Problems with Elimination Bowel Flashcards
Predisposing factors for constipation:
Diet: Low fiber, low fluid
Neurological: spinal cord, MS, Parkinson’s,
Sedentary (decreases movement)
Laxative abuse (impaired motor activity)
Travel
Ignoring urge
SE of drugs
Psychosocial problems
More common and problematic in Infants-geriatrics
Hypothyroidism
Colorectal CA
IBS
Pelvic floor disorders (prolapse, obstruction, intussusception)
Signs and symptoms of constipation:
Hard, pebbly stools
Painful defecation
Straining
Can’t go when desired
Abdominal pain
Weight loss
Blood in stool
Physical examination for constipation includes:
VS
Inspection
Skin (dehydration, hypothyroidism)
Nutritional status
Hernia
Anus (growths, injury, prolapse, wink)
Back (r/o spinal lesions)
Auscultate
BS in all quadrants (BS high pitched or absent)
Palpate abdomen
Digital rectal exam
Mass, stricture, fissures, fistula, prolapse, inflammation, lesions
Impaction or hard stool
Sphincter tone
MSE (Mental Status Exam)
Neuro exam
Pelvic exam for prolapse
Diagnostics for constipation
No tests for common constipation
For differentials:
CBC, TSH, potassium & calcium
KUB (flat plate abdominal xray)
UA
Glucose
Barium enema
Colonoscopy (especially if 10 lb weight loss, anemia, rectal bleeding)
Stool for occult blood
ROME Criteria- constipation
Diagnostic criteria for functional constipation
Must include two or more of the following:
- Straining during at least 25% of defecations
- Lumpy or hard stools in at least 25% of defecations
- Sensation of incomplete evacuation for at least 25% of defecations
- Sensation of anorectal obstruction/blockage for at least 25% of defecations
- Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor.
- Fewer than three defecations per week
Loose stools are rarely present without the use of laxatives
Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis
The Rome Criteria alone is insufficient criteria for irritable bowel syndrome
Differentials for Constipation:
Constipation
Obstruction
Hypothyroidism
Mental health
Fecal impaction
Neurologic disorder
MS
Spinal cord injury
Cancer
Drug use
Crohn’s disease
DM (in chronic dysmotility)
Treatment for constipation:
Exercise
Increase fiber: vegetable, legumes
Water
If laxative dependent, it may take 4 to 6 weeks to restore normal bowel function by stopping the laxative and using non-pharmacological approaches
Change medications as appropriate
Enema
Pharmaceutical
Laxative:
- Bulk forming (retain fluid, increase mass) Psyllium, methylcellulose
- Stimulant (stimulate colonic nerves) castor oil, bisacodyl, senna
- Stool softener (emollient laxative) docusate
- Osmotic (push in water to colon) Polyethylene glycol, lactulose, magnesium and phosphate salts, gycerin
- Lubricate-mineral oil
Chloride channel activators: Activator of gastrointestinal epithelial cells- Lubiprostone
Other: Linaclotide-increases intestinal fluid & accelerates transit. Elevating guanylate cyclase-C
Guanylate cyclase-C reduces activation of colonic sensory neurons, reducing pain & activates colonic motor neurons, which increases smooth muscle contraction and thus promotes bowel movements
Followup for Constipation:
Repeat assessment in 4 to 6 weeks
Have patient keep a diary
Failure to improve may indicate something other than constipation. Refer!
Predisposing factors of hemorrhoids:
Caused by local trauma (passage of hard stool –constipation-, straining, heavy lifting,
prolonged diarrhea, vaginal delivery, or anal sex)
Found commonly in patients w/anal surgical procedures; inflammatory bowel disease;
granulomatous diseases (extrapulmonary tuberculosis, sarcoidosis); malignancy
(squamous cell anal cancer, leukemia); and communicable diseases (HIV infection,
syphilis, chlamydia)
Signs and symptoms of hemorrhoids:
Painless bleeding with BM
Pruritus
Prolapse
Pain if thrombosed
Moisture
Visible mass
Leaking of feces
Physical examination of hemorrhoids:
VS
Inspection-observe for skin tags, prolapse, irritation, fissures, condyloma (genital warts)
Anoscopy for internal hemorrhoids, fissures, masses
Palpate
-Abdomen for masses
-Digital Rectal exam (DRE)
Diagnostics for hemorrhoids:
Hct, Hbg if bleeding
Anoscopy, digital exam–really not helpful unless mass
Colonoscopy
Stool for guaiac
Air contrast barium enema for atypical bleeding
Differentials for hemorrhoids:
Hemorrhoids
Condyloma acuminate (genital warts from HPV)
Rectal prolapse
Rectal bleeding
- Cancer
- Polyps
- Anal fissure
- Fistula
- Perianal abscess
- IBD-UC, CD
- Diverticulosis
- Pelvic tumor
Treatment for hemorrhoids:
No tx if asymptomatic: maintain regular BMs, comfort measures
Dietary mgt: increase fiber, fluids to maintain soft stools so that passage is without straining or prolonged sitting.
Medical/Surgical
- Sitz bath tid prn
- Thrombosed-ice, incision/evacuation of clot
- Topical nifedipine, nitroglycerine, sphincter botox injection (temporary anesthesia)
- Internal-band ligation
Medication
- Bulk forming laxative (psyllium)
- Osmotic laxative (polyethylene glycol)
- Stool softener
- Topical hydrocortisone (Anusol HC), pramoxine HCL (for itching, irritation)
Follow up for hemorrhoids:
Not unless problems, changes in symptoms
If symptoms persist beyond 2 weeks, then reevaluate
Refer/consult
- Urinary retention, fever after procedure
- Acute thrombosis of external hemorrhoid
- If continue to bleed, produce intractable pain, prolapse
Anal Fissures are:
An anal fissure is a tear in the anoderm distal to the dentate line
(see visual on next slide)
One of the most common benign anorectal conditions that may result
from high anal pressure
An anal fissure is the result of the stretching of the anal mucosa
beyond its normal capacity
Acute anal fissure typically heals within 6 weeks with conservative tx
The muscle by the tear spasms causing pain.
