Constipation

1
Constipation

• Assessment

2
Constipation

• More common in people gt65
• 26 men 34 women complain of constipation
• Related to low food intake, not fibre or fluid

3
Assessment

• Goals of assessment make a diagnosis with a view
  to safely manage symptoms
• History
• Examination
• Investigations

4
Differential diagnosis

• Due to disease of anus/rectum/colon
• Due to systemic disease
• No structural or systemic disease
• Due to medication, immobility, environment

5
History

• Duration
• Bowel motions/week, consistency
• Straining/symptoms of rectal outlet delay
• Urine and faecal incontinence
• Abdo pain (?relieved by evacuation)
• Red flags weight loss, rectal pain/bleeding
• Mood, cognition, diet

6
More History

• Past history
• Medication laxatives now and past,
• analgesics, anticholinergics (include
  antidepressants, antipsychotics, antispasmodics,
  antihistamines) antihypertensives, anti-cancer
  drugs

7
What if limited history from patient?

• Caregivers
• Relatives
• Notes
• Bowel record

8
Bowel record

• Frequency
• Consistency
• Associated symptoms
• Bristol stool charts

9
Examination 1

• Abdominal examination
• appearance
• tenderness
• masses
• bowel sounds

10
Examination 2

• Rectal examination
• Appearance of perineum
• Appearance of anus
• Perianal sensation
• Anal wink
• Anal tone
• Pain or tenderness
• Contents of rectum
• Wall smoothness, ?masses

11
Investigations

• Bloods (which?)
• Plain abdominal x-ray
• Colonoscopy, CT abdo, other?

12
Assessment of constipation

• History
• Examination
• Investigations
• With a view to making a diagnosis in order to
  safely manage symptoms

13
Older people and illness I

• More illnesses
• More functional impairment
• More medication
• Frail elderly have less reserve
• Non-specific presentation of illness

14
Older people and illness 2

• More detective work required
• Small changes can make a big difference
• Very rewarding

15
80 year old frail rest home resident

• Reports constipation over several months
• Bowel motions less often, some hard stools
• Abdominal and rectal exam normal
• No medication
• What next?

16
Afternoon tea
17
Mrs A aged 82

• Constipation 5 months
• Urinary faecal incontinence 3 months
• Weight loss 20kg
• No PR bleeding
• Past Hx COPD, hypertension, osteoporosis, type
  2 diabetes, forgetful last 1 year

18
More history

• Medications
• diltiazem, celiprolol, quinapril,
• alendronate, inhalers, paracetamol
• Social
• Lived with husband, independent simple ADLs,
  low walking frame

19
Examination

• Distended abdomen
• Percussible bladder
• Dilated anus
• Perineum distended
• Rectum full of hard faeces

20
Case continued

• Bloods normal
• AXR some dilated bowel loops, faeces
• Diagnosis faecal impaction
• IDC inserted
• Rx enemas, Coloxyl/senna, Movicol

21
Transfer to OPH

• Loose stools 1-2 daily, IDC still
• Abdomen soft, non-tender, bs normal
• PR hard faecal mass at finger tip
• Rx more enemas and movicol
• Loose stools 1-2 daily
• What next?

22
Case continued 2

• Repeat AXR still faeces sigmoid
• Gastro review ? flexi sig or colonoscopy
• Declined, suggested high enema with Foley
• Good result, mass resolved

23
Case continued

• Loose stools 1-2/day, weary of movicol
• What next?

24

• Encouraged self management
• To keep bowel diary
• MMSE 27/30

25
Case continued

• Unable to keep bowel diary
• ACE-R 74/100 (fluency 1/14 suggests impaired
  executive function)
• Discharged home once daily formed stool on
  Movicol 1 sachet daily with Coloxyl/senna if no
  motion that day
• Husband to keep bowel diary, Mrs A to use commode

26
Outcome

• 6 months later, doing well at home
• Bowels fine
• 10kg weight gain with food supplements
• Husbands heart condition a problem, planning to
  move to retirement unit