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SPECIAL REPORT

Managing Constipation and Faecal Impaction in Primary Care Constipation and Faecal Impaction MOVICOL® Ready to Take macrogol 3350, sodium hydrogen carbonate, sodium chloride, potassium chloride

Bowel Preparation for Gastro-Intestinal Investigations Faeces in the News and Through the Ages Tumours That Block the Large Bowel and Screening Lifestyle, Dietary and Drug Causes of Constipation Why We Need Sewage Systems to Get Rid of our Faecal Waste Congenital Constipation

Published by Global Business Media


NEW

t Constipation relief

that fits into daily life

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MOVICOL® Ready to Take Prescribing Information. Refer to full summary of Product Characteristics (SmPC) before prescribing. Presentation: Each Each 25 ml sachet of MOVICOL Ready to Take contains: 13.125 g Macrogol 3350, 0.3508 g Sodium chloride, 0.1786 g Sodium hydrogen carbonate, 0.0502 g Potassium chloride. Indications: For the treatment of constipation and faecal impaction in adults and adolescents (12 years and above). Alternative MOVICOL products are available for children below 12 years. Dosage and administration: Chronic Constipation: Adults, adolescents and older people: 1-3 sachets daily in divided doses, according to individual response. For extended use, the dose can be adjusted down to 1 or 2 sachets daily. As for all laxatives, prolonged use is not usually recommended. A course of treatment does not normally exceed 2 weeks, although this can be repeated if required. Extended use may be necessary in the care of patients with severe chronic or resistant constipation, secondary to multiple sclerosis or Parkinson’s disease, or induced by regular constipating medication in particular opioids and antimuscarinics. Faecal Impaction: It is recommended that patients using Movicol Ready to Take for faecal impaction take an additional 1.0 litre of fluid per day. A course of treatment for faecal impaction with Movicol Ready to Take does not normally exceed 3 days. Adults, adolescents and older people: 8 sachets daily,

all of which should be consumed within a 6 hour period. Patients with impaired cardiovascular function: For the treatment of faecal impaction the dose should be divided so that no more than two sachets are taken in any one hour. Sufficient fluid intake (2.0 to 2.5 litres daily) is recommended to maintain good health. In the treatment of chronic constipation or faecal impaction, no dosage change is necessary in patients with renal insufficiency. Contraindications: Intestinal perforation or obstruction due to structural or functional disorders of the gut wall, ileus and severe inflammatory conditions of the intestinal tract, such as Crohn’s disease, ulcerative colitis and toxic megacolon. Hypersensitivity to macrogol, or any of the excipients. Warnings and precautions for use: The fluid content of Movicol Ready to Take does not replace regular fluid intake and adequate fluid intake must be maintained. Diagnosis of impaction should be confirmed. If patients develop any symptoms indicating shifts of fluids/electrolytes the product should be stopped immediately. Interactions: There is a possibility that the absorption of concomitantly administered medication could be transiently reduced. Pregnancy and lactation: Can be used during pregnancy and lactation. Undesirable effects: Reactions related to the gastrointestinal tract are the most

common and include: abdominal pain, abdominal distension, nausea, vomiting, dyspepsia, diarrhoea, flatulence, borborygmi and anal discomfort. Allergic reactions, including anaphylactic reactions, dyspnoea and skin reactions (e.g. angioedema, urticarial, pruritus, rash and erythema) can occur. Other effects can include electrolyte disturbances, headache and peripheral oedema. Legal category: P. Cost: 10 sachets £2.57, 30 Sachets £7.72. MA Number: PL 20142/0019 For further information contact: Norgine Pharmaceuticals Limited, Norgine House, Moorhall Road, Harefield, Middlesex, UB9 6NS. 01895 826606. E-mail: medinfo@norgine.com MOVICOL® is a registered trademark of the NORGINE® group of companies. Date of preparation: September 2016 Version number: UK/MOV/0716/0133(1).

The image of the individual is for illustrative purposes only and the person depicted is a model. MOVICOL, NORGINE and the sail logo are registered trademarks of the Norgine group of companies. Date of preparation: September 2016. UK/MOV/0716/0134(1).

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Medical Information at Norgine Pharmaceuticals Ltd on 01895 826606.


SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

SPECIAL REPORT

Managing Constipation and Faecal Impaction in Primary Care Constipation and Faecal Impaction MOVICOL® Ready to Take macrogol 3350, sodium hydrogen carbonate, sodium chloride, potassium chloride

Contents

Bowel Preparation for Gastro-Intestinal Investigations Faeces in the News and Through the Ages Tumours That Block the Large Bowel and Screening Lifestyle, Dietary and Drug Causes of Constipation Why We Need Sewage Systems to Get Rid of our Faecal Waste Congenital Constipation

Foreword

2

Constipation and Faecal Impaction MOVICOL® Ready to Take –

3

Dr Charles Easmon, Editor

macrogol 3350, sodium hydrogen carbonate, sodium chloride, potassium chloride Dr Charles Easmon, Editor

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks

Problem Bowels Faecal Impaction of the Colon The Non-Laxative Treatment Options for Faecal Impaction Laxatives MOVICOL Ready to Take (macrogol 3350 plus electrolytes) is an osmotic laxative which can be used to treat chronic constipation and faecal impaction Summary – Preventative Advice in Both Constipation and Faecal Impaction

Bowel Preparation for Gastro-Intestinal Investigations 7 John Southern, Medical Correspondent

