are red flags in constipation
Severe and persistent unresponsive to treatment
Absolute constipation including not passing air
Rectal bleeding
Wt loss, IDA, night sweats
PMH and Fx of UC or polyps
What does passing hard and lumpy stools indicate
Lack of fibre
Dehydration
Significance of onset of constipation
Acute could be pathological
Chronic normally benign
Significance of having diarrorhoea as well as constipation in relation to age
Young is IBS
Over 45- cancer if mucoid especially
Over 60- diverticular disease
What is tenesmus
Ever present need to empty bowels but very little if any passed
What does tenesmus suggest
Cancer or any persistent mass in rectal area
What does bleeding in faeces or on wiping indicate alongside constipation
Haemorrhoids
Anal fissure
Diverticular disease
Cancer
What does bloating and constipation indicate
IBS
What does weight gain, feeling cold and reduced appetite with constipation indicate
Hypothyroidism
What does bone pain and constipation indicate
Hypercalcaemia from bone metastases
What does polyuria and polydipsia with constipation indicate
Hypercalcaemia
Risk factors for constipation
History of endocrine, back and neurological disorders
Family history of FAP and HNPCC
Medications such as opiates, iron supplements
Low fibre diet
Dehydration
What does hair loss, especially in outer third of eyebrow, dry skin and malar rash indicate in constipation presentation
Hypothyroidism
What could mass on examination with constipation pt be
Faecal mass
Cancer of GI tract or ovarian mass
Crohns mass
What does lax anal tone on examination of constipation pt suggest
Neurological disorder
Neurological causes of constipation
MS
Parkinsons
Spinal chord compression
Diabetic neuropathy
Bloods investigations for constipation
FBC- anaemia
U and Es- hypercalcaemia and hypokalaemia
TFTs- hypothyroidism
Further investigations that could be carried out for constipation
FOBT
CA19-9
What is CA19-9 used for more
To monitor relapse, recovery and recurrence
What is a proctoscopy
Dilator used to visualise inside of rectum and anus
Differences between rigid and flexi sigmoidoscopy
Rigid only goes as far as sigmoid colon whereas flexi reaches splenic flexure
Rigid only for visualising whereas flexi can take biopsies and remove polyps
Flexi requires sedation and bowel preparation of enema
What is a barium enema
Barium enema inserted and AXR taken at various points
Most common met sites of colorectal cancer
Liver
Lungs
Ovaries
Lymph nodes
Diet advice for people with constipation
Cereal high in fibre
Whole meal bread
Fruit and veg
Can get fibre supplements
Name of a fibre supplement
Methylcellulose
Short term management of constipation
Stool softeners such as paraffin oil and arachis oil enemas
Osmotic laxatives such as lactulose, magnesium salts
Peristalsis stimulants
Problems with stool softeners
Should only be used in short term as leads to steatorrhoea and anal seepage
Problems with osmotic laxatives
Only used in short term as leads to dehydration and tolerance
Who shouldnt osmotic laxatives be used in
Renal failure
Fluid restriction
Diurised
Examples of peristalsis stimulants
Glycerol suppositories
Senna
What laxative acts as oth softener and stimulant
Docusate
What is last resort medication used for constipation
Enemas
In an old person who is constipated what must consider
Immobility
Lack of drive to go to toilet
Medications- mainly opioids
What can cause constipation in cancer patients
Bone mets
Tumour compressing spinal chord or cauda equina
What is best laxative if taking opioids
Methylnaltrexone- is an opioid receptor antagonist
Presentation of bowel obstruction
Colicky abdo pain
Absolute constipation
Distended abdomen
Nausea and vomiting- more common in SBO
What diameter loops indicate small bowel obstruction
Over 3cm
What diameter loops indicate large bowel obstruction
Over 6cm
What diameter large bowel loops indicate imminent perforation
Over 9cm
Best way to confirm bowel obstruction
AXR
Most common causes of large bowel obstruction
Sigmoid volvulus
Cancer
Diverticulitis
Can be mechanical such as hypothyroidism
What does coffee bean sign indicate
Large bowel has twsisted on itself- sigmoid volvulus
Management of sigmoid volvulus
NBM
NG tube
IV fluids given to replace electrolytes building up in obstruction
Surgery using sigmoidoscope first but if unsuccessful or peritonitic then open
Why do you get constipation after surgery
Opiates
General anaesthetic
Manipulation of bowels puts into state of paralysis
Also embarassment of having to go on ward
General grading of tumours
TMN
Classification of colon cancer
DUKES
What are DUKES criteria
A- no spread into muscularis propria
B- invaded beyond muscularis propria
C- in lymph nodes
D- metastasised to other organs
Dukes A category
90% survival at 5 years
Surgically removed laparascopically
Dukes B category
65% survival at 5 years
Surgically removed as well as adjuvant chemotherapy
Problem with chemo in colorectal cancers
Most resistant and have to give multidrug therapies
Why are colorectal cancers most resistant to chemo
Reflection of their adaptations to constant dietary exposures- for example often produce efflux pumps for proteins
Dukes C category
30-45% survival at 5 years
Surgically removed as well as adjuvant chemotherapy
Dukes D category
5-10% survival at 5 years
Treatment palliative
Important risk factors for colorectal cancer
Smoking Lack of exercise Obesity Fibre deficient potentially Red meats Saturated fats
Protective factor of colorectal cancer
Aspirin
