1. Constipation - Update GS Duthie

2. Assessment Constipation Constipation –Infrequent –Hard –Difficult Evac Abdominal Pain Abdominal Pain –( important for surgical options ) –Not resolved by colectomy

3. Assessment Previous History Previous History –Medical (surgery/gynae) –Social Current Treatment Current Treatment 2 week diary (or more) 2 week diary (or more) Dietary assessment Dietary assessment

4. Assessment Exclude organic causes Exclude organic causes History History Examination Examination PR / Sigmoidoscopy PR / Sigmoidoscopy Radiology Radiology Endoscopic Endoscopic

5. Assessment Large Bowel Transit Large Bowel Transit –Pellets One day / Three day One day / Three day –Scintigraphic Oro-Caecal Transit Oro-Caecal Transit –Breath test –Scintigraphic Proctography Proctography –Radiol –MRI –Scintigraphic

6. Assessment Doctor Doctor Nurse Practitioner Nurse Practitioner Physiologist Physiologist Multi disciplinary meeting ? Multi disciplinary meeting ? ? Psychology ? Psychology

7. Diagnosis Transit Slow / No Obstruction Transit Slow / No Obstruction –Treat for Transit Transit Slow / Obstructive Transit Slow / Obstructive –Treat for Obstruction then Transit Transit Normal / Obstructive Transit Normal / Obstructive –Treat for Obstruction

8. Diagnosis Transit Normal / No Obstruction Transit Normal / No Obstruction –Reassess –? IBS –Somatisation –Psychology / Psychiatry Remember the Childrens Act Remember the Childrens Act

9. Treatment Treat based on QoL Treat based on QoL Agree acceptable Outcome Agree acceptable Outcome Use Minimal Acceptable Treatment Use Minimal Acceptable Treatment Surgery is LAST Option Surgery is LAST Option Stomas often give poor results Stomas often give poor results Reassess transit after treating obstruction Reassess transit after treating obstruction Reconsider psychological assessment Reconsider psychological assessment

10. Assessment 2 Physiological Assessment Physiological Assessment –Early if ? Megarectum/Colon Recto-anal reflex Recto-anal reflex May help define Obstruction May help define Obstruction Late if ? Surgery Late if ? Surgery –Anal Ultrasound Remember Diarrhoea/Sphincter Injury Remember Diarrhoea/Sphincter Injury Don’t Mix Well Don’t Mix Well

11. Slow Transit Dietary Manipulation Dietary Manipulation –CUT Fibre Intake Laxative Therapy Laxative Therapy –High Doses –Poly-pharmacy Rectal Irrigation Rectal Irrigation

12. Slow Transit ACE ACE Neuromodulation Neuromodulation –(funding issues) Stoma – Ileostomy Stoma – Ileostomy –Especially if considering colectomy Colectomy + IRA (2 years) Colectomy + IRA (2 years)

13. Obstructive Causes Anismus / Spastic Pelvic Floor Anismus / Spastic Pelvic Floor Failure of Pelvic Floor (physics) Failure of Pelvic Floor (physics) Rectoceles Rectoceles Intussussception Intussussception

14. Anismus No “surgical” option No “surgical” option Stomas Bad Stomas Bad Laxatives (PEG) Laxatives (PEG) Biofeedback Biofeedback Consider Neuromodulation Consider Neuromodulation –Beware test “enthusiasm” –Funding

15. Failure of Pelvic Support Almost impossible to resolve Almost impossible to resolve –? Urinary symptoms –Multidisciplinary Approach Physiotherapy Physiotherapy Sacro-colpo-rectopexy Sacro-colpo-rectopexy –(Rectopexy) Neuromodulation (funding) Neuromodulation (funding) Express Procedure Express Procedure

16. Rectoceles (? Biofeedback) (? Biofeedback) Irrigation Irrigation Repair Repair Surgical / Gynae (USS sphincter) Surgical / Gynae (USS sphincter) ?STARR ?STARR –Medium / Long term results –? logic

17. Intussussception (?biofeedback) (?biofeedback) Irrigation Irrigation Rectopexy (poor longterm results) Rectopexy (poor longterm results) STARR STARR –Repeatability –Longevity

18. Solitary Rectal Ulcer Is a Pathological diagnosis Is a Pathological diagnosis Refer for Specialist Assessment Refer for Specialist Assessment

19. Megarectum / Colon Refer for Specialist Assessment Refer for Specialist Assessment