Preparation Procedure Summary

Faeces in the News and Through the Ages John Southern, Medical Correspondent

8

Editor Dr Charles Easmon MBBS MRCP MSc Public Health DTM&H DOccMed

Some Experts are more Expert than Others A Terrible Legacy Summary

Senior Project Manager Steve Banks

Tumours That Block the Large Bowel and Screening 10

Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org

The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles. © 2017. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

Dr Charles Easmon, Editor

The Stages of Bowel Cancer The Importance of Timely Screening Taking Account of Family History

Lifestyle, Dietary and Drug Causes of Constipation Denis Burkitt, Staff Writer

11

The Importance of Exercise A Sensible Diet Keep Hydrated Other Possible Causes of Constipation Summary

Why We Need Sewage Systems 13 to Get Rid of our Faecal Waste Denis Burkitt, Staff Writer

An Historic Problem Possible Causes of Constipation Other Causes Summary

Congenital Constipation Dr Charles Easmon, Editor

15

Making the Diagnosis Treatment Summary

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SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Foreword C

ONSTIPATION HAS been the butt of many

that need. It is easy to take as a liquid that does

jokes and puns (including this one) but it

not need anything added to it.

and faecal impaction are serious conditions that

Faecal impaction of partially digested food in the

affect the lives of adults and children. They lead to

large intestine (anus, rectum, colon) is the equivalent

discomfort, pain and a lack of ability to concentrate

of a blocked drain and is hard to treat. It can lead to

as just a few of the many complications. Genetic

overflow ‘diarrhoea’, pain, gas and great frustration

causes (like Hirschsprung’s disease) may need

and embarrassment. Apart from the laxative treatment,

surgery (the ‘pull-through procedure’) and should

it is important to remember that most people who have

be detected early. Medication causes, like opiates,

had a faecal impaction will need a bowel retraining

may need specific therapy that counters their

program because the normal sensations and reflexes

effects. Lifestyle causes can be prevented by

have been disrupted.

more exercise, more dietary roughage and good

The General Practitioner is in an ideal position to

hydration. The sedentary lifestyle with a poor diet

listen sympathetically to their patient’s bowel habit

and poor hydration is to be actively discouraged

history and to suggest safe, effective, and easy to

by you as the patient’s doctor. However, severe

use treatments.

constipation or faecal impaction both require laxative treatment before considering the need for digital rectal removal and/or an enema. The most effective laxatives are those that are hyperosmotic and ‘Movicol Ready to Take’ meets

Dr Charles Easmon Editor

Dr Charles Easmon is a medical doctor with 30 years’ experience in the public and private sectors. After qualifying as a physician, he developed his interests in occupational medicine, public health and travel diseases.

2 | WWW.PRIMARYCAREREPORTS.CO.UK


SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Constipation and Faecal Impaction MOVICOL® Ready to Take – macrogol 3350, sodium hydrogen carbonate, sodium chloride, potassium chloride

Primary Care Reports

Dr Charles Easmon, Editor The health of a country’s people could be determined by the size of their stools and whether they floated or sank, not by their technology1.

Problem Bowels Sitting on the loo to open your bowels is done on a fairly regular basis and mostly without excessive strain or discomfort. How frequently you have a bowel movement varies from person to person but 95% of healthy adults are estimated to have a pattern that ranges from three times a day to three times a week. In constipation, bowel movements will either happen less often than expected or the stool is hard, dry and difficult to pass. Many instances of constipation are related to diet, lifestyle, medications or other factors that make the stools hard and difficult to pass with ease and comfort (sometimes it is caused by an illness or digestive disorder). Faecal impaction is a significant step up from constipation wherein a ‘plug’ of hard stool blocks the colonic lumen and can cause many problems outlined later in this article. The word compliance is what many doctors grew up with but it has been replaced by adherence. Compliance was about patients following a doctor’s instructions and sticking to them whereas adherence is more about patients following a regime that they understand, have ‘bought in to’ and can see the benefits versus the risks of sticking to the regime. Adherence is made easier by making simple things easy. Adding water to a sachet of powder yourself, seems easy enough but if you have to do it two or three times day you may become less and less interested in doing it compared to opening up a liquid and pouring it into a cup or suitable vessels. With Movicol Ready To Take, the manufacturer, Norgine, has taken out a step and hence made the process easier to adhere to. In the same way, it is easier to

pour your prepared tea from a Thermos flask than to get up four times to make a new cup of tea each time. A Japanese doctor was once asked what is the difference between the Japanese medical consultation style and the British. His reply was as follows: “In the United Kingdom you doctors were often used to sitting on high and telling the patient below what they needed to do and take. The failure of this method is seen in the cupboards of many thousands of elderly people who have repeat prescriptions of multiple drugs sitting there unused and unopened at home. The Japanese style is more like this - ‘Welcome, Patient X. As a medical expert I have reviewed you treatment options and I can discuss at least 3 with you. The first, which is my personal preference, would involve doing A and B with treatment C. The upsides are D and E, but the downsides are F and G. The second option, which you may prefer, is doing H with treatment option ‘I’ and this also has upsides and downsides. The third choice, which is not my preference but might suit you best, would involve J and K with the following up and downsides. Now patient X please think these options over and lets together agree a treatment path that you have chosen based on the available information’. It does not take much to see that ‘adherence’ would be higher in this model, which has now been adopted, in many General Practice training sessions.

