Case studies

Select one of the case studies below to read further.

Causes of constipation

Changes to diet and lifestyle can be significant risk factors for constipation, particularly in the older adult population. The case study below, provided by Professor Enrique Rey, Head of the Division of Digestive Diseases, Hospital Clinico San Carlos, Spain, outlines the causes of constipation and the impact of this condition in terms of health and quality of life.

An 84 year old female had a medical history of osteo-arthritis and high blood pressure, but no reports of abnormal bowel activity; defecation every one to two days, normal stool consistency and no other relevant symptoms of constipation. She was also active, walking for 15-30 minutes on a daily basis and cooking independently.

After her husband passed away, she experienced symptoms of depression and constipation. She became less active, stopped cooking for herself and subsequently experienced weight loss.

She was admitted to a nursing home where her constipation got worse, with bowel movements only every three to seven days and hard stool consistency.

She was treated with anti-depressants and was referred to a gastroenterologist to assess her weight loss.

Treatments for her constipation were not effective and she went on to suffer faecal incontinence, requiring intensive nursing care.

Misdiagnosis

Misdiagnosed chronic constipation can lead to faecal impaction and faecal incontinence. Symptoms of this can be mistaken for diarrhoea, as shown in the case study below from a care home community where residents were suffering misdiagnosed chronic constipation. Case study provided by PromoCon, part of UK charity Disabled Living, which works to improve the lives of older people with bladder or bowel problems by offering product information, advice and practical solutions to both professionals and the general public.

A small care home was reported as having an outbreak of Clostridium difficile (C. difficile), as several residents had developed diarrhoea. Infection control measures were immediately implemented and faecal samples were sent for analysis for C.difficile and toxins.

C.difficile was not found so further assessment of the residents was initiated. Per-rectal examinations of the residents discovered that some were suffering from faecal impaction and what was originally thought to be diarrhoea was in fact constipation with overflow.

Faecal incontinence

Urinary and faecal incontinence can be the result of mistreated constipation, specifically in patients who experience a delay in bowel evacuation (rectal outlet delay) and the lack of a tailored approach. This case study, provided by PromoCon, is of a care home resident who is experiencing incontinence due to an inappropriate treatment regimen. It highlights the importance of adequate training of care home staff, to ensure patients are being diagnosed accurately and their condition managed appropriately.

A 78 year old female with a history of falls was no longer able to look after herself, particularly in terms of shopping and meal preparation. She gave up her home to live in a care home.

She presented with some urinary and faecal incontinence, so was referred to the local continence service for assessment. During the continence assessment, the patient questioned the need to take laxatives (senna and lactulose) as she was now experiencing diarrhoea.

On review it became apparentĀ that it was ‘routine practice’ in the care home to put all new residents who were ‘constipated’ on laxatives within the first few days of admission.

Detailed discussion with the lady discovered that she had not been eating or drinking well when living at home and was only a ‘little constipated’ when she was admitted. Rather than leave her to settle into a routine of a well-balanced diet and plenty of drinks before making any changes, the home had used laxatives within a few days. The result of a balanced diet, appropriate drinks and laxatives led her to experience diarrhoea.

The laxatives were immediately stopped and the diarrhoea was resolved within a couple of days. She no longer experienced any faecal incontinence and her urinary leakage has improved.

Mortality

In extremely rare cases, ignored and untreated constipation can be fatal. This case study was published in 'From Death We Learn', developed by the Government of Western Australia Department of Health. It helps to raise awareness of the shortfalls in the management of various conditions including constipation, which can lead to death.1

A female patient was admitted to a mental health unit in Western Australia, suffering from schizoaffective disorder with prior history of constipation. During admission, the patient’s constipation worsened and after 11 days, she complained of abdominal discomfort and was found to have acute bowel obstruction. She was transferred to a general ward where she had chest and abdominal x-rays. However, soon after, the patient collapsed and died.

Post-mortem examination found the patient died as a result of aspiration of vomitus with bowel obstruction, caused by constipation. She was taking a cocktail of medications, which may have caused her constipation. Despite no records being found that document her previous complaints, the constipation was so severe that physical examination would have obviously noted the extent of her distended abdomen.

Recommendations from the coroner included: physical examination of patients on arrival and bowel charts to monitor patients receiving multiple medications.

References

Click to view full reference list

  1. Government of Western Australia Department of Health, From Death We Learn, 2009.