Chronic Constipation

Chronic Constipation
No organ in the body is so misunderstood, so
slandered and maltreated as the colon!
Sir Arthur Hurst, 1935
Besides death, constipation is the big fear in
hospitals
Robert McCrumm
Dr Stephen Bridger
Myths?
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Simple
Usually an underlying cause
Primary constipation uncommon
Not a ‘real disease’
Minimal impact on QOL
Caused by poor diet, poor lifestyle
Improved by Diet, fluids, exercise
Wide variety of effective laxatives
Treatment unrewarding
Definition
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Patient Definition:
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Hard Stools
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Infrequent stools (<3 per week)
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Excessive straining
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Sense of incomplete bowel
emptying
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Excessive, unsuccessful time spent
on toilet
Rome 3
Must include at least 2 of the following
(1) At least 25% of bowel movements associated with
Straining
Lumpy or hard stools
Incomplete bowel evacuation
Anorectal obstruction
Need for manual manoeuvres
< 3 bowel movements per week
(2) Loose stools rarely present without the use of laxatives
(3) Insufficient criteria for IBS
Used in Clinical Trials
Correlates with symptoms of
straining and difficult
evacuation
Also correlates with colonic
transit (Type 1 or Type 7
stool is correlated with
slow or rapid colonic
transit Degen LP, Phillips SF. How well
does stool form reflect colonic transit? Gut
1996;39:109-113.
Majority of “constipated”
patients have stools that are
Type 1-3
University of Bristol, Scand J Gastroenterol, 1997
Other Symptoms and
Consequences of Constipation
Nausea +/- vomiting
Abdominal and Rectal pain
Nausea and reduced appetite
 weight loss
Flatulence
Behavioral disturbances in
Loss of appetite
dementia  increased use of
Lethargy
Depression
psychotropic medications
Extra staff time needed for
increased toileting needs
Overall increased number of
medications in the regime
Quality of Life
Impact as severe as Diabetes,
IHD, Rheumatoid Arthritis
Social and mental health
particulary affected
Estimates that > 13 million
work days lost to constipation
in USA/year
Systematic review: impact of constipation on quality of life in adults
Belsey et al Alim, Ther & Pharm 2010
Epidemiology
• North American prevalence 2 – 27%!
• Using Rome 2, about 63 million Americans
with chronic constipation
• Women, non-whites, >60’s, low income,
little exercise, poor education
• >65’s, 26% men, 34% women
Costs
Economic Costs
• UK National study, 2 x nos of GP visits for pts
between 65 – 74 yrs, 5 x nos of visits for pts >
75
• about 2.5 million Americans undergo Ixs for
Constipation annually at a cost of $2700/pt
(based on 1994 paper!)…85% of those pts will
be prescribed long term laxatives
• In 1994, In US, about 90,000 pt hospitalised for
constipation
• In 2004 (Levy et al), $660 million OTC Laxatives
sold (US)
Management
NEJM
Case 1
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42 yr old Staff Nurse
Childhood abdominal pain + constipation
‘life-long laxative use’
Liquid paraffin, glycerine supps,
senna+++, unsuccessful trials of movicol
• Wide variety of other symptoms:
intermittent nausea, bloating, headaches
etc
• Occupational health issues
Case 1 Ixs
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FBC, Renal, Calcium, TFTs normal
Colonoscopy normal
Gut transit, normal…less than 5 days
Manometry normal
Pelvic US and laparoscopy (under genie)
normal
Case 1 Mx
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Inpatient admissions
Enemas
Biofeedback
Escalating doses of movicol
Bisacodyl
Picolax
Dietician
Case 1
• What Next?
Case 1
Subtotal colectomy and ileo-rectal
anastomosis
Stormy post operative course, leak, septic
shock, ITU, Inotropes
Indications for Surgery
• 4 Major Criteria
– The patient has chronic, severe, and disabling symptoms from
constipation that are unresponsive to medical therapy.
– The patient has slow colonic transit of the inertia pattern.
– The patient does not have intestinal pseudo obstruction, as
demonstrated by radiologic or manometric studies.
– The patient does not have abdominal pain as a prominent symptom.
• The outcome of surgical treatment was illustrated in a study that
included 74 patients with severe, refractory slow-transit constipation
who underwent colectomy and ileorectostomy
• Postoperative complications included small bowel obstruction (9
percent) and prolonged ileus (12 percent).
• Most patients were satisfied with the results of surgery (97 percent)
and reported a good or improved quality of life (90 percent) during a
mean follow-up period of 56 months.
Case 2
• 66 yr old Outpt Nurse
• Admitted with intractable nausea, poor
appetite, bloating, LIF and RIF discomforts
• Diagnosed with IBS in 1967
• Longstanding constipation, Bowels open
once per week, increasingly struggling…
Case 2
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Tonsillectomy and adenoidectomy 1946
IBS 1967
Ovarian Cystectomy 1972
Hysterectomy (for fibroids) 1975
BSO for ovarian cancer 1978
Anterior and post vaginal repair 1997
Cholecystectomy 1987
GORD 1988
Hypertension
Coccyectomy and fusion of L4/5/S1 2000
Ig A nephropathy 2004
Laparatomy for omental infarction 2008
Laparatomy for division of adhesions April 2010
Case 2
DAY 2
DAY 4
DAY 6
Case 2
• OGD/Colon/Abdo CT/Brain MRI/Shape
study/FBC/Ca/LFTs/TFTs/Igs/AIP etc
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• Diagnoses:
• ‘Chronic intestinal Dysmotility’,
– Slow transit constipation,
– Abdo/pelvic adhesions
Case 2
• Drugs were rationalised (Calcium
antagonists + Amitripyline stopped)
• Unsuccessful trials of senna, lactulose,
bisacodyl
• Some success with 4 sachets of
movicol/day + sodium docusate
• Trials of maxolon, misoprostol…
Case 2
• What next?
Case 2
• Prucalopride 1 mg od for a month
• Headaches, increasing nausea
• Didn’t work
• Awaiting review by London Specialist
• Pt desperate for surgery
Case 3
• Complex
• 69 year old woman
• Abdo pain, colicky, poorly localised, LIF and
back discomforts radiating to her groin
• Wind and bloating
• BO 2x per week with 4 sachets of movicol per
day
• Known Diverticulosis, Colonoscopy a year ago
• PMH: Mastectomy 10 yrs ago,
• FH: 2 rels with bowel cancer (70’s),+ cousin with
UC
Case 3
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Previously investigated at St Mary’s
Slow motility
Features of “chronic intestinal Pseudo-obstruction”
Diagnosis of a rare neuromuscular disorder of the small
and large bowel…”alpha-epitope deficiency in the inner
circular layer of intestinal smooth muscle”
• Associated detrusor muscle dysfunction …need to selfcatheterise 4 x per day…recurrent UTIs
• Her previous GI symptoms had improved with tegaserod
(Zelmac)…subsequently withdrawn
Case 3
• What next?
Case 3
• Prucalopride 1 mg od June 2010
• Now taking 2mg od
• Much better: reduced abdo pain, Much
less wind and bloating, Bowels open once
daily…still taking movicol but only 2
sachets 2x or 3x per week
• Negatives: “My GP won’t prescribe it”.
She’s happy to pay £90 per month
Any Questions?