Faecal Impaction of the Colon The stool becomes hard and blocks the colon causing faecal impaction. The symptoms of faecal impaction include: abdominal discomfort, pain and bloating, leakage

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SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

MOVICOL works as an osmotic (hydrating agent) laxative, which bulks, softens and lubricates the stool, encouraging peristalsis

of liquid stool, feeling the need to push (tenesmus), nausea, swelling of the rectum, a loss of sensation in and around the anus, rectal prolapse, vomiting, headache, malaise (a generally sick feeling) and these can be associated with unexplained weight loss and a lack of desire to eat. More severe symptoms that can occur with faecal impaction include: tears in the colon wall, haemorrhoids, tissue death (necrosis) of rectal tissue injury, anal bleeding, anal tears, tachycardia, dehydration, hyperventilation, fever, confusion, agitation and faecal incontinence can be associated with urinary incontinence.

The Non-Laxative Treatment Options for Faecal Impaction Manual Removal – Digital removal of faeces (DRF) and/or Enema or water irrigation If a laxative or a suppository doesn’t unblock the faeces then a gloved finger into the rectum may be needed to remove the blockage and this may be combined or separate from the use of an enema. Although only a small number of patients require DRF, it is an essential part of their care and all NHS organisations must have a policy for manual bowel evacuation. …for a small group of patients – such as some who have sustained a spinal cord injury (SCI) or have a neurological condition such as multiple sclerosis – it is an essential part of their bowel-care routine2.

Laxatives The English word “laxative” comes from Old French laxative, which came from the Latin laxatus. The Latin word Laxare means, “to loosen”, while the Latin word Laxus means “loose, lax”. Reference books indicate that the noun meaning “a laxative medicine” in the English language emerged around 1386 A.D.3 4 | WWW.PRIMARYCAREREPORTS.CO.UK

MOVICOL works as an osmotic (hydrating agent) laxative which bulks, softens and lubricates the stool, encouraging peristalsis. Some osmotic laxatives work on the colon (hyperosmotic agents like Movicol) and others work on both the small and large intestine (attracting and retaining water in the hollow of the intestine, thus softening the stool and they also increase intraluminal pressure). Treating Constipation 1) Lifestyle Changes in diet and lifestyle are often recommended as the first treatment of constipation. Exercise, avoiding dehydration and increasing daily fibre intake can help. High fibre foods include plenty of fruit, vegetables and cereals. Other foods that can help are: Almonds, Apples/Apple Juice, Artichokes, Bananas, Basil, Beets, Blueberr y, Carob, Cranberry, Coconut, Cornmeal, Dandelion, Dates, Dried apricots, Endive, Fenugreek, Figs, Flaxseed, Grapes, Kale, Liquorice, Mangos, Molasses, Oranges, Papayas, Parsley, Peaches/Apricots, Pears, Persimmons, Pineapple, Plums, Prunes/Prune Juice, Rhubarb, Rutabagas, Soybeans, Strawberry, Tamarind, Tangerine, Tomato, Tomato Juice, Vanilla, Walnuts, Watercress, Winter Squash, Yams, Olive oil. 2) Bulk-producing agents These are also known as bulk-forming agents, bulking agents, and roughage and they generally take from 12 to 72 hours to work. They work by making the stool become bulkier and retain more water. Examples include methylcellulose and dietary fibre, ispagula and sterculia. 3) Stimulant laxatives These stimulate waves of contraction in the colon


SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

that pass along the colon and propel the stools forward. Examples of stimulant laxatives are senna, bisacodyl and sodium picosulfate. 4) Stool softeners Stool softeners soften and lubricate the stool and so helps with bowel movement. Medicines used as stool softeners are arachis oil containing enemas, bulking agents, surfactants or ‘wetting agents’ such as docusate. Some osmotic laxatives such as the macrogols also soften the stool. 5) Peripheral opioid receptor antagonists Naloxegol (Moventig) is indicated for the treatment of opioid-induced constipation (OIC) in adult patients who have had an inadequate response to laxative(s). The active ingredient is a PEGylated derivative of the mu-opioid receptor antagonist naloxone and functions as a peripherally-acting mu-opioid receptor antagonist in the gastrointestinal tract, thereby decreasing the constipating effects of opioids without impacting opioid-mediated analgesic effects on the central nervous system.4 Methylnaltrexone bromide (Relistor) is a subcutaneous injection which is indicated for the treatment of opioid-induced constipation when response to laxative therapy has not been sufficient in adult patients, aged 18 years and older. It is a selective antagonist of opioid binding at the mu-receptor.5 6) Selective serotonin (5-HT4) receptor agonists Prucalopride (Resolor) is indicated for symptomatic treatment of chronic constipation in adults in whom laxatives fail to provide adequate relief. Prucalopride is a selective, high affinity serotonin (5-HT4) receptor agonist.6

7) Osmotic laxatives These laxatives are virtually unabsorbed from the gastro intestinal track and have the ability to increase the amount of water in the bowel. Examples of osmotic laxatives are macrogol, lactulose and saline laxatives such as magnesium hydroxide

MOVICOL Ready to Take (macrogol 3350 plus electrolytes) is an osmotic laxative which can be used to treat chronic constipation and faecal impaction.

