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Transanal Irrigation As a Treatment for Bowel Dysfunction

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Transanal Irrigation As a Treatment for Bowel Dysfunction Transanal irrigation as a treatment for bowel dysfunction Michelle Henderson, Bowel Specialist Nurse; Linda Tinkler, Academic Research Nurse; Yan Yiannakou, Lead Consultant Neurogastroenterologist, Durham Bowel Dysfunction Service, University Hospital North Durham, County Durham and Darlington NHS Trust [email protected] This article is reprinted from Gastrointestinal Nursing vol 16 no 4 May 2018 clinical Transanal irrigation as a treatment for bowel dysfunction Abstract Transanal irrigation (TAI) is a treatment for bowel dysfunction, with UK approval in patients with constipation and faecal incontinence. This article is intended for health-care professionals involved in the management of patients with bowel dysfunction and describes what TAI is and the proposed method of action. It also considers the latest evidence related to the safety and efficacy of TAI. There is now a potentially overwhelming range of equipment available on prescription to deliver this treatment. The factors to consider in the appropriate selection of equipment for individual patients will be considered, alongside an algorithm for the selection of equipment to aid health professionals with this choice. ransanal irrigation (TAI), also known as Mechanism of action Michelle Henderson, Bowel Specialist Nurse; rectal irrigation, is used throughout the Proposed mechanisms of action include simple Linda Tinkler, Academic TUK as a treatment for bowel dysfunction, mechanical washout in the recto-sigmoid colon, Research Nurse; Yan and it has recently received National Institute increased colonic peristalsis stimulated by the Yiannakou, Lead Consultant for Health and Care Excellence (NICE) approval washout or a combination of these (Christensen Neurogastroenterologist, for treating both constipation and faecal and Krogh, 2010). A scintograpic study (Figure 1) Durham Bowel Dysfunction Service, University Hospital incontinence (NICE, 2018). Following adequate has shown that, on average (mean), the irrigation North Durham, County training by a specialist, TAI is self-administered fluid reaches just beyond the right colonic flexure, Durham and Darlington by the patient (or by their carer or other health and antegrade colonic propulsions are induced NHS Trust professional), at home, usually sitting on the toilet through the colon. This occurred especially in those [email protected] or commode chair. with spinal cord lesions and faecal incontinence, Warm tap water (36–38°C) is instilled into where most of the recto-sigmoid and descending the rectum and sigmoid colon via the anus, colon was emptied. In patients with idiopathic using either a rectal catheter or a cone. When constipation, only 59% of the recto-sigmoid the catheter or cone is removed, the water is colon emptied; however, this was sufficient for expelled, along with the contents of the rectum, patients to feel benefit from TAI. For all 19 patients sigmoid colon and possibly descending colon. in this study, bowel function and quality of life TAI can re-establish controlled bowel evacuation, improved, reinstating predictability and control enabling the user to choose the time and place of over defaecation (Christensen et al, 2003). evacuation (Emmanuel, 2010). Christensen et al (2003) suggested that, for Key words Frequency of irrigation and volume of water patients with faecal incontinence, efficient Constipation used (typically 70–1000 ml) varies depending on emptying of the colon and rectum means Efficacy the patient’s response and tolerance. Where there that new faeces does not reach the rectum Equipment is electrolyte imbalance, Norton and Coggrave for around 2 days, reducing leakage between Faecal incontinence (2016) anecdotally advised the use of normal irrigations. In patients with constipation, regular Safety saline and monitoring of electrolyte balance. If evacuation of the recto-sigmoid area can promote the tap water available is not drinkable, bottled transport through the entire colon, preventing This article has been subject to double-blind peer review © 2018 MA Healthcare Ltd © 2018 MA Healthcare water is advised (Emmanuel et al, 2013). impaction (Emmanuel, 2010). This article is reprinted from Gastrointestinal Nursing vol 16 no 4 May 2018 clinical including multiple sclerosis and Parkinson’s disease (Emmanuel, 2010). TAI is an effective treatment for chronic constipation that has proven refractory to medical management (Emmett et al, 2015). Chronic constipation is a common condition, occurring in 14% of the community, particularly in women, and increasing in prevalence as the population Image supplied to the authors by Coloplast ages (Suares and Ford, 2011). Patients with obstructed