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Continence 2.2 > Lesson 14: Disorders Of Defecation > Flashcards

Lesson 14: Disorders Of Defecation Flashcards

1
Q

Diarrhea - Acute

A
  • <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

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2
Q

Diarrhea - Chronic

A

Caused by
- Chronic motility disorder (ie. IBS)
- Chronic inflammatory disorder (ie. Crohns or UC)
- Specific food intolerances/malabsorption syndrome
- Peristalsis stimulants

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3
Q

Diarrhea - Assessment

A
  • Onset + duration of problem
  • Stool frequency, volume, consistency, color, odor
  • Prior stool patterns
  • Any associated symptoms
    — Cramping
    — Nausea
    — Vomiting
    — Incontinence
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4
Q

Acute Diarrhea - Presentation

A

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

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5
Q

Chronic Diarrhea - Presentation

A

Evidence of IBD
- Cramping pain
- Blood in stool
- Weight loss
- Nocturnal diarrhea
- Nausea/vomiting

Evidence of IBS
- Epigastric pain relieved by bowel movements

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6
Q

Management - Chronic Diarrhea

A

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

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7
Q

Management - Acute Diarrhea

A

Rehydrate if indicated

Rx
- Antibiotics if bacterial infection
- Antimotility agents
- Bismuth subsalicylate
- Probiotics

Dietary medications to thicken stool
- BRAT diet

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8
Q

Management - Diarrhea d/t fecal incontinence

A

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

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9
Q

Diarrhea Management - Skin Care

A

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)

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10
Q

Constipation

A

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

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11
Q

Simple Constipation

A

Occasional difficulty with stool elimination
- Dietary issues
- Environmental factors
- Pregnancy

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12
Q

Functional Normal Transit Constipation - Pathology

A
  • 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
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13
Q

Functional Normal Transit Constipation - Presentation

A
  • Hard, dry stools
  • Straining with defecation
  • Use of laxatives, suppositories, enemas
  • <3 stools per week
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14
Q

Functional Normal Transit Constipation - Management

A

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

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15
Q

Functional Normal Transit Constipation - Patient Education

A
  • Colon function + health
  • Importance of fiber + fluid
  • Importance of responding to urge to go
  • Correct posture
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16
Q

Slow Transit Constipation - Pathology

A

Constipation d/t bowel dysfunction

Reduced in frequency + amplitude of peristaltic waves

17
Q

Slow Transit Constipation - Etiology

A

Neurologic process disrupts autonomic pathways to bowel

Autonomic neuropathy d/t diabetes

IBS

18
Q

Slow Transit Constipation - Clinical Presentation

A
  • Very infrequent urge to defecate (1-4 times/month)
  • Very large bowel movements
  • Bloating + anorexia
  • Poor response to fiber + laxatives
19
Q

Slow Transit Constipation - Diagnostics

A
  • colonic motility study
  • video capsule endoscopy
  • motility study with wireless motility capsules
20
Q

Slow Transit Constipation - Management

A

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

21
Q

Obstructed Defecation - Pathology

A

Difficulty eliminating stool d/t outlet obstruction

Stool does not pass through anal canal normally

22
Q

Obstructed Defecation - Etiology

A

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

23
Q

Obstructed Defecation - Clinical Presentation

A
  • Difficult stool elimination that persists even when consistency is normal
  • Excessive straining + feelings of incomplete emptying
  • Use of digital maneuvers to facilitate evacuation
24
Q

Obstructed Defecation - Diagnostics

A

Defecography

25
Q

Obstructed Defecation - Management

A

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

26
Q

Irritable Bowel Syndrome - Criteria

A

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

27
Q

Irritable Bowel Syndrome - Classifications

A

Constipation-predominant
- CP-IBS or IBS-C

Diarrhea-predominant
- DP-IBS or IBS-D

Mixed pattern
- IBS-M

Pain-predominant
- PP-IBS

28
Q

Irritable Bowel Syndrome - Etiology/Pathology

A
  • 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
29
Q

Irritable Bowel Syndrome - Assessment

A
  • Based on history + physical + symptom diary
  • Use of Bristol Stool Chart
30
Q

Irritable Bowel Syndrome - Diagnostics

A
  • 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

31
Q

Irritable Bowel Syndrome - Management

A

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

32
Q

Irritable Bowel Syndrome - Patient Education

A
  • Identify + address concerns
  • Emphasize no malignancy/ non-life threatening
  • Focus is symptom management
33
Q

Hierarchy of Laxatives

A

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

Continence 2.2 (14 decks)

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