Women often report disturbing digestive symptoms referable to the lower gastrointestinal tract. Some of these disorders are common and more frequent in women; some are uniquely female problems. Many women suffer from digestive problems and all require at least colon cancer risk assessment and screening. Gastroenterology and endoscopy nurses are well positioned to enhance the educational needs of women. This article reviews management guidelines for colonic digestive health.
Irritable Bowel Syndrome
As a cause of industrial absenteeism, irritable bowel syndrome (IBS) is second only to the common cold. Twenty percent of American women suffer IBS, most reporting abdominal pain and discomfort, urgency, and altered bowel habits (Camilleri, 2001). More than half of these afflicted women say that IBS limits their activities in sports, recreation, travel or their sex lives. Seventy-eight percent report that the condition limits what they can eat. According to a national public opinion survey funded by Glaxo Wellcome, Inc., one third of women IBS patients feel their doctor doesn’t understand their discomfort (Schulman, Ronca, & Bucuvalas, Inc., 1999). Many seek additional information from gastroenterology nurses including written educational materials. One survey performed by a national public opinion research organization funded by Glaxo Wellcome reported that 80% of ambulatory care nurses felt that there was a need to better educate people with IBS about their condition and treatment (Schulman et al.).
IBS is a disorder of gastrointestinal motility, psychological stress, and visceral hypersensitivity (Camilleri, 2001). This visceral hyperalgesia refers to the IBS patient’s lower threshold for the perception of visceral pain and has become the target of management for the multisymptom complex of IBS.
The hallmark symptoms of IBS are pain, altered bowel habits with constipation, diarrhea, or alternating movements; bloating; stool mucus; the sensation of incomplete defecation and relief of the symptoms with defecation, enemas, or passage of stool or gas (Camilleri, 2001). Often women report to gynecological clinics because their predominant symptoms focus on lower abdominal or pelvic pain.
Irritable bowel syndrome is diagnosed by recognizing the hallmark symptoms and fulfilling clinical criteria for diagnosis. Table 1 lists the clinical criteria updated in a meeting of the International Congress of Gastroenterology in Rome (Thompson, 1999). When these criteria are used, the diagnosis of IBS is reliable and durable. Patients should be asked to describe their discomfort and their bowel movements. The practitioner should be careful about discussing the characteristics of the symptoms in lay terms. As an example, when inquiring about incomplete defecation, ask “Do you feel that when you leave the toilet, there is still more inside?” These criteria help establish a positive diagnosis of IBS, rather than an exclusionary diagnosis after a negative testing evaluation.
Diagnostic testing in IBS is limited to hematology, biochemistry, and age and risk-appropriate colon cancer screening (Tolliver, 1994). Lactose maldigestion is not more common in women, but could confuse symptomology (DiPalma, 1988).
The traditional management of IBS utilizes bulk agents, antispasmotics, anticholinergics, and antidepressants. A new paradigm addresses visceral hypersensitivity attempting to raise the threshold for discomfort while improving the symptom complex. Certain tricyclic antidepressants like nortriptyline, amitriptyline, desipramine, or trazodone may be helpful. Antagonists to 5 hydroxy tryptamine (5-HT3) receptors like ondansetron (Zofran, GlaxoSmithKline, Research Triangle, NC), granisetron (Kytril, GlaxoSmithKline), cilansetron (Solvay Pharmaceuticals, Marietta, GA), and alosetron (Lotronex, GlaxoSmithKline), are efficacious. The more specific agent for diarrhea-predominant IBS, alosetron, was recently voluntarily withdrawn from the market because of colon ischemia and constipation-related adverse experiences.
5-HT4 agonists may become available for constipation-predominant IBS. The 5-HT4 agonists cisapride (Propulsid, Janssen Pharmaceuticals, Titusville, NJ) and prucalopride (Resolor, Janssen Pharmaceuticals) probably will not be available in the near future. Tegaserod (Zelnorm, Novartis Pharmaceuticals Corporation, East Hanover, NJ) could be marketed soon, but is also having approval problems. Kappa-opiod antagonists, such as fedotozine, show promise.
