Constipation and defecation dynamics. Alesha Sayner Continence Physiotherapist Western Health

Transcription

1 Constipation and defecation dynamics Alesha Sayner Continence Physiotherapist Western Health

2 Acknowledgements Super awesome manager (You can pay me later) Western Continence Service Western Health Library Service Footer Text 2

3 Outline Constipation Functional - Structural - Behavioural Differential diagnosis What physiotherapists can contribute The ins and outs of rectal balloon therapy *Disclaimer: The pun in unintentional *Further disclaimer: Maybe the pun is intentional Bowels are evil and complex REALLY super fantastically interesting and them team work can be really rewarding! Footer Text 3

4 What I WON T be talking about In depth lifestyle changes Dietary contributors Pharmacy/medications The aging population Aperients Slow transit constipation Neurological/systemic/metabolic contributors Toilet position, bowel regimes, detailed defecation dynamics Internal therapies and informed consent Surgical or medical management (i.e. Botox) The importance of the multi-disciplinary team Constipation is MASSIVE!!!!!!!!!!!! Footer Text 4

5 Have you heard of the movie Constipation? I can t say I have That s because it hasn t come out yet. You re welcome Footer Text 5

6 How do we define constipation? Rome 3 Criteria for functional constipation ( Fewer than 3 bowel movements per week Straining 25% of the time Lumpy or hard stools 25% of the time Sensation of anorectal obstruction/ blocking 25% of the time Sensation of incomplete emptying 25% of the time Manual maneuvering required to defecate 25% of the time Footer Text 6

7 What else? Other symptoms to watch for Abdominal bloating or discomfort Pain on defecation anal or abdominal Rectal bleeding Spurious diarrhea Low back pain Feeling of incomplete emptying Digitating stool Tenesmus Footer Text 7

8 Prevalence and other interesting stuff Global prevalence 11-18% (Suares & Ford, 2011) Many studies incorporate standard measures such as fibre intake adjustment, increasing fluids, increasing exercise +/- the use of aperients prior to biofeedback modalities (McCrea, Miaskowski, Stotts, Macera, & Varma, 2008) Push effort during defecation should be no more than 50-70% of maximum push effort (Rao & Patcharatrakul, 2016) Footer Text 8

9 Structure and function Structural and functional issues can co-exist Proximal colonic activity -? Volume and stool consistency Rectum acts as a reservoir for storage of stool During rectal filling Requirement for rectal wall compliance Autonomic neurons for sensation/perception of stool volume and consistency Activation of rectoanal inhibitory reflex Voluntary EAS contraction until able to reach toilet Intact IAS for continence (McCrea, Miaskowski, Stotts, Macera, & Varma, 2008; Wald et al 2014) Image adapted from Footer Text 9

10 Defecation Reach level of critical fill Squat position straighten anorectal angle More obtuse to Relaxation of EAS and puborectalis IAP coordinated with pelvic pressures Allows stool to enter lower rectum Mobile perineum to allow for descent Spontaneous rectosigmoid contraction Continuous until the rectum is perceived as empty (Nikjooy et al., 2015; Bharucha, 2006) Footer Text 10

11 Constipation - Behaviour Footer Text 11

12 Constipation behaviour and adaptation? Maladaptive learning Painful defecation in childhood Painful defecation post surgically Pelvic trauma or sexual abuse Toilet aversion/social impact Stress/anxiety Dietary changes elderly? (Whitehead, di Lorenzo, Leroi, Porrett, & Rao, 2009; Leroi, Berkelmans, Denis, Hémond, & Devroede, 1995; McCrea, Miaskowski, Stotts, Macera, & Varma, 2008; Rao, Tuteja, Vellema, Kempf, & Stessman, 2004) Footer Text 12

13 Differential diagnosis in constipation Assessment modalities Digital rectal examination (DRE) Anorectal Manometry (ARM) Defecography EMG of the pelvic floor Balloon expulsion test (BET) Magnetic Resonance Imaging (MRI) Structural and functional issues can co-exist Lack of adequate specificity of tests Dx No single test combination required (Wald, Bharucha, Cosman, & Whitehead, 2014) Footer Text 13

14 Differential diagnosis DRE Accessible Sensation testing Good NPV(91%) Simulated defecation Anal canal pressure Palpate puborectalis? Widening of anorectal angle Appropriate training?? Under utilized?? (Lawrentschuk and Bolton 2004; Wald, Bharucha, Cosman, & Whitehead, 2014) Footer Text 14

