Constipation Flashcards by Owen Vineall

What does constipation mean

Stools passed irregularly or with difficulty

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Categories of constipation

Abnormal peristalsis
Hard faeces
Bowel obstruction
Patient not pushing

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Main causes of abnormal peristalsis

IBS
Medications such opiates, CCBs and iron supplements
Hypothyroidism
Hypercalcaemia
Hypokalaemia
MS
Diabetic neuropathy

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Main causes of hard faeces

Lack of fibre

Dehydration

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Main cause of bowel obstruction leading to constipation

Adenocarcinoma
Sigmoid volvulus
Pelvic masses such as uterine fibroids or ovarian cancer
Colonic stricture from Crohns, radiotherapy, diverticular disease

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Main causes of patient not being able to push in consitpation

Anal fissure
Haemorrhoids
Pelvic floor dysfunction

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What must always remember about constipation for people whove been in hopsital for a while

Discomfort from going so mental

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What are red flags in constipation

Severe and persistent unresponsive to treatment
Absolute constipation including not passing air
Rectal bleeding
Wt loss, IDA, night sweats
PMH and Fx of UC or polyps

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What does passing hard and lumpy stools indicate

Lack of fibre

Dehydration

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Significance of onset of constipation

Acute could be pathological

Chronic normally benign

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Significance of having diarrorhoea as well as constipation in relation to age

Young is IBS
Over 45- cancer if mucoid especially
Over 60- diverticular disease

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What is tenesmus

Ever present need to empty bowels but very little if any passed

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What does tenesmus suggest

Cancer or any persistent mass in rectal area

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What does bleeding in faeces or on wiping indicate alongside constipation

Haemorrhoids
Anal fissure
Diverticular disease
Cancer

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What does bloating and constipation indicate

IBS

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What does weight gain, feeling cold and reduced appetite with constipation indicate

Hypothyroidism

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What does bone pain and constipation indicate

Hypercalcaemia from bone metastases

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What does polyuria and polydipsia with constipation indicate

Hypercalcaemia

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Risk factors for constipation

History of endocrine, back and neurological disorders
Family history of FAP and HNPCC
Medications such as opiates, iron supplements
Low fibre diet
Dehydration

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What does hair loss, especially in outer third of eyebrow, dry skin and malar rash indicate in constipation presentation

Hypothyroidism

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What could mass on examination with constipation pt be

Faecal mass
Cancer of GI tract or ovarian mass
Crohns mass

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What does lax anal tone on examination of constipation pt suggest

Neurological disorder

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Neurological causes of constipation

MS
Parkinsons
Spinal chord compression
Diabetic neuropathy

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Bloods investigations for constipation

FBC- anaemia
U and Es- hypercalcaemia and hypokalaemia
TFTs- hypothyroidism

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Further investigations that could be carried out for constipation

FOBT | CA19-9

What is CA19-9 used for more

To monitor relapse, recovery and recurrence

What is a proctoscopy

Dilator used to visualise inside of rectum and anus

Differences between rigid and flexi sigmoidoscopy

Rigid only goes as far as sigmoid colon whereas flexi reaches splenic flexure Rigid only for visualising whereas flexi can take biopsies and remove polyps Flexi requires sedation and bowel preparation of enema

What is a barium enema

Barium enema inserted and AXR taken at various points

Most common met sites of colorectal cancer

Liver Lungs Ovaries Lymph nodes

Diet advice for people with constipation

Cereal high in fibre Whole meal bread Fruit and veg Can get fibre supplements

Name of a fibre supplement

Methylcellulose

Short term management of constipation

Stool softeners such as paraffin oil and arachis oil enemas Osmotic laxatives such as lactulose, magnesium salts Peristalsis stimulants

Problems with stool softeners

Should only be used in short term as leads to steatorrhoea and anal seepage

Problems with osmotic laxatives

Only used in short term as leads to dehydration and tolerance

Who shouldnt osmotic laxatives be used in

Renal failure Fluid restriction Diurised

Examples of peristalsis stimulants

Glycerol suppositories | Senna

What laxative acts as oth softener and stimulant

Docusate

What is last resort medication used for constipation

Enemas

In an old person who is constipated what must consider

Immobility Lack of drive to go to toilet Medications- mainly opioids

What can cause constipation in cancer patients

Bone mets | Tumour compressing spinal chord or cauda equina

What is best laxative if taking opioids

Methylnaltrexone- is an opioid receptor antagonist

Presentation of bowel obstruction

Colicky abdo pain Absolute constipation Distended abdomen Nausea and vomiting- more common in SBO

What diameter loops indicate small bowel obstruction

Over 3cm

What diameter loops indicate large bowel obstruction

Over 6cm

What diameter large bowel loops indicate imminent perforation

Over 9cm

Best way to confirm bowel obstruction

AXR

Most common causes of large bowel obstruction

Sigmoid volvulus Cancer Diverticulitis Can be mechanical such as hypothyroidism

What does coffee bean sign indicate

Large bowel has twsisted on itself- sigmoid volvulus

Management of sigmoid volvulus

NBM NG tube IV fluids given to replace electrolytes building up in obstruction Surgery using sigmoidoscope first but if unsuccessful or peritonitic then open

Why do you get constipation after surgery

Opiates General anaesthetic Manipulation of bowels puts into state of paralysis Also embarassment of having to go on ward

General grading of tumours

TMN

Classification of colon cancer

DUKES

What are DUKES criteria

A- no spread into muscularis propria B- invaded beyond muscularis propria C- in lymph nodes D- metastasised to other organs

Dukes A category

90% survival at 5 years | Surgically removed laparascopically

Dukes B category

65% survival at 5 years | Surgically removed as well as adjuvant chemotherapy

Problem with chemo in colorectal cancers

Most resistant and have to give multidrug therapies

Why are colorectal cancers most resistant to chemo

Reflection of their adaptations to constant dietary exposures- for example often produce efflux pumps for proteins

Dukes C category

30-45% survival at 5 years | Surgically removed as well as adjuvant chemotherapy

Dukes D category

5-10% survival at 5 years | Treatment palliative

Important risk factors for colorectal cancer

``` Smoking Lack of exercise Obesity Fibre deficient potentially Red meats Saturated fats ```

Protective factor of colorectal cancer

Aspirin