Fecal Distribution Changes Using Colorectal Ultrasonography in Older People with Physical and Cognitive Impairment Living in Long-Term Care Facilities: A Longitudinal Observational Study

The Effectiveness of Transabdominal Ultrasonography in Managing Chronic Constipation in the Elderly, with a Focus on the Underlying Pathological Conditions

Chronic constipation is more common in the elderly and associated with numerous diseases. For the diagnosis of chronic constipation in the elderly, it is essential to exclude constipation secondary to colorectal cancer or other causes. Chronic constipation in the elderly also often requires lifestyle modifications, as well as drug treatments because of the involvement of pathologies such as reduced colonic transport capacity and rectal hyposensitivity. Therefore, it is extremely important to evaluate the pathophysiology of both the colon and the rectum. Transabdominal ultrasonography (TUS) is a key technique for providing comprehensive medical care and allows simultaneous functional assessment and exclusion of organic diseases related to constipation such as colorectal cancer. Although several studies have reported the clinical utility of TUS for chronic constipation, which includes its simplicity, noninvasiveness, and low cost, the majority were in children. Thus, there are limited studies in adults. Herein, we review the utility of TUS for indirect assessment of colonic transit time using several TUS parameters that can be applied clinically, as well as treatment options for chronic constipation. The constipation index (i.e., mean transverse diameter of the colon), assessed by TUS, is a useful indirect indicator of colonic transit time. If the constipation index is <21.2, increased fiber or treatment with osmotic agents should be used. If the constipation index is ≥21.2, then the ratio of the left to the right lateral colonic diameters should be evaluated. If this value is ≥0.5, a secretagogue or bile acid transporter inhibitor should be administered. It is noteworthy that nursing care is becoming increasingly important in Japan's super-aging society. A significant proportion of nursing care is provided to patients with chronic constipation, a cohort that is predicted to grow in the future. In these patients, fecal masses often remain in the rectum, which may require an enema or stool extraction. Therefore, it is important to assess both the presence of feces in the rectum and the consistency of the feces. Recently, portable ultrasound (US) devices equipped with artificial intelligence have been developed and used clinically for treatment of patients with chronic constipation in nursing care. Rectal findings using portable US devices can aid in selecting appropriate constipation treatments. Thus, portable US will likely become increasingly important as a next-generation examination device in nursing care. TUS (including portable US) is noninvasive, simple, and repeatable and will become a fundamental modality in the management of chronic constipation.

Ultrasound assessment of gastrointestinal luminal contents: a narrative review

Gastro-intestinal ultrasound (GIUS) is a non-invasive and cost-effective tool, widely used as a first-line diagnostic method in patients presenting with abdominal complaints, especially in patients affected by inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis. In this setting, gastro-intestinal ultrasound has been especially used to evaluate the bowel wall features (thickening, stratification, vascularization) and complications related to IBD (fistulas, abscesses). Nevertheless, gastro-intestinal ultrasound can be also used to detect and evaluate the content of several segments of the gut. In fact, there is a growing interest in utilizing GIUS for suspected functional disorders, where assessing intestinal content may play a significant diagnostic role, as well as directing therapy. In our review, we provided a sonographic description of GIUS appearances of bowel content in various pathological and physiological conditions, offering potential applications in clinical practice and providing insights for further research.

Prevalence of constipation and associated factors in university hospital inpatients

Objectives

We aimed to determine (1) the prevalence of constipation among inpatients, (2) the prevalence and symptoms of difficult defecation among constipated inpatients, and (3) the factors associated with constipation.

Methods

We performed a retrospective cohort study over a single day at one university hospital. We analyzed the nursing records for inpatients who had been hospitalized for at least 3 days. The survey items included the symptoms associated with defecation difficulty and nutritional intake. The symptoms of difficult defecation were defined as (1) fewer than three spontaneous bowel movements per week; (2) lumpy or hard stools (Bristol stool form scale types 1-2); (3) straining during defecation; and (4) the sensation of incomplete evacuation during defecation, based on the Roma-IV diagnostic criteria. Constipation was defined as the presence of two or more symptoms of defecation difficulty. Univariate and multivariate analyses were performed to determine the constipation status of the patients.

Results

The prevalence of constipation in the university hospital was 12.2%, and the department with the highest prevalence of difficulty with defecation was the Psychiatry Department (64.1%). Of the patients with constipation, 36.8% exhibited symptoms of defecation difficulty other than low frequency of defecation. The factor that was significantly associated with constipation after admission was pre-admission constipation (odds ratio=8.92, p<0.01).

