Altered bowel or bladder activity in the elderly

Chapter 33 Altered bowel or bladder activity in the elderly



Case 33.1



1. What are the possible causes of constipation commencing in a man of this age?
• Lifestyle changes (eg: decreasing the level of physical activity), insufficient fluid intake, change in diet (less fibre or less fat).

• Carcinoma of the colon or rectum.

• A large polyp in the colon.

• Chronic peridiverticulitis.

2. What specific questions do you need to ask?

A full history should be taken. Specifically:


• a full dietary history is needed, including fluid, fibre and fat intake

• details of any changes in activity levels during this time period

• details of any changes in his energy levels, and details of unusual fatigue

• details about his stools: colour, consistency, shape (long and thin may suggest partial obstruction)

• query if there is any pain on defecation

• ask if the weight loss been intentional and, if not, has it been gradual or over a short period of time

• query if there was any recent illnesses

• query if there is any family history of colon cancer

• obtain details about medications (including over-the-counter and herbal remedies)

• query any symptoms which may relate to hypothyroidism.

3. On examination, you find no abnormalities, although you have not done a rectal examination. What will you do now? Why?

Refer for further investigations, to eliminate serious pathology.


4. If he was to be investigated for this problem, what do you think would be included in the first round of tests? Why?
• Full blood count: to test for anaemia which may be a result of occult bleeding from the gastrointestinal tract.

• Erythrocyte sedimentation rate (ESR): an elevation would indicate the possibility of an underlying pathology.

• Haemoccult test: to check for blood in the stools due to occult bleeding.

• If there were symptoms of hypothyroidism, thyroid function tests should be done.

• The decision to do a colonoscopy would depend on the clinical judgment of the medical practitioner, based on the patient’s history, physical examination and investigative findings.


Case 33.2



1. With this information only, what are the possible causes of her symptoms?
• The addition of small amounts of diarrhoea in a patient who has suffered from constipation for many years suggests that there may be partial obstruction in her colon. The diarrhoea may be ‘spurious’ diarrhoea.

• There is also a possibility that the diarrhoea is unrelated to her constipation, and is due to a completely different pathology.

• Rosy may have started to use laxatives to help relieve her constipation. This commonly causes the patient to alternate between constipation and diarrhoea.

• It may be dietary related.

2. What questions do you need to ask?

A full history should be taken. Specifically:


• questions which give us more information regarding the nature of her diarrhoea should be asked (eg: precipitating factors, associated pain, colour, presence of mucus etc.)

• a full dietary history is needed

• details of any changes in his energy levels, and details of unusual fatigue

• ask if there is any pain on defecation

• details of any recent illnesses

• query if there is any family history of colon cancer

• obtain details about medications (including over-the-counter and herbal remedies)

• query any symptoms which may relate to hyperthyroidism.

3. On examination, you find no abnormalities, although you have not done a rectal examination. What will you do now? Why?

Refer for further investigations, to eliminate serious pathology.


4. If she was to be investigated for this problem, what do you think would be included in the first round of tests? Why?
• Full blood count: to test for anaemia which may be a result of occult bleeding from the gastrointestinal tract.

• ESR: an elevation would indicate the possibility of an underlying pathology.

• Stool culture.

• Haemoccult test: to check for blood in the stools due to occult bleeding.

• If there were symptoms of hyperthyroidism, thyroid function tests should be done.

• The decision to do a colonoscopy would depend on the clinical judgment of the medical practitioner, based on the patient’s history, physical examination and investigative findings.


Case 33.3



1. Using only this information, list the possible causes of Rita’s:
a constipation
• Change in her diet (she has a reduced appetite).

• Lack of adequate fluid intake.

• Decreased physical activity (this may be due to her fatigue, as well as the recent knee injury which may have limited her movements).

• Bowel carcinoma (sigmoid or rectal) — always need to consider this in an elderly patient with these symptoms.

• Chronic peridiverticulitis (often difficult to clinically differentiate from a malignancy).

b rectal bleeding
• Haemorrhoids.

• Bowel carcinoma (sigmoid or rectal).

• Chronic peridiverticulitis.

c anorexia, fatigue and general feeling of unwellness
• Dietary changes.

• Underlying malignancy or another type of chronic disease.

2. What extra questions do you need to ask?

A full history is required, but most specifically:


• more details about her current diet, fluid intake and physical activity are required, including how any of these have changed in the last year

• family history of bowel cancer

• query the presence of any rectal bleeding in the past

• question how did her haemorrhoids presented in the past

• more detail about her past bowel patterns

• Possibility of any ‘spurious diarrhoea’, which may not necessarily be perceived by the patient as actual diarrhoea, but could indicate partial obstruction in her colon.

3. What type of drug is Actonel? What is it used for?

It is a biophosphonate, used to inhibit osteoclast mediated bone resorption. It is thus useful in the treatment of osteoporosis.


4. What do you need to examine in this patient?

A full physical examination is required, but in particular:


• abdominal examination

• assess for signs of anaemia (there may be occult bleeding in addition to the frank blood loss)

• look for signs of liver dysfunction (there may be liver metastases from a bowel carcinoma).

5. Do you think that all her symptoms could be related to the same pathology? At this point, what are you thinking?

It is possible that they are all related to the presence of a bowel carcinoma.


6. Explain the significance of each of the following investigation results:
a a sign of ‘shifting dullness’

Indicates the presence of fluid in the abdominal cavity.


b palmar erythema

There are a number of causes of palmar erythema, including liver dysfunction, hyperthyroidism and rheumatoid arthritis.


c clubbing

There are a number of causes of clubbing, including liver dysfunction, some cardiorespiratory disorders and inflammatory bowel disease.


d pallor of the conjunctiva

Indicative of anaemia.


7. Could her constipation be related to the physical signs found on examination? Can you now narrow your differential diagnosis?

Yes. If we were to find the ‘one best fit’ diagnosis, we would be suggesting that Rita has a malignancy in her colon (probably rectosigmoid area) which has metastasised to her liver. Her constipation would be due to the partial obstruction of the gastrointestinal tract as a result of the tumour, and the metastatic spread to the liver has caused ascites and liver dysfunction. One of the consequences of liver dysfunction is the inability to metabolise oestrogen adequately. The level of the hormone rises in the blood, and can cause palmar erythema. Clubbing also occurs in liver disease, although the precise pathophysiological mechanism by which this occurs is somewhat obscure.


It is also necessary to consider the possibility that her constipation is not related to her physical signs. In this situation, the constipation may be due to a lifestyle issue or chronic peridiverticulitis, and her physical signs related to a primary liver disorder.


8. Do you need to refer this patient? What investigations are required? Why?

Yes — she needs to be investigated for the possibility of malignant disease, especially considering her advise that she ‘is not herself’ and is anorexic. It is also important that she has a rectal examination from a medical practitioner.


She needs to initially have the following investigations:


• full blood count (to assess for anaemia)

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Altered bowel or bladder activity in the elderly

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