Primary Care Reports

MOVICOL Ready to take can be used in children over 12 years, adults and the elderly. In constipation, the recommended dose is 1 to 3 sachets a day, in divided doses, according to the individual response. A course of treatment does not normally exceed two weeks but this can be repeated if required. For extended use the dose can be reduced to 1 to 2 sachets a day. As for all laxatives, prolonged use is not recommended. In faecal impaction, the recommended dose is 8 sachets a day. However, the diagnosis of impaction or faecal loading of the rectum should be confirmed by physical or radiological examination of the abdomen and rectum. In faecal impaction, the patient is advised to take an additional 1litre of fluid per day. No change in dosage is required for patient with liver or kidney insufficiency. Patients with impaired cardiac function taking the faecal impaction dose should not take more than two sachets in any one hour. A course of treatment dose not normally exceed 3 days. MOVICOL Ready to Take is contraindicated in intestinal perforation or obstruction due to structural or functional disorder of the gut wall, ileus, severe inflammatory conditions of the

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SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

As a General Practitioner encourage all your patients to drink plenty of water every day to prevent dehydration, to eat foods that are high in fibre (whole wheat, pears, oats, and vegetables), reduce their intake of foods that are high in sugar, and encourage them to exercise daily to help the digestive system function as it should

intestinal tract, such as Crohn’s disease and ulcerative colitis and toxic megacolon or if there is hypersensitivity to the active substances or to any of the excipients. If patients develop any symptoms indicating shifts of fluids/electrolytes (e.g. oedema, shortness of breath, increasing fatigue, dehydration, cardiac failure) Movicol Ready to Take should be stopped immediately and electrolytes measured and any abnormality should be treated appropriately. The absorption of other medicinal products could transiently be reduced due to an increase in gastro-intestinal transit rate induced by Movicol Ready to Take. The macrogol 3350 in MOVICOL Ready to Take is virtually unabsorbed from the gastrointestinal tract. It acts by virtue of its osmotic action in the gut, which induces a laxative effect. Macrogol 3350 increases the stool volume, which triggers colon motility via neuromuscular pathways. The physiological consequence is

an improved propulsive colonic transportation of the softened stools and a facilitation of the defecation. Electrolytes combined with macrogol 3350 are exchanged across the intestinal barrier (mucosa) with serum electrolytes and excreted in faecal water without net gain or loss of sodium, potassium and water7.

Summary – Preventative Advice in Both Constipation and Faecal Impaction As a General Practitioner encourage all your patients to drink plenty of water every day to prevent dehydration, to eat foods that are high in fibre (whole wheat, pears, oats, and vegetables), reduce their intake of foods that are high in sugar, and encourage them to exercise daily to help the digestive system function as it should. This advice should especially be emphasised for any of your patients on opioids.

References: 3 4 5 6 7 1 2

http://www.all-creatures.org/health/Denis-Burkitt-McDougall-fiber.html Accessed 18/1/2017 https://www.nursingtimes.net/clinical-archive/continence/digital-removal-of-faeces/5057949.article http://www.medicalnewstoday.com/articles/10279.php Accessed 16/1/2017 http://www.medicines.org.uk/emc/medicine/30483 http://www.medicines.org.uk/emc/medicine/31634 http://www.medicines.org.uk/emc/medicine/23204 http://www.medicines.org.uk/emc/medicine/32313

Norgine Pharmaceuticals Limited have provided financial support by way of sponsorship for the production and distribution of this report. The topic and author are chosen independently by Primary Care Reports. Norgine Pharmaceuticals Limited have no editorial input into the content of the report other than a review for medical accuracy.

UK/MOV/0217/0152. Date of preparation: April 2017

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SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Bowel Preparation for Gastro-Intestinal Investigations John Southern, Medical Correspondent

Primary Care Reports

A

DOCTOR colleague told me about a wealthy man who wanted a full bowel investigation. He was instructed with regard to the bowel preparation and the restricted diet and fluids required. However, it was reported that he was seen quaffing champagne the night before the procedure. When the radiologist saw the bowel Magnetic Resonance Imaging (MRI) scans they were rather predictably blocked by faeces. The wealthy man complained and my doctor colleague had the rare pleasure of telling him that ‘The radiology does not lie. I am afraid you are full of shit.’

Preparation High quality bowel preparation is required for colonoscopy1, virtual colonography2 and the use of capsule endoscopy3. The best colonoscopist and the best cameras need a clear view of the gut for what might be very small precancerous polyps. Ideally the bowel is prepared by a combination of exclusion and specific therapy4. The exclusion is in foods and dark coloured drinks. The therapy is a laxative preparation. Various National Health Service (NHS) and private hospital guidelines5,6 exist in this area. All focus on 3 key areas: 1) The food intake before a colonoscopy Two days before the procedure no food with fibre. Items in this category include fruit, lentils, pulses, vegetables, nuts, seeds, wholemeal bread, brown rice and high fibre breakfast cereals. Then, one day before the procedure, the last food intake should be a light breakfast in the morning followed by clear fluids only and the first 50% of the laxative. 2) The fluid intake before a colonoscopy Patients are advised to drink at least 2 litres (8-10

cups) of clear fluids daily and avoid ‘red’ drinks and cordials. 3) The osmotic laxative medication before a colonsocopy.

Procedure 50% of this is usually taken the day before the procedure and the rest the morning of the procedure. These laxatives are the osmotic type and any bulk-forming laxatives (brans, methylcellulose etc) are not to be taken in the preceding days. In addition, advice is given 3-4 days before to stop any medication containing iron or loperamide.

Summary A good and clear view of as much of the colon as possible is key to detecting lesions. In the same way, none of us could properly identify a suspect through a dirty mirror, the bowel must be cleansed and not blocked by food or dark liquids. The tools to ensure ‘clear pipes’ include an effective osmotic laxative after appropriate preparation. Bad bowel preparation wastes medical, administrative and patient time and can delay vital diagnoses.

