Anatomy And Physiology Of The Bowel

1. Digestive System The digestive system is a series of hollow organs joined in I long twisting tube from the mouth to the anus The process starts when food is chewed and swallowed then passes form the mouth into the oesophagus there it is pushed on to the stomach where the food mixes with digestive juices it is churned and mixed up before it is slowly released in to the small intestine. The food will then dissolve further as juices from the pancreas and the liver are mixed together with the food. Once the small intestine has absorbed all the nutrients form the food it passes on to the large intestine. The large intestine as well as acting as a passage way for the removal of body waste it acts as a provisional reservoir for water. As water is absorbed the contents of the large intestine changes from watery liquid to semi solid faeces. The faeces moves down through the colon into the rectum and out through the anus when the brain send s a signal to indicate that its time to empty the rectum. Questions 2. The bowels act as a receptacle for body waste. 3. A normal bowel habit can be described as a person havening a bowel movement between 2-3 times a day or 2-3 times a week. 4. Constipation is a decrease in the frequency and amount of an individuals usual bowel action, which is usually associated with the difficulty and sometimes painful passage of hard, dry pellet shaped stools which may be followed by a feeling of incomplete emptying. 5. The symptoms of constipation can be• Altered bowel habit • Infrequent hard pellet like stools • Feeling of incomplete evacuation • Abdominal pain • Flatulence/bloating • Nausea/vomiting • Urinary dysfunction • Poor appetite • Malaise Any one or a combination of these can cause constipation. 6 Simple constipation is usually related to diet, fluid, lifestyle, any of these or a combination can cause constipation.

Karen Wagstaff

7 Secondary constipation is usually linked to a disease, medical condition or drug therapy. 8 Chronic constipation can be described as being constipated on a regular basis and never having a normal bowel movement. 9 Patient groups that can present with chronic constipation are the elderly and infirm, due to poor mobility inability to prepare nutritious food and lack of exercise can put them at risk. Pregnancy can cause constipation due to the increased size of the uterus and increased levels of progesterone, which reduces colonic activity. Young children can present with chronic constipation due to poor appetite, lack of fluids throughout the day especially in school aged children who can be restricted in what they drink and also their fear of using school toilets or any toilet other than their home toilet. Patients that are ill can become chronically constipated due to poor appetite, medication or simply by being bed bound. 10

Drugs that may cause constipation are:-

Drug Family

Most Common Use

Antacids (aluminium) Relieve heartburn Anti cholinergics

Relieving symptoms of Parkinson's, treat depression, anxiety, and nervousness

Anticonvulsants

Control epilepsy and other seizure disorders

Antidepressants

Treat symptoms of depression

Anti hypertensives

Lower blood pressure

Anti psychotics

Treat symptoms of certain psychosis

Bild acid sequestrants

Reduce cholesterol

Calcium supplements(3)

Supplement dietary calcium

Diuretics

Fluid retension

Iron Supplements

Iron deficiency or anemia

Opiates

Pain relievers

Karen Wagstaff

Constipation can be caused by a variety of medications. These medications affect the nerve and muscle activity in the large intestine (colon) and may also bind intestinal liquid. This may result in slowed colonic action (slow and/or difficult passing of stool). Drugs which may cause diarrhoea include: Antacids (Magnesium) Antibiotics Antidepressants Beta Blockers Diuretics Iron preparations Hypoglycaemic preparations (Sorbital) 11 Osmotic agents can work to relive constipation by helping retain fluid in the large bowel by osmosis or by changing the pattern of water distribution in the gut. In other words hydrate the stool to make an easier passage from the rectum to the anus. Stool softeners lower the surface tension of the colonic contents. They allow fat and fluid to break through and soften the faeces. They can also stimulate the bowel. They provide moisture to the stool and prevent excessive loss of water. Bulking agents will increase the faecal mass by adding volume to the colonic contents. Stimulant laxatives cause rhythmic muscular contractions in the intestines. Lubricants can help by making the anus and rectum moist to aid the passage of the stool. Examples of this are KY jelly, or any lubricating enema that will help stimulate a bowel movement. Also oral preparations can lubricate the process.

