Problems with Elimination Bowel

Question 1

Predisposing factors for constipation:

Answer 1

 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)

Question 2

Signs and symptoms of constipation:

Answer 2

 Hard, pebbly stools
 Painful defecation
 Straining
 Can’t go when desired
 Abdominal pain
 Weight loss
 Blood in stool

Question 3

Physical examination for constipation includes:

Answer 3

 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

Question 4

Diagnostics for constipation

Answer 4

 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

Question 5

ROME Criteria- constipation

Answer 5

 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

Question 6

Differentials for Constipation:

Answer 6

 Constipation
 Obstruction
 Hypothyroidism
 Mental health
 Fecal impaction
 Neurologic disorder
 MS
 Spinal cord injury
 Cancer
 Drug use
 Crohn’s disease
 DM (in chronic dysmotility)

Question 7

Treatment for constipation:

Answer 7

 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

Question 8

Followup for Constipation:

Answer 8

 Repeat assessment in 4 to 6 weeks
 Have patient keep a diary
 Failure to improve may indicate something other than constipation. Refer!

Question 9

Predisposing factors of hemorrhoids:

Answer 9

 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)

Question 10

Signs and symptoms of hemorrhoids:

Answer 10

 Painless bleeding with BM
 Pruritus
 Prolapse
 Pain if thrombosed
 Moisture
 Visible mass
 Leaking of feces

Question 11

Physical examination of hemorrhoids:

Answer 11

 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)

Question 12

Diagnostics for hemorrhoids:

Answer 12

 Hct, Hbg if bleeding
 Anoscopy, digital exam–really not helpful unless mass
 Colonoscopy
 Stool for guaiac
 Air contrast barium enema for atypical bleeding

Question 13

Differentials for hemorrhoids:

Answer 13

 Hemorrhoids
 Condyloma acuminate (genital warts from HPV)
 Rectal prolapse
 Rectal bleeding

• Cancer
• Polyps
• Anal fissure
• Fistula
• Perianal abscess
• IBD-UC, CD
• Diverticulosis
• Pelvic tumor

Question 14

Treatment for hemorrhoids:

Answer 14

 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)

Question 15

Follow up for hemorrhoids:

Answer 15

 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

Question 16

Anal Fissures are:

Answer 16

 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.

Question 17

Signs and symptoms of an anal fissure:

Answer 17

 Tearing, sharp pain w/passage of stool
 Small amount of bright red blood on the toilet paper or on the surface of stool

Question 18

Physical examination of anal fissure:

Answer 18

 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

Question 19

Diagnosis of anal fissure:

Answer 19

Spread the buttocks apart gently, looking carefully in the posterior
midline. Patients are often too uncomfortable to tolerate a digital
rectal examination or anoscopy.

Question 20

Differential for anal fissure:

Answer 20

 Irritable bowel disease (IBD)
 Lactose intolerance
 Infectious colitis
 Ulcerative colitis (UC)
 Perianal ulcers or sores
 Anorectal fistula
 Solitary rectal ulcer syndrome

Question 21

Treatment of anal fissure:

Answer 21

 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.

Question 22

Follow up for anal fissure:

Answer 22

 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

Question 23

Fecal incontinence:

Answer 23

 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

Question 24

Signs and symptoms of fecal incontinence:

Answer 24

 Constant rectal area moisture.
 Sudden urge to defecate followed by incontinence
 Leakage of stool without awareness
 Sometimes gas, bloating
 Sometimes diarrhea, constipation

Question 25

Physical examination of fecal incontinence:

Answer 25

 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.

Question 26

Diagnostics for fecal incontinence:

Answer 26

 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)

Question 27

Differentials for fecal incontinence:

Answer 27

 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)

Question 28

Treatment for fecal incontinence:

Answer 28

 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.

Question 29

Follow up fecal incontinence:

Answer 29

 Advice & support should be offered.  6-monthly reviews of symptoms and symptom control, and monitor the need for specialist assessment.