References: 1

http://bit.ly/2lrk5SV Accessed 20/1/2017

2

http://bit.ly/2kWtkKk Accessed 20/1/2017

3

https://www.nice.org.uk/Guidance/IPG101 Accessed 20/1/2017

4

http://bit.ly/2kzBoji Accessed 18/1/2017

http://bit.ly/2kzBoji Accessed 20/1/2017

5

6

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http://bit.ly/2lvMeVd Accessed 20/1/2017 WWW.PRIMARYCAREREPORTS.CO.UK | 7


SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Faeces in the News and Through the Ages John Southern, Medical Correspondent

The study of human excrement has led to better understandings of diet, survival, logistics, trade and migration through the ages of both humans and animals

F

AECES HAS many and varied names and is used as an insult in all languages. The word ‘crap’ is assumed by many to have derived from the name of famous, royalwarranted Victorian plumber called Thomas Crapper1,2. He shocked ‘gentile’ society of the time by having bath and toilet facilities on display through the windows of his showroom. However, the word ‘crap’ for faeces preceded his name and it was the American soldiers (G.I.s) in First World War Britain to whom we can attribute the association. Since they already called faeces ‘crap’ when they saw the name of the plumber they naturally started calling it a ‘crapper’. Hence this example of reverse etymology. The term ‘W.C’ comes from Water Closet one of the many products that Thomas Crapper would have sold to royalty and the public.

Some Experts are more Expert than Others Television (TV) food or nutrition ‘experts’ are rarely a scientifically credible3 bunch since few if any are qualified dieticians4. Dieticians study and are regulated by the Health and Care Professions Council5 (HCPC)6 and supported by their body, The British Dietetic Association7. Technically almost anyone can call himself or

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herself a ‘nutritionist’ despite the fact that some have ‘qualifications’ that can be acquired and some of these are more ‘dubious’ than others. For a while the non-medically trained ‘Dr’ Gillian McKeith8,9 had a large presence in TV space and she was notable for her fascination with excrement. This fascination is shared across many and varied cultures. It has been reported that in Germany a special type of loo allows you to poo on a flat surface10 to enable it, subsequently, to be analysed. We know that generally what goes in affects what comes out in many different ways. In data science, the terms “Rubbish in, Rubbish out’ applies and this can also be used in the human context.

A Terrible Legacy The people of Haiti were presumably pleased to see international help arrive after their earthquake of 2010. However, the United Nations11 staff that arrived left a terrible legacy12 of more than 7,500 unnecessary deaths because they bought with them a food and water transmissible disease and had inadequate sanitation. This led to an ‘imported’ cholera outbreak13 that severely affected (and still affects14) the poor Haitians who already had one major problem to deal with.


SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Primary Care Reports Who would study faeces and who would put any value on it? Dinosaur excrement, known as coprolites15,16 has significant auction value. In the last few years, prices have been as low as a few dollars17 and as high as thousands of pounds18. The study of human excrement has led to better understandings of diet, survival, logistics, trade and migration through the ages of both humans and animals.

Summary Excrement is an essential part of human and animal life and history. Its mismanagement can and does lead to human deaths, diseases and disasters. Its controlled management by toilets and sewage systems has moved much of the world forward in terms of public health, sanitation and hygiene but caution is and always will be required. Its historical significance and value can never be underestimated.

Excrement is an essential part of human and animal life and history. Its mismanagement can and does lead to human deaths, diseases and disasters References: http://www.thomas-crapper.com/The-History-of-Thomas-Crapper.html Accessed 20/1/2017 http://theplumber.com/thomas-crapper-myth-reality/ Accessed 20/1/2017 3 https://www.bda.uk.com/news/view?id=153&x[0]=news/list Accessed 20/1/2017 4 https://www.healthcareers.nhs.uk/explore-roles/allied-health-professionals/dietitian Accessed 20/1/2017 5 http://hpc-uk.org/ Accessed 20/1/2017 6 https://www.bda.uk.com/professional/practice/professionalism/regulation Accessed 20/1/2017 7 https://www.bda.uk.com/ Accessed 20/1/2017 8 https://www.theguardian.com/media/2007/feb/12/advertising.food Accessed 20/1/2017 9 http://www.badscience.net/category/gillian-mckeith/ Accessed 20/1/2017 10 http://blog.young-germany.de/2010/02/on-the-ledge-german-toilets/ Accessed 20/1/2017 11 http://www.un.org/apps/news/infocusRel.asp?infocusID=91 Accessed 20/1/2017 12 https://www.nytimes.com/2016/08/18/world/americas/united-nations-haiti-cholera.html?_r=0 Accessed 20/1/2017 13 http://www.bbc.co.uk/news/world-latin-america-20024400 Accessed 20/1/2017 14 http://edition.cnn.com/2016/10/10/americas/hurricane-matthew-haiti/index.html Accessed 20/1/2017 15 http://dinosaurs.about.com/od/dailylifeofadinosaur/a/dinosaurpoop.htm Accessed 18/1/2017 16 http://www.enchantedlearning.com/subjects/dinosaur/glossary/Coprolite.shtml Accessed 20/1/2017 17 http://www.fossilsforsale.co.uk/coprolitesdung.htm Accessed 20/1/2017 18 http://www.cbsnews.com/news/longest-fossilized-poop-to-be-sold-at-auction/ Accessed 20/1/2017 1 2

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SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Tumours That Block the Large Bowel and Screening Jo Roth, Staff Writer Bowel cancer is one of the most common types of cancer diagnosed in the UK. – almost 9 in 10 cases of bowel cancer occur in people aged 60 or over1.

If constipation or faecal impaction are caused by a tumour, the outcome can be very negative unless the tumour is benign

F

OR MANY years clinicians have had the scientific evidence that the earlier bowel cancer is detected the better the prognosis. If constipation or faecal impaction are caused by a tumour, the outcome can be very negative unless the tumour is benign. The extensive vascular system of the gastro-intestinal tract is such that, once a tumour breaches the gut lumen, it will already have spread extensively. This is why regular screening for colonic cancer is important. The early stages of the disease are treatable by surgery, chemotherapy 2, radiotherapy3 and immunotherapy4.

