The proper and normal functioning of the gastrointestinal tract is central to the normal functioning of the human body. The gastrointestinal tract serves to provide as means of providing nutrients to the cells of the body. The unprocessed and unutilized part of the food is evacuated from the body by the lower portion of this tract. The small and large intestines are referred to as bowels and their normal motility and performance is essential to maintain the integrity of the digestive system. The dysfunction of the bowels can result in constipation, diarrhoea and faecal incontinence. The underlying causes of bowel dysfunction maybe primarily associated with the bowel inflammatory conditions or it may result from other secondary factors which include injuries to the spinal cord, as a result of the side effects of certain medications or due to certain endocrine disorders as well as improper diets and infectious agents. Proper diagnosis and management of bowel dysfunction is essential for the health of the patient. The treatment is related to the type and the extent of the disease. This paper will encompass the pathologies which are associated with bowel dysfunction and serve to explain their underlying reasons along with their diagnostic criteria and the most appropriate treatment according to the condition of the patient.
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According to the National Institutes of Health Clinical Center, "Bowel dysfunction refers to problems with the frequency, consistency and/or ability to control your bowel movements." This serves to explain the meaning that alterations in the motility of the small intestine and the normal bowel function can result in conditions which are referred to as bowel dysfunction. Constipation, diarrhoea and faecal incontinence are examples of bowel dysfunction.
Constipation is a condition which may result due to a reduction in the bowel motility, hard faecal matter which cannot be expelled or if the amount of faecal matter is less than the amount which can be defecated. The defining factor of constipation can vary from one person to another as the bowel habits between different patients are variable. This is because a bowel frequency ranging from one per day to three per week is considered to be normal. If this frequency is reduced to less than one time in a period of three days, it can be referred to as constipation. If constipation exists for a long time, a more severe condition which is known as impaction may result. In this state the faecal matter is accumulated in the bowel and it becomes really hard. Also the liquid part of the faeces may appear in the stool as they manage to make space through the impaction and leak. The factors that lead to constipation may be associated with an imbalanced diet which has low fibre content. Diets in which consumption of liquids as well as solid food is reduced can also lead to constipation. Pain in the anorectal region which may be associated with haemorrhoids and fissures can also be predisposing factor of constipation. A normal abdominal pressure is essential for the push of the faecal matter and eventually for the normal bowel movements but reduction in this pressure due to injury to the floor of the pelvis can lead to constipation. Diseases of the nervous system, psychological disorders, inactive lifestyles and secondary conditions which include diabetes and hypothyroidism account for other reasons. Constipation can also be induced by medicines which include antidepressants, antihistamines as well as anti-cholinergic drugs. Prior to menstruation as well as during pregnancy, females may experience this condition.
There are two main pathophysiologies associated with constipation. These include alterations in the normal movements of the colon which can result due to nervous problems that lead to improper transmission of signals required for the normal evacuation of the bowel. It can also occur due to improper diet as well as hormonal imbalances. The other pathophysiology involves problems with the path of egress of the faecal matter. This involves pathologies of the floor of the pelvis as well as the anorectum.
Faecal incontinence another type of bowel dysfunction results due to loss of control over the evacuation of faeces which occur without any voluntary stimulation. Incontinence occurs mainly in the elderly as well as in patients suffering from pathologies of nervous system and those suffering from physical handicaps. It can also occur in young children. Faecal incontinence in women occurs after deliveries which can lead to damage to the sphincter of the anal canal. Hence impairment in the normal functioning of the anal sphincter as well as the nerves which control the defection reflex can lead to incontinence. Prolonged constipation, congenital anomalies affecting the anatomy of the rectum and the anus can also be associated with incontinence
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Diarrhoea is a form of bowel dysfunction in which the bowel habits deviate from normal. "A precise definition of diarrhoea is elusive, given the considerable variation in normal bowel habits. An increase in stool mass, stool frequency, and/or stool fluidity are perceived as diarrhoea by most patients." Diarrhoea can result from many reasons which include the effect of viruses such as rotavirus and astrovirus. Deficiencies of enzymes such as lactase can also account for diarrheal diseases. Infectious agents like bacteria which include shigella, salmonella and campylobacter as well as malabsorption resulting from reduction in the available surface area of the small intestine or infections with giardia lamblia which disrupts the normal absorptive capacity of the mucosal cells can also lead to diarrhoea. Other secondary reasons of diarrhoea include hyperthyroidism and the disruption of the neural functioning of the gastrointestinal tract which occurs in diabetic neuropathy as well as irritable bowel syndrome.
Diarrhoea which occurs due to malabsorption is associated with decreased absorptive capacity of the gut and hence the content of the stools increases which results in diarrhoea. Diarrhoea induced by deficiencies of enzymes and the use of certain drugs like antacids occurs due to increase in the osmolality of the contents of the gut and hence this leads to increased movement of fluid out of the mucosal cells and results in diarrhoea. On the other hand diarrhoea due to viruses and bacteria occurs due to their damaging effect on the epithelial lining of the mucosa of the gastrointestinal tract. The disruption of the neural activity of the gastrointestinal tract leads to alterations in the motility of the tract which results in a reduction in the time of the passage of substances from the intestine. This leads to diarrhoea.
