May 2014 - Devon Sessional GPs

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Minutes of the Exeter Sessional GPs Group
Darts Farm – 6 May 2014
The meeting was kindly sponsored by:
Ali Earp
Galderma
Kate Fuller
Grunenthal
James Harrison
Pfizer
Attendance:
28 members
Welcome:
Dr Megan James opened the meeting and thanked the reps.
Clinical meeting
Megan welcomed the speaker Miss Trish Boorman, Consultant Colorectal Surgeon
RDE
It’s a “Bum” Job – but somebody’s got to do it – Miss Trish Boorman –
Consultant Colorectal Surgeon
Faecal incontinence – complaint of involuntary leakage:
 Solid stools
 Liquid
 Gas
Prevalence:
 10-20% in female over 65yrs
 10% in male over 65 years
 25% in residential care homes
 40% in nursing homes
 4% after vaginal delivery
Enormous impact on lifestyle – e.g. life revolves round toilet, unable to go out etc.
Causes:
 Damage to anal area – prolapse, piles, fissures etc.
 Bowel motility issues
 Stool consistency – diarrhoea
 Neurological – motor or sensory MS, diabetes mellitus, post hysterectomy
Risks with childbirth increased by:
 Vaginal delivery
 Forceps
 Birth weight above 4kg
 Multiple pregnancies
 Abnormal presentation
The damage may not appear until patient in their 40s or 50s.
Conservative management:
 Constipating drugs – loperamide – liquid better than tablets as more easy to
titrate in small amounts
 Enema, suppositories or laxatives if the problem is constipation with overflow
 Anal plug, absorbent pads
 Pelvic floor – exercises or biofeedback
 Irrigation – takes about 20 minutes – alternate days may be enough
Surgery:
 Sphincter repair for mechanical defect
 Augmentation of functionally deficient but intact sphincter – bulking agents or
sacral nerve stimulation
 Haemorrhoid, fissure or fistula surgery
 Prolapse repair
 (Bypass – stoma – rarely used and may not stop the leak)
History:
 Consistency
 Frequency
 Obstetric history
 Previous surgery for haemorrhoids etc.
 Perianal sepsis
 Abuse
Examination:
 Tone / squeeze
 Rectocele, prolapse or piles – note that rectocele seen on defecating
proctogram can be normal
 Impaction
 Mass
 Trapping of faeces in a rectocele can lead to incontinence
Investigations:
 Endoscopy
 Endoanal ultrasound (EAUS)
 Ano-rectal physiology (ARP)
 ? Defecating proctogram – patient has phosphate enema to clear bowel then a
mushy paste inserted via anus – films taken with patient coughing, straining,
squeezing and emptying bowel – use the results in conjunction with
symptoms.
Haemorrhoids:
Management:
 Diet
 Bowel regulation
 Topical treatment
 Injection rarely used now
 Banding
 Haemorrhoidectomy – rarely used now
 Haemorrhoidal artery ligation operation (HALO) +/- recto-anal repair (RAR)
done under general anaesthetic – advantages – no resection, day case,
repeatable, less painful, minor complications only, no urinary retention, can
return to work next day.
 Stapled haemorrhoidopexy – done under general anaesthetic – better
management of the prolapse element. Purse string suture of mucosa above
dentate line and a ring of tissue is taken out. Advantages – infrequent and
minor complications, less pain than haemorrhoidectomy, quicker recovery,
good aesthetic results, patients very satisfied.
Management of prolapsed thrombosed internal haemorrhoids:
 Analgesia
 Local anaesthetic cream
 Ice packs
 Tip bed head down
 Laxatives
 Topical diltiazem or GTN
 It takes 3-4 days for recovery to begin and two weeks before settled
completely – surgery not done as results in sphincter damage in 60%
Other painful conditions:
 Abscess
 SCC
 Fissure – conservative management is diet, bowel regulation, topical GTN or
diltiazem. If no help then options are botox injection, fissurectomy with
advancement flap or rarely lateral sphincterotomy
 Perianal haematoma – differentiated from thrombosed pile as covered by skin
rather than mucosa, a clot under the anal verge. Managed with analgesia and
laxatives.
Sphincter augmentation:
 Bulking agents – solesta – a submucosal injection to reform the haemorrhoidal
cushions. 3 year data show sustained improvement in continence.
 Sacral nerve stimulation – stimulate sacral nerve to modify neural reflexes that
influence lower bowel, anal sphincter and pelvic floor. A test wire inserted as
day case procedure is trialled for 2-3 weeks. If successful then permanent
implant inserted with a controller which can be used to change the stimulation
level. It lasts 8-10 years, can be life changing. Patients carry a pacemaker
card – x ray at airport affects it, cremation rules apply as per pacemaker.
 Posterior tibial nerve stimulation (PTNS) – non-invasive, low or no risk,
outpatient procedure, no embarrassment, little training needed, nurse led
procedure, time effective – 30 mins per week for 12 weeks and then top up
may be needed, 66-82% success rate.
Rectal prolapse:
 Complete / full thickness or occult
 Can bleed or ulcerate
 Very elderly can have a minimal procedure – e.g. Delorme’s procedure – done
via rectum but does require general anaesthetic. Has a high recurrence rate so
not suitable in young.
 Permacol “Thiersch” wire can be used in very frail – local anaesthetic
 Anterior Delormes is a simple repair
 Stapled trans anal rectal resection (STARR) – done less often now
 Laparoscopic ventral mesh rectopexy is a good method
Perianal itch:
 Eczema or psoriasis
 Allergic dermatitis
 Infections
 Systemic disease – e.g. diabetes mellitus
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Foods – caffeine, tomatoes, citrus
Medications – steroids, antibiotics
Idiopathic
Perianal conditions including haemorrhoid, fissure, tumour
Management – water to wash, bidets, wipe with non-perfumed wet wipe then
dry carefully, wear gloves at night, cotton underwear.
Housekeeping
Megan thanked Miss Boorman and reminded members to sign the attendance register.
Megan also asked that anyone who wishes to express an interest in a CPR session
should e mail using the web site contact. The session will only be viable if there are
at least fifteen participants – there will be a charge for the session.
Future ESGPG Meetings
3rd June 2014 – Functional Illness and Medically Unexplained Symptoms, Dr. Jo
Bromley, Consultant Psychiatrist
1st July 2014 – Gastroenterology update, Dr. Shyam Prassad, Consultant
Gastroenterologist
5th August 2014 - SUMMER SOCIAL EVENT – Details to follow
2nd September 2014 – The Movement Disorders Clinic Dr. Sarah Jackson
7th October 2014 - Hospice Update Dr. Becky Baines
4th November 2014 - Contraceptive Update Dr. Jane Bush Lead for contraceptive
services, NDHC
2nd December 2014 - Diabetes update, Dr. Tom Fox Consultant endocrinologist
Meeting time
Please note that the meetings are now scheduled to start at 7pm with the guest speaker
planned to commence at 7.30pm.
Committee Contacts
Dr Megan James (chairman)
Dr Laura Davies (website co-ordinator)
Dr Lynne Reid (appraisal support co-ordinator)
Dr Nimita Gandhi (educational co-ordinator)
Dr Sarah Hemingway (funding co-ordinator)
Dr Anna Beazley (treasurer)
Dr Kathryn Shore (minutes’ secretary)
Dr Clair Homeyard (social secretary)
Dr Megan James (LMC link)
[email protected]
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