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Disorders of Defecation

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Disorders of Defecation Section V: Disorders of Defecation Disordered defection is a very common problem among individuals of all ages; the continence nurse needs to understand common disorders as a basis for assessment and management. This section will focus on the most common disorders: diarrhea, constipation, obstructed defecation, and irritable bowel syndrome. OBJECTIVES: 1. Define the following terms: diarrhea; functional normal transit constipation; functional slow transit constipation; obstructed defecation; irritable bowel syndrome. 2. Identify etiologic factors for each of the following: diarrhea; functional normal transit and slow transit constipation; obstructed defecation; irritable bowel syndrome. 3. Outline factors to be included in the assessment of an individual with a defecation disorder. 4. Outline options for normalizing stool consistency in the patient with diarrhea and in the patient with constipation. 5. Identify three options for containment of stool in the patient with diarrhea and fecal incontinence, and advantages and disadvantages of each. 6. Discuss indications and options for “top down” versus “bottom up” colonic cleansing programs for the patient with fecal impaction or colonic distention. 7. Identify management guidelines for the patient with functional slow transit constipation. 8. Identify indications for referral of the patient with a defecation disorder. 9. Given a patient situation, provide appropriate assessment and counseling. Emory University WOCNEC Copyright © 2016 97 10. Briefly explain the pathophysiology of “pelvic floor dyssynergia” and options for management. 11. Explain why a woman with a rectocele may need to exert digital pressure against the posterior vaginal wall to effectively empty the rectum. 12. Explain the recommended “hierarchy” of use for laxatives, and identify guidelines for use of each of the following: • bulk laxatives (e.g., psyllium, Citrucel, Fibersure) • osmotic laxatives (e.g., saline laxatives, lactulose, sorbitol, and Polyethylene glycol solutions) • stimulant laxatives (bisacodyl, senna) 13. Describe management guidelines and options for each of the following: IBS-D; IBS-C; IBS-M LEARNING ACTIVITIES: •Study Core Content •Read Chapters 14 and 15 •Complete Learning Exercises on Blackboard Emory University WOCNEC Copyright © 2016 98 Disorders of Defecation (Study Guide: Core Content) General Principles: •Defecation disorders are a common problem among all age groups, partially due to the refined diet typical of industrialized civilizations. •Common disorders include: diarrhea, constipation, and irritable bowel syndrome. Diarrhea •Definition: Usually defined as either > 3 loose or liquid stools in 24 hours, or > 200 gm of stool in 24 hours World Health Organization (WHO) defines diarrhea as “passage of 3 or more loose or liquid stools per day, or more than is normal for the individual”. Patients use the term “diarrhea” to describe any episodes of increased frequency, volume, and/or liquidity of stool; must do follow-up questioning to determine the specific problem. Patients may also report problems with fecal incontinence as “diarrhea”, probably because diarrhea is more socially acceptable so easier to report. •Causes: Acute onset (lasting < 14 days) ∼Infectious agents (gastroenteritis) ∼Acute exacerbation of chronic inflammatory process ∼Initiation of enteral feedings in patient who is malnourished or has atrophy of villi Chronic diarrhea (lasting > 30 days): ∼Chronic motility disorder (Irritable Bowel Syndrome-Diarrhea Predominant, IBS-D) ∼Chronic inflammatory condition (Inflammatory Bowel Disease) ∼Specific food intolerance (lactose intolerance) ∼Stimulant agents in colon (e.g., bile salts in colon 2° to ileal resection) ∼Unrecognized peristaltic stimulants (magnesium-based antacids, sorbitol, etc.) •Assessment Guidelines: Determine duration of problem, prior stool patterns, and current stool patterns (frequency, volume, consistency, color, odor), and associated symptoms. Acute onset: assess for indicators of systemic illness, dehydration, etc. Chronic diarrhea: assess for evidence of IBS or IBD (e.g., cramping pain, bloody stools, weight loss indicators of IBD); review medication history—prescription and Emory University WOCNEC Copyright © 2016 99 over the counter; review surgical history to rule out ileal resection; have patient complete “dietary intake and bowel elimination” chart to identify any dietary offenders. Refer to gastroenterologist if further workup or medical intervention required •Management of Diarrhea ∼Address causative factors (e.g., Lactaid for pt with lactose intolerance; Questran for patient with history of ileal resection; antibiotics + probiotics for C Difficile) ∼Initiate measures to thicken