Lesson 14: Disorders Of Defecation Flashcards
Diarrhea - Acute
- <14 days
- Sudden onset with rapid resolution
Caused by
- Infectious process
- Acute exacerbation of chronic inflammatory process
- Initiation of tube feed after extended NPO status
Diarrhea - Chronic
Caused by
- Chronic motility disorder (ie. IBS)
- Chronic inflammatory disorder (ie. Crohns or UC)
- Specific food intolerances/malabsorption syndrome
- Peristalsis stimulants
Diarrhea - Assessment
- Onset + duration of problem
- Stool frequency, volume, consistency, color, odor
- Prior stool patterns
- Any associated symptoms
— Cramping
— Nausea
— Vomiting
— Incontinence
Acute Diarrhea - Presentation
S/S of systemic illness
- Fever
- Chills
- Joint point
- General malaise
S/S of dehydration
- Dry mouth
- Tenting of skin
- Concentrated urine
- Dizziness
- Lethargy
- Hypotension
Chronic Diarrhea - Presentation
Evidence of IBD
- Cramping pain
- Blood in stool
- Weight loss
- Nocturnal diarrhea
- Nausea/vomiting
Evidence of IBS
- Epigastric pain relieved by bowel movements
Management - Chronic Diarrhea
Correct etiologic factors
C.Diff
- Antibiotics
- Probiotics
- ?fecal transplant
IBD
- Anti-inflammatories
- Immunomodulators
IBS
- Education
- Counseling
- Symptom management
Malabsorption
- Dietary modifications
Ileal resection
- Bile salt binding agents
Management - Acute Diarrhea
Rehydrate if indicated
Rx
- Antibiotics if bacterial infection
- Antimotility agents
- Bismuth subsalicylate
- Probiotics
Dietary medications to thicken stool
- BRAT diet
Management - Diarrhea d/t fecal incontinence
Anorectal pouch
- Adheres to skin around anus
- Can connect to drainage bag
- Ensure skin is clean + dry
- Treat denuded areas with crusting
Bowel management system
- FlexiSeal
- Only if stool is liquid or high volume
- Contraindications
— Clotting disorders
— Rectal pathology
— Lax sphincter
- Irrigate tube routinely to avoid blockage
Diarrhea Management - Skin Care
If intact skin
- Moisture-barrier ointment with zinc oxide
If damaged skin
- Zinc oxide to damaged skin
- Crusting with ostomy powder prior to zinc application
- Hydrophilic paste (ie. Triad)
Constipation
Def: 2 or more of the following for the past 6 months
- Straining with >25% of bowel movements
- Lumpy or hard stools with >25% of bowel movements
- Sensation of incomplete evacuation with >25% of bowel movements
- Sensation of obstruction or blockage with >25% of bowel movements
- Less than 3 bowel movements per week
Infrequent loose stools unless laxative administered
Simple Constipation
Occasional difficulty with stool elimination
- Dietary issues
- Environmental factors
- Pregnancy
Functional Normal Transit Constipation - Pathology
- Bowel works but insufficient stimulation for mass movements + defecation
- Normal peristaltic activity in response to distension, eating, and parasympathetic stimulation
- Caused by factors outside the bowel
— Insufficient fiber + fluid
— Immobility + activity
— Medications (opioids, antacids, anticholinergics) - Hard, small stools cannot distend colon enough to cause mass movements
Functional Normal Transit Constipation - Presentation
- Hard, dry stools
- Straining with defecation
- Use of laxatives, suppositories, enemas
- <3 stools per week
Functional Normal Transit Constipation - Management
Colonic clean out if evidence of retained stool/impaction
- Top-down approach is best
— Osmotic laxatives
— Stimulant agents
- Bottom-up approach
— If patient lacks sensory awareness/sphincter control
— More predictable time frame for effect
— Include fleet enemas or milk+molasses enema
- Increase activity
- Eliminate constipating medications
- Assure adequate fluid + fiber intake
— 2 L water ; 25-38g fiber / day
— High fiber diet
— Bran mixtures
— Fiber supplements
— Softener + stimulant combo
Functional Normal Transit Constipation - Patient Education
- Colon function + health
- Importance of fiber + fluid
- Importance of responding to urge to go
- Correct posture
Slow Transit Constipation - Pathology
Constipation d/t bowel dysfunction
Reduced in frequency + amplitude of peristaltic waves
Slow Transit Constipation - Etiology
