I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
When Fiber is Not Enough: Current Thinking on Constipation Management
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B owel dysfunction is a common problem and associated with significant morbidity. Chronic constipation affects a significant percentage of the population in Western countries (55% to 30%, depending on the criteria used to define constipation), and laxatives are among the most commonly used drugs.1 While most individuals respond well to self-treatment, a subset of patients does not respond to standard interventions, underscoring recognition that the pathology of constipation is diverse and multifactorial.2,3
Understanding Constipation
Characteristics of normal bowel function. Normal defecation can be characterized as elimination of formed bulky stool with minimal effort - ie, no excessive straining and no sensation of incomplete emptying. Factors contributing to normal defecation include adequate intake of fiber and fluid, normal colonic motility, and coordination between the muscle groups controlling stool elimination (the abdominal and pelvic floor muscles).4-6 Effective management of the patient with chronic constipation is dependent upon accurate identification of the dysfunctional factor(s) and implementation of appropriate corrective strategies.
Definition of constipation. The term constipation means different things to different people. Clinicians typically define constipation as abnormal infrequency of bowel movements, while patients frequently use the term to indicate difficult defecation (straining at stool), hard stools, or a sensation of incomplete evacuation.4,7-9 The most commonly accepted indicators of chronic constipation include the presence of at least two of the following for at least 3 months: 1) straining with defecation at least 25% of the time; 2) lumpy or hard stools at least 25% of the time; 3) sensation of incomplete emptying at least 25% of the time; and 4) less than three bowel movements per week.4,9 The need to facilitate defecation via perineal support, intravaginal pressure, or manual evacuation of stool is included as a diagnostic criterion in some centers.8
Risk factors for constipation. Although the pathology underlying chronic constipation is not completely understood, the epidemiologic data clearly suggest the following as risk factors: female, aging, low caloric intake, inactivity, number of medications taken, low income level, and low education level. Other factors associated with increased risk are depression, physical abuse, and sexual abuse. Although these factors appear to be associated with chronic constipation, they should not be construed as causative factors; they are based on correlational data only.1,4,8
Etiology and Pathology of Chronic Constipation
Chronic constipation is commonly categorized as either primary or secondary. Secondary constipation is caused by an identifiable pathology - ie, factors other than colonic motility and pelvic floor muscle function, while primary (idiopathic) constipation has no apparent cause and is thought to result from intrinsic disorders of colonic motility and/or pelvic floor function.1,5,7,8
Secondary constipation. Initial evaluation of the patient presenting with complaints of chronic constipation should include evaluation for specific causative factors. Conditions commonly resulting in constipation include the following:7-10
* neurologic disorders such as Parkinson's Disease or spinal cord lesions
* metabolic disorders including hypothyroidism, hypercalcemia, or diabetes mellitus
* medications such as opioid analgesics, anticholinergic agents, calcium channel blockers, antiparkinsonian drugs, sympathomimetics (eg, pseudoephedrine), antipsychotics, diuretics, antihistamines, calcium-based antacids and calcium supplements, iron supplements, and nonsteroidal anti-inflammatory agents
References:
1. Candelli M, Nista E, Zocco M, Gasharrini A. Idiopathic chronic constipation: pathophysiology, diagnosis, and treatment. Hepatogastroenterology. 2001;48:1050-1057.
2. DeLillo A, Rose S. Functional bowel disorders in the geriatric patient: constipation, fecal impaction, and fecal incontinence. Am J Gastroenterol. 2000;95(4):901-905.
3. Wald A. Constipation. Med Clin North Am. 2000; 84(5):1231-1246.
4. Waldrop J, Doughty D. Pathophysiology of bowel dysfunction and fecal incontinence. In: Doughty D, ed. Urinary and Fecal Incontinence: Nursing Management, 2nd ed. St. Louis, Mo.: Mosby; 2000:325-352.
5. Briejer M, Schuurke J, Sarna S. Idiopathic constipation: too few stools and too little knowledge. Trends Pharmacol Sci. 1999;20(1):1-3.
6. Heitkemper M. Physiology of defecation. In: Doughty D, ed. Urinary and Fecal Incontinence: Nursing Management, 2nd ed. St. Louis, Mo.: Mosby;2000:313-322.
7. Dosh E. Evaluation and treatment of constipation. J Fam Pract. 2002; 51(6):555-560.
8. American Gastroenterological Association. American Gastroenterological Association medical position statement: guidelines on constipation. Gastroenterology. 2000;119:1776-1778.
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21. Neal LJ. "Power pudding": natural laxative therapy for the elderly who are homebound. Home Healthcare Nurse. 1995;13(3):66-71.
22. Oullet LL, Turner TR, Pond S, et al. Dietary fiber and laxation in postop orthopedic patients. Clinical Nursing Research. 1996;5(4):428-440.
23. Badiali B, Corazziari E, Habib F, et al. Effect of wheat bran in treatment of chronic nonorganic constipation: a double-blind controlled trial. Dig Dis Sci. 1995;40(2):349-356.
24. Yakobowich M. Prescribe with care: the role of laxatives in the treatment of constipation. Journal of Gerontologic Nursing. 1990;16(7):4-11.
25. Skidmore-Roth L. Mosby's 2002 Nursing Drug Reference. St. Louis, Mo.: Mosby;2000.
26. van Gorkom B, deVries E, Karrenbeld A, Kleibeuker J. Review article: Anthranoid laxatives and their potential carcinogenic effects. Alimentary Pharmacology and Therapeutics. 1999;13(4):443-452.
27. Baker D. Tegaserod for the treatment of constipation-predominant irritable bowel syndrome. Reviews in Gastroenterologic Disorders. 2001;1(4):187-198.
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