Disorders of Defecation

Home , Anismus, Bristol stool scale, Defecography, Fecal impaction, Obstructed 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.

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

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).

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 hard dry stools, or difficulty with stool elimination.

Patients also classify feelings of incomplete emptying, abdominal cramping and bloating, and inability to defecate on schedule or when desired as constipation.

Rome III Criteria (criteria for diagnosis developed by international group of gastroenterologists):

Any 2 (or more) of following symptoms for last 3 months (symptoms for at least 6 months) in patients who do not meet criteria for Irritable Bowel Syndrome)

•Straining with >25% of bowel movements •Lumpy or hard stool with >25% of bowel movements •Sensation of incomplete evacuation with >25% of bowel movements •Sensation of obstruction or blockage with >25% of bowel movements •Less than 3 bowel movements per week •Infrequent loose stools unless laxative taken

Emory University WOCNEC Copyright © 2016 102 •Causes/Types: --Simple constipation: transient (occasional) constipation: due to dietary or environmental issues or pregnancy --Functional normal transit constipation --Functional slow transit constipation

Functional Normal Transit Constipation.

Description: No inherent problems with bowel function – bowel responds normally to distention (i.e., with peristaltic waves). Constipation is thought to be caused by extrinsic factors (factors outside the bowel that affect bowel function) such as

--insufficient fiber and fluid intake (though there is limited and conflicting research related to the effect of fiber and fluid on stool consistency); --immobility and inactivity; --poor toileting habits (habitually ignoring the urge to defecate); and --medications (e.g., narcotics, anticholinergics, calcium-based antacids)

Impact of low fiber diet: formation of hard, small-caliber stools that fail to distend the colon sufficiently to stimulate peristalsis. Prolonged contact between the colonic mucosa and the stool results in further drying of the stool; the colon then collapses around the small-diameter stool. As a result of all of these factors, the amount of pressure required to force the small hard stools through the narrowed colon is significantly increased. (Results in abdominal straining.)

Recommended daily fiber intake: 14 g/1000 calories (about 25 g/day for women and about 38 g/day for men) --Benefits: softens stool, increases stool bulk, reduces colonic transit time, promotes normal bacterial balance within colon --Guidelines: Assure adequate fluid intake Titrate fiber intake to desired stool consistency (soft formed, like a smooth sausage – Type 4 on Bristol Stool Scale – see Chapter 11 Core Curriculum for Bristol Stool Chart)

Clinical signs/symptoms normal transit constipation:

•Hard dry stools; stool frequency < 3/week •Patient may describe difficulty with elimination/need to strain or to use laxatives, suppositories, or enemas. •Pain not typically reported with normal transit constipation •Good response to laxatives

•Laxatives/colon “cleanout” to eliminate retained stool

•Fiber supplements (or high fiber diet) + fluids + increased activity (if possible) + reduction or elimination of constipating medications (anticholinergics, aluminum- based antacids, etc.) to produce normal stool consistency (See Chapter 17, Core for list of high fiber foods)

•For patient with opioid-induced constipation not responding to fiber, fluid, stool softeners, and laxatives, may request order for methylnaltrexone (Relistor) – blocks effects of opioids on gut without altering effects on central nervous system, so get relief of constipation without compromising pain control. Currently given subcutaneously.

Suggested initial program for patient on moderate – high dose opioids: fiber supplement as tolerated (+ fluids), softeners such as docusate daily or twice daily, osmotic laxatives daily (e.g., polyethylene glycol); stimulant laxatives (e.g., senna) as needed (if no bowel movement x 1 – 2 days)

Slow Transit Constipation (Chronic Idiopathic Constipation)

Description: Marked reduction in frequency and amplitude of propagating contractions (peristaltic waves) – possible etiologic factors include:

--neurologic lesion that disrupts autonomic nerve pathways (e.g., spinal cord injuries at sacral level)

--neurologic disorder (e.g., autonomic neuropathy in patient with diabetes).

--constipation-predominant irritable bowel syndrome (IBS-C): should consider this when cramping pain is a predominant symptom (discussed in more detail later).

--idiopathic slow transit constipation (condition characterized by very slow colonic motility of unknown etiology)

Presentation: --very infrequent urge to defecate/bowel movements (1 – 4 times per month) --bloating and anorexia common with severe cases (distention and impacted stool in proximal colon rather than rectum) --when bowel movements do occur, they are frequently very large --usually minimally responsive to fiber therapy and standard laxative therapy (may increase bloating/distention)

Diagnosis: Colonic motility study (patient ingests radiopaque pellets – flat plate of abdomen is done 4 - 5 days later to evaluate progression through colon). Also known as Sitz marker study. Alternatives include wireless motility capsules and video capsule Endoscopy.

