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Evaluating the patient with faecal incontinence M62 Course 2004 Mr E S Kiff
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Diagnosis HISTORY EXAMINATION INVESTIGATION
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History LISTEN to what is being said LISTEN to the problem LISTEN to the effect on their life
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The specific questions Urgency Consistency Frequency Defaecation Prolapse Wiping Leakage
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Urgency Diarrhoea Weak voluntary muscle Quantify – how long have you got - incontinent en route?
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Consistency Solid, formed Soft, loose Watery Variable Explosive
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Frequency Diarrhoea – think upstream Formed – think irritability, sensory
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Can you go? Connective tissue weakness – prolapse Long term strainer End stage neuropathy
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Prolapse Grape - mucosal, think eversion of anus Tomato – full thickness rectal Vaginal – rectum,bladder,uterus,small bowel
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Difficulty wiping clean Prolapse Low anal tone Slow to regain tone
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Leakage during the day Low resting tone Prolapse
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Causes of incontinence Brain Body Bowel Bottom
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Brain and cord CVA – IAS weakness? Emotion, anxiety Cord injury MS Peripheral neuropathy Think bladder, think legs
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Body Mobility Elderly Exposure of minor weakness
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Bowel Inflammatory bowel disease Neoplasia Coeliac Drugs OVERFLOW
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Bottom Connective tissue Muscle – neuropathy, tear or BOTH Combination Congenital
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Examination Abdomen Perineum Anal canal and pelvic floor Sigmoidoscopy
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Examination of the anus Position Gape Strain Length and angle Muscle bulk Connective tissue Voluntary contraction
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Investigations The colon Anorectal physiology Endoanal ultrasound Defecating proctography MR scan
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Anorectal physiology Anal manometry Vector-volume analysis Rectal perception of distension Proctometrogram Recto-anal reflex PNTML EMG Other tests
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Endo-anal ultrasound Beware over reporting Tears found later in life = neuropathy Tears are not all or nothing
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Summary Listen to the story Ask the questions Examine the bottom Do the tests Fit the jigsaw together Consider the alternatives for treatment
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References Investigation of faecal incontinence. Buchanan et al. Hosp.Med.2001;62:533- 537 AGA position on anorectal testing. Gastroenterology.1999;116:732-760 The clinical use of anorectal physiology studies. Ann R Coll Surg Eng. 1983; Suppl 1: 27-29
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