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Constipation & Irritable Bowel Syndrome

Week 213 JAMES WILCOCKSON

 PC
 78 year old female presents with the following symptoms
 Feeling as though back passage is constantly full
 Going to the toilet 7 times a day on a bad day
 Change in bowel motion to pellets
 General uncomfortable feeling
 3 Case Presentation
 HPC
 9 years ago, first symptoms of feeling back passage being full. Going to the toilet more frequently, only
passing a few small motions.
 Previously (before 9 years ago) she was going once a day.
 Went to see a private consultant due to runny motions rather than due to frequency and colonoscopy came
back normal.
 No trigger 9 years ago.
 Continued dealing with increase in frequency of passing stools.
 Went to see GP due to, passing pellets so frequently that they made her feel dirty all the time. ‘It’s
uncomfortable and really unpleasant.’
 GP referred her.
 She goes to the bathroom 2-7 times days and passes a small quantity of pellet like stools.
 There is no urgency with the bowels, but some with bladder. No blood or fat. No N&V. No abdominal
cramping. Nothing makes it worse or better. It changes day to day.
 Passing little amounts of stool; hard, but small motions.
 Most concerning: constantly feeling dirt and feeling like she’s staining her underwear
4 Case Presentation
 PMH
 Back pain, hypertension, angina, px breast cancer with surgical excision and
radiotherapy. Bladder repair (20years ago). Gland removal from neck.

 DH
 Benzofluazide, Ramipril, (blood pressure) Diltiazem (angina), aspirin
 Laxatives = magnesium hydroxide bd
5 Case Presentation
 FH
 Sister  Lung cancer dx 74
 Mother  PE (following surgery)
 Father  Bleeding ulcer, followed by cardiac arrest on surgical table

 SH
 Widow
 Sociable, Drives
 Non-smoking  gave up 40 years ago and smoked 10 a day since young
 Non-drinking
6 Specific Questions
 Check definition- <3x a week or hard to pass
 Duration
 Stool size and consistency
 Straining
 Associated symptoms- nausea, vomiting, weight loss
 Pain on defecation
 Rectal bleeding
 Intercurrent diarrhoea
 Fluid and fibre intake
 Depression, lack of exercise
 Management including over the counter
 Metabolic or endocrine disease (thyroid disorders, hypercalcaemia, diabetes,
phaeochromocytoma, Hirshsprung’s disease)
 Neurological problems (autonomic neuropathy, spinal cord injury, multiple sclerosis)
 Drug history- e.g. codeine, dihydrocodeine etc that can cause constipation
7 GI Examination
http
://geekymedics.com/abdominal-examination
/
 Introduction
 Inspection – hands, arms, eyes, mouth, neck, chest
 Abdomen
 Detailed inspection
 Palpation
 Percussion
 Auscultation
 Thank patient
 Summarise
 Further tests – check hernial orifices, PR exam, inspect genitalia
 Differential diagnosis – e.g. constipation, pancreatitis, acute appendicitis
8 Case Presentation
 Inv
 Over the year:
 Colonoscopy  all okay, slight prolapse of the vagina  childbirth
 FBC  all okay

 Tx
 Saw consultant last Thursday and laxatives  has had good days and
bad days since using
9 Constipation
10 Constipation
Definition
Infrequent BMs (>3/wk) or passing BMs less often than normal or
difficulty, straining or pain.

Causes Neuro
Obstruction MS
Mechanical: adhesions, hernia, Ca, Myelopathy
inflammatory strictures, pelvic mass
Cauda equina syndrome
Pseudo-obstruction: post-op ileus
Elderly
Pain
Diet / Dehydration
Anal fissure
IBS
Proctalgia fugax
Toxins
Endocrine / Electrolytes
Opioids
Endo: <T4
Anti-mACh
Electrolytes: <Ca, <K, uraemia
11 Constipation - Treatment
General Stimulant: intestinal motility and
Drink more secretion
> Dietary fibre CI: obstruction, acute colitis
Bulking: faecal mass peristalsis SE: abdo cramps
CI: obstruction and faecal Bisacodyl PO or PR
impaction
Senna
Bran
Docusate sodium
Ispaghula husk (Fybogel)
Sodium picosulphate (rapid)
Methylcellulose
Osmotic: retain fluid in the bowel Softeners
Lactulose Useful when managing
MgSO4 (rapid)
painful anal conditions
Suppositories Liquid paraffin
Glycerol (stimulant) Enemas
Phosphate enema (osmotic)
12 Constipation – SBA Question
During your on-call, you are bleeped to see an 80-year-old woman on the
ward who has not opened her bowels for the last 4 days. She is no known to
have a history of constipation. On examination, her observations are within
normal range, the abdomen is soft and there is mild discomfort at the left iliac
fossa. Bowel sounds are present and on PR examination, the rectum is empty.
You consult your registrar who asks you to prescribe an osmotic laxative.
What is the most appropriate treatment?

A. Isaghula husk
B. Docusate sodium
C. Lactulose
D. Senna
E. Methylcellulose
13 Irritable Bowel Syndrome
14 Irritable Bowel Syndrome
Definition
Disorders of enhanced visceral perception bowel symptoms for which
no organic cause can be found.
Dx: ROME Criteria Exclusion criteria
>40yrs
Abdo discomfort / pain for > 12wks which has
2 of: Bloody stool
Anorexia
Relieved by defecation Wt. loss
Change in stool frequency (D or C) Diarrhoea at night
Change in stool form: pellets, mucus

+ 2 of:
Urgency
Incomplete evacuation
Abdo bloating / distension
Mucous PR
Worsening symptoms after food
15 Irritable Bowel Syndrome
Ix
Bloods: FBC, ESR, LFT, coeliac serology, TSH
Colonoscopy: if >60yrs or any features of organic disease

Rx
Exclusion diets can be tried
Bulking agents for constipation and diarrhoea (e.g. fybogel).
Antispasmodics for colic/bloating (e.g. mebeverine)
Amitriptyline may be helpful
CBT
16 IBS – SBA Question
You see a 25-year-old woman who presents with a 24-hour history of watery
diarrhoea. She states that she opened her bowels 11 times since her onset of
symptoms. Associated symptoms included nausea and vomiting with abdominal
cramps and pain which started in the evening following a barbeque meal in
the afternoon that day. The patient is alert and orientated and her observations
include a pulse rate of 69, blood pressure of 124/75 and temperature of 37.1 oC.
On examination, her abdomen is soft, there is a marked tenderness in the
epigastric region and bowel sounds are hyperactive. The patient is normally fit
and well with no past medical history. The most likely diagnosis is:

A. Irritable bowel syndrome