Management:

--May try fiber and fluids initially (and with caution – fiber increases stool production and can exacerbate symptoms in patient with slow transit); if symptoms are worsened by fiber, discontinue use

--Primary management: softeners and osmotic laxatives + targeted medications Daily softeners help prevent hardening of stool during prolonged transit through colon Osmotic laxatives (e.g., polyethylene glycol) pull fluid into bowel and keep stool more fluid Targeted medications (e.g., medications that increase motility by altering levels of neurotransmitters, e.g., lubiprostone; linaclotide) Patient education is critical to dispel negative attitudes re: routine use of laxatives

Obstructed Defecation:

Description: Difficulty eliminating stool due to outlet disorders (can’t effectively eliminate stool from rectum, even when stool is soft.) May be due to: --structural anomalies (e.g., rectocele, rectal prolapse, rectoanal intussusception, perineal descent) --functional disorders of the pelvic floor (e.g., pelvic floor dyssynergia, also known as anismus or non-relaxing puborectalis syndrome)

•Rectocele: protrusion of rectum and posterior vaginal wall into vaginal vault; commonly seen in women who have had traumatic deliveries or pelvic surgery resulting in damage to pelvic floor nerves and muscles

•Rectoanal intussusception: with straining, distal rectum intussuscepts into anal canal, thus creating total obstruction to stool elimination

•Perineal descent: weakened pelvic floor muscles resulting in abnormal “descent” of pelvic floor with straining; this causes anterior rectal wall to partially occlude the anus

•Rectal prolapse: protrusion of rectal mucosa through anal canal, resulting in obstruction of anal canal (uncommon)

•Pelvic floor dyssynergia (also known as nonrelaxing puborectalis syndrome or anismus). Inability to effectively relax the external anal sphincter and pelvic floor muscles; patient contracts abdominal muscles but simultaneously maintains pelvic muscle contraction, which prevents straightening of the anorectal angle and maintains anal canal closure.

Clinical Presentation: •May have coexisting problems with hard stool or may have soft stool but difficulty with elimination

•Digital evacuation or perineal pressure frequently required to facilitate rectal emptying; e.g., woman with rectocele may find it helpful to place 1 – 2 fingers into the vagina and exert pressure against the posterior vaginal wall to reduce the rectocele and permit stool evacuation; pt with perineal descent may find it helpful to apply manual pressure to the external perineum (prevents excessive descent).

•Feelings of incomplete emptying and excessive straining are common symptoms

Diagnosis: Defecography (barium “pseudostool” instilled into rectum; patient placed on radiolucent commode chair and fluoroscopy performed while patient tries to eliminate “pseudo-stool” – can “see” what happens with attempted elimination)

Management (depends on specific problem)

•Assessment (baseline) of patient with general complaint of “constipation”

History

∼Bowel elimination patterns: stool frequency, volume, consistency, use of laxatives/suppositories/enemas/herbal agents to stimulate bowel movements

∼Bowel elimination patterns prior to onset of current problems

∼Onset of problems with elimination: way in which elimination patterns changed, any associated events, management approaches

∼Current activity levels, fiber intake, fluid intake

∼Prescription and over the counter meds (note calcium-based antacids may contrib.- ute to constipation)

∼Medical-surgical history with particular attention to neurologic disorders, GYN history, pelvic procedures, etc.

--Abdominal exam to rule out colonic distention: percuss along length of colon. Normal percussion note is tympanic/resonant with patchy dullness over transverse colon (where stool is stored prior to defecation)

--Anorectal exam: note sphincter tone at rest, response to finger insertion, ability to voluntarily contract the sphincter and any apparent areas in which sphincter muscle deficient, ability to effectively relax the sphincter when asked to “relax and push my finger out”, any stool in rectal vault and consistency. Assess for evidence of rectocele, perineal descent, intussusception with straining.

∼Bowel Chart: ask patient to keep record of bowel movements (time, volume and consistency of stool, amount of straining, any additional maneuvers or aids required to eliminate stool – may also ask patient to record dietary and fluid intake)

•Management

Patient with Normal Transit Constipation

--“Clean out” if indicated (patient with colonic distention and/or rectal impaction

Determine whether “top- down” (laxatives) or “bottom up” (suppositories/enemas) or combined approach is needed.

“Top down” usually best option because it assures cleansing of entire colon and is typically preferred by patients. Can instruct patient to take “usual laxative” nightly till passing mushy stool (or can increase usual dose and give nightly till passing mushy stool). For patient who does not have a “usual” laxative, can recommend a stimulant agent (senna or bisacodyl) or osmotic agent (magnesium agents, saline agents, lactulose, sorbitol, polyethylene glycol)

“Bottom up” is better approach for patient who lacks sensory awareness and sphincter function (e.g. patient with cord injury and neurogenic bowel) – because “bottom up” methods have predictable time frame for results, whereas time frame for results from laxatives is highly variable. Use of top down agents for this patient would place

him/her at significant risk for incontinent episodes – whereas with “bottom up” can tell patient “If you take this enema – or use this suppository – at 7:00 am, you can safely leave your home at 9:00 am.

