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

The next mins An overview Primary care management cIBS Faecal impaction When to refer Novel therapies

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

Epidemiology and Cost Constipation is more common in –Women (X3) –> 65 years –Non-whites –Poor socio-economic background Most common treatment is laxatives –3 million people (USA) –> $725 million

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)

Rome II Criteria At least 12 weeks in the preceding 12 months, of 2 or more of the following –straining in > 25 % defaecations –hard stools in >25 % defaecations –incomplete evacuation in >25 % defaecations –anorectal obstruction / blockage in >25 % defaecations –digitation >25 % defaecations –<3 defaecations / week

Specialists Primary care ~75% non-consulters ~70% female ~30% male ~25% consulters

Constipation: Aetiology Aetiology Structural Functional Secondary (systemic) Drugs and Diet Endocrine Metabolic Neurological Primary (bowel problem) Colon or rectum

“Primary” Constipation Structural l Cancer l Strictures l Megacolon/rectum H Hirschsprung’s H Idiopathic l Outlet obstruction l Anal stenosis l Rectocele l Prolapse u Functional l c- IBS l Colonic inertia l Iatrogenic (post pelvic surgery) l Evacuatory dysfunction l Rectal hyposensitivity l Anismus l Proctalgia fugax l ‘anal fixators’

Treatment: functional constipation Vast majority don’t 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

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

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

Bowel-retraining programme Package of care Psychosocial counselling Optimisation of medication / diet/laxatives Pelvic floor co-ordination exercises ‘Biofeedback’ techniques

Pelvic floor co-ordination exercises Posture Diaphragmatic breathing Abdominal bracing exercises Balloon expulsion Splinting

‘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

Novel therapies

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

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

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)

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

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

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

Posterior Tibial Nerve Stimulation 2003 used for FI Neuromodulation of sacral plexus via the posterior tibial nerve Achieved by –Percutaneous –transcutaneous

PTNS- Indications Just FI, so far Studies in constipated patients awaited

PTNS Cheap equipment costs –Needles £200 –Pads £3 –Stimulator boxes £80

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