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Constipation Assessment Constipation • More common in people >65 • 26% men 34% women complain of constipation • Related to low food intake, not fibre or fluid Assessment • Goals of assessment: make a diagnosis with a view to safely manage symptoms • History • Examination • Investigations Differential diagnosis • Due to disease of anus/rectum/colon • Due to systemic disease • No structural or systemic disease • Due to medication, immobility, environment 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 More 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? • • • • Caregivers Relatives Notes Bowel record Bowel record • Frequency • Consistency • Associated symptoms • Bristol stool charts Examination 1 • Abdominal examination appearance tenderness masses bowel sounds 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 Investigations • Bloods (which?) • Plain abdominal x-ray • Colonoscopy, CT abdo, other? Assessment of constipation • History • Examination • Investigations With a view to making a diagnosis in order to safely manage symptoms Older 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 2 • More detective work required • Small changes can make a big difference • Very rewarding 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? Afternoon tea 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 More history • Medications: diltiazem, celiprolol, quinapril, alendronate, inhalers, paracetamol • Social: Lived with husband, independent simple ADL’s, low walking frame Examination • • • • • Distended abdomen Percussible bladder Dilated anus Perineum distended Rectum full of hard faeces Case continued • Bloods normal • AXR some dilated bowel loops, faeces++ Diagnosis: faecal impaction • IDC inserted • Rx enemas, Coloxyl/senna, Movicol 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? Case continued 2 • • • • Repeat AXR: still faeces ++ sigmoid Gastro review ? flexi sig or colonoscopy Declined, suggested high enema with Foley Good result, mass resolved Case continued • Loose stools 1-2/day, weary of movicol • What next? • Encouraged self management • To keep bowel diary • MMSE 27/30 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 Outcome • • • • 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
