Regaining Bowel Control. Yvette Perston Functional Bowel CNS Queen Elizabeth Hospital Birmingham

Transcription

1 Regaining Bowel Control Yvette Perston Functional Bowel CNS Queen Elizabeth Hospital Birmingham

2 GI Tract

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5 Sigmoid Colon and Rectum

6 Anterior Resection

7 What is Anterior Resection Syndrome (LARS)? Disordered bowel function after rectal resection, leading to a detriment in quality of life (Bryant et al, 2012) If present at one year after surgery (or stoma closure) then it is likely to be present after 10 years (Sturiale et al, 2015)

8 The Morning Routine? How much longer! 8

9 What are the symptoms? Bowel frequency Urgency Fragmentation Clustering Incomplete evacuation Nocturnal defaecation Pain on defaecation Soiling Faecal Incontinence Flatus incontinence Bloating Tenesmus Evacuation difficulties

10 It just goes straight through me!

11 How long does it last? Very common after surgery or reversal Can continue to improve for at least 12 months. After 2 years no further improvement

12 Why is it important? Quality of Survivorship now important as cancer has become a long term condition Reduces QoL Severe anxiety 40% Embarrassment 48% Non return to work Cost to individual & family Cost to society

13 Patient Experience (DeSnoo & Faithfull, 2006) Qualitative interviews, 7 patients, 1 year post op. Themes: Adapting to physical changes Psychological adaptation (unpredictability) Stigma Lack of confidence Reluctance to discuss symptoms Feeling of being ungrateful

14 Who is at risk? Men > women Elderly >75yrs Multiparous women Pelvic infections Low anastomosis Pelvic radiotherapy Pre-op RT increases risk by 2.5 fold Pre-op dysfunction

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16 Why does it happen? Reduced rectal capacity/compliance Nerve damage Reduced capacity for water reabsorption Alteration in sphincter function Alteration in sensation LARs increased gastrocolic response

17 Radiotherapy & Chemotherapy Radiotherapy Diarrhoea Rectal pain May cause long term alterations Chemotherapy Diarrhoea Constipation

18 Incidence Dutch TME study 39% surgery alone 62% & pre-op RT Urgency up to 87% Incontinence up to 79% Frequency up to 75% May improve 6-12 months (van Duijvendijk et al, 2002)

19 Assessment Symptoms PR exam Strictures Sensation Sphincter assessment NB disease recurrence

20 The Low Anterior Resection Syndrome Score (LARS score). Tina Yen-Ting Chen et al. BMJ Open 2014;4:e by British Medical Journal Publishing Group

21 Access No waiting cards Available from NACC INCONTACT Continence Foundation ( RADAR keys These are available from RADAR (

22 Access Disabled toilets Toilet finder apps Need a loo website Flush - toilet finder application for Android or iphone

23 Diet May have heightened gastrocolic reflex Regular meals Moderate fibre Soluble fibre better than insoluble Starch to help thicken Chew thoroughly Drink separately to eating Avoid fizzy drinks

24 Diet which may cause looser stools Caffeine Artificial sweeteners Alcohol Nicotine Spices Milk products Chocolate NB drugs Metformin Olestra

25 Products which may help with flatus Peppermint oil Charcoal tablets Mint tea Cardomom seeds Aloe Vera Probiotic drinks Acidophilus

26 Probiotics/Prebiotics Over the counter - Lepicol VSL#3 Fermented foods Kimchi Sauerkraut

27 FODMAP Diet

28 Medication Loperamide syrup 1mg per 5mls At least 30mins before food. Safe long term Titrate dose to stool consistency Fybogel Thickens and bulks so easier to empty Codeine Beware sedative effect May form dependence

29 Medication Amitrityline Low dose nocte Reduces tenesmus Reduces urgency Cholestyramine Helps thicken stool Smooth muscle relaxants eg Buscopan Helps cramps May reduce bloating

30 Correct Position

31 Your Bowel is a Creature of Habit Regular habits Abdominal massage Undisturbed Relaxed No newspapers!

32 Hygiene Moist toilet tissue Don t flush! Barrier creams Cotton underwear Sitz bath Bidet Bidet shower (toilet hose)

33 Healthy Living Regular exercise 20mins per day BMI weight control Yoga Pilates

34 Exercise Cycling shorts EVB sports shorts/leggings Loperamide 30mins before aerobic exercise Lower impact Pelvic floor safe Pelvic floor first app

35 Pelvic floor exercises Contraction of external sphincter Short pull ups Long holds Half way holds At least x3 daily For at least 2-3 months Maintenance x3 weekly

36 Urge Suppression In safe environment Increase by 30 secs daily Use half way hold Relaxation techniques Don t run!

37 Biofeedback Pelvic floor exercises Balloon Distension Correct straining technique Minimal adverse effects

38 Additional Help Anal plugs Peristeen Renew

39 Controlled Emptying Suppositories GS s Bisacodyl Enemas Microlax

40 Rectal Irrigation Warm tap water Used on toilet Not retained Varying quantities Daily or as needed Empties L side Needs to be taught Equipment available on prescription

41 Sacral Nerve Stimulation Permanent stimulator Stimulates sacral nerve 34 pts Minimum 12 mnths f/up 75% success Improved FI symptoms (Collie et al, 2015) Reduced frequency (Jarrett et al, 2005) Reduced urgency (Tjandra et al, 2008) Reduced nocturnal defaecation (Schwandner, 2013)

42 Percutaneous Tibial Nerve Stimulation Neuromodulation Tibial nerve 12 weekly treatments 6 pts 50% improved symptoms

43 What to do next? Speak to your: surgeon oncologist Nurse GP Ask for referral to continence service Self referral Advice from Beating Bowel Cancer Online Leaflets helpline

44 Thank you for listening Any Questions?