Karen Wagstaff

12

Bulk forming drugs = Examples of these are Bran, Isphagula, Bran Sterculia, Methylcelullose.

13

Stimulants =

Examples of these are Bisacody , Senna, Docusate.

Osmotic =

Examples of these are Lactulose, Magnesium hydroxide, Movicol.

Stool softening agents

Examples of these are Arachis Oil, Liquid Paraffin, Decusate.

Rectal preparations

Phosphate enema, Glycerin suppositories

Bulk forming agents increase faecal mass by adding volume, and by acting as a transmitter to aid bacteria, which adds to the overall faecal mass. Stimulants increase intestinal movement by sending peristaltic waves to encourage a bowel movement. Lactulose acts by speeding up the passage of the stool through the large intestine, this allows less water to be absorbed by the body so the faces becomes more liquid and is passed more easily. Stool softening agents ease the passage of the stool by softening it and lubricating the anus to aid defecation. They allow fat and fluid to penetrate and soften the faeces. they can also act as a stimulant. Rectal preparation help clear the bowel, these can aid in the preparation for surgery or further investigations.

14

An ideal bowel movement can be defined as passing a semi-solid stool with a soft consistency, with no urgency or straining.

.

Karen Wagstaff

15

Facts

10% of the populations are affected by constipation. 25% of the elderly are affected by constipation Constipation is more prevalent in women. Only 13 consultants out of 1000 have expertise in the field of constipation. Up to 73% of patients on long stay wards are prescribed laxatives.

16

Constipation can be defined as a decrease in the frequency and amount of an individuals usual bowel action, which is usually associated with the difficulty and sometimes painful passage of hard, dry, pellet shaped stools which may be followed by a feeling of incomplete emptying.

17

Some of the causes of simple constipation are –poor diet lack of fluid and or fibre. Avoiding or ignoring the signals to go to the toilet. Lack of exercise. Old age can be a contributing factor in that elderly tend to be less active, can reduce their food and fluid intake due to ill health or decreased mobility.

18

Causes of secondary constipation can be diseases of the bowel, neurological disorders such as Parkinson or spinal disorders, some procedures such as barium studies can cause constipation, also some drugs can lead to constipation for example opioids, or iron.

19

The effects of secondary constipation can be the slow decent of food through the gut causing the contents to remain longer and allowing more fluid to be absorbed causing harder stools to form.

20

Many things can affect the bowel such as changes in morning routine, reducing fluid and fibre in you diet, the lack of exercise. Emotions can have an affect on your bowel by either making you constipated or have diarrhoea.

Karen Wagstaff

21

A person’s quality of life can be affected by constipation by causing depression, pain bloating feeling generally unwell. People can often become irritable due to pain it can also have an effect on mobility.

22

Complications that can be associated with constipation Haemorrhoids, this can happen due to continuous straining. Faecal impaction and urinary incontinence is also a complication of constipation. It can also cause diverticular disease.

23

Faecal impaction can be defined as a mass of compressed faeces in the rectum, colon. This is one of the main complications of constipation.

24

Faecal impaction can be cause by a number of things. Underlying diseases can be the cause such as Neurological, Renal disease, Diabetes, Hypothyroidism or Cardiovascular disease. Confusion and depression can also cause faecal impaction due to the patient not being aware that they need to go or being so depressed that they don’t care. Fluid and diet restrictions can impact faecal impaction. Poor mobility and lack of exercise can also cause this. One other cause is due to the abuse of laxatives.

25

Patients with Neurological diseases, the elderly and patients with dementia or depression are the most likely to be affected. Also patients with disabilities are prone to faecal impaction.

