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home - Colon - Diagnostic Pathways for Colonic Disease - Faecal Incontinence Written by Dr Sebastian Zeki
Knowledge
Assessment
Methods GMP
Knows the physiology of intestinal absorption, secretion and motility SCE 1
Understands the biochemical processes occurring within the gut
lumen and at mucosal level

Has awareness of the factors controlling these processes – in
particular the neuro-endocrine influences

Understands the range of mechanisms by which diarrhoea can result
from disturbances in each of these processes

Knows the causes of both acute and chronic diarrhoea
Knows the range of investigations appropriate to determining the
cause of the patient’s diarrhoea and is aware of the range of
therapeutic possibilities

Skills
Makes a detailed clinical assessment of patients that present with
either acute or chronic diarrhoea

Recognises the potential need for urgent fluid replacement CbD,
Makes appropriate use of microbiology and other relevant laboratories in reaching a diagnosis

Shows ability to interpret results, reach a diagnosis and formulate a
treatment plan

Behaviours
Reacts appropriately to the urgency of the clinical presentation
Always shows sympathy and understanding especially when the
patient is distressed

Faecal Incontinence

Faecal Incontinence OverflowReduced storage capacityWeakness of inter-nal anal sphincterWeakn external anal sphincter onlyWeakness of pubo-rectalis muscleDecreased percep-tion of rectal sensa-tion Childhood encopresis; diarrhea in institutionalized, elderly, or psychotic patientsInflammatory bowel disease, radiation therapy, or proctectomyAnal sphincterotomy, systemic sclerosis Vaginal delivery with sphincter defect; pudendal neuropathySpinal cord lesion, peripheral neuropa-thy, "high" tear after vaginal deliverySpinal cord lesion, diabetes, multiple sclerosis, megarectum Constipation or withholding behavior; use of constipating medications; dementia; psychosis; impaction found on digital exam; "overloaded colon" on AXRHistory of colitis or proctitis; radiation therapy for prostate cancer; rectal surgery; frequent, urgent small stools; normal anal sphincters and puborectalis muscleIncontinence of small amounts of liquids or mucus; no sensation of stool loss; rectal seepage onlyDecreased resting tone, with normal squeeze pressure and contraction of the puborectalis muscleVaginal delivery with prolonged labor, use of forceps, known tear with or without repair; urge incontinence; weak squeeze pressure with normal contraction of the puborectalis muscle; possible anterior external sphincter defectWeak contraction of the puborectalis muscle with weak or absent squeeze pressure; decreased perianal sensation with gaping of the anus (spinal cord lesion); urinary incontinence (spinal cord lesion)Weak contraction of the puborectalis muscle with weak or absent squeeze pressure; decreased perianal sensation with gaping of the anus (spinal cord lesion); urinary incontinence (spinal cord lesion); nocturnal incontinence; capacious rectum with overflow (megarectum only); decreased perianal sensation with gaping of the anus (spinal cord lesion only); urinary incontinence Flexible sigmoidoscopySpecific testing for patients with diarrhea Endorectal ultrasonography in patients with suspected sphincter disruption Anorectal manometry if structurally intact sphincters Medical therapy and/or biofeedback for motivated patients who have intact sphincters and manometry showing preserved rectal sensation Surgical repair for patients with mechanical sphincter disruption in whom medical therapy is unsuccessful Other sphincter restoring procedures in patients with major inconti- Anatomy of the anal canal, rectum, and distal colon illustrat-ing the mechanisms for preserving continence -Anorectal manometry-Anal USS-Balloon expulsion test-PNTMLIf suspected prolapse confirmed on defecography then may need surgery Weak sphincter/ defect + normal PNTML Biofeedback Other result Weak sphincter/ defect + abnormal PNTML Anterior sphincter repairSphincter augmentation injectionGracilic muscle transposition +/- stimulationColostomy Biofeedback or surgery Obtain specific anorectal testing Specific treatment Written by Dr Sebastian Zeki

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