“Combined approach” best option for patient with rectal impaction who has sensory awareness and sphincter control. Use enemas (+ gentle manual disimpaction if needed) to eliminate impacted stool; then use laxatives to cleanse proximal bowel.

“Bottom Up”: --Fleet enema (consider giving through balloon-tipped catheter if patient lacks sphincter control) --“Milk and Molasses” enema – mix half and half – warm in microwave till mixed, then cool – give 2 – 4 ounces at a time and wait 30 – 60 minutes to allow penetration and softening of stool – then attempt manual breakup/repeat as needed.

Can also use suppositories but usually not as effective as enemas

--Measures to Produce Soft Formed Stool Eliminate constipating medications if possible Encourage activity Provide adequate fluid and fiber

Guidelines for Fluid Intake: 30 cc/kg body wt/day or about 2 liters/day for adults

Titrate fiber to establish soft formed stool (like smooth sausage)

--Options for increasing fiber intake:

1.) Dietary modifications. Give patient a list of high fiber foods and help him/ her to plan very specific changes to assure adequate fiber intake (note easiest approach is to eat high-fiber cereal each morning, e.g., Fiber One). See Chapter 17 Core Curriculum

2.) Bran formula (power pudding)

1 cup unprocessed Miller’s Brand (Hodgson Mill brand) 1 cup applesauce ¼ cup prune juice

Begin with 1-2 tablespoons each day and increase daily dose each week until stool is soft and formed. Assure adequate fluid intake (30cc/Kg body wt/24hrs—8 oz after ingestion of the bran formula).

Warn patient to expect increased bloating/gas and increased stool frequency for 2-4 weeks (takes time for colon to “adjust” to the increased fiber intake— colonic function will normalize within a few weeks).

Begin with 1-2 scoops/day (or recommended dose) and increase daily dose each week until desired stool consistency is obtained. Assure adequate fluid intake (approximately 30cc/Kg/24hrs—8 oz following ingestion of the bulk agent).

*Note fiber supplements available in multiple forms: powders that are mixed in water or juice; cookies; “gummies”; even fiber-enriched water

*Citrucel does not undergo fermentation in gut so usually causes less gas

4.) For patient on fluid restriction: cannot use bulk laxatives or bran because increased fiber without increased fluid places the patient at risk for impaction or obstruction. For these patients, usually best to use a softener + stimulant (e.g., docusate + senna or bisacodyl) titrated to produce desired results.

*Stool softeners are not usually needed if adequate bulk and fluids are pro- vided, because the bulk holds water in the stool and naturally “softens” the stool.

--Teach patients to respond promptly to urge to defecate!

This is the time when the stool is easiest to eliminate. The patient should also be taught to assume the optimal position when attempting to defecate (sitting with feet flat on the floor; leaning forward slightly with the back straight to further increase intra-abdominal pressure).

Patient with Clinical Presentation Slow Transit Constipation

--Refer to gastroenterologist for further workup (e.g., transit study)

--Primary treatment: stool softeners + laxatives and targeted medications

Targeted medications

--Lubiprostone (Amitiza) now approved for chronic constipation in adults; also approved for constipation-predominant Irritable Bowel Syndrome (IBS-C). Common side effects: nausea, diarrhea, headache.

--Linaclotide (Linzess) approved for chronic idiopathic constipation in adolescents and adults, but not in children. Common side effect: diarrhea

--Surgical Options (for patients who respond poorly to medical therapy):

..Colectomy with ileorectal anastomosis ..ACE Procedure (antegrade continence enema) -- creation of small one-way stoma into proximal colon to permit introduction of a catheter for colonic lavage on routine basis to maintain stool elimination). Patient sits on toilet, inserts catheter into colon, and instills water, saline, or hypertonic solution to flush colon from proximal to distal. Usual frequency of lavage: daily or QOD.

--Sacral neuromodulation. Early studies show significant improvement in bowel function among patients who failed to respond to dietary modifications, laxatives, and biofeedback. Further studies needed.

Patient with Clinical Presentation Obstructed Defecation

--Refer to gastroenterologist for workup (usually incudes defecography, i.e., barium “pseudostool” instilled into rectum; patient placed on radiolucent commode chair and fluoroscopy performed while patient tries to eliminate “pseudo-stool” – can “see” what happens with attempted elimination)

--Management (depends on specific problem):

Rectocele: pessary vs surgery

Pelvic floor dyssynergia: fiber + fluid to establish soft formed stool that is easier to eliminate; biofeedback/behavioral therapy to teach patient to relax pelvic floor muscles and to coordinate abdominal muscle and pelvic muscle function (focus on deep breathing/avoid intense straining, etc.)

