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’ • • • • • • • • 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 • • • • • • • 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 • • • • • • 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 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 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 • • • • • Acute medical emergency Remove the offending stimulus eg pr Elevate patients head Inspect skin & toe nails Medicate with nifedipine Indications for Digital Rectal Examination • • • • • • • • Sensation Tone Outcome Medication Presence Effect & Evaluation Removal Stimulation Indications to perform a Manual Removal of Faeces • • • • • • 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 . Any questions? Contact details: [email protected] With thanks to… Norgine Pharmaceuticals Ltd. for providing an educational grant to support this workshop.