In the interim, most GI providers rely on bulk agents for managing bowel irregularity, sometimes adding loperamide or cholestyramine for severe diarrhea or polyethylene glycol (PEG) laxative (MiraLax, Braintree Laboratories Inc., Braintree, MA) for constipation-predominant IBS (Horwitz 2001). Pain-predominant patients sometimes benefit from the smooth muscle relaxants dicyclomine, L-hyoscyamine, or the tricyclic antidepressant, trazodone. For this chronic, debilitating syndrome, extensive patient education is essential.
Symptoms of constipation are common with the prevalence reported as high as 20% (Locke, 2000). Female sex is an independent risk factor for constipation. Constipation may be a disorder of stool frequency, volume, or difficulty in passage. The symptoms usually have an insidious onset of many years, often dating to childhood. Many women “suffer in silence” and have not sought primary or specialty care for persistent symptoms. Sometimes, symptoms are unmasked or exacerbated by new conditions or medications. Table 2 lists common medications that are known to cause constipation.
Normal stool habit is reported to be three times a day to three times a week (Thompson, 1999). Using simply a frequency definition of constipation, however, ignores the majority of patients who have straining, hard stool, and unproductive urges. It is not unusual for patients to have constipation while having several stools daily. Rome consensus criteria consider these broader complaints (Table 3).
Structural colon abnormalities such as fissure, stricture, or neoplasia, metabolic disorders (hypothyroidism, hyperparathyroidism, diabetes), or neurologic conditions can cause constipation. Those individuals meeting clinical criteria for diagnosis should have careful physical examination and laboratory evaluation addressing the possibility of these conditions. The choice of flexible sigmoidoscopy or colonoscopy should be based on stool occult blood testing results and colon cancer screening indications.
The vast majority of constipated patients have colonic inertia, but those who don’t respond to treatment may need further diagnostic testing to consider pelvic floor function abnormalities. This testing might include colon marker studies (Sitz Marker), anorectal manometry, or x-ray defecography.
The medical treatment for constipation is as varied and subjectively based as its definition. High fiber diet and avoidance of “stimulant” laxatives is encouraged. After bulk agents, practitioners use hyperosmolar, saline, lubricant, or stimulant laxatives as necessary. These measures are often inadequate and constipation patients may not have satisfactory results despite additional medications and combinations.
Some practitioners use lactulose, which is a poorly absorbed disaccharide. It is metabolized by colonic flora and results in water being retained in the intestinal lumen. As it is fermented, lactulose produces gas, which can cause abdominal discomfort, bloating, and cramps. As an alternative, gut lavage solutions (Colyte, Schwarz Pharma, Milwaukee, WI or GoLYTELY and NuLYTELY, Braintree Laboratories) have been used with success, but these agents are designed to be given in large volumes as a single dose for colon cleansing for diagnostic and surgical procedures. When given regularly in small doses, the fluid and electrolytes in gut lavage agents are absorbed. The sodium load poses a threat to heart and renal failure patients and those with delicate fluid balance.
A new, tasteless PEG laxative (MiraLax, Braintree Laboratories) was developed that, unlike the lavage solutions in low volume, has no salt absorption. MiraLax is safe and effective, and is well tolerated by patients (DiPalma 1999, 2000). Since it is not fermented, gas and cramps are minimal.
Colon Cancer Screening
Colon cancer is the second most common cause of cancer death in the United States. Approximately 150,000 people are diagnosed each year and as many as half die from colon cancer. Once considered a “man’s disease,” it is now known that colon cancer affects men and women equally. Early detection of cancers and premalignant polyps decreases cancer deaths. It has been stated that careful surveillance and removal of cancer precursor polyps could eliminate colon cancer (Rex, 2000).
All Americans are at risk for colon cancer and should undergo screening after age 50 (Rex, 2000). Having a first degree relative with colon cancer or adenomatous polyp increases the risk 1.5 to 2 times and these individuals should have regular examinations of the entire colon beginning at age 50 or at an age 10 years earlier than the age of the index family member (Rex). Other disorders such as familial polyposis, ulcerative colitis, or cancer family syndromes impart a high risk, advocating earlier and more extensive screening.
