ConstipationConstipation

AssessmentAssessment

ConstipationConstipation

• More common in people >65

• 26% men 34% women complain of constipation

• Related to low food intake, not fibre or fluid

AssessmentAssessment

• Goals of assessment: make a diagnosis with a view to safely manage symptoms

• History

• Examination

• Investigations

Differential diagnosisDifferential diagnosis

• Due to disease of anus/rectum/colon

• Due to systemic disease

• No structural or systemic disease

• Due to medication, immobility, environment

HistoryHistory

• 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

More HistoryMore History

Past history

Medication: laxatives now and past,

analgesics, anticholinergics (include antidepressants, antipsychotics, antispasmodics, antihistamines) antihypertensives, anti-cancer drugs

What if limited history from patient?What if limited history from patient?

• Caregivers

• Relatives

• Notes

• Bowel record

Bowel recordBowel record

• Frequency

• Consistency

• Associated symptoms

• Bristol stool charts

Examination 1Examination 1

• Abdominal examination

appearance

tenderness

masses

bowel sounds

Examination 2Examination 2

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

InvestigationsInvestigations

• Bloods (which?)

• Plain abdominal x-ray

• Colonoscopy, CT abdo, other?

Assessment of constipationAssessment of constipation

• History

• Examination

• Investigations

With a view to making a diagnosis in order to safely manage symptoms

Older people and illness IOlder people and illness I

• More illnesses

• More functional impairment

• More medication

• Frail elderly have less reserve

• Non-specific presentation of illness

Older people and illness 2Older people and illness 2

• More detective work required

• Small changes can make a big difference

• Very rewarding

80 year old frail rest home resident80 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?

Afternoon teaAfternoon tea

Mrs A aged 82Mrs 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

More historyMore history

• Medications:

diltiazem, celiprolol, quinapril,

alendronate, inhalers, paracetamol

• Social:

Lived with husband, independent simple ADL’s, low walking frame

ExaminationExamination

• Distended abdomen

• Percussible bladder

• Dilated anus

• Perineum distended

• Rectum full of hard faeces

Case continuedCase continued

• Bloods normal

• AXR some dilated bowel loops, faeces++

Diagnosis: faecal impaction

• IDC inserted

• Rx enemas, Coloxyl/senna, Movicol

Transfer to OPHTransfer 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?

Case continued 2Case continued 2

• Repeat AXR: still faeces ++ sigmoid

• Gastro review ? flexi sig or colonoscopy

• Declined, suggested high enema with Foley

• Good result, mass resolved

Case continuedCase continued

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

• What next?

• Encouraged self management

• To keep bowel diary

• MMSE 27/30

Case continuedCase 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

OutcomeOutcome

• 6 months later, doing well at home

• Bowels fine

• 10kg weight gain with food supplements

• Husband’s heart condition a problem, planning to move to retirement unit