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 LookHave a LookHave 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: Hard lumps like nuts

Type 2: Lumpy sausage

Type 3: Sausage with cracked surface

Type 4: Sausage with smooth surface

Type 5: Soft blobs with well-defined margins

Type 6: Fluffy with ragged

edges

Type 7: Watery, no solid pieces

* Reproduced by kind permission of Dr Ken Heaton, Bristol University.

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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

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

Fibre don’t over do it

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, co-danthrasate, 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 DYSREFLEXIAUnique 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

• Sensation• Tone• Outcome• Medication• Presence• Effect & Evaluation• Removal• Stimulation

Indications for Digital Rectal Examination

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

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Any questions?

Norgine Pharmaceuticals Ltd. for providing an Norgine Pharmaceuticals Ltd. for providing an educational grant to support this workshop.educational grant to support this workshop.

Contact details:

alison.bardsley@continence-uk.com

With thanks to…