stool: Dietary modifications: bananas, rice, applesauce, green plantains. Note ingestion of green plantains associated with significant reduction in stool frequency, volume, weight Fiber supplements: psyllium based products (e.g. Metamucil) 1-2 teaspoons in 3-4 ounces of water 2 – 4 times daily. ∼Consider antidiarrheal medications (anti-motility agents such as loperamide are helpful but must rule out any infectious process before giving anti-motility agent). Bismuth subsalicylate (Pepto Bismol) frequently recommended as OTC for acute traveler’s diarrhea. ~Probiotics have been shown in a number of studies to be beneficial in prevention and management of acute diarrhea; however, further study is needed to determine best specific agents and doses. ∼Initiate measures to contain stool and protect skin for patient with severe diarrhea and fecal incontinence. Options for stool containment: 1.) Fecal Incontinence collector (manufactured by Hollister & ConvaTec) Considerations: Safe; must have sufficient intact skin to obtain seal Procedure: --Clean and dry skin --Shave or clip perianal hair --Treat any denuded skin ( dust on skin barrier powder and “seal” with a moist finger or by “blotting” over the powder with an alcohol free liquid barrier film) --Spread buttocks apart and press fecal collector firmly into place (fold collector at midpoint, firmly attach midpoint to skin of natal cleft, then press the sides into place). Emory University WOCNEC Copyright © 2016 100 2) Nasal trumpet inserted into anal canal and connected to bedside bag (off-label use) Considerations: Can be used when perianal skin is very denuded; works only for liquid stool; limited research indicates device is safe for short term use Guidelines: --Attach shaft end of 8mm (32 Fr) nasopharyngeal airway to bedside bag --Use hemostat to clamp the tubing beneath the sample port on the drainage bag. --Instill mineral oil through the flange end of the trumpet (do not overfill) --Release the clamp and allow mineral oil to drain into the BSB. --Place patient in sidelying position with knees toward chest. --Gently insert the trumpet flange end first into the rectum. --Pull back gently till slight resistance is felt. --Stabilize tubing to prevent tension. 3) Internal Bowel Management Systems Flexiseal (ConvaTec), Acti-Flo (Hollister), DigniShield (Bard) Considerations: can be used with denuded skin; low pressure balloon prevents leakage without causing anorectal necrosis; works only with liquid stool. Fairly new devices so limited data available – reports to date are positive (however, adverse effects have been reported when devices used incorrectly). Considerations: •Must follow manufacturers’ directions for use (note contraindications include: sensitivity to any components of system; clotting disorders; recent history of rectal or lower colon surgery, i.e., in past year; anorectal injury, stricture or stenosis; anorectal tumor; severe hemorrhoids; fecal impaction; damage or inflammation involving rectal mucosa; patient who requires enemas or has in- dwelling rectal device) •Must strictly avoid overfilling of balloon (should never add water without first deflating balloon completely) Note some of the newer devices have incor- porated safety mechanism that prevents overinflation (e.g., ConvaTec) •Staff education/competency testing essential •Routine irrigation as directed very important in maintaining patency and reducing leakage Much more expensive than fecal pouch or nasal trumpet so typically used for patients whose diarrhea is expected to last longer than 5 – 7 days (approved for up to 29 days of continuous use: then must be removed and left out for several days prior to reinsertion) Emory University WOCNEC Copyright © 2016 101 Note: Use of large bore Foley catheters for management of liquid stool is considered contraindicated since there is no data to show safety and there ARE reports of anorectal necrosis. Skin Care Measures: --Intact skin: Moisturizer/moisture barrier combination --Damaged skin: absorptive skin barrier paste (zinc oxide ointment products) or strips of zinc-oxide impregnated gauze (Viscopaste) applied to affected area. (may help to apply clear film dressing, e.g., Tegaderm or OpSite, over each buttock as a cover dressing). This minimizes soiling of paste and transfer of paste to underpads or linens.) *Caution staff to apply thick layer of paste and to remove only the soiled layers -- using a perineal cleanser -- then to reinforce the paste (as opposed to removing all of the paste following each incontinent episode). Note: if skin denuded, can first “crust” with pectin powder and alcohol-free liquid barrier film and can then apply the protective zinc oxide ointment/paste Constipation •Definition: change in normal bowel habits characterized by reduced frequency of bowel movements, passage of
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