Neurologic process disrupts autonomic pathways to bowel
Autonomic neuropathy d/t diabetes
IBS
Slow Transit Constipation - Clinical Presentation
- Very infrequent urge to defecate (1-4 times/month)
- Very large bowel movements
- Bloating + anorexia
- Poor response to fiber + laxatives
Slow Transit Constipation - Diagnostics
- colonic motility study
- video capsule endoscopy
- motility study with wireless motility capsules
Slow Transit Constipation - Management
GI referral for definitive diagnosis + management
Rx
- Stool softeners daily
- Osmotic laxatives daily with stimulant PRN
- Lubiprosone
— For management of chronic constipation
- Linaclotide
— Approved for idiopathic STC
Surgical
- Colectomy with ileorectal anastomosis
- Antegrade continence enema
- Sacral neuromodulation
Obstructed Defecation - Pathology
Difficulty eliminating stool d/t outlet obstruction
Stool does not pass through anal canal normally
Obstructed Defecation - Etiology
Structural defects
- Rectocele: straining causes rectum to bulge into vaginal vault
- Rectoanal intussusception: straining causes rectum to intussuscept into anal canal
- Perineal descent: pelvic floor drops of position with straining/partially occludes anus
- Rectal prolapse: rectum protrudes through anal canal and blocks anus
Obstructed Defecation - Clinical Presentation
- Difficult stool elimination that persists even when consistency is normal
- Excessive straining + feelings of incomplete emptying
- Use of digital maneuvers to facilitate evacuation
Obstructed Defecation - Diagnostics
Defecography
Obstructed Defecation - Management
Rectocele
- Pessary
- Surgical intervention
Perineal descent
- Maintenance of soft + formed stool
- Strengthen pelvic floor muscles
Rectal prolapse
- Surgical repair
Rectoanal intussusception
- Surgical repair
Pelvic floor dyssynergia
- Measures to create soft, formed stool
- Biofeedback for relaxation of pelvic floor muscles
Irritable Bowel Syndrome - Criteria
Recurrent abdo pain/discomfort for at least 3 days/month with 2 or more of the following
- Pain/discomfort improved with defecation
- Onset of pain/discomfort associated with change in stool frequency
- Onset of pain/discomfort associated with change in stool form/consistency
Irritable Bowel Syndrome - Classifications
Constipation-predominant
- CP-IBS or IBS-C
Diarrhea-predominant
- DP-IBS or IBS-D
Mixed pattern
- IBS-M
Pain-predominant
- PP-IBS
Irritable Bowel Syndrome - Etiology/Pathology
- Abnormal permeability of intestinal mucosa
- Alternation in bacterial balance in gut
— Inflammation alters gut motility
— Enteric nervous system dysfunction - Autonomic nervous system dysfunction
- Alteration in immune system function
- Psychological distress
- Role of diet
Irritable Bowel Syndrome - Assessment
- Based on history + physical + symptom diary
- Use of Bristol Stool Chart
Irritable Bowel Syndrome - Diagnostics
- Fecal occult blood to r/o cancer
- Hemoglobin to r/o anemia
- Erythrocyte Sedimentation Rate to r/o inflammatory process
- Testing for Celiac disease
Additional testing only for “red flag” symptoms
- Bleeding
- Anemia
- Fever
- Unintended weight loss
- Family history of colorectal cancer
- Frequent nocturnal symptom
- Recent onset + progressive severity
- Recent antibiotic use
- Abdominal mass
- Lymphadenopathy
Irritable Bowel Syndrome - Management
Diet
- Trial reduction in fermentable carbs + lactose
- Dietary intake + symptom chart to identify individual food triggers
Pharmacologic
- IBS-C
— Fiber + fluid titration, lubiprostone
- IBS-D
— Loperamide, diphenoxylate, cholestyramine
— Alosetron for severe cases in women
—— Can cause severe ischemic colitis
- PP-IBS
— Hyoscyamine, amitriptyline, nortriptyline
Irritable Bowel Syndrome - Patient Education
- Identify + address concerns
- Emphasize no malignancy/ non-life threatening
- Focus is symptom management
Hierarchy of Laxatives
Fiber supplements
- Bulk laxatives + fluids
Osmotic + hypertonic agents
- Saline cathartics
— Milk of Magnesia
— Magnesium Citrate
— Fleet Enema
- Lactulose agents
- Sorbitol agents
- Polyethylene Glycol agents
— Miralax
— Colyte
Stimulant agents
- Sennosides
- Bisacodyl
- Glycerin