Conclusions

Subjective assessment has limitations for the accurate determination of constipation status. In addition, patients with a history of constipation before admission require early interventions to aid defecation following their admission.

Constipation: a neglected condition in older emergency department patients

Constipation and fecal impaction are common issues with the potential for significant morbidity in older people presenting to the Emergency Department (ED). While many of these patients present with classical symptoms of constipation or fecal impaction, atypical presentations are also frequent. These atypical presentations may include paradoxical diarrhea, fecal incontinence, urinary retention or overflow incontinence, hyperactive or hypoactive delirium, anorexia/dysphagia, and syncope. In addition, various clinical conditions (such as dementia, Parkinson's disease, dehydration, and hypothyroidism) and medications (such as opiate analgesics, anticholinergics, diuretics, calcium channel blockers, anti-parkinsonian drugs, and oral iron supplements) are associated with constipation and should be considered during the diagnostic process in the ED. This narrative review specifically focuses on the prevalence, presentation, diagnoses, and management of constipation in older ED patients.

A Handheld Ultrasound Device Can Predict Constipation with Rectal Fecal Retention in a Palliative Care Setting

Although handheld ultrasound devices (HUDs) are commonplace, their ability to diagnose fecal retention (FR) remains unclear. This prospective observational study examined HUDs' usefulness in diagnosing FR in patients with constipation in a palliative care setting. Between 10 December 2020 and 30 June 2022, we compared rectal ultrasonographic findings obtained using HUDs with clinical manifestations in 64 males and 70 females (48%, 52%, 68 ± 11 years old) with constipation who had undergone computed tomography (CT). FR was diagnosed using a HUD and compared with CT and digital rectal examination (DRE) results. In total, 42 (31%), 42 (31%), and 41 (31%) patients were diagnosed using HUDs, CT, and DRE, respectively. Thirty-nine (93%) patients in the CT group were also diagnosed with FR using HUDs. A total of 89 of 92 patients with a negative CT diagnosis also had a negative HUD diagnosis. Among the 41 patients in the DRE group, 37 were also diagnosed with FR using HUDs. Among 93 patients with a negative DRE diagnosis, 86 had a negative HUD diagnosis. The sensitivity, specificity, positive predictive value, and negative predictive value of HUDs for CT were 93%, 97%, 93%, and 97%, respectively. Those of HUDs for DRE were 88%, 94%, 86%, and 95%, respectively. The concordance rates for FR diagnosis were 128/134 for CT and HUDs and 123/134 for DRE and HUDs. HUD was useful for diagnosing FR in this setting. HUDs could provide valuable support for appropriate treatment selection. Developing a constipation treatment algorithm based on rectal ultrasonographic findings is warranted in the future.

Editorial: Sonographic assessment of colonic content-A new tool for constipation? Authors' reply

This article is linked to Mathias et al papers. To view these articles, visit https://doi.org/10.1111/apt.18029 and https://doi.org/10.1111/apt.18100

Evaluating Accuracy of Rectal Fecal Stool Assessment Using Transgluteal Cleft Approach Ultrasonography

BACKGROUND

Transabdominal ultrasound is used to detect fecal impaction, but the rectum is difficult to visualize without bladder urine or with gastrointestinal gas.

OBJECTIVE

We developed a transgluteal cleft approach that is unaffected by these factors and sought to determine if our ultrasound method could detect and classify fecal matter in the lower rectum using this approach.

METHODS

We classified ultrasound images from hospitalized patients into four groups: Group 1 (bowed and rock-like echogenic areas), Group 2 (irregular and cotton candy-like hyperechoic areas), Group 3 (flat and mousse-like hyperechoic areas), and Group 4 (linear echogenic areas in the lumen). Stool characteristics were classified as hard, normal, and muddy/watery. Sensitivity and specificity were determined based on fecal impaction and stool classification accuracy.

RESULTS

We obtained 129 ultrasound images of 23 patients. The sensitivity and specificity for fecal retention in the rectum were both 100.0%. The recall rates were 71.8% for Group 1, 93.1% for Group 2, 100.0% for Group 3, and 100.0% for Group 4. The precision rates were 96.6% for Group 1, 71.1% for Group 2, 88.9% for Group 3, and 100.0% for Group 4. Our method was 89.9% accurate overall.