The Stages of Bowel Cancer The staging of bowel cancer is based on the work of Cuthbert Duke5 (an English pathologist in the 1930s), hence the name Duke’s staging. Stage A – Tumour confined to the mucosa. Stage B – Tumour infiltrating through muscle. Stage C – Lymph node metastases present. Stage D – Distant metastases6. A recent overview article in the New England Journal of Medicine7 makes some excellent points about screening in terms of age and acceptance. One of these messages is that doctors or clinicians should not focus on what they think the best screening method is, but to improve adherence, listen to what the patient is most prepared to do – since some screening is better than none and some types will lead to a blank refusal to comply.

The Importance of Timely Screening In the same article which, it can be argued, is designed for a United States audience but has

principles that can be applied worldwide, it is recommend that screening begins at the age of 50 years, be tailored between the ages of 75 and 85 years and be discontinued after 85 years. The options described as available for screening include: 1) Faecal Occult blood testing with A) Highly sensitive guaiac-related factors or B) immunochemical tests (every 2 years) 2) Blood or stool DNA testing - approved in the United States by the Food and Drug Administration (FDA) 3) Flexible sigmoidoscopy with the benefit being limited to cancer detection in the distal colon (rectum, sigmoid, and descending colon), 4) CT scanning or virtual colonography 5) Colonoscopy every 10 years

Taking Account of Family History Family history, of course, plays a crucial role in screening and the related advice. Those with a first-degree relative who had bowel cancer before the age of 60 years would be advised to undergo colonoscopy at 40 years or an age 10 years younger than when the relative first presented with disease (whichever is earlier). Those with Ulcerative Colitis should also be regularly screened.

References: http://www.nhs.uk/Conditions/Cancer-of-the-colon-rectum-or-bowel/Pages/Introduction.aspx Accessed 20/1/2017 2 http://www.nhs.uk/Conditions/Chemotherapy/Pages/Definition.aspx Accessed 20/1/2017 3 http://www.nhs.uk/Conditions/Radiotherapy/Pages/Introduction.aspx Accessed 20/1/2017 4 http://www.cancerresearch.org/cancer-immunotherapy/impacting-all-cancers/colorectal-cancer Accessed 20/1/2017 5 http://www.anzjsurg.com/view/0/dukesStagesColorectal.html Accessed 20/1/2017 6 http://www.cancerresearchuk.org/about-cancer/bowel-cancer/stages-grades/dukes-staging Accessed 20/1/2017 7 http://www.nejm.org/doi/full/10.1056/NEJMcp1512286 Accessed 21/1/2017 1

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SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Lifestyle, Dietary and Drug Causes of Constipation Denis Burkitt, Staff Writer Western diets are so low on bulk and so dense in calories, that our intestines just don’t pass enough volume to remain healthy1,2.

C

ONSTIPATION IS a very common problem that affects at least 80% of people at some time during their lives. In the United States, treatment for constipation accounts for more than 2.5 million visits to doctors’ offices each year, with at least $800 million spent annually for laxatives. Although adults of all ages can suffer from constipation, the risk of this problem increases dramatically after age 65 in both men and women3.

The obese man or woman on their sofa eating pizza, guzzling cola drinks and binge-watching ‘Game of Thrones’ are in for a nasty surprise when they try to open their bowels. These people are literally the ‘sitting ducks’ for lifestyle causes of constipation and faecal impaction. Clearly, they should exercise more, keep properly hydrated and eat healthier. As a General Practitioner, your advice on this subject can be very succinct.

The Importance of Exercise On the subject of exercise, tell them not to focus on gym membership since that requires

Primary Care Reports

additional money, motivation and time and a surprisingly high number of people relapse within a few months of signing up. Instead, encourage them to commit to at least 90 minutes per week of any exercise that gets their heart rate up, their breathing faster and makes them feel at least a bit tired. This is likely to be aerobic exercise and can be split over the week into 10-30 minute sessions. For some this will be walking or running faster up stairs, on the flat or doing any one of the many home-based exercises available and possible. For others, it will involve swimming or joining in a class or group activity from football to walking. Remind them that the bowel has muscle and for it to perform well that muscle needs to be stimulated by the effects of general exercise.

A Sensible Diet On the subject of diet the normal advice about healthy, diverse and ’rainbow4 platter’ foods applies. You can explain that a cereal for breakfast, a sandwich for lunch and pasta for an evening meal is all brown or white and like pouring‘cement’ down the intestinal drain. The fibre content of the diet ideally needs to be at least 25-30 grams per day every day to

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SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Encourage them to commit to at least 90 minutes per week of any exercise that gets their heart rate up, their breathing faster and makes them feel at least a bit tired

both soften the stool and encourage proper bowel function.

Keep Hydrated On the subject of hydration, too many fizzy drinks would dehydrate rather than hydrate. Ideally, your patients should think Oral Rehydration Salts5 (ORS) but, failing this, a volume of at least 2-3 litres per day is the advice that you can give. This might be as water, flavoured water, tea, coffee, milk, stew, soups or fruit juices with all the usual caveats of not too much of anything that has known negative health effects and, of course, it has to be palatable to the individual concerned. Another suggested approach is to introduce the concept of daily ‘servings’ of water to prevent the stool becoming dry and hard. A ‘serving’ is a full glass and your advice is for adults to have at least 6-8 of these per day.