defaecation syndrome, functional defaecation disorder, chronic idiopathic constipation or constipation-predominant irritable bowel syndrome can benefit from TAI (Emmett Before transanal irrigation After transanal irrigation The bowel is loaded with stool The descending colon and et al, 2015). Recent NICE guidance (2018)— rectum are empty of stool focussing on the Coloplast Peristeen system— recognised that TAI can reduce constipation Figure 1. Scintographic images of the colon before and after transanal irrigation and faecal incontinence in patients with bowel dysfunction, supporting earlier findings. Table 1. Indications for transanal irrigation Chronic constipation Chronic faecal incontinence Applicability Idiopathic, IBS-C, opioid-induced, Idiopathic, IBS-D, neurological or TAI is indicated as a treatment for constipation neurological or result of obstructive result of obstructive defaecation defaecation syndrome, in which syndrome, in which symptoms are and/or faecal incontinence and should only be symptoms are present for over 6 months present for over 6 months and there initiated when conservative approaches have and there is inadequate response to: is inadequate response to: proven inadequate (Table 1). • At least two types of laxatives used at • Biofeedback therapy A full patient assessment should be undertaken maximum tolerated dose • Lifestyle changes prior to initiating TAI, during which red flags • Biofeedback therapy • Constipating medication • Lifestyle changes should be excluded. These include blood in faeces, • Specialist initiated drugs if indicated and weight loss, abdominal pain, new or continuing available locally, such as Prucalopride, changes in bowel habits and family history of Lubiprostone, Linaclotide, Naloxegol colorectal cancer or inflammatory bowel disease Note: IBS=irritable bowel syndrome, either constipation-dominant (-C) or diarrhoea-dominant (-D) (IBD) (Emmanuel et al, 2013). If present, TAI is contraindicated until malignant disease is excluded Patient benefits or IBD becomes quiescent. Patient assessment TAI was first used in patients with neurogenic should include an assessment of the patient’s bowel dysfunction, a significant number of whom motivation for undertaking this treatment, as develop constipation and/or faecal incontinence. well as the presence of any conditions affecting Levinthal et al (2013) studied gastrointestinal dexterity, mobility or cognition. Medical and symptoms in 218 people with multiple sclerosis. surgical history should be ascertained to identify Constipation and faecal incontinence were any contraindications or circumstances requiring common, reported by 36.6% and 15.1% of extra care (Table 2). All patients should undergo the study population respectively. Previously, digital rectal examination to exclude anorectal Christensen et al (2006) had definitively obstruction (that is, the rectum could be loaded established the benefit of TAI for patients with with faeces), anal stenosis, anal stenosis or spinal cord injuries. They undertook a large painful conditions, such as anal fissure. Results (n=87), randomised controlled, multi-centre trial and patient consent to proceed with TAI should of TAI (using Peristeen) and conservative bowel be documented according to local policy (Norton management strategies in patients with spinal and Coggrave, 2016). cord injury. TAI significantly reduced constipation and faecal incontinence when compared with Efficacy conservative strategies. Subsequent observational Several studies document the success of TAI studies have shown TAI to be effective in patients in patients with spinal cord injury and cauda with other neurogenic bowel conditions, equina syndrome. The most robust of these was Ltd © 2018 MA Healthcare This article is reprinted from Gastrointestinal Nursing vol 16 no 4 May 2018 clinical a randomised controlled trial that compared Table 2. Circumstances when transanal irrigation is TAI with conservative bowel management over contraindicated or should be discontinued or used a 10-week period. TAI was more effective, with caution significantly reducing the severity of constipation Contraindicated or Used with caution and faecal incontinence. Additional benefits discontinued • Cognitive impairment included greater general satisfaction, reduced • Active inflammatory bowel • Congestive cardiac failure time spent on bowel management (from 74 disease • Faecal impaction to 47 minutes per day) and fewer urinary tract • Acute diverticulitis • Inactive inflammatory bowel disease • Anal or colorectal stenosis infections (Christensen et al, 2006). In the author’s • Low blood sodium • Change in bowel habit, • Long-term steroid therapy experience, the time taken for TAI can be as little until cancer is excluded • Painful anal conditions, including fissure, fistula, as 15 minutes. Subsequent prospective
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