15 Differential diagnosis DRE and BET (Caetano, Santa-Cruz, & Rolanda, 2016) BET Sensitivity 67% (Caetano, Danta-Cruz, & Rolanda, 2016) Sensitivity 50% (Rao, 2008) Specificity 80% NPV 72% Left lateral lie V s seated (Ratuapli, Bharucha, Harvey, & Zinsmeister, 2013) DRE Sensitivity 80% Specificity 84% NPV 64% Neither suitable for screening when used in isolation Footer Text 15

16 Differential diagnosis ARM Contraction V s relaxation Canal pressures/rectal pressure activity Rectal propulsive force > 20% reduction in canal pressures (Rao, 2008; Wald, Bharucha, Cosman, & Whitehead, 2014) Footer Text 16

17 Differential diagnosis Defecography (Rafiei et al., 2017) Barium injection and radiographic analysis Footer Text 17

18 Dyssynergic Defecation DD What is DD (Dyssynergic Defecation)? Reportedly present in 28%-33 of people presenting with constipation (Nyam et al 1996; Rao et al 2010) Inappropriate relaxation and coordination of the PFM complex at time of emptying Impaired push effort due to: Inappropriate relaxation of the PFM complex Poorly coordinated rectal, anal and abdominal muscles (Lee, Jung & Myung, 2013; Rao 2008) < 20% reduction in anal canal pressure during simulated defecation Inadequate expulsion at defecation Consider balloon expulsion test (Bharucha, Wald, Enck, & Rao, 2006; Wald, Bharucha, Cosman, & Whitehead, 2014; McCrea, Miaskowski, Stotts, Macera, & Varma, 2008)) Footer Text 18

19 Anorectal angle what we expect (Nikjooy et al., 2015) Footer Text 19

20 (Nikjooy et al., 2015) (Nikjooy et al., 2015) Footer Text 20

21 (Rao & Patcharatrakul, 2016) Footer Text 21

22 EMG patterns what might we see with anal BFB EMG? (Lee, Jung, & Myung, 2013) Footer Text 22

23 DD Profiling. Profiling (Rao et al., 2004) Footer Text 23

24 DD Social impact (Rao et al., 2004) Footer Text 24

25 Physiotherapy Introduce role/introduce the session Voluntary reporting do we need to dig? The importance of the subjective assessment and measures such as Bowel diary and Bristol stool chart Standard treatments for constipation will not impact dyssynergic defecation Psst..Clinical hint!!!! (Pourmomeny et al, 2011) Biofeedback interventions superior to aperients, diet, exercise and diazepam in DD (Chiaroni et al,. 2006; Heyman et al., 2007; Rao et al., 2010) Footer Text 25

26 Standard treatment Avoid constipating medications Stool softeners if required Increase fibre 30g daily Increase fluids Increase general exercise Bowel regime Avoid manual manoeuvres such as digitating Footer Text 26

27 Recommended pathway for DD Education Simulated defecation training (+ pelvic floor relaxation) 15 minutes of diaphragmatic breathing 3 x daily? Positioning? Appropriate context (Nikjooy et al., 2015)? Individualised +/- Internal therapy Practicing simulated defecation Internal therapy I.e. Balloon expulsion, endo anal biofeedback (Wald, Bharucha, Cosman, & Whitehead, 2014) Footer Text 27

28 Rectal balloon therapy Why Defecation training Improving abdominal push effort Ano-rectal coordination (EAS/levator ani coordination) Functional training Coordination training for FI EAS coordination Sensation testing and training Internal sphincter de-sensitisation/improve sensory threshold Impaired sensation Specificity 80-90% Sensitivity 50% (Rao, 2008; Chiarioni, Kim, Vantini, & Whitehead, 2014; Rao, Ozturk, & Laine, 2005) Footer Text 28

29 Rectal Balloon Therapy Why again. (Staring to sound like my 3 year old) Inexpensive Bedside/community level Can identify patients with DD Validation and reproducibility Found to be reliable for assessment of DD High level of agreement with anorectal manometry and EMG 2 minute upper limit for evacuation = 100% reproducible 1 minutes upper limit = 98% reproducible (Chiarioni, Kim, Vantini & Whitehead, 2014; Lee & Kim, 2014) Footer Text 29

