Constipation - Update

1
Constipation - Update

• GS Duthie

2
Assessment

• Constipation
• Infrequent
• Hard
• Difficult Evac
• Abdominal Pain
• ( important for surgical options )
• Not resolved by colectomy

3
Assessment

• Previous History
• Medical (surgery/gynae)
• Social
• Current Treatment
• 2 week diary (or more)
• Dietary assessment

4
Assessment

• Exclude organic causes
• History
• Examination
• PR / Sigmoidoscopy
• Radiology
• Endoscopic

5
Assessment

• Large Bowel Transit
• Pellets
• One day / Three day
• Scintigraphic
• Oro-Caecal Transit
• Breath test
• Scintigraphic
• Proctography
• Radiol
• MRI
• Scintigraphic

6
Assessment

• Doctor
• Nurse Practitioner
• Physiologist
• Multi disciplinary meeting ?
• ? Psychology

7
Diagnosis

• Transit Slow / No Obstruction
• Treat for Transit
• Transit Slow / Obstructive
• Treat for Obstruction then Transit
• Transit Normal / Obstructive
• Treat for Obstruction

8
Diagnosis

• Transit Normal / No Obstruction
• Reassess
• ? IBS
• Somatisation
• Psychology / Psychiatry
• Remember the Childrens Act

9
Treatment

• Treat based on QoL
• Agree acceptable Outcome
• Use Minimal Acceptable Treatment
• Surgery is LAST Option
• Stomas often give poor results
• Reassess transit after treating obstruction
• Reconsider psychological assessment

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Assessment 2

• Physiological Assessment
• Early if ? Megarectum/Colon
• Recto-anal reflex
• May help define Obstruction
• Late if ? Surgery
• Anal Ultrasound
• Remember Diarrhoea/Sphincter Injury
• Dont Mix Well

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Slow Transit

• Dietary Manipulation
• CUT Fibre Intake
• Laxative Therapy
• High Doses
• Poly-pharmacy
• Rectal Irrigation

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Slow Transit

• ACE
• Neuromodulation
• (funding issues)
• Stoma Ileostomy
• Especially if considering colectomy
• Colectomy IRA (2 years)

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Obstructive Causes

• Anismus / Spastic Pelvic Floor
• Failure of Pelvic Floor (physics)
• Rectoceles
• Intussussception

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Anismus

• No surgical option
• Stomas Bad
• Laxatives (PEG)
• Biofeedback
• Consider Neuromodulation
• Beware test enthusiasm
• Funding

15
Failure of Pelvic Support

• Almost impossible to resolve
• ? Urinary symptoms
• Multidisciplinary Approach
• Physiotherapy
• Sacro-colpo-rectopexy
• (Rectopexy)
• Neuromodulation (funding)
• Express Procedure

16
Rectoceles

• (? Biofeedback)
• Irrigation
• Repair
• Surgical / Gynae (USS sphincter)
• ?STARR
• Medium / Long term results
• ? logic

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Intussussception

• (?biofeedback)
• Irrigation
• Rectopexy (poor longterm results)
• STARR
• Repeatability
• Longevity

18
Solitary Rectal Ulcer

• Is a Pathological diagnosis
• Refer for Specialist Assessment

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Megarectum / Colon

• Refer for Specialist Assessment