Constipation & Faecal Incontinence

Question 1

Constipation can mean different things to everyone; state some interpretations of constipation

Answer 1

• Harder stools than normal
• Infrequent or increased time between bowel movements
• Difficulty or pain on passing stool

Question 2

State some changes that occur in the small and large bowel with ageing

Answer 2

Small bowel

• decreased absorption of some nutrients (usually associated with bacterial overgrowth) e.g. folic acid, calcium, iron
• Motility decreases

Large Bowel

• Peristaltic speed is reduced- slower transit time
• Peristaltic strength is reduced due to muscle atrophy
• Weakened connective tissue leading to diverticula
• Increases sensroy threshold for the urge to open bowels/reduced rectal sensation

Question 3

State some potential causes of constipation, consider:

• Bowel pathology
• Metabolic pathology
• Drugs
• Other

Answer 3

Bowel pathology

• Strictures
• Diverticular disease
• Rectal prolapse
• Anal fissue

Metabolic

• Hypothyroidism
• Hypercalcaemia

Drugs

• Chronic laxative use
• Opiates
• Fe supplements
• CCBs
• Antidepressants (particularly tricylic agents)
• Antipsychotics

Other

• Dementia
• Immobility
• Dehydration
• Lack of fibre
• Neurogenic dyfunction

Question 4

State some symptoms and signs of constipation

Answer 4

• Reduced appetite
• Vomitting & nausea
• Abdo pain
• Abdo distentsion
• Urinary retention
• Delerium
• Faecal incontinence and overflow diarrhoea

Question 5

What investigations would you do if you suspect constipation, include:

• Bedside
• Bloods
• Imaging

Answer 5

Bedside

• DRE

Bloods

• FBC
• U&Es
• Calcium
• TFTs

Imaging

• Abdo x-ray: to rule out bowel obstruction
• ?Colonoscopy
• ?CT abdo or barieum enema

Question 6

Discuss the management of consipation

Answer 6

• Non-pharmacological
  
  • Adequete fluid intake
  • Adequete fibre intake
  • Positioning when trying to defecate
  • Get into a routine
  • Exercise
  • Medication review
• Pharmacological
  
  • Laxatives
    
    • Stimulants e.g. senna, sdoium docusate
    • Softners e.g. lactulose, docusate sodium
    • Bulking e.g. ispaghula husk, fybogel
    • Osmotic
  • Enemas
    
    • Glycerol suppository
    • Arachis oil
    • Phosphate

Question 7

If a pt is constipated you must also check for…?

Answer 7

Urinary retention

Question 8

State some potential complications of chronic constipation

Answer 8

• Stercoral perforation
• Ischaemic bowel disease
• Anal fissures
• Haemorrhoids

Question 9

It is abnormal for there to be faeces in the rectume at any time unless passing stool; true or false?

Answer 9

True

Question 10

State some potential causes of faecal incontinence

Answer 10

• Overflow incontinence (accounts for 50% of faecal incontinence)
• Neurogenic dysfunction
• Anal sphincter can gape due to number of factors including haemorrhoids & chronic constipation

Question 11

Should you do a DRE in faecal incontinence?

Answer 11

YES- need to see if stool in rectum and assess anal tone

Question 12

What pharmacological agents can you use in chronic diarrhoea?

Answer 12

Loperamide

Question 13

Discuss how you should manage diarrhoea and/or faecal incontinence

Answer 13

• Exclude alll underlying causes e.g. do stool culture, faceal calprotectin, faecal occult test, imaging
• Treat underlying cause e.g. treat impaction if overflow diarrheoa
• Stop any precipitating medications
• Low dose loperamide

Question 14

State some potential complications of faecal incontinence

Answer 14

• Loss of dignity
• Decreased quality of life e.g. might not leave house
• Moisture lesions/sores