- Acute anal fissures have a 80-90% healing rate with conservative tx
- Chronic anal fissure have a 40% healing rate.
Signs and symptoms of an anal fissure:
Tearing, sharp pain w/passage of stool
Small amount of bright red blood on the toilet paper or on the surface of stool
Physical examination of anal fissure:
Acute fissure appears as a fresh laceration on anus, much like a paper cut
A chronic fissure has raised edges exposing the white tissue…. Chronic anal fissures are often accompanied by external skin tags
Diagnosis of anal fissure:
Spread the buttocks apart gently, looking carefully in the posterior
midline. Patients are often too uncomfortable to tolerate a digital
rectal examination or anoscopy.
Differential for anal fissure:
Irritable bowel disease (IBD)
Lactose intolerance
Infectious colitis
Ulcerative colitis (UC)
Perianal ulcers or sores
Anorectal fistula
Solitary rectal ulcer syndrome
Treatment of anal fissure:
Supportive measures (fiber, sitz bath, topical analgesic) and one of the topical vasodilators (nifedipine or nitroglycerin BID) for one month.
Patients who are constipated should receive a stool softener or laxative.
The treatment goal is to relax the internal anal sphincter, initiate and maintain atraumatic passage of stool, and relieve pain.
Fiber and water and exercise to solve constipation- bowel routine
Sitz bath: Warm sitz baths, which can relax the anal sphincter and improve blood flow to the anal mucosa
2% Lidocaine jelly is often prescribed for patients with an anal fissure for pain control.
Follow up for anal fissure:
After 4 weeks still present, repeat treatment for 4 more weeks.
If continues, endoscopy (eval for Crohn’s)
Use alternate vasodilator
Does patient want surgery? Refer to GI/general surgery.
- Lateral internal sphincterotomy
- Botox injection
- Anal advancement flap
Fecal incontinence:
Involuntary loss of solid or liquid feces
Urge versus Passive
- Urge fecal incontinence: desire to defecate, but incontinence occurs despite efforts to retain stool. Weak external sphincter + decreased rectal capacity, hypersensitivity
- Passive fecal incontinence: lack of awareness of the need to defecate before the incontinent episode. Weak internal sphincter
Risk factors
- Older age
- Dementia
- Diarrhea
- Fecal urgency
- Urinary incontinence
- Diabetes mellitus
- Hormone therapy
Signs and symptoms of fecal incontinence:
Constant rectal area moisture.
Sudden urge to defecate followed by incontinence
Leakage of stool without awareness
Sometimes gas, bloating
Sometimes diarrhea, constipation
Physical examination of fecal incontinence:
Auscultation of Bowel sound: Is there a quiet area surrounded by hyperactive sounds indicating liquid stool bypassing an obstruction by impaction or tumor etc?
Palpate for mass or tenderness of the bowel
Inspection perianal area
May reveal chemical dermatitis, suggesting chronic incontinence, a fistula*, prolapsing (protruding internal) hemorrhoids, or rectal prolapse (lining of the rectum protrudes through anus). Perianal sensation should be tested by evoking the anocutaneous reflex (light pin prink to perianal region evokes anal wink sign).
Digital rectal exam
To detect obvious anal pathology (such as a mass or fecal impaction) and provide a basic assessment of the anal resting tone
Ask patient to bear down and to squeeze against your finger
- Weak squeeze pressure and normal contraction of the puborectalis suggests the presence of external anal sphincter weakness.
Diagnostics for fecal incontinence:
Stool studies
Endoscopy
If patient fails initial management, then anorectal manometry* (to check function) and endorectal ultrasound** (to check for structural abnormalities of the anal sphincters, the rectal wall, and the puborectalis muscle)
Differentials for fecal incontinence:
Colorectal cancer
Fecal Impaction
IBS: Crohn disease (auto immune dx causing bowel ulcerations)
IBS: Ulcerative colitis (severe inflammation of bowel lining)
Traveler’s diarrhea
Acute or Chronic diarrhea of many etiologies
Fistulae
Cauda equina syndrome (neurological condition with a variety of causes)
Treatment for fecal incontinence:
Conservative therapy:
- Combination of dietary changes
- Antimotility drugs will control the majority of patients who have loose stools (loperamide)- watch for rebound effect of constipation
- Bulking agent (psyllium) with plenty of water
If impacted, disimpaction and prevention of constipation
Biofeedback: (PT referral)
- Cognitively retraining the pelvic floor and the abdominal wall musculature
- Useful with intact anal sphincters and urge incontinence or decreased rectal sensation
Anterior sphincter repair:
- If not responding to initial mgt or if known sphincter injury
Bulking agent injection (Solesta®):
- Enhance resting anal pressures improving passive incontinence
Sacral nerve stimulation: implantation of a permanent device may improve resting and squeeze pressures of the anal sphincter, rectal sensation, and increasing retrograde colonic propagating sequences
Stoma formation/colostomy:
- Often results in a significant and maintained improvement in quality of life.
Follow up fecal incontinence:
Advice & support should be offered.
6-monthly reviews of symptoms and symptom control, and monitor the need for specialist assessment.