30 Rectal balloon therapy What - Equipment Rectal balloon Consider latex V s latex free 60mls syringe 3 way Luer lock Lubrication Gloves Tissues Bluey? Commode Footer Text 30

31 Filling the balloon To deflate balloon Maintains balloon volume and allows drawing of air to syringe Allows addition/subtraction of air Footer Text 31

32 What does the process look like? Footer Text 32

33 Getting to know the balloon Footer Text 33

34 Rectal Balloon Therapy How No standard methodology General - Filling Double glove?? Latex allergy Patient in side lie Knees/hips flexed Insertion of deflated balloon Lubricated++++ Insert to above anal verge 10mls increment filling with air or; Fill with water (50mls) to mimic full rectum/sensation to defecate (Pourmomeny, Emami, Amooshahi & Adibi, 2010; Chiaroni, Kim, Vantini & Whitehead, 2014) What are we looking for? (Chiaroni, Kim, Vantini & Whitehead, 2014; Lee & Kim, 2014) Footer Text 34

35 Rectal balloon therapy for DD Muscular coordination at 1 st sensation Diaphragmatic breathing/body scanning Increased IAP/Increased rectal pressure/reduced EAS pressure X reps Functional training May wish to use enema 1-2 hours prior to session Confidence and comfort Although not necessary (Lee & Kim 2014) 50mls air/water Seated on commode May increase if 1 st sensation not yet met??? Ability to expel (Rao, 2007) Aim for expulsion within 1-2 minutes Repeat Typically 4-6 sessions reinforce at 3, 6 and 12 months (Lee, Jung, & Myung, 2013) Footer Text 35

36 The literature - Consensus. Standard constipation measures are important Differential diagnosis is important High heterogeneity in methodology An adjunct to usual therapy BFB/Internal therapies are labour intensive One study demonstrated BFB to be superior to balloon therapy Importance of multi-disciplinary team -?? Feasibility Minimal studies around home based training Footer Text 36

37 Biopsychosocial Bio Check Psychosocial Psychological stressors may exacerbate symptoms (Rao et al., 2004) BFB therapy can assist with improving quality of life in patients with DD Correlation between constipation severity and mental and physical health QOL outcomes (Albiani, Hart et al. 2013) Prevalence of OCD, anxiety, depression, psychotocism and somatization (Rao et al., 2007) Successful therapy goals = QOL and patients satisfaction (Lewicky-Gaupp, Morgan, Chey, Muellerleile, & Fenner, 2008) Goals must be REALISTIC, FLEXIBLE, NEGOTIABLE!!!!! Footer Text 37

38 Conclusions Constipation requires a MDT approach Differential diagnosis is important Psychological impact across all domains Biofeedback techniques are accessible and inexpensive HOWEVER more research needed Adjuncts only Rectal balloon therapy/bet can be a very useful and reliable way to assess and manage DD Practice! Goal setting Talk to your patients and reassure! Footer Text 38

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40 References Albiani, J. J., Hart, S. L., Katz, L., Berian, J., Del Rosario, A., Lee, J., & Varma, M. (2013). Impact of Depression and Anxiety on the Quality of Life of Constipated Patients. Journal of Clinical Psychology in Medical Settings, 20(1), doi: /s Bharucha, A. E. (2006). Pelvic floor: anatomy and function. Neurogastroenterology & Motility, 18(7), doi: /j x Bharucha, A. E., Wald, A., Enck, P., & Rao, S. (2006). Functional anorectal disorders. Gastroenterology, 130(5), Caetano, A. C., Santa-Cruz, A., & Rolanda, C. (2016). Digital Rectal Examination and Balloon Expulsion Test in the Study of Defecatory Disorders: Are They Suitable as Screening or Excluding Tests? The Canadian Journal of Gastroenterology & Hepatology, doi: /2016/ Chiarioni, G., Kim, S. M., Vantini, I., & Whitehead, W. E. (2014). Validation of the Balloon Evacuation Test: Reproducibility and Agreement With Findings From Anorectal Manometry and Electromyography. Clinical Gastroenterology and Hepatology, 12(12), doi: /j.cgh Footer Text 40

