Stoma care and Rectal disorders

Question 1

Rectal and Anal disorders

Answer 1

Anal fissure is a tear or ulcer in the lining of anal canal.

Symptoms:
Bleeding, persistent pain when pooing, Linear split in anal mucosa

Treatment
ACUTE: <6 weeks
- Bulk forming laxative, osmotic laxative,
- Short term topical prep using local anaesthetic (lidocaine) or simple analgesia (paracetamol) can be given for prolonged burning pain after poo.

CHRONIC: >6 weeks
GTN ointment (rectogesic)
ALT - Oral or Topical diltiazem or nifedipine.

Haemorrhoids (piles) is a abnormal swelling of vascular mucosal around anus.
- Internal piles - painless
- External piles - itchy or painful
Common in pregnancy.

NON DRUG:
Increase dietary fibre, fluid intake and good perianal hygiene.

DRUG:
Bulk forming laxative for constipation
Simple analgesics. AVOID opioids - can cause constipation, AVOID NSAID - can cause bleeding
Topical preps available containing local anaesthesia, corticosteroids, astringents, lubricants and antiseptics. (Anusol etc)
- Topical preps with local anaesthetics only use for a few days - they can sensitise the anal skin. AVOID excess usage too.
- Topical steroids for anal area only should be used short term and occasionally (max 7 days)
Long term can cause ulceration and permanent skin damage and ADRENAL SUPRESSION.

Question 2

Pregnancy with Rectal/Anal disorder

Answer 2

• Bulk forming laxatives SAFE to use.
• ONLY simple soothing products if topical haemorrhoidal prep is needed. (AVOID local anaesthetic or steroids).

Question 3

Specialist treatments in Rectal/Anal disorders

Answer 3

Rubber bad ligation

Injection sclerotherapy

Infrared coagulation

Haemorrhoidectomy

Question 4

Stoma care

Answer 4

Stoma is a artificial opening in the abdomen that helps to hold a bag that releases digested content (faeces , urine)

Most commons 1s are colostomy, ileostomy. Other is urostomy.

• Enteric coated and MR meds UNSUITABLE for PTs with ileostomy as there wont be enough release of API b4 its digested and released out of the body.
• Sorbitol (excipient) containing drugs can have laxative effect.
• Soluble tabs, Liquids, Caps and uncoated tabs suitable as their dissolution is quicker.

Question 5

Stoma and Meds

Answer 5

Analgesia:
- Paracetamol is best
- Opioids can cause constipation in colostomy Pts.’
- Aspirin & NSAIDs can cause gastric irritation and bleeding in colostomy.

Antacids:
- Mg - diarrhoea. Al - constipation risk of these increased with stomas.

Antidiarrhoeal drugs:
Loperamide and codeine reduce intestinal motility and reduce water and Na output from ileostomy.
Pts with stoma susceptible to fluid and Na depletion which can = Hypokalaemia. BUT K+ supplementation not needed.
- Hypokalaemia = increase digoxin toxicity risk.

Diuretics:
Caution with ileostomy due to risk of dehydration and K+ depletion.
- Use potassium sparing diuretic (eplerenone, spironolactone etc)

Iron preps:
- Cause diarrhoea - ileostomy. Constipation - colostomy.
- Sore skin possible and stools can be black.

Laxatives:
- Can cause rapid and severe loss of water and electrolyte so caution usage.
Colostomy - BULK forming laxative better than stimulants.
- Stool softeners can be useful.

Potassium Supplements:
- Liquid preferred to MR
- Split daily doses - helps avoid osmotic diarrhoea.