Average risk screening options for colon cancer include digital rectal exams and stool occult blood testing beginning at age 50, then yearly, with flexible sigmoidoscopy performed at 4–5 year intervals (Rex, 2000). Another screening strategy uses colonoscopy at age 50 and then at 10-year intervals (Rex). Ten year colonoscopy screening became a Medicare-covered benefit on July 1, 2001. Examination of the entire colon for screening and surveillance after removal of a polyp is superior when compared to barium enema x-ray screening (Winawer, 2000).
Screening for first-degree relatives of those with colon cancer or polyp should use total colonoscopy every 5 years beginning 10 years before the index case age. The other high-risk conditions should have colonoscopy screening at intervals of 1–2 years dictated by their conditions. Patients who have adenomatous polyps should have colonoscopic surveillance at 3–5 year intervals (Rex, 2000).
Preliminary evidence suggests that some measures can help prevent colon cancer. Reduction of animal fat, an increase in vegetables and fiber in the diet, and use of calcium and the vitamin folic acid could help (Janne, 2000). Currently, there is ongoing chemopreventive research for colon cancer and there are suggestions of prevention from aspirin or the cox-2 inhibitor pain medicines, celecoxib, (Celebrex, Searle & Co., Chicago, IL), and rofecoxib, (Vioxx, Merck & Co., West Point, PA).
The strong female preponderance of constipation and its prevalence during pregnancy raise the possibility that sex hormones contribute to lower digestive symptoms. Progesterone can inhibit smooth muscle and constipation in pregnancy occurs most often when circulating progesterone concentrations are highest. Women pass harder stools and some studies have shown prolonged gut transit in the luteal phase of the menstrual cycle (Wald, 1981). Conflicting data exist regarding the role of sex hormones during menses, but women should be questioned about digestive complaints related to menses.
Bowel Dysfunction Following Hysterectomy
While some women relate constipation, rectal dysfunction, and loss of the defecatory urge to previous hysterectomy, these mechanisms are poorly understood (Radley, 1999). Confounding the evaluation of the relationship of gastrointestinal symptoms and hysterectomy is the recognition that a large number of hysterectomy patients have IBS. The reason for the frequency of the association of IBS with women undergoing diagnostic laparoscopy or elective hysterectomy is unclear, but IBS patients have an increased prevalence of abnormal menstrual bleeding and dyspareunia (Heaton, 1993). It may be difficult to distinguish gynecologic from bowel origins of pelvic pain and gynecologists often fail to recognize IBS.
Vaginal hysterectomy combined with posterior repair has been reported to increase complaints of severe straining, incomplete evacuation, and digital evacuation (Heaton, 1993). Estrogen, hormonal replacement therapy, and progesterone might unmask or promote new symptoms after hysterectomy. Additionally, other frequently prescribed medications such as iron or nonsteroidal antiinflammatory medications can cause bowel dysfunction.
Constipation is a frequent symptom after hysterectomy. Use of clinical criteria for diagnosis (Rome II) is encouraged. Examination with flexible sigmoidoscopy, colonoscopy, or barium enema examination could reveal structural abnormalities. Sometimes, melanosis coli is seen. Melanosis is a benign and reversible discoloration of the colonic mucosa usually resulting from the use of anthraquinone laxatives, such as cascara sagrada, senna, aloe, and frangula (Schiller, 1999). Pelvic floor dysfunction should be suspected in those with inadequate responses to treatment.
It is perceived that the need for management of postsurgical bowel dysfunction is underestimated. Many women with bowel dysfunction following hysterectomy require dietary modifications, medicinal bulk agents, or stimulation in the form of suppositories. Table 4 lists commonly used laxatives. Clinical experience with PEG laxative (MiraLax) has been very good.
Fecal incontinence is defined as the involuntary loss of stool or soiling when socially inappropriate. Incontinence is under-reported and estimated to affect as many as 60% of institutionalized patients. Although considered a major problem of the elderly, younger groups are affected and fecal incontinence is eight times more common in women than men (Lamah, 1999). These distressing and incapacitating symptoms can be devastating, especially in young women.
