Constipation: treatment in primary care, when to refer and novel therapies....

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Constipation treatment in primary care, when to
refer and novel therapies....

• Lee Dvorkin
• Consultant General , Colorectal Laparoscopic
  Surgeon
• Spire Roding Hospital

Department of Surgery North Middlesex
University Hospital
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The next 20-30 mins

• An overview
• Primary care management
• cIBS
• Faecal impaction
• When to refer
• Novel therapies

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Constipation

• 2nd most common GI symptom
• 3 of population (2 - 34)
• 1 have intractable symptoms
• Often in combination with FI

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Epidemiology and Cost

• Constipation is more common in
• Women (X3)
• gt 65 years
• Non-whites
• Poor socio-economic background
• Most common treatment is laxatives
• 3 million people (USA)
• gt 725 million

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Constipation

• A subjective term reported by patients when their
  bowel habit is perceived to be abnormal
• Wide variety of symptoms
• Objective criteria now exist
• Rome II (Thompson et al., 1999)

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Rome II Criteria

• At least 12 weeks in the preceding 12 months, of
  2 or more of the following
• straining in gt 25 defaecations
• hard stools in gt25 defaecations
• incomplete evacuation in gt25 defaecations
• anorectal obstruction / blockage in gt25
  defaecations
• digitation gt25 defaecations
• lt3 defaecations / week

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Specialists
25 consulters
Primary care
75 non-consulters
70 female
30 male
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Constipation Aetiology
Aetiology
Primary (bowel problem)
Secondary (systemic) Drugs and
Diet Endocrine MetabolicNeurological
Structural
Functional
Colon or rectum
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Primary Constipation

• Functional
• c- IBS
• Colonic inertia
• Iatrogenic (post pelvic surgery)
• Evacuatory dysfunction
• Rectal hyposensitivity
• Anismus
• Proctalgia fugax
• anal fixators

• Structural
• Cancer
• Strictures
• Megacolon/rectum
• Hirschsprungs
• Idiopathic
• Outlet obstruction
• Anal stenosis
• Rectocele
• Prolapse

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Treatment functional constipation

• Vast majority dont need referral or Ix unless no
  response to simple measures
• Treatment focussed on underlying cause....
• Combination of softener and stimulant
• High fibre for slow transit
• Suppositories for evacuatory dysfunction
• Colonic Irrigation
• Bowel retraining / Biofeedback
• Novel therapies including surgery

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cIBS treatment

• Stress relief
• Hypnosis/Yoga
• Mebeverine 135mg tds before meals
• Laxatives (avoid lactulose)
• Antidepressants (avoid constipating ones)
• Diet-wheat exclusion, reduce fibre

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Faecal Impaction

• PR
• Elderly, immobile patients
• No red flag symptoms
• Treat with enemas then reassess

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Bowel-retraining programme

• Package of care
• Psychosocial counselling
• Optimisation of medication / diet/laxatives
• Pelvic floor co-ordination exercises
• Biofeedback techniques

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Pelvic floor co-ordination exercises

• Posture
• Diaphragmatic breathing
• Abdominal bracing exercises
• Balloon expulsion
• Splinting

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Biofeedback

• Physiological parameter (sphincter pressure)
  displayed on a screen visible to the patient
• Patients are re-educated, and learn how to
  co-ordinate the activity of the pelvic floor and
  anal sphincters

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Novel therapies
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Colectomy/Proctocolectomy for constipation

• Poor results
• High complication rates
• Rectal and small bowel dysmotility reduces
  effectiveness of colectomy
• Even stoma unsatisfactory but good results in
  selected few

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ACE

• Good results esp. with neurological disease
• Intubate stoma with water or osmotic laxative
• High stoma complication rate

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Prucalopride

• NICE approved
• Women only
• Failed 2 different laxatives after 6 months
• If no response after 4 weeks unlikely to work
• Selective serotonin agonists leads to colonic
  motility (1-2mg od)

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Sacral Nerve Stimulation

• Stimulation of S3
• neuromodulation effect on ascending pathways,
  local autonomic system
• Locally (sphincter pressures, rectal sensation)
• Distant (gut motility)
• 2 stage procedure
• Trial period 3 weeks
• Permanent implant

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Indications

• Constipation
• not NICE approved
• Largest study to date, Kamm et al 2010, Gut.
• Sig improvement in no of defecations, straining,
  incomplete emptying and abdo pain
• Used in both slow transit and obst defecation
• Difficult to achieve complete resolution of
  symptoms

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SNS Problems

• Expensive
• Test box 200, Lead 2000, Battery 8000
• Post operative problems
• Infection, nerve damage, battery lasts 6-8 years
• Loss of efficacy over time
• Requires regular re-programming
• Pregnancy
• Must be switched off during pregnancy
• c-section to avoid lead displacement

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Posterior Tibial Nerve Stimulation

• 2003 used for FI
• Neuromodulation of sacral plexus via the
  posterior tibial nerve
• Achieved by
• Percutaneous
• transcutaneous

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PTNS- Indications

• Just FI, so far
• Studies in constipated patients awaited

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PTNS

• Cheap equipment costs
• Needles 200
• Pads 3
• Stimulator boxes 80

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Conclusions

• Simple therapies often effective
• Tailor treatment to underlying pathophysiology
• Refer to exclude underlying disease or if simple
  measures ineffective
• Avoid surgery!