What is normal/healthy bowel?

Melissa Goodall (Specialist Learning Disability Dietitian)Meg Sanders (Specialist Community Dietitian)

• Aim of this session: to give you an insight into why constipation can be a problem and provide you with a practical approach to be able to identify and successfully manage constipation

• Plan:

- How the bowel works

- Constipation and its causes

- Management of constipation

- Recording bowels

- When to contact health professionals

How the bowel works

How the bowel works

Bowel has 2 major functions:

1) Digesting food and absorbing the nutrients into the blood stream

2) Eliminating waste products at an appropriate time

Bowel control is a complex process and involves the coordination of many different nerves and muscles.

Bowel habits vary from person to person!

Signs of a healthy bowel

• Being ‘regular’ is a way of describing good bowel habits or normal bowel function.

• Being regular means that soft, yet well-formed motions are easily passed

• Poop motion should happen anywhere from 1-3 times a day to 3 times a week

• Key question to ask: ‘Was the stool sausage-like and easy to pass?’

Not just being regular

• For example, you should be able to:

- Hold on for a short time after you feel the first urge to go to the toilet

- Pass a bowel motion within about a minute of sitting down on the toilet

- Pass bowel motion easily and without pain

- Completely empty your bowel when you pass a motion

Constipation

• Constipation is a symptom many of us have experienced transiently, and which generally improves with a slight lifestyle change and maybe a single dose of over-the-counter laxatives. But for many people, the symptom is not short-lived.

• Our bowels have a significant impact on our health and wellbeing. Poor bowel health and chronic constipation affects millions of people and prevents them from fully enjoying their lives. Many people are needlessly suffering because of the taboo nature of the subject, and a lack of understanding of the issue.

Constipation – the reality

Nearly 1 in 5 people feel embarrassed talking to their GP about constipation.

71,430 people in England were admitted to hospital with constipation in 2017/18, equivalent to 196 people a day. 52,715 (around three quarters) of those were unplanned emergency admissions, equivalent to 144 per day.

£162 million was spent by NHS England on treating constipation in 2017-18 alone - this is equivalent to the cost of funding 7043 newly-qualified nurses

for a year.

Prevalence of constipation in individuals with Learning Disabilities

• 17%-51%

• 70% within LD compared to 50% of general population

• Similar figures found for children

• Constipation is a problem from early in the life course of people with learning disabilities

• Constipation more likely for people with Down Syndrome and Cerebral Palsy

• Hypothyroidism, Depression and Diabetes exacerbate constipation – these conditions more prevalent within LD

Constipation can cause complications

• Hemorrhoids

• Rectal bleeding

• Anal fissures (tears in skin around anus)

• Rectal prolapse (the lowest part of the large intestine detaches and pushes out of the anus)

• Faecal impaction (hard, dry stool is stuck in the body and unable to be expelled naturally)

Constipation

• It can mean different things to different people – for some it is about how often they poop, for others it is associated with straining, not emptying their bowels completely or the consistency of poop – all are valid descriptions

• There are 3 main subtypes of constipation:1) Slow-transit constipation – when poop takes long time to move

through the large intestine. There is more water absorption along the way, leaving you with dry, hard poop.

2) Evacuation disorder – everything is moving at normal speed through the large intestine, but it is not quite right with the final ‘push’, resulting in constipation.

3) Constipation predominant irritable bowel syndrome (IBS) – for some managing this constipation can improve other symptoms of IBS, including gut pain and bloating

Potential causes of constipationLow levels of activityDecreased stimulation of gut muscles

Medication or supplementsDifferent types can impact the bowels, such as directly affecting the gut-muscle movements or increased fluid absorption

Stress, anxiety or depressionAltered communication via the gut-brain axis

Changes in routineOur bowels are creatures of habit and changing your eating and sleeping times can confuse them

Ignoring the urge to goThis allows more time for the water to be absorbed, resulting in a hard and dry poop, which is difficult for your gut to push

Not eating enough wholegrain fibreWholegrain fibre can help, add bulk to the poop, giving your gut muscles more to work with

Childhood toiletingFeeling pressure or being regularly interrupted can lead to the development of poo pooping habits

History of physical or psychological abuseTrauma can impact the function of muscles involved in pooping via the gut-brain axis

PregnancyBoth hormonal changes and the physical compression of the uterus on the intestine

Constipation - management

• Routine; positioning and technique; listen to your body

Toilet habits

• Exercise; bowel massage

Physical activity

• Fluid; fibre

Dietary factors

Toilet habits

Routine

1. Give 5-10 min to sit and relax on the toile; even if

there is no poop it is important to make it daily

routine. What can be relaxing? Listening to

music/reading?

2. Aim to sit on the toilet at the same time each

day. The mass movement in the morning increases

post meal and after coffee, so worth

maximising chances by dedicating time then.

Positioning and technique

1. Check the pooping position

2. Train pooping muscles

Listen to the body –when there is the

urge – go. Withholding can

cause constipation.

Bowel – training exercises

• Correct pooping position

- Ensure your knees are

slightly higher than hips

- Leaning forward, prop

your elbows on top of your

knees

- Ensure your spine is straight and bulge out your tummy

- Relax and lower your shoulders

Physical activity

First line approach –is exercise part of routine at least 3

times per week for at least 30 min?

NO – Regularly moving your body

can make a big difference

YES –

1. Exercise timing –gentle post meal exercise may help

promote mass movement to get

/thing’ moving

2. Bowel massage

How to identify if there is a problem with constipation

Observe if the person you are caring for has any of the following:

• Having to strain to pass a stool

• Not having a bowel movement for 3 days

• Streaks of blood on the stool or toilet paper (usually as a result of passing large, hard stool)

• Complaints of abdominal pain that improves once they have been to the toilet

• Starting to soil when they have previously been clean

Be alert! - Red flags – ask for an urgent medical attention

- Persistent unexplained change in bowel habits

- Palpable mass in the lower right abdomen or the pelvis

- Persistent rectal bleeding without anal symptoms

- Passing narrower stools

- Family history of colon cancer or IBD

- Severe, persistent constipation that is unresponsive to treatment

Bowel recording chart

• Please ensure that the bowel recording chart is being completed – all care settings that care for residents should record bowel movements in a daily chart

• Bristol Stool Chart (or Bristol Stool Form Scale) – is an aid to help everyone understand what type of stools are being passed and it reduces confusion and misunderstandings

• Type 1-3 indicates constipation

• Type 3-4 are ideal stools

• Type 5-7 may indicate diarrhoea and urgency (always consider overflow)

Regulations

• The health and Social Care Act 2014: Regulation 14 states ‘People must have their nutritional needs assessed and food must be provided to meet those needs’

• Bowel care standards Audit Tool for Care Home/supported living – The Standards for Good Bowel Care should be implemented in all Care Homes/supported living – further information can be found in Bowel care Guideline - ???

Thank you