Complex phenomena of anatomic and physiologic factors interplay to maintain continence. Operative and obstetric injury may lead to fecal incontinence. Denervation of the pelvic floor is related to childbirth and prolonged straining. It should also be recognized that fecal impaction is the leading cause of incontinence. Rectal distension inhibits anal sphincters and leads to leakage of liquid stool. The etiology of fecal incontinence also includes various local pathologies, nervous system disorders, and rectal prolapse.
Evaluation begins with careful history and physical examination. Gastrointestinal nurses can encourage patients to report this problem as up to 50% of patients do not disclose incontinence to their doctors (Lamah, 1999). The perineal skin should be examined carefully and digital rectal exam should assess rectal and squeezing tone. The cutaneous anal reflex should be tested. Proctosigmoidoscopy is advised. A variety of tests may be helpful to evaluate incontinence unresponsive to simple measures including anal manometry, barium x-ray defecography, endosonography, and electromyography.
Minor incontinence often responds to stool-bulking agents and high fiber diet. Antidiarrhea agents such as diphenoxylate (Lomotil, Searle & Co., Chicago, IL), codeine, and loperamide (Imodium, Janssen Pharmaceuticals) are useful. Loperamide is preferred to diphenoxylate as it not only delays colonic transit, but also improves resting anal canal pressures. Pelvic floor exercises, biofeedback, and surgical treatment may be needed.
Rectal prolapse refers to the condition when rectal tissue protrudes from the anal canal. It is usually caused by long-standing straining and contributes to incontinence. Surgical correction is often necessary.
Anal outlet bleeding manifested by bright red hematochezia or blood on the toilet paper is common from hemorrhoids and anal fissure. Concern is always present that bleeding is from diverticular disease or neoplasm, necessitating a careful history to distinguish true lower gastrointestinal hemorrhage and examination for cancers, polyps, and other sinister causes of bleeding. Half of Americans have hemorrhoids by age 60 and they also frequently develop during pregnancy from fetal pressure or straining to stool (Gerdom, 2001). Constipation, diarrhea, and aging can also lead to hemorrhoids.
Anal fissure is a tear of the lining of the anal canal. Patients may see blood or have pain, burning, or itching. Like hemorrhoids, causes are related to abnormal bowel habits, constipation or diarrhea, and difficult passage of large, hard stool.
Visual examination of the external anus and digital rectal examination may show fissures, internal or external hemorrhoids, or thrombosed hemorrhoids. Acute fistulas may be exquisitely tender. Proctosigmoidoscopy is recommended to exclude other causes of hematochezia.
Management principles for anal outlet bleeding focus on the underlying bowel habit rather than the anorectal finding of hemorrhoid or fissure. Diarrhea should be addressed, considering lactose maldigestion and dietary restriction if diagnostic testing confirms its prescence. Loperamide or diphenoxalate might be necessary for symptom management.
Constipation needs to be eliminated using diet, bulk, or laxatives. One option is to use MiraLax PEG laxative initially as 68g to 85g (which is four to five times the usual 17g dose), then regularly, 17g daily until stool habit is controlled and symptoms resolve.
To relieve pain or itching associated with hemorrhoids, clinicians usually use Preparation H or Anusol with or without hydrocortisone. These are available as creams and suppositories. Sitz baths can be accomplished by having the patient sit or squat in a warm water bath three or four times daily, followed by cleansing with witch hazel. Moisturizers can avoid drying and irritation of the perineal region from water. Balneol is a suitable moisturizer for the anus and perineum.
Occasionally, surgery is needed for hemorrhoids or fissures. Hemorrhoids can additionally be managed using banding, sclerotherapy, or infrared coagulation techniques. Nitroglycerine ointment or botulinum injections have been found useful for relaxing the anal sphincter to allow healing of anal fissures (Gerdom, 2001).
Colonic digestive disorders often lead to symptoms that women find embarrassing or distasteful to discuss. Gastroenterology and endoscopy nurses have the opportunity to educate women about these problems and to encourage patients to discuss these complaints with their healthcare practitioner. Awareness of the colonic digestive disorders commonly afflicting women and therapies useful for managing these disorders will enable the GI nurse to more effectively support and care for women with GI complaints.
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