Fecal Incontinence and Constipation Medicated Cork or Dynamite Daniel C. Sadowski Royal Alexandra Hospital Edmonton

1. Fecal Incontinence and Constipation�Medicated Cork� or Dynamite?Daniel C. SadowskiRoyal Alexandra HospitalEdmonton, Ab.

2. What are the available diagnostic tools? Accurate history and physical assessment are critical

10. IBS-C vs Chronic constipation KEY MESSAGE: IBS-C and CC share most dys-motility symptoms; the predominance of abdominal pain distinguishes them. Additional Information: Irritable Bowel Syndrome with Constipation (IBS-C) and Chronic Constipation (CC) have many symptoms in common, such as straining, hard stools, and feeling of incomplete evacuation. Patients with CC appear to experience less abdominal discomfort, and in some cases, no discomfort at all. In patients with IBS-C, abdominal pain is more prevalent. The differentiating factor between IBS-C and CC is the presence or absence of abdominal pain as a predominant symptom. IBS-C and CC can be thought of as lying along a spectrum of abdominal discomfort, with mild discomfort on the left and abdominal pain on the right. References Thompson WG et al. Gut. 1999;45(suppl 2):II43-II47. Drossman DA et al. Gastroenterology. 1997;112:2120-2137.KEY MESSAGE: IBS-C and CC share most dys-motility symptoms; the predominance of abdominal pain distinguishes them. Additional Information: Irritable Bowel Syndrome with Constipation (IBS-C) and Chronic Constipation (CC) have many symptoms in common, such as straining, hard stools, and feeling of incomplete evacuation. Patients with CC appear to experience less abdominal discomfort, and in some cases, no discomfort at all. In patients with IBS-C, abdominal pain is more prevalent. The differentiating factor between IBS-C and CC is the presence or absence of abdominal pain as a predominant symptom. IBS-C and CC can be thought of as lying along a spectrum of abdominal discomfort, with mild discomfort on the left and abdominal pain on the right. References Thompson WG et al. Gut. 1999;45(suppl 2):II43-II47. Drossman DA et al. Gastroenterology. 1997;112:2120-2137.

11. Constipation Clinical Assessment History Red Flags Secondary causes: Medications: Endocrine factors: D.M., Hyothyroidism, hypercalcemia, porphyria, renal failure Depression Eating disorders Neurological (MS, Parkinson�s, spinal cord tumors)

12. Drugs and Constipation Anticholinergics: Antispasmodics Antidepressants Antipsychotics Cation-containing agents: Iron Supplements Aluminum (antacids, sucralfate) Neurally active agents: Opiates Antihypertensives (calcium channel blockers) Ganglionic blockers

13. �Red Flags� Age over 50 year Severe symptoms not previously investigated Rectal bleeding, fever, weight loss Nocturnal symptoms Abnormal lab (Anemia, iron deficiency) Family history of colon neoplasia, IBD Palpable abdominal or rectal mass

14. Clinical Assessment Lab: TSH, FBG, calcium Consider referral for colonoscopy/ACBE for new onset constipation over age 50 In most cases, management can be initiated with a minimum of investigations Specialized tests for suspected outlet type constipation

15. Lifestyle changes1st Line Treatment Education, reassurance Diet Fiber Fluids Exercise Stress management Sleep

16. Osmotic laxatives Lactulose, sorbitol, milk of magnesia, PEG (Colyte) PEG 3350 Oral Fleet Laxative ? Uptake of water in the colon ? Stool frequency and consistency Side effects Bloating Overuse or extended use can cause dehydration Hyper Mg if chronic kidney failure

17. Stool Softeners Docusate (Colace, Surfac) My personal experience has not been impressive with these products Side Effects: none but don�t work very well either

18. Stimulant laxatives Senna, Cascara, Bisacodyl I use these only in combination with osmotic laxatives Side effects: Abdominal cramps Severe diarrhea ?? Cathartic colon

19. Other Drugs Modulon Dicetyl Both appear to have an effect on the sensory component of gut function. No improvement in stool frequency Zelnorm No longer available Misoprostol (Cytotec) Colchicine Lubiprostone (Amitiza available in USA)

20. My �training� regime For slow transit constipation: Daily osmotic laxative to keep stool consistency soft Glycerin Supp. upon arising daily Sit on toilet daily after breakfast (coffee) for 30 minutes Dulcolax or senna if no BM for 3 days or if discomfort

22. Post-op patients and constipation Immobility NPO, dehydration Narcotic analgesics Pre-existing Surgical ileus Non-pharmacologic measures often effective Rectal cleansing Relistor (opiod induced constipation)

23. Disordered Defecation Outlet Type Constipation: Clues to diagnosis: Difficulty (straining) to pass even soft stool No response even to high dose laxatives Patient spends long periods of time on the toilet Prolapse of rectal mucosa Digital manipulation required

24. Specific tests for Suspected Outlet type Constipation GI Motility Lab referral for suspected outlet type: Balloon expulsion test 50 cc balloon/stop watch Anal relaxation with strain Test for Mega-rectum Video Defecography

28. Testing for Fecal Incontinence Ano-rectal manometry will often reveal weak internal and/or external anal sphincters

32. Summary Most cases of chronic constipation can be managed with minimal investigations Be aware of outlet type constipation as this has a different investigation and management pathway Multiple therapeutic modalities available for fecal incontinence