Other Possible Causes of Constipation Other lifestyle factors that may lead to constipation include jet lag and travel and this may be because of combinations of changes of mealtimes, diet and lack of convenient access to toilets. A rarer cause of constipation perhaps similar to those rich ladies who simply must have a caesarean and are labelled ‘too posh to push’ are those who feel they are ‘too busy to poo’. This lifestyle trait ignores the fact that the reflex action is developed to encourage us to poo at appropriate times and those who ignore this too often blunt the reflex and, not surprisingly, get constipation as a result. Prescription and over the counter medicines can lead to constipation. Anticholinergics6, because

they affect the interaction between nerves and muscles of the bowel. Anticholinergics may be in muscle relaxants or used to treat the overactive bladder. Narcotics such as codeine and morphine. Laxative overuse or abuse interestingly can be a cause because, in a way, they teach the bowel to become ‘lazy’ and reliant on them and, in their absence, normal muscular and peristaltic action does not resume as it should. Iron and vitamins containing iron can lead to constipation as can calcium supplements and antacids that contain aluminum. Drugs used to treat seizure disorders, Parkinson’s disease, hypertension and schizophrenia may all exacerbate the problem. Systemic diseases such as multiple sclerosis, Parkinson’s disease (independent of medication), diabetes or thyroid disease may lead to constipation as may complications from pelvic or colorectal surgery. Local diseases or problems such as a spinal cord injury, irritable bowel syndrome, diverticultis or uterine prolapse may cause it as well. If the process of defaecation is painful, it is understandable that it will be held back and so those with local pain or discomfort around the anus caused by an anal fissure or haemorrhoids may become constipated.

Summary Preventing constipation and faecal impaction aligns with all the sensible advice you as a General Practitioner would want to give all your patients about lifestyle in terms of eating, exercising, drinking well and managing their life stressors, diseases, medications and their travel arrangements.

References: 1

https://www.drmcdougall.com/misc/2013nl/jan/burkitt.pdf Accessed 20/1/2017

2 3 4 5

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https://www.drugs.com/health-guide/constipation-and-impaction.html Accessed 20/1/2017 http://lifehacker.com/what-it-means-to-eat-the-rainbow-1594799068 Accessed 20/1/2017 http://www.who.int/maternal_child_adolescent/documents/fch_cah_06_1/en/ Accessed 20/1/2017 https://www.parkinsons.org.uk/content/anticholinergics Accessed 20/1/2017


SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Why We Need Sewage Systems to Get Rid of our Faecal Waste Denis Burkitt, Staff Writer

Primary Care Reports

America is a constipated nation.... If you pass small stools, you have to have large hospitals1.

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HE RIVER Thames (‘Old Father Thames2’) has a tidal flow, which meant that, throughout London’s history, organic matter flowed up but then flowed straight back again. This meant that in the 1800s, for example, a dead donkey at point A in the Thames on a Monday morning would be back where it started by Monday evening. The Thames was full of decaying human and animal waste (It is better now but still managed to make comedian and National Treasure David Walliams3 very sick when he did his 140-mile charity swim for Sport Relief in 2011). The most powerful people in British society sat in the Houses of Parliament in the 1850s (as now), which inconveniently for them sat on the banks of the Thames. On a hot day, they might naturally have liked to have opened the windows but to do so would expose them to the most horrendous and noxious smells. This ‘great stink’ of 1851 finally led the politicians to agree to the very large and expensive public health spend of a proper sewage system designed by engineer Joseph Bazelgette4 from which we all still benefit today. Then, as always, it takes a ‘great stink5’ to get politicians to act in their citizen’s interests (it was the fastest passed legislation in history).

An Historic Problem The sewer problem of London has many historical parallels and another of these is what happened in Rome more than 2,300 years ago, when it had become one of the world’s largest megacities supporting a population of more than 1 million people. 1 million people create a lot of waste. This waste was initially transported down a sophisticated sewage system – the Cloaca Maxima6. Sewage systems need maintenance and, predictably, without it, that of Rome became blocked. It took Agrippa7 in 33 BC (the son-inlaw of Augustus/Octavian) to clean up the mess. Apparently, he was so pleased with his

achievement that a boat was sailed through the Cloaca Maxima with great fanfare once it had been cleared. The harms of blocked waste are, of course, one of the keys to constipation. Constipation is the end result of a process that may have many causes but it results in great frustration to the sufferers as they sit on the toilet straining to get rid of their waste. The straining can be painful and can lead to bleeding and haemorrhoids. The mental distress caused by constipation can be significant.

Possible Causes of Constipation To propel faeces out of the rectal sphincter smooth muscles needs via peristaltic movement to be able to shift the waste bit by bit in the right direction towards the opening. If the waste is more solid, then the more propulsive force is needed. Problems can arise if: 1) The smooth muscle is defective 2) The nervous system is defective 3) The waste content is too firm or hard 4) The process of propelling the waste is painful because of disease or inflammation 5) Drugs have affected or caused any of the above problems 6) A systemic disease has caused any of the above problems 7) A blockage has occurred due to a benign or malignant tumour The seven points above give us clinicians many clues to help prevent, manage, detect and treat causes of constipation and faecal impaction. The most well-known nervous system disorder linked to constipation is the congenital anomaly of Hirschprung’s disease but it can of course be affected by multiple sclerosis and many other such disorders. Roughage in diet has been the mantra of many clinicians, nutritionists and dieticians. In Western

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SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Roughage in diet has been the mantra of many clinicians, nutritionists and dieticians. In Western countries, there has been an explosive growth in diet fads and, as should be expected, some of these fads will more likely lead to constipation than others countries, there has been an explosive growth in diet fads and, as should be expected, some of these fads will more likely lead to constipation than others.