Karen Wagstaff

26 Bowel Management Some self help measures that can be put in place are changing your fluid and diet intake. Positioning yourself on the toilet properly, not perching or hovering, but sitting firmly on the seat. By making time to use the toilet and not rushing. By adding some form of exercise in to your routine. Mechanical measure that can be put in place are having abdominal massages, digital stimulation to re educate the bowel, suppositories or enemas can be given to help stimulate the bowel and so encourage the passage of the stool. Manual and surgical removal are usually done when all else fails as these are very invasive methods. Lifestyle changes can be implemented by changing routine education in the benefit of fluids and fibre in the diet. Exercising, even if it’s only a walk every day. Making sure the bathroom is private and accessible. Recommending that the patient has at least 24 grams of fibre a day and that their fluid intake is between 1-2 litres a day. Also explaining the importance of 5 portions of fruit and vegetables per day. 27 Fibre content in foodBread White slice Wholemeal slice Brown Breakfast cereals All bran Cornflakes Porridge Weetabix Fruit Apple Banana Blackberries Orange Pear Rice/pasta Brown rice Karen Wagstaff

Grams 0.5 2

10 0.2 2 2 2 1 3.1 1 3 1.5

Vegetables Baked beans Lettuce Peas canned Potatoes jacket Potatoes boiled Sprouts Biscuits Digestives Oatcakes Cake Rich fruit cake Sponge Nuts All nuts

5 0.2 4.1 1.4 1 4.8 0.6 1.5 1 0.5 2

Pasta White rice Wholemeal pasta

28

2 0.5 5

Fibre is both soluble and insoluble.

The difference between the two are that soluble fibre is effectively broken down by enzyme producing bacteria present in the colon to produce energy and gas and bulky stools. Insoluble fibre is less easily broken down by bacteria in the colon, but can hold water which helps to increase the stool weight. Foods high in soluble fibre areFruit Vegetables/pulses (e.g. peas beans) Oats Barley Seeds Foods high in insoluble fibre areFruit and vegetables with their skins on Wholegrain cereals (wheat, rye, rice) Nuts and some pulses 29 What measures can be implemented on:Bowel habit –re- education Toilet training –get a routine make time and make sure you have privacy Diet – change your dietary habits increase fluids and fruit and vegetables Exercise- try some form of exercise, incorporate in to daily life style. 30 • • • • •

31

What symptoms may lead you to consider underlying disease? Blood Pain Mucus Sudden weight loss Changes in normal bowel habit (become constipated or develop loose stools)

What might cause severe diarrhoea? • Infection • Food poisoning • Bowel disease • Misuse of laxatives Karen Wagstaff

• •

32

Medication Alcohol/Drugs

Crohn's disease causes inflammation in the small intestine. Crohn's disease usually occurs in the lower part of the small intestine, called the ileum, but it can affect any part of the digestive tract, from the mouth to the anus. The inflammation extends deep into the lining of the affected organ. The inflammation can cause pain and can make the intestines empty frequently, resulting in diarrhoea. Ulcerative colitis is a disease that causes inflammation and sores, called ulcers, in the lining of the large intestine. The inflammation usually occurs in the rectum and lower part of the colon, but it may affect the entire colon. Ulcerative colitis rarely affects the small intestine except for the end section, called the terminal ileum. Ulcerative colitis may also be called colitis or proctitis. The inflammation makes the colon empty frequently, causing diarrhoea. Ulcers form in places where the inflammation has killed the cells lining the colon; the ulcers bleed and produce pus. Diverticular disease is the formation of small pouches (diverticula) in the colon. When these are not inflamed or irritated, the condition is called diverticulosis. If the diverticula become infected or irritated, diverticulitis develops.

Irritable Bowel Syndrome is not a disease. It's a functional disorder, which means that the bowel doesn't work as it should. With IBS, the nerves and muscles in the bowel are extra-sensitive. For example, the muscles may contract too much when you eat. These contractions can cause cramping and diarrhoea during or shortly after a meal. Or the nerves can be overly sensitive to the stretching of the bowel (because of gas, for example). Cramping or pain can result.

Karen Wagstaff

33

Diminished rectal distension occurs in the elderly due to

Karen Wagstaff