CONCLUSION

Transgluteal cleft approach ultrasound scanning can detect and classify fecal properties with high accuracy.

Diagnostic Ability of Ultrasonography Compared with Computed Tomography for Assessing Rectal Feces

Objectives

Chronic constipation is a common gastrointestinal disorder, and management is crucial. Computed tomography (CT) is useful for evaluating rectal fecal mass but limited owing to radiation exposure, cost, and inaccessibility at certain facilities. Ultrasonography (US) avoids these pitfalls, but it is unknown whether it accurately assesses rectal feces. In this study, we evaluated the diagnostic performance of US compared with CT as the gold standard for assessing rectal feces.

Methods

We prospectively evaluated rectal fecal mass retention using US performed within 1 h of CT to assess the degree of agreement between methodologies. Rectal stool findings were evaluated on three levels: no stool (R1), presence of stool (R2), and hard stool filling (R3).

Results

The sample included 100 patients (55 men, 45 women), of whom 47 were constipated. The kappa coefficients for rectal content detection were excellent between US and CT (p <0.001). Eighty-two cases (R1: 46 cases; R2: 28 cases; R3: 8 cases) were matched with CT and US findings, and 18 were not. Cases that did not match had low urine or high gas volumes. CT and US findings showed high agreement in constipation (kappa coefficient 0.674, p <0.001) and non-constipation groups (kappa coefficient 0.677, p <0.001). All cases with R3 on CT were found in the constipation group, while more than half of the cases with R1 on CT were in the non-constipation group.

Conclusions

CT and US showed high agreement in evaluating rectal fecal mass retention, indicating that US can substitute CT.

Current Treatment Practices for Adult Patients with Constipation in Japan

BACKGROUND

The prevalence of constipation in Japan is estimated to be 2-5%. Constipation is a disease found in older adults. In particular, Japan is an aging society, with 65% of men and 80.5% of women aged 65 years or older accounting for the majority of its population. Chronic constipation may be associated with survival, cardiovascular events, decreased quality of life, and death. This study summarizes the recent findings regarding constipation treatment practice in Japan.

SUMMARY

Until recently, the diagnosis of constipation was mainly based on medical interviews; however, with the recent development of handheld ultrasound devices, both physicians and nurses can easily and objectively diagnose fecal retention. Magnesium oxide and stimulant laxatives have been the mainstay treatments; however, since 2012, more than five new drugs for treating constipation have become available in Japan.

KEY MESSAGES

Magnesium oxide is less effective in patients who use acid-secretion inhibitors and patients who have undergone total gastrectomy and should be cared for hypermagnesemia. In addition, regular use of stimulant laxatives may lead to colonic inertia and decreased bowel movements; therefore, they should be used only occasionally. The following is an overview of the different uses of conventional and newer laxatives for treating constipation.

Relief from behind: enemas, the back door enforcement to help treating chronic constipation in adults

INTRODUCTION

Chronic constipation is a frequent symptom encountered in the daily clinical practice. The treatment of this condition mainly relies on the use of laxatives. However, patients' satisfaction with this approach is limited, and alternative measures are often added to the treatment. Among these, particularly frequent worldwide is the use of enemas, even though literature data on its scientific validity are scarce.

AREAS COVERED

In this article, by an extensive online search of Medline (through PubMed), Scopus, Cochrane CENTRAL, EMBASE, and the Science Citation Index, the available literature data on the use of enemas in adult patients with chronic constipation, also in the perspective of available guidelines on treatment of this pathological condition, were analyzed.

EXPERT OPINION

Although the use of enemas remains a frequently employed method and it is considered as useful by many physicians as an adjunctive support for the treatment of chronic constipation in adults, this practice is not substantiated by rigorous scientific data, and some studies are available only for specific instances (fecal impaction, transanal irrigation). Thus, waiting for more robust scientific data, enemas treatment should be carried out on an individual patient's basis, according to the experience of the caring physicians.

