Bowel Workshop
Alison Bardsley – Continence Advisor and
Continence Service Manager, Oxon.
Clinical Director – Continence UK
Supported by an educational grant from
Function of the Large Bowel
• Storage of food prior to elimination
• Absorption of remaining water, electrolytes
and some vitamins
• Synthesis of Vitamin K and some
Vitamin B by colonic bacteria
• Secretion of mucus to lubricate the faeces
• Elimination of food residual
How to Know when it’s time to ‘go’
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Faeces move from sigmoid colon into the rectum
Full rectum
Adopt correct posture
Raise intra-abdominal pressure
Internal and external anal sphincters relax
Rectum contracts to expel stool
Should pass soft formed stool with minimal effort
Sphincter “snaps shut” after completion
THE IDEAL BOWEL MOVEMENT
• The feeling you want to go is definite but not irresistible
• Once you sit on the toilet there is no delay
• No conscious effort or straining
• The stool glides out smoothly & comfortably
• Followed by a pleasant feeling of relief
Have a Look
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Change in ‘normal’ bowel habit persistent for 6 weeks
Undiagnosed rectal bleeding
Undiagnosed rectal pain
Blood/slime in stool
Accompanying abdominal pain/vomiting
Anorexia and weight loss
Suspected infected stool
*Refer to national colorectal cancer screening guidelines
BRISTOL STOOL FORM SCALE*
Type 1:
Type 2:
Type 3:
Type 4:
Type 5:
Type 6:
Type 7:
9
Hard lumps like nuts
Lumpy sausage
Sausage with
cracked surface
Sausage with
smooth surface
Soft blobs with
well-defined margins
Fluffy with ragged
edges
Watery, no solid pieces * Reproduced by kind permission of Dr Ken Heaton, Bristol University.
Risk factors for Constipation
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Medical condition
Medication
Toileting facilities
Mobility
Nutritional intake
Fluid Intake
Diet
Fibre softens stools and speeds transit
 Caffeine stimulates the gut
 Artificial sweeteners can cause diarrhoea
 Advice on fibre moderation if stool loose or
increase if hard
 Gradual caffeine reduction
 Look for sensitivities in diet
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Fibre don’t over do it
Dietary Fibre:
18-30g per day
Fluid Intake:
1.5 to 2 litres per day
Fruit and vegetables:
5 portions per day
Introduce fibre
gradually
if in doubt,
liaise with dietician
for specialist advice
Insoluble & Soluble Fibre
• Insoluble - bulking (laxative) agents help
prevent constipation
– Examples: Oats, fruit, vegetables and pulses
• Soluble – help reduce blood cholesterol
levels & can help control blood sugar
levels
– Examples: Wholegrain cereals and
wholemeal bread
What about laxatives?
Choice of agent will depend
on
• Presenting symptoms
• Nature of complaint
• Efficacy
• Side –effects
• Speed of action
• Patient acceptability
• Compliance
• Cost
Types of laxatives
• Bulk forming
– Fybogel®, Celvevac® Normacol®, Regulan®
Relieve constipation by increasing faecal
mass which stimulates peristalsis
Usually work within 24 -36 hours
Stimulant Laxatives
• Senna, Bisacodyl, co-danthramer, codanthrasate, dioctyl, docusol
Stimulate an increase in colonic motility
(peristalsis) and mucus secretion
Rapid acting 8-12 hours
Faecal Softener
• Liquid paraffin, arachis oil
Lubricate and soften faeces to promote a
bowel movement by lowering surface
tension of colonic contents and allowing
fat and fluid to penetrate.
Osmotic/iso-osmotic Laxatives
• Lactulose and Magnesium salts – Osmotic
Act by drawing fluid from the body into the bowel by
osmosis
• MOVICOL® - iso-osmotic
MOVICOL increases stool water content and directly
triggers colonic propulsive activity and defaecation.
4 in 1 mode of action: Bulks, softens, stimulates and
lubricates.
Enemas & Suppositories
• Phosphate, Sodium citrate, Bisacodyl,
Glycerine
Uses:
Acute or severe constipation
Retention or evacuation
Stimulation or lubricant
NEUROLOGICAL DISEASE
• Most patients will have a degree of
dysfunction or suffer from constipation
• Caused by:– Loss of mobility
– Constipating medication
– Obstetric trauma
– Anal sphincter mechanism impairment
– Dysphagia
– Cognitive problems
– Inadequate care & facilities
– Lack of understanding of care needs
AUTONOMIC DYSREFLEXIA
Unique to spinal injury above T6
SYMPTOMS
 Headaches
 Severe hypertension
 Flushing above the lesion
 Sweating below the lesion
 Blotching of the skin
 Nasal congestion
 Bradycardia / tachycardia
 Palpitations
 Dilation of the pupils
SYMPTOMS
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Headaches .
Severe hypertention
Flushing above the lesion
Sweating below the lesion
Blotching of the skin
Nasal congestion
Bradycardia / tachycardia
Palpitations
Dilation of the pupils
TREATMENT
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Acute medical emergency
Remove the offending stimulus eg pr
Elevate patients head
Inspect skin & toe nails
Medicate with nifedipine
Indications for Digital Rectal
Examination
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Sensation
Tone
Outcome
Medication
Presence
Effect & Evaluation
Removal
Stimulation
Indications to perform a Manual
Removal of Faeces
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Failure of other bowel techniques
Loading or impaction
Incomplete defaecation
Inability to defaecate
Neurogenic cause of bowel dysfunction
Spinal Injury patients
Consent and legal issues
Lawful Consent
• Consent should be given by
someone with the mental
ability to do so
• sufficient information should be
given to the patient
• Consent must be freely given
Considerations –
• Adults unable to give consent
• Children
Conclusion
• Health care practitioners
play a key role
• An holistic assessment is
essential
• Establish the underlying
cause and thus plan
treatment accordingly
• Patient/general
public
education on prevention
of constipation
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Any questions?
Contact details:
alison.bardsley@continence-uk.com
With thanks to…
Norgine Pharmaceuticals Ltd. for providing an
educational grant to support this workshop.