faecal incontinence and constipation Flashcards
reversible causes of faecal incontinence
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.
most common cause of feacal incontinence
faecal impaction with overflow diarrhoea
second most common cause is neurogenic dysfunction
medical management for faecal incontinence
Loperamide hydrochloride
CANT TOLERATE
Codeine phosphate or co-phenotrope
who do you not loperamide hydrochloride to
hard or infrequent stools
acute diarrhoea without a diagnosed cause
an acute flare-up of ulcerative colitis.
what should raise suspicios of impaction with overflow
smearing, small amount of type 1 stool or copious type 6/7 stool with no sensation of defaecation
risk of constipation
a risk of stercoral perforation and ischaemic bowel in those chronically constipated
define constipation
defecation that is unsatisfactory because of infrequent stools, difficulty passing stools, or the sensation of incomplete emptying.
define chronic constipation
least 12 weeks in the preceding six months.
define faecal loading/impaction
retention of faeces to the extent that spontaneous evacuation is unlikely.
social risk factors of constipation
- 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.
psychological risk factors of constipation
- Anxiety and/or depression.
- Somatization disorders.
- Eating disorders.
- History of sexual abuse.
physical risk factors of constipation
Female sex.
Older age.
Pyrexia, dehydration, immobility.
Sitting position on a toilet seat compared with the squatting position for defecation
complications of chronic constipation
Haemorrhoids or anal fissure.
Progressive faecal retention, distension of the rectum, and loss of sensory and motor function.
Faecal loading and impaction.
complications of chronic faecal loading and impaction
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.
non specific symptoms seen in elderly constipated
- Confusion or delirium, functional decline.
- Nausea or loss of appetite.
- Overflow diarrhoea.
- Urinary retention.
medical management for constipation
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
constipation criteria
frequency - passing stools less than once every 3 days
consistency - hard stool
difficulty
- initiating evacuation despite regular bowel motions
- feeling of incomplete evacuation
stool hard then what can cause be
dehydration
problems with act of defecation
muscular or neurological
medications which affect transit time
pain killers - opiates/codeine
antispasmodics
aluminium containing antacids
anticholinergics
verapamil
medications that cause water loss or reduce transit
diuretics
antihypertensives
complications of constipation
urinary retention overflow diarrhoea bowel obstruction rarely bowel perforation faecal impaction
non pharmacological management for constipation
- 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
pharmacological management for constipation
first line bulk forming laxative - fybogel -
osmotic laxatives - lactulose/macrogels/phosphate enemas
stimulant bisacodyl/senna
stool softener laxatives - docusate
how do bulk forming laxatives work
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.
how do osmotic laxatives work
soften the stool makes them easier to pass by increasing the amount of water in your bowels.
how do stimulant bisacodyl work
stimulating nerves that control the muscles lining the digestive tract.
how does senna work
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.
how does stool softener laxatives work
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).
If someone has opiod induced constipation what do u do
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).
management of faecal loading and/or impaction
hard stools - oral macrogol
soft stools - oral macrogol plus oral stimulant laxatives
iNADEQUATE OR TOO SLOW
bisacodyl or mini enema
How to examine faecal incontinence
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).
cuases of faecal incontinece
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)
complications of faecal constipation
stercoral perforation
ischaemic bowel