Bowel dysfunction can serve to be a reason for discomfiture in patients and hence it is the duty of the medical staff to assist patients in overcoming this condition considering the physical as well as the psychological impact of this condition. The patient needs to be comforted and a proper history is essential because many patients avoid presenting all the complaints associated with bowel dysfunction. The most widely accepted notion for assessing and diagnosing constipation is based on the 'Rome' diagnostic criteria. According to this criterion, the presentation by the patient of 2 or more than 2 symptoms from the list confirms the presence of constipation. These symptoms include complain of strain at the time of defecation, the content of the faeces is hard and the number of bowel movements are two or even lower than that in the entire week. The patient can also complain that after defecation, it is felt that complete exit of stools has not occurred. In diarrhoea the patient the symptoms presented by the patient include pain, the urgent need to defecate and irritation in the anal region. The patients of faecal incontinence often confuse the condition with diarrhoea. The patient presents the symptoms that extreme urgency is felt and that no control over the faecal evacuation is present.
In the conditions of bowel dysfunction it is important that proper history of the patient should be taken. This should include questions about the dietary habits of the person which is to assess the presence of a balanced diet. The onset of the symptoms along with the relieving and aggravating factors should also be assessed. The intensity as well as the particular time when the problem is encountered should also be noted. The patients should be asked for any medications that he is taking. Also any previous surgical operations as well as previous injuries and problems should be questioned about. This assists in finding the underlying condition for the pathology and assists in reaching a proper diagnosis and treatment. It is important that a nurse should recognize the difficulty experienced by the patient with regards to bowel dysfunction. Many reasons associated with such issues might not be discussed and it is the duty of the nurse to provide proper counselling to the patients and make them comfortable. The nurses should provide attention to the problems of the sufferers and provide them practical suggestions and ensure them about their heath. In the long run the patient should be asked questions about their problem on a regular basis and issues should not be left on the basis that the nurse believes that they are already known.
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Rectal examination is an essential diagnostic measure used in bowel dysfunction. This examination encompasses checking the perianal skin for problems like haemorrhoids or fissures. The integrity of the anal sphincter can also be checked as well as the presence of any pain. Faecal masses can also be palpated if the patient has constipation. This also shows the presence of blood and the colour of the faeces. Tests performed for checking for disorders of the bowel include radiologic examination in which the barium swallow, barium enema, CAT scan and gastrointestinal series are performed. The laboratory tests include routine blood tests as well the test of the feces. The feces are tested to check for the presence of infectious organisms or the presence of blood in the stools. Other techniques utilized include sigmoidoscopy, proctoscopy, endoscopy and colonoscopy. These methods are done to check for the integrity and condition of different parts of the gastrointestinal tract. For constipation, another test which is known as defecography is also performed.
The proper history and diagnosis of the patient assists in choosing the required treatment accordingly. The pharmacological treatment which is prescribed for diarrhoea might also prove to be useful for patients suffering from faecal incontinence. It includes drugs which reduce the motility of the gastrointestinal tract. Diphenoxylate and loperamide lie in this class of drugs. Bismuth salicylate, methylcellulose and aluminium hydroxide belong to the other class which are referred to as adsorbents because they basically adsorb the foreign agents and provide a protective layer on the mucosal lining of the intestine. The anti-motility agents are more effective in treating the condition. These drugs which include loperamide and diphenoxylate also serve to be helpful for patients suffering from faecal incontinence but the dosage needs to be properly prescribed to prevent side effects like difficulty in defecation and abdominal discomfort. The pharmacological therapy for constipation includes laxatives. Irritants and stimulants are a class of laxatives which irritate the intestinal wall and increase the bowel movement. These include senna and castor oil. Bulk laxatives are another class of drugs which function in the colon by retaining water and distending the bowel and hence leading to more bowel movements. Methylcellulose, bran and psyllium seeds lie in this category. Emollient laxatives are drugs which work towards softening the faeces and hence assisting in defecation. They include docusate sodium and docusate potassium. Lubricants which include mineral oil and glycerine suppositories also assist in the evacuation of hard faeces.
Biofeedback therapy is a treatment meant for patients suffering from faecal incontinence. It works towards training the patient through lessons which are designed to create habits in the patient for strengthening the sphincter muscles and improve the defecation reflex mechanism as well as to improve the sensory system working. Surgery is the last resort if the condition does not improve by other means. Surgical procedures include repairing the sphincter, colostomy and the insertion of an artificial sphincter.
Diarrhoea on the other hand is treated on the basis of the effecting cause. A proper history is important for the determination of the underlying cause. It is essential that rehydration be provided to patients suffering from diarrhoea which includes oral rehydration therapy. The diet of the patient should be restricted to foods which are not spicy or very oily until the condition of the patient becomes normal. If diarrhoea is resulting from food allergies which include sensitivity to gluten as well as dairy products, it is essential that they should be restricted as well.
Biofeedback mechanism has also proven to be of help in patients suffering from constipation.