Download Case Presentation-Rectal Pain

Case Presentation
Lisa Marie Ruppert, MD
Assistant Attending-Rehabilitation Service
Assistant Program Director-Cancer Rehabilitation Fellowship
Assistant Professor of Rehabilitation Medicine-Weill Cornell Medical College
Disclosure
• I have NO RELEVANT financial disclosures.
Case Presentation-Rectal Pain
• DF is a 58 year old female with history of
rectal cancer status post low anterior
resection in 2001.
• She was noted to have osseous and pelvic
recurrence in 2008 for which she is status
post tumor resection, partial sacrectomy,
FOLFOX chemotherapy and radiation
therapy.
• Her course was complicated by bowel
dysfunction and rectal pain
History
• Her symptoms started in 2009 after completion
of radiation therapy.
• Pain description:
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Sharp and localized to the rectum
Constant
Pain increases prior to/with bowel movements
Associated with a sensation of spasm/tightness with
passage of stool
History
• Bowel pattern
– She noted significant constipation followed
by incontinence with soft stool consistency
– Self managed with manual disimpaction 6-7
times per day
History
• She is followed by Palliative Medicine for her pain
– Prior treatments have included:
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Hypogastric plexus neurolysis 9/2014
Fentanyl patch 300micrograms every 48 hours
Fentanyl buccal tablet 400micograms as needed
Oxycodone IR 30mg orally every 8 hours as needed
Gabapentin 300mg orally every 8 hours
Belladonna-opium rectal suppository as needed
Hydrocortisone rectal suppository as needed
• She was referred for recommendations on bowel
program and therapeutic modalities for her pain
Question
• What is the mechanism of action of
Belladonna and Opium suppositories?
A. Smooth muscle contraction and pain relief
B. Smooth muscle relaxation and pain relief
C. Skeletal muscle contraction and pain relief
D. Stool softener and pain relief
Answer B
• Belladonna and Opium suppository mechanism
of action
– The pharmacologically active agents present in
the belladonna component are atropine and
scopolamine which block the action of
acetylcholine at parasympathetic sites in smooth
muscle, secretory glands, and the CNS causing a
relaxation of smooth muscle and drying of
secretions. The principle agent in opium is
morphine which binds to opiate receptors in the
CNS, causing inhibition of ascending pain
pathways, altering the perception of and
response to pain.
History
• Past Medical History
– Hyperlipidemia
• Family History
– Parents: MI
– Paternal grandfather: rectal cancer
– Mother, maternal aunt: breast cancer
History
• Review of Systems
– As per history
– No urinary frequency, urgency, hematuria,
dysuria, incontinence
– No tingling, numbness or weakness in the
lower extremities
– No saddle anesthesia
Physical Examination
• CN II-XII grossly intact
• ROM full except to hip flexion bilaterally which was
decreased-resulted in pelvic floor pain
• Strength 5/5 throughout the bilateral upper and
lower extremities
• Sensation intact to light touch and pinprick except to
S2-S5 bilaterally which was decreased when
compared to face
• Reflexes 2+ and symmetrical throughout
Physical Examination
• Rectal examination
– Radiation skin changes and fixed scar tissue
to perineum
– Tight rectal sphincter
– DAP present
– VAC-difficulty coordinating both contraction
and relaxation on command, tone was
decreased
Assessment
• Rectal pain and bowel dysfunction were
thought to be related to scar tissue
involving the pelvic floor musculature and
sphincter from surgical intervention and
radiation therapy and nerve injury from
surgical intervention, radiation therapy and
possibly chemotherapy
Recommendations
• Bowel program
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Psyllium (e.g.Metamucil)
Adequate hydration
Dietary modifications
Pelvic floor therapy for scar tissue mobilization,
sensory retraining, biofeedback and muscle
coordination
• Pain management
– Follow up with Palliative Medicine
– Pelvic floor therapy
– Lidocaine gel 3ml per rectum prior to bowel
movements
Question
• What is the role of psyllium in management
of constipation?
A. Acts as a stool softener
B. Increases peristalsis and reduces transit time
C. Decreases peristalsis and increases transit
time
D. Results in relaxation of the internal/external
anal sphincters
Answer B
• Psyllium is a soluble fiber. It absorbs water
in the intestine to form a viscous liquid
which promotes peristalsis and reduces
transit time.
Question
• Which of the following is the correct sequence of events in
normal defecation?
A. Colonic contraction to move stool from colon to rectum, rectal
distension, relaxation of the internal anal sphincter, conscious urge,
relaxation of external anal sphincter and puborectalis muscles allowing
defecation
B. Colonic contraction to move stool from colon to rectum, rectal
distension, relaxation of external anal sphincter and puborectalis muscles,
conscious urge, relaxation of the internal anal sphincter allowing
defecation
C. Colonic contraction to move stool from colon to rectum, relaxation of
the internal anal sphincter, relaxation of external anal sphincter and
puborectalis muscles, conscious urge, rectal distension allowing defecation
D. Conscious urge, colonic contraction to move stool from colon to rectum,
rectal distension, relaxation of the internal anal sphincter, relaxation of
external anal sphincter and puborectalis muscles allowing defecation
Answer A
• The sequence of events in normal defecation
includes colonic contraction to move stool from
the colon to the rectum. Stool then distends the
rectum, stretching the puborectalis muscle
resulting in reflex relaxation of the internal anal
sphincter. Conscious urge to defecate then
occurs. Under voluntary control, the external
sphincter and puborectalis muscles relax,
allowing defecation.
Kirshblum, S. Campagnolo, D. Spinal Cord Medicine. Second Edition. Wolters Kluwer/Lippincott Williams and Wilkins.
Philadelphia. 2011
Initial Follow up
• Patient reported
– Difficulty with manual therapies, therapy
focused on biofeedback and muscle
coordination
– Still required manual removal of stool 6-7
times per day
– Had not initiated psyllium
– Lidocaine variable efficacy
Initial Follow Up Recommendations
• Initiation of psyllium and stressed
hydration and dietary modifications
• Collaborated with Women’s Health
– Discontinued Belladonna opium ,
hydrocortisone, lidocaine gel
– Initiated diazepam suppository nightly
– Continued pelvic floor therapy
Further Follow up
• Patient reported
– Initiated psyllium and working towards all
dietary modifications
– Continued use of diazepam suppository
– Improved tolerance with manual therapies
– Daily bowel movement followed by rectal
check to ensure emptying
Follow up
• Improved understanding of pain
– Pressure-urge to defecate
– Inflammatory pain/sensitivity during passage of stool
(intermittent, tolerable, resolves upon evacuation)
– Minimal pain between bowel movements
• Activity based-resumed biking for cardiovascular exercise
• Decreased fentanyl transdermal to 100micrograms every 48
hours with hope of further titration
• Off breakthrough Oxycodone and fentanyl buccal