Ultrasonographic Evaluation of Large-Bowel Obstruction With Fecal Impaction: A Case Report

Traditionally, large bowel obstruction (LBO) can be due to a neoplasm, most often colorectal cancer. Also, fecal impaction (FI) is a common disease, which occurs in a variety of ages and is significantly increased in the elderly. This case report is of LBO caused by FI, in which ultrasonography (US) proved to be useful for diagnosis and follow-up. A 60-year-old female had abdominal pain after taking a laxative as part of bowel preparation for colonoscopy. The US diagnostic findings were a marked dilation of the bowel, due to watery stool, in the ascending colon, and a clear FI, in the descending colon. Computed tomography showed similar findings to the US. There was a large amount of defecation after treatment and US demonstrated an improvement in the ileus. Ten days after admission, a colonoscopy revealed no stenosis or tumor, as a cause for the ileus.

Expert Consensus Document: Diagnosis for Chronic Constipation with Faecal Retention in the Rectum Using Ultrasonography

Chronic constipation is a common gastrointestinal disorder in older adults, and it is very important to manage chronic constipation. However, evaluating these subjective symptoms is extremely difficult in cases where patients are unable to express their symptoms because of a cognitive or physical impairment. Hence, it is necessary to observe the patient’s colonic faecal retention using objective methods. Ultrasonography observation for colonic faecal retention is useful for diagnosing constipation and evaluating the effectiveness of treatment. Since there was no standard protocol for interpreting rectal ultrasonography findings, we developed an observation protocol through an expert consensus. We convened a group of experts in the diagnosis and evaluation of chronic constipation and ultrasonography to discuss and review the current literature on this matter. Together, they composed a succinct, evidence-based observation protocol for rectal faecal retention using ultrasonography. We created an observation protocol to enhance the quality and accuracy of diagnosis of chronic constipation, especially rectal constipation. This consensus statement is intended to serve as a guide for physicians, laboratory technicians and nurses who do not specialise in ultrasound or the diagnosis of chronic constipation.

Development of colonic transit time and ultrasound imaging tools as objective indicators for assessing abnormal defecation associated with food intake: a narrative review based on previous scientific knowledge

Background

Functional gastrointestinal disorders (FGIDs) involve chronic or persistent gastrointestinal symptoms. Laboratory tests show no organic lesions, and the symptoms are due to dysfunction. The most typical FGID is irritable bowel syndrome (IBS). In IBS patients, defecation disorders are common and have adverse effects on daily life. The proper evaluation and analysis of colonic transit are important for the management of defecation disorders in IBS patients. In addition, dietary intake and lifestyle affect colonic transit. An accurate assessment of such factors can guide management, leading to improvements in colonic transit and the resolution of defecation disorders.

Main topic

The Rome IV diagnostic criteria for IBS are based on subjective symptoms, which must be communicated and explained by the patient, limiting their application. Colonic transit time and ultrasonography are objective tools that can be used to diagnose IBS. In particular, previous studies used colonic transit to accurately distinguish between constipation and normal stool passage and to assess delayed gastrointestinal motility. Diet and lifestyle modifications can improve colonic transit and ameliorate bowel dysfunction.

Conclusion

Colonic transit can be improved by modifying lifestyle factors. Defecation disorders in IBS patients may be resolved by focusing on such factors. In the future, methods of visualizing defecation disorders due to impaired gastrointestinal motility and objective indicators of the associated abdominal symptoms need to be investigated.

Abdominal Stiffness Evaluation in Massage for Constipation

According to the experience of nurses and physiotherapists, the abdomen of constipated people becomes softer after abdominal massage. However, the relationship between the decrease in abdominal stiffness and the benefits of abdominal massage has not been examined quantitatively and is unclear. Furthermore, devices for measuring stiffness have been designed to measure relatively hard areas such as the shoulders and do not take into account the lateral outflow of the target tissue, which can be a problem when measuring the stiffness of soft areas such as the abdomen. To address these issues, this study presents a stiffness sensor suitable for measuring abdominal stiffness and investigates the relationship between the reduction in abdominal stiffness and the benefits of abdominal massage. The solution to prevent the lateral outflow of the target is the realization of a stopper, including a contact detection device, which enables a wide-area contact around the targeted area. The sensor consists of a stopper, probe, spring, and time-of-flight (ToF) sensors. The probe and spring provide appropriate pressure and deformation to the abdomen, whereas the stopper prevents the probe from being pushed into the abdomen more than necessary. The ToF sensor measures the deformation length when the deformation is stopped by the stopper. The abdominal stiffness can be derived from the deformation length. The investigation results indicate that the reduction in abdominal stiffness corresponds to the improvement of the stool condition or the maintenance of a healthy stool condition, whereas the maintenance of abdominal stiffness indicates the maintenance or deterioration of the stool condition.