41 References Heymen, S., Scarlett, Y., Jones, K., Ringel, Y., Drossman, D., & Whitehead, W. E. (2007). Randomized, Controlled Trial Shows Biofeedback to be Superior to Alternative Treatments for Patients with Pelvic Floor Dyssynergia-Type Constipation. Diseases of the Colon & Rectum, 50(4), doi: /s Kashyap, A. S., Kohli, D. R., Raizon, A., & Olden, K. W. (2013). A prospective study evaluating emotional disturbance in subjects undergoing defecating proctography. World journal of gastroenterology, 19(25), Lawrentschuk, N., & Bolton, D. M. (2004). Experience and attitudes of final-year medical students to digital rectal examination. The Medical journal of Australia, 181(6), 323. Lee, B. E., & Kim, G. H. (2014). How to perform and interpret balloon expulsion test. Journal of neurogastroenterology and motility, 20(3), 407. Lee, H. J., Jung, K. W., & Myung, S.-J. (2013). Technique of functional and motility test: how to perform biofeedback for constipation and fecal incontinence. Journal of neurogastroenterology and motility, 19(4), 532. Footer Text 41

42 References Leroi, A. M., Berkelmans, I., Denis, P., Hémond, M., & Devroede, G. (1995). Anismus as a marker of sexual abuse. Consequences of abuse on anorectal motility. Digestive diseases and sciences, 40(7), doi: /bf Lewicky-Gaupp, C., Morgan, D. M., Chey, W. D., Muellerleile, P., & Fenner, D. E. (2008). Successful Physical Therapy for Constipation Related to Puborectalis Dyssynergia Improves Symptom Severity and Quality of Life. Diseases of the Colon & Rectum, 51(11), doi: /s McCrea, G. L., Miaskowski, C., Stotts, N. A., Macera, L., & Varma, M. G. (2008). Pathophysiology of constipation in the older adult. World journal of gastroenterology, 14(17), doi: /wjg Nikjooy, A., Maroufi, N., Ebrahimi Takamjani, I., Hadizdeh Kharazi, H., Mahjoubi, B., Azizi, R., & Haghani, H. (2015). MR defecography: a diagnostic test for the evaluation of pelvic floor motion in patients with dyssynergic defecation after biofeedback therapy. Medical journal of the Islamic Republic of Iran, 29, 188. Pourmomeny, A. A., Emami, M. H., Amooshahi, M., & Adibi, P. (2011). Comparing the efficacy of biofeedback and balloon-assisted training in the treatment of dyssynergic defecation. Canadian journal of gastroenterology = Journal canadien de gastroenterologie, 25(2), doi: /2011/ Footer Text 42

43 References Rafiei, R., Bayat, A., Taheri, M., Torabi, Z., Fooladi, L., & Husaini, S. (2017). Defecographic Findings in Patients with Severe Idiopathic Chronic Constipation. Korean J Gastroenterol, 70(1), Rao, S. S. C., & Patcharatrakul, T. (2016). Diagnosis and Treatment of Dyssynergic Defecation. Journal of neurogastroenterology and motility, 22(3), 423. Rao, S. S. C., Seaton, K., Miller, M. J., Schulze, K., Brown, C. K., Paulson, J., & Zimmerman, B. (2007). Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation. Journal of Psychosomatic Research, 63(4), doi: /j.jpsychores Rao, S. S. C., Tuteja, A. K., Vellema, T., Kempf, J., & Stessman, M. (2004). Dyssynergic defecation: demographics, symptoms, stool patterns, and quality of life. Journal of clinical gastroenterology, 38(8), 680. Rao, S. S. C. M. D. P. F. (2008). Dyssynergic Defecation and Biofeedback Therapy. Gastroenterology Clinics of North America, 37(3), doi: /j.gtc Footer Text 43

44 References Ratuapli, S., Bharucha, A. E., Harvey, D., & Zinsmeister, A. R. (2013). Comparison of rectal balloon expulsion test in seated and left lateral positions. Neurogastroenterology & Motility, 25(12), e813-e820. doi: /nmo Wald, A., Bharucha, A. E., Cosman, B. C., & Whitehead, W. E. (2014). ACG clinical guideline: management of benign anorectal disorders. The American journal of gastroenterology, 109(8), doi: /ajg Whitehead, W. E., di Lorenzo, C., Leroi, A. M., Porrett, T., & Rao, S. S. (2009). Conservative and behavioural management of constipation. Neurogastroenterology and motility : the official journal of the European Gastrointestinal Motility Society, 21 Suppl 2, doi: /j x Woodward, S., Norton, C., & Chiarelli, P. (2014). Biofeedback for treatment of chronic idiopathic constipation in adults. The Cochrane database of systematic reviews, (3). Footer Text 44