Constipation; Charles-Bonnet syndrome; Incontinence

Question 1

Name four causes of neurological caused constipation [4]

Answer 1

• Parkinson’s disease
• Hirschsprung disease
• spinal cord injury
• multiple sclerosis

Question 2

Name three causes of metabolics [3] and endocrinological [3] caused constipation

Answer 2

Metabolic:
- Hypercalcaemia (and hypocalcaemia)
- diabetes mellitus
- hypokalaemia

Encondrine:
- Panhypopituitarism
- hypothyroidism

Question 3

Which Rheumatological disorder can cause constipation? [1]

Answer 3

Systemic sclerosis

Question 4

Which medication classes can cause constipation?

Answer 4

Anticholinergics
- eg antihistamines, antipsychotics, antiparkinsonian medications, antispasmodics

Iron supplements

CCBs

Opiates

TCA antidepressants

Question 5

Describe what is meant by Faecal impaction [1]

Answer 5

The term ‘impaction’ is commonly used to refer to the retention of faeces in the rectum and colon to the extent that spontaneous evacuation is unlikely.

Question 6

What are red flags concerning constipation? [5]

Answer 6

• Weight loss
• Rectal bleeding
• Family history of colorectal cancer
• Sudden change in bowel habit
• Abdominal pain
• Iron deficiency anaemia

Question 7

Describe different types of laxatives used, with examples and when they should be used [4]

Answer 7

Bulk-forming: e.g. fybogel - ispaghula husk
- Increase the bulk of stool: triggers stretch receptors and promotes peristalsis.
- Usually offered first line

Osmotic laxatives: e.g lactulose or macrogols
- exert an osmotic effect drawing water into the bowel lumen.
- should be offered after bulk-forming laxatives.
- They are also very effective in faecal impaction and infrequent bowel motions.

Stimulants: e.g. senna
- stimulate the local nervous system within the gut wall that increases colonic contractility and secretions.
- They may be used second-line and better for patients with difficulty emptying rather than infrequent motions.

Softeners: e.g. sodium docusate
- Docusate lowers the surface tension, which leads to water and fats penetrating the stool.

Question 8

QuesMed

What are the common causes of constipation in the elderly? (8)

Answer 8

• Malignancy
• Poor diet
• Thyroid dysfunction
• Diabetes
• Diverticular disease
• Electrolyte abnormalities (particularly calcium)
• Dementia
• Psychological causes (anxiety, depression, lack of privacy)

Question 9

QuesMed

What is the first line laxative for chronic constipation? [1]

Answer 9

A bulk-forming laxative such as ispaghula (along with plenty of oral fluid)

Question 10

What is the first line laxative for drug-induced constipation? [1]

Answer 10

A stimulant laxative e.g. senna or bisacodyl

Question 11

What is the treatment of chronic constipation in children? [1]

Answer 11

Treatment of chronic constipation is with a movicol disimpaction regimen, followed by maintenance movicol, in tandem with a high fibre diet and parenting advice about encouraging good toilet habits.

Question 12

Answer 12

Movicol x

Question 13

Describe what is meant by Charles-Bonnet syndrome? [1]

What is characterised by? [3]

Answer 13

Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. They have insight that the hallucinations are not real and have no other cognitive impairment

Triad of:
- Intact cognition
- Ocular pathology
- Visual hallucination

Question 14

What are the underlying causes of faecal incontinence?
What other risk factors would suggest to a dx of each?

Answer 14

Colorectal cancer:
- suggest by weight loss, altered bowel habit; blood in stool; polyps; FHx

IBD:
- blood in stool; abdominal pain; systemic symptoms

Coeliac disease:
- persistent, unexplained gastrointestinal symptoms, such as acid reflux, diarrhoea, steatorrhoea, weight loss, abdominal pain, reduced appetite, bloating, and constipation

Gastroenteritis:
- sudden-onset diarrhoea, faecal urgency, blood or mucus in the stool, and associated symptoms such as nausea, vomiting, and systemic malaise.

Irritable bowel syndrome
- abdominal pain which may be associated with bloating and/or defaecation, accompanied by a change in stool form and/or frequency (most commonly diarrhoea).

Question 15

What might cause sphincter dysfunction and therefore faecal incontinence? [5]

Answer 15

Haemorrhoids

Obstetric injury
- more likely following forceps delivery, episiotomy, delayed second stage of labour, infant birth weight > 4 kg, and occipito-posterior presentation
- can happen several years after event

Perianal trauma or surgery

Rectal prolaspe

Pelvic floor dysfunction

CES

MS

Question 16

Describe the presentation of constipation woth overflow diarrhoea [2]

Answer 16

• The person may report hard, lumpy stools, which may be large and infrequent, and having to use manual methods to extract faeces.
• Most often observed in people who are older, who reside in an institution, and/or who are cognitively impaired.

Question 17

Refer adults using a suspected cancer pathway (for an appointment within 2 weeks) for colorectal cancer if they are aged: [3]

Answer 17

• 40 years and over with unexplained weight loss and abdominal pain.
• 50 years and over with unexplained rectal bleeding.
• 60 years and over with iron‑deficiency anaemia, changes in bowel habit, or tests show faecal occult blood.

Question 18

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for:
Colorectal cancer in: [2]

Answer 18

• All adults with a rectal or abdominal mass.
• Adults aged under 50 years with rectal bleeding and any of abdominal pain, change in bowel habit, weight loss, and/or iron‑deficiency anaemia.

Question 19

What is the first-line antidiarrhoeal drug? [1]

Answer 19

loperamide hydrochloride
- If loperamide hydrochloride is contraindicated or not tolerated, codeine phosphate or co-phenotrope may be possible alternatives.

Question 20

Prescribe loperamide with caution if the person has…? [1]

Answer 20

Hepatic impairment — due to reduced first-pass metabolism and the risk of hepatic accumulation.