CBL

MR SALMAN’S BOWEL
PROBLEM
Mr Salman a 78-year-old man, with no close relatives, who has lived alone
since he lost his wife three years ago has become increasingly frail over the
past two years. He cooks infrequently, eats little fruit and almost no
vegetables. Mr Salman rarely visits his friends or the shops; if he goes for a
walk, it is a short one, as he is now frightened of the traffic.
He has severely restricted his intake of fluids in the evening and has even cut
out his cup of hot milk before bed, as he does not want to visit the toilet
during the night. Mr Salman has never had any gastrointestinal complaints in
the past, but recently he has not opened his bowels for more than two weeks.
His doctor has advised him to drink more fluids and has prescribed lactulose
QUESTIONS
■ What are functions of large gut?
Key Points

■ Secretion
■ Absorption of water and electrolytes
■ Formation of feces
■ Storage of feces
■ Expulsion of feces
■ Production of Vit B and K
■ Describe the normal process of defecation
Key Points

Mass movements of colonic content usually after a meal, push the content into the
rectum and distend it.
Distension stimulates sensory receptors in the rectum and initiate the defecation
reflex, a reflex involving parasympathetic nerves in the sacral spinal cord, together
with conscious awareness of the urge to defecate.
At the same time the smooth muscle of the internal anal sphincter is relaxed and the
somatic nerves supplying striated muscle in the external anal sphincter are inhibited,
allowing the sphincter to relax.
Voluntary control of defecation is learnt in early childhood and involves voluntary
contraction of the external anal sphincter.
■ What are the causative factors for the development of constipation?
Key Points

■ Constipation is a condition in which faecal material moves too slowly

through the large intestine. As a result too much water is reabsorbed;
hard, dry feces which are difficult to move and very abrasive are
produced.
■ Infrequent or difficult defecation is a common problem in the elderly as
ageing is associated with a decline in both secretory activity and motility
in the gut.
■ Emotional problems, inactive or sedentary lifestyle, lack of fiber and
fluid in the diet, intestinal muscle weakness, a neurogenic disorder or an
iatrogenic effect.
■ Outline the factors in the history which may be contributing to Mr
Salman’s constipation
Key Points

■ Inadequate fiber (roughage) and fluids in his diet.

■ He is also inactive, taking only occasional short walks, which also
increases the likelihood of constipation
■ Comment on the pharmacological management of constipation
Key Points

There are four main types of laxative:

■ bulk-forming preparations, such as ispaghula
■ hyperosmolar or saline solutions
■ faecal softeners/wetting agents
■ Stimulant or irritant laxatives
■ To which category of drugs does lactulose belong?
Key Points

Lactulose is a hyperosmotic liquid containing a disaccharide of galactose

and fructose which is not absorbed from the intestine. The recommended
dosage is 15 ml twice a day. It passes unchanged into the colon and produces
an osmotic effect, directing fluids into the colon content, which expands the
bowel and initiates peristalsis.
■ What advice might be useful for Mr Salman?
Key Points

Increasing fruit and vegetable content in diet.

Exercise and social interaction
Maintain his fluid intake during the day, to avoid dehydration and promote
colonic transit