Can irritable bowel syndrome be detected by ultrasound?

Functional gastrointestinal disease is one in which gastrointestinal symptoms persist chronically or recurrently. This disease is challenging because it does not have an organic cause that can be detected in routine laboratory tests. Among them, the symptoms of irritable bowel syndrome (IBS), which is a type of functional gastrointestinal tract disease, include abnormal bowel movements associated with abdominal pain. However, no specific test has been established to definitively diagnose these diseases, including IBS. The traditional Rome IV diagnostic criteria are used to diagnose IBS by assessing subjective symptoms. However, it has been suggested that IBS is difficult to diagnose using the Rome IV criteria among unconscious or cognitively impaired patients. It is recommended that abdominal ultrasonography be used to assess IBS with diarrhea and constipation. Previously, constipation among elderly people who ingested food orally was objectively assessed by ultrasound, and colonic fecal distribution patterns were classified in constipated patients and healthy people. Objective visualization of the large intestine was used to assess constipation. Therefore, fecal retention among adults and elderly individuals was reported using ultrasonography. It was suggested that stool retention could be confirmed by observing the hyperechoic region of the rectum. Strong hyperechoic regions with acoustic shadows in the rectum indicate the presence of hard stools, thus enabling medical workers to identify constipation. In the future, ultrasonography may be useful for diagnosing IBS in unconscious patients or those with cognitive decline.

Deep learning-based classification of rectal fecal retention and analysis of fecal properties using ultrasound images in older adult patients

AIM

The present study aimed to analyze the use of machine learning in ultrasound (US)-based fecal retention assessment.

METHODS

The accuracy of deep learning techniques and conventional US methods for the evaluation of fecal properties was compared. The presence or absence of rectal feces was analyzed in 42 patients. Eleven patients without rectal fecal retention on US images were excluded from the analysis; thus, fecal properties were analyzed in 31 patients. Deep learning was used to classify the transverse US images into three types: absence of feces, hyperechoic area, and strong hyperechoic area in the rectum.

RESULTS

Of the 42 patients, 31 tested positive for the presence of rectal feces, zero were false positive, zero were false negative, and 11 were negative, indicating a sensitivity of 100% and a specificity of 100% for the detection of rectal feces in the rectum. Of the 31 positive patients, 14 had hard stools and 17 had other types. Hard stool was detected by US findings in 100% of the patients (14/14), whereas deep learning-based classification detected hard stool in 85.7% of the patients (12/14). Other stool types were detected by US findings in 88.2% of the patients (15/17), while deep learning-based classification also detected other stool types in 88.2% of the patients (15/17).

CONCLUSIONS

The results showed that US findings and deep learning-based classification can detect rectal fecal retention in older adult patients and distinguish between the types of fecal retention.

Safety and efficacy of a defecation care algorithm based on ultrasonographic bowel observation in Japanese home-care settings: a single-case, multiple-baseline study

AIM

To verify the efficacy of defecation care based on handheld ultrasonographic observations for functional constipation by visiting nurses skilled in bowel ultrasonography.

METHODS

Home-care patients with suspected functional constipation receiving nursing visits were recruited in this multiple-baseline, single-case experiment with intervention points shifted by 1 week. A total of 15 older adults were categorized into 3-, 4-, 5- or 6-week intervention phases. Ultrasonographic observations of fecal retention in the colorectum and defecation care based on observations during the ordinal physical assessment were reviewed. Tau-U was used for confirming the efficacy of the intervention by measuring the number of non-artificial and artificial defecations, as well as hard stools per week, and the amount of non-stimulant and stimulant laxatives, enemas and suppositories per week. For evaluating safety, adverse events, such as bowel obstruction and incontinence-associated dermatitis, were confirmed.

RESULTS

No adverse events were observed. Statistical analysis showed that hard stools and artificial defecation reduced, and that their effect sizes were significant (Tau = -0.48, P < 0.01; Tau = -0.53, P < 0.01). Even the amounts of stimulant laxative and glycerin enema reduced, and their effect sizes were significant (Tau = -0.56, P < 0.01; Tau = -0.34, P = 0.04).

CONCLUSIONS

Thus, defecation care based on ultrasonographic assessment by nurses in home-care settings is safe and effective for improving constipation symptoms and reducing laxative use. Geriatr Gerontol Int 2020; ••: ••-••.