Excessive perineal descent is best managed with measures to establish soft formed stool and biofeedback to improve pelvic muscle function

Intussusception and rectal prolapse: require surgical repair

∼Begin with bulk laxatives (fiber supplements) and fluid unless contraindicated

∼Add osmotic/hypertonic agents as needed; this category includes saline cathartics such as Milk of Magnesia, Magnesium Citrate, and Fleets Phospho Soda; lactulose agents (e.g., Chronulac, Cephulac, Heptalac, etc.); sorbitol agents; and polyethylene glycol formulas (e.g., Miralax, Colyte, etc.) These agents are safe for repetitive and long-term use if needed—however, they are usually used on a PRN basis

∼Use stimulant agents only when needed and on short-term basis; these agents include bisacodyl (Dulcolax) and senna (Senokot)

May use suppositories/mini-enemas on PRN basis to stimulate defecation.

Irritable Bowel Syndrome

•Definition: current diagnostic criteria include: recurrent abdominal pain or discomfort at least 3 days/month in the past 3 months associated with two or more of the following: --Improvement with defecation --Onset associated with a change in stool frequency --Onset associated with a change in stool form (appearance)

Note many patients also experience extraintestinal symptoms: fatigue, malaise, joint pain, etc. Also note that IBS is generally defined as a functional disorder with no changes in bowel wall structure. Three classifications/patterns of IBS: --constipation-predominant (CP-IBS, also known as IBS-C) --diarrhea-predominant (DP-IBS, also known as IBS-D) --mixed pattern IBS, i.e., bowel patterns alternating between diarrhea and constipation (IBS-M) --pain-predominant (PP-IBS)

Etiology and pathology unclear; current data suggest some combination of the following:

--Abnormal permeability of intestinal mucosa (“leaky gut”) --Alterations in GI bacterial balance (changes in bacterial composition may cause inflammatory response that alters intestinal permeability and causes enteric nervous system dysfunction, altering peristaltic activity). Note antibiotics and proton pump inhibitors can contribute to alterations in bacterial balance --Autonomic nervous system dysfunction --Altered immune system function --Psychological distress

Role of diet in IBS remains controversial – some data suggesting that bacterial breakdown of poorly digested carbohydrates may cause increased gas production and pain in some patients – these patients may benefit from diet low in fermentable carbohydrates.

•Assessment

∼Diagnosis typically based on careful history and physical examination; helpful to have patient complete symptom diary and to use validated tool such as Bristol Stool Chart to report usual stool consistency.

--Diagnostic studies limited to fecal occult blood testing, H & H to rule out anemia, serum tests to rule out inflammatory process (e.g., erythrocyte sedimentation rate). Additional tests should be done if there are “red flag” symptoms.*

∼Assess patient’s concerns (many patients are concerned that they may have a life- threatening illness—understandable since change in bowel habits one of the indicators of colorectal cancer). Very beneficial to provide education regarding basis for symptoms and principles of management

*“Red Flags” that further investigation needed: bleeding, anemia, fever, unintended wt loss > 10 lbs, strong family history colorectal cancer; frequent nocturnal symptoms; recent antibiotic use; recent onset and progressive symptoms; abdominal mass; lymphadenopathy

Note: Should “rule out” celiac disease in patients with IBS-D and IBS-M

∼Patient education the most critical element: need to explain that IBS is a common disorder that can cause significant distress, but it is not life- threatening and not malignant in nature. Explain that currently there is no cure but that symptoms can usually be effectively controlled ∼Dietary modifications helpful for some patients. Despite limited evidence to support link between IBS and diet, restriction of gas-forming foods is frequently the first step in treatment (can do 2-week trial in which fermentable carbohydrates and lactose are restricted or eliminated to determine whether this helps to reduce symptoms). Can also have patient maintain records of food and fluid intake and symptoms to identify his/her individual “triggers”. ∼Exercise/activity and stress management have been shown to be helpful in reducing symptoms.

∼Pharmacologic therapy dependent on predominant symptom --Constipation-predominant. Begin with dietary fiber (slowly increase to 20 g/day).

If needed, add osmotic laxative or lubiprostone (on trial basis)

--Diarrhea-predominant. Loperamide (PRN or on prophylactic basis); diphenoxylate with atropine on trial basis; and/or cholestyramine on trial basis

--Pain-predominant. Hyoscyamine on trial basis; dicyclomine on trial basis; and/ or amitryptiline or nortriptyline for refractory pain

Meds that may be considered for selected patients: ∼Alosetron (5 HT-3 antagonist): reduces motility in small bowel and colon; approved only for severe diarrhea-predominant IBS in women who have failed other therapies. Can cause severe ischemic colitis

∼Rifaximin for IBS patients without constipation

Refer to IBS specialist if patient fails to respond to standard therapy