faecal incontinence and constipation

Question 1

reversible causes of faecal incontinence

Answer 1

faecal loading (for more information see managing faecal incontinence in specific groups)

• potentially treatable causes of diarrhoea (for example, infective, inflammatory bowel disease, irritable bowel syndrome)

warning signs for lower gastrointestinal cancer

rectal prolapse or third-degree haemorrhoids

acute anal sphincter injury including obstetric and other trauma

acute disc prolapse/cauda equina syndrome.

Question 2

most common cause of feacal incontinence

Answer 2

faecal impaction with overflow diarrhoea

second most common cause is neurogenic dysfunction

Question 3

medical management for faecal incontinence

Answer 3

Loperamide hydrochloride

CANT TOLERATE

Codeine phosphate or co-phenotrope

Question 4

who do you not loperamide hydrochloride to

Answer 4

hard or infrequent stools
acute diarrhoea without a diagnosed cause
an acute flare-up of ulcerative colitis.

Question 5

what should raise suspicios of impaction with overflow

Answer 5

smearing, small amount of type 1 stool or copious type 6/7 stool with no sensation of defaecation

Question 6

risk of constipation

Answer 6

a risk of stercoral perforation and ischaemic bowel in those chronically constipated

Question 7

define constipation

Answer 7

defecation that is unsatisfactory because of infrequent stools, difficulty passing stools, or the sensation of incomplete emptying.

Question 8

define chronic constipation

Answer 8

least 12 weeks in the preceding six months.

Question 9

define faecal loading/impaction

Answer 9

retention of faeces to the extent that spontaneous evacuation is unlikely.

Question 10

social risk factors of constipation

Answer 10

• Low fibre diet or low calorie intake.
• Difficult access to toilet, or changes in normal routine or lifestyle.
• Lack of exercise or reduced mobility.
• Limited privacy when using the toilet.

Question 11

psychological risk factors of constipation

Answer 11

• Anxiety and/or depression.
• Somatization disorders.
• Eating disorders.
• History of sexual abuse.

Question 12

physical risk factors of constipation

Answer 12

Female sex.
Older age.
Pyrexia, dehydration, immobility.
Sitting position on a toilet seat compared with the squatting position for defecation

Question 13

complications of chronic constipation

Answer 13

Haemorrhoids or anal fissure.

Progressive faecal retention, distension of the rectum, and loss of sensory and motor function.

Faecal loading and impaction.

Question 14

complications of chronic faecal loading and impaction

Answer 14

Faecal incontinence, which can be embarrassing and distressing.

Chronic dilatation of the colon may cause megacolon.

Bowel obstruction, perforation, or ulceration.

Recurrent urinary tract infections, obstructive uropathy.

Rectal bleeding.

Rectal prolapse.

Question 15

non specific symptoms seen in elderly constipated

Answer 15

• Confusion or delirium, functional decline.
• Nausea or loss of appetite.
• Overflow diarrhoea.
• Urinary retention.

Question 16

medical management for constipation

Answer 16

bulk forming laxative - ispaghula

osmotic laxative - macrogol

INEFFECTIVE
lactulose

IF TWO LAXATIVES ARE USED FROM DIFF CLASSES FOR AT LEAST 6 MONTHS

Prucalopride - stimulates GI motility

Question 17

constipation criteria

Answer 17

frequency - passing stools less than once every 3 days

consistency - hard stool

difficulty

• initiating evacuation despite regular bowel motions
• feeling of incomplete evacuation

Question 18

stool hard then what can cause be

Answer 18

dehydration

Question 19

problems with act of defecation

Answer 19

muscular or neurological

Question 20

medications which affect transit time

Answer 20

pain killers - opiates/codeine

antispasmodics
aluminium containing antacids
anticholinergics
verapamil

Question 21

medications that cause water loss or reduce transit

Answer 21

diuretics

antihypertensives

Question 22

complications of constipation

Answer 22

urinary retention
overflow diarrhoea
bowel obstruction
rarely bowel perforation
faecal impaction

Question 23

non pharmacological management for constipation

Answer 23

• increasing dietary fibre - decrease in portion sizes and lack of dietary fibre lead to reduce motility - 30MG of fibre per day
• sorbitol - natural osmotic laxative - draws water into the gut leading to the softening of stools

ensure adequate fluid intake - maintain bowel contents and normal transit time

maintain mobility - immobility reduce muscle tone in the bowel and abdominal walls leading to constipation

review toileting conditions

• lack of privacy
• waiting for busy staff
• position

regular toileting - making use of gastrocolic reflex

Question 24

pharmacological management for constipation

Answer 24

first line bulk forming laxative - fybogel -

osmotic laxatives - lactulose/macrogels/phosphate enemas

stimulant bisacodyl/senna

stool softener laxatives - docusate

Question 25

how do bulk forming laxatives work

Answer 25

Increase the bulk of stools by enabling fluid to be retained within the faeces. Increasing the mass increases peristalsis. Must have adequate fluid hydration to prevent intestinal obstruction. Caution with frail. Not suitable for those taking opioids.

Question 26

how do osmotic laxatives work

Answer 26

soften the stool makes them easier to pass by increasing the amount of water in your bowels.

Question 27

how do stimulant bisacodyl work

Answer 27

stimulating nerves that control the muscles lining the digestive tract.

Question 28

how does senna work

Answer 28

Stimulates muscle in the wall of the large bowel to squeeze harder than usual, pushing stools along and out. Their effect is usually within 8-12 hours. A bedtime dose is recommended so you are likely to feel the urge to go to the toilet sometime the following morning.

Question 29

how does stool softener laxatives work

Answer 29

Makes the surface of the stools permeable, water can be absorbed, which increases the fluid content of hard stools.These work by wetting and softening the faeces. The most commonly used is docusate sodium (which also has a weak stimulant action too).

Question 30

If someone has opiod induced constipation what do u do

Answer 30

do not prescribe bulk forming laxatives

Offer an osmotic laxative and a stimulant laxative (or docusate is an alternative which also has stool-softening properties).

Question 31

management of faecal loading and/or impaction

Answer 31

hard stools - oral macrogol

soft stools - oral macrogol plus oral stimulant laxatives

iNADEQUATE OR TOO SLOW
bisacodyl or mini enema

Question 32

How to examine faecal incontinence

Answer 32

Inspect the anus—and ask the patient to strain as if at stool. Look for inflammation, deformities, large haemorrhoids (internal or external), and prolapse

• Rectal examination—assess anal tone by the pressure on the finger after asking the patient to ‘tighten’; feel for faeces and tumour; it is easy to miss even large internal haemorrhoids, unless proctoscopy is performed
• Abdominal examination—feel for the descending colon. Work proximally to assess colonic faecal loading (this may be misleading)
• Neurological examination—look for signs of a peripheral neuropathy and other neurological damage. Check perianal sensation (sacral dermatomes).

Question 33

cuases of faecal incontinece

Answer 33

disorders of the anal sphincter

• sphincter laxity (from many causes)
• severe haemorrhoids
• rectal prolapse
• tumours
• constipation

any cause of fecal urgency - IBD

disorders of the neurological control of the ano-rectal muscle and sphincter:

• LMN lesions (neuropathic incontinence)
• spinal cord lesions
• cognitive impairment (neurogenic incontinence)

Question 34

complications of faecal constipation

Answer 34

stercoral perforation

ischaemic bowel