Other Causes The inflammatory bowel diseases of Ulcerative Colitis (UC) and Crohn’s disease are amongst the most painful, embarrassing and disabling of all diseases and, as can be expected, the bleeding cracked mucosa’s of the bowel (UC) or any part of the gastro-intestinal tract (Crohn’s) will lead to problems with defecation. Drug side-effects are written on every Summary of Product Characteristics (SPC) but often we as doctors pay limited attention to these for our patients or down play their significance in terms of quality of life. Patients, of course, also take over- the- counter drugs, some of which can also cause or contribute to constipation. The biggest problem drug group is the opiates and, for cancer patients, the added burden of

constipation or faecal impaction adds another level of distress and discomfort. Other systemic diseases that can contribute to constipation apart from Multiple Sclerosis and Crohn’s, already mentioned, include diabetes and thyroid disorders. In associated articles in this series the detection of bowel tumours is discussed but the key phrase ‘change of bowel habit’ should be imprinted in the minds of all our patients and us as clinicians. Forgetting to ask or explore this simple issue can have disastrous consequences for the patient.

Summary External waste systems are needed to deal with the products of our internal waste systems. Both can get blocked and both need maintenance. Every day the equivalent of a flag waving Roman boat should safely sail through our Cloaca Maxima and, unlike the Thames of the recent past, we should aim to ‘drop the dead donkey8’!

References: 1

https://todayinsci.com/B/Burkitt_Denis/BurkittDenis-Quotations.htm Accessed 20/1/2017

2

http://londonist.com/2015/07/who-was-old-father-thames Accessed 20/1/2017

3

http://metro.co.uk/2011/09/08/david-walliams-serious-stomach-bug-hinders-thames-charity-swim-143210/

Accessed 20/1/2017

4

http://www.bbc.co.uk/history/historic_figures/bazalgette_joseph.shtml Accessed 20/1/2017

5

http://www.bbc.co.uk/history/trail/victorian_britain/social_conditions/victorian_urban_planning_04.shtml

Accessed 20/1/2017

6

https://www.britannica.com/topic/Cloaca-Maxima Accessed 20/1/2017

7

https://www.britannica.com/biography/Marcus-Vipsanius-Agrippa Accessed 20/1/2017

8

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http://www.imdb.com/title/tt0098781/ Accessed 20/1/2017


SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Congenital Constipation Dr Charles Easmon, Editor

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USCLES NEED nerves and without ner ves muscles cannot per form their actions. The bowel muscles without nerves cannot perform the peristaltic movements that expel faeces through the anus. In the congenital condition of Hirschsprung’s disease1 part of the colon and rectum (large intestine) lacks nerves and this may be a short (short-segment) or long (long-segment) section of the colon and the deficiency starts from the anus upwards. The disease can be on its own or part of other congenital conditions such as Down’s syndrome2, Waardenburg syndrome3, cartilage-hair hypoplasia4, the Smith-Lemli-Opitz syndrome (type II) and primary central hypoventilation syndrome5 (known as Ondine’s curse6). Undetected Hirschsprung’s disease leads to massive enlargement of the bowel (megacolon) and, of course, constipation. The neonate or child will present with vomiting (sometimes green or brown), constipation, abdominal distension, lots of gas, sometimes bloody diarrhea and intestinal obstruction. It is four times more common in boys than girls.

Making the Diagnosis An early clue to diagnosis may be failure to have a first bowel movement within 48 hours of birth.

Any clinician putting a finger in the rectum needs be ready for an explosion of stool. If the condition is not detected early then the child will have slow growth or development, and lack energy because of anaemia. The diagnosis is finally made by a biopsy that confirms the lack of nerve cells but, prior to that, X-rays or pressure tests (manometry) may give useful indications.

Treatment Treatment consists of surgery with a resection of the part of the colon that lacks nerves to connect the ‘functioning’ part to the anus, this is called a ‘Pull-through Procedure7’. For longsegment disease obviously more needs to be resected and this can lead to intestinal hurry and requires advice to increase daily fluid intake. In some instances a temporary ostomy is required before the final re-attachment of functioning colon to anus.

Summary The large intestine (anus, rectum and colon) grows from two foot at birth to 5 foot long8 in an adult. It can be affected by several congenital conditions. Sharp eyed clinicians can spot these problems early and encourage early effective treatment.

References: Also called aganglionosis, congenital aganglionic megacolon, congenital intestinal aganglionosis, and megacolon. 2 http://www.ndss.org/Down-Syndrome/What-Is-Down-Syndrome/ Accessed 20/1/2017 3 https://ghr.nlm.nih.gov/condition/waardenburg-syndrome Accessed 20/1/2017 4 http://emedicine.medscape.com/article/885807-overview Accessed 20/1/2017 5 https://ghr.nlm.nih.gov/condition/smith-lemli-opitz-syndrome Accessed 20/1/2017 6 http://www.medicinenet.com/script/main/art.asp?articlekey=9634 Accessed 20/1/2017 7 http://hirschsprungs-disease.com/surgical-procedures/soave-procedure/ Accessed 20/1/2017 8 http://hypertextbook.com/facts/2001/AnneMarieThomasino.shtml Accessed 20/1/2017 1

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SPECIAL REPORT: MANAGING CONSTIPATION AND FAECAL IMPACTION IN PRIMARY CARE

Notes:

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Primary Care Reports – Managing Constipation and Faecal Impaction in Primary Care – Norgine  

Primary Care Reports – Managing Constipation and Faecal Impaction in Primary Care – Norgine

Primary Care Reports – Managing Constipation and Faecal Impaction in Primary Care – Norgine  

Primary Care Reports – Managing Constipation and Faecal Impaction in Primary Care – Norgine