Christine Norton, PhD, MA, RN, is Burdett professor of gastrointestinal nursing, King’s College London and nurse consultant, St Mark’s Hospital, Harrow.
My patient reports bleeding with defecation and can feel some haemorrhoids. Should I advise a high-fibre diet?
A high-fibre diet is the best treatment for haemorrhoids, but it can never be presumed that bleeding is due to this. Colon cancer is the second most common cancer killer in Europe. It is easily treated if caught early, but later survival is poor. Patients with rectal bleeding, particularly if they are over 50, who have a family history or have unexplained anaemia or weight loss should be referred for assessment. Bleeding detected from a stool sample (faecal occult blood test) is the basis of a new national bowel screening programme in the UK. You may find that your patients ask you more about bowel cancer once awareness is raised by this programme.
Probiotics are becoming very fashionable – should I recommend them to my patients?
Probiotics are the so-called ‘good bacteria’ that we all have by the billion in the colon. Their role in creating and maintaining a healthy immune system is increasingly recognised; indeed mice raised in a sterile laboratory with no bacteria are extremely unhealthy. So we need these bacteria for health. There is good evidence that sufficient quantities of these bacteria can treat gut inflammation. However, there is not evidence for a role in disease prevention in healthy individuals and some brands of drinks and yoghurts may not contain sufficient bacteria. It is premature to recommend probiotics to everyone (and they can be expensive), but selected patients may benefit.
I have heard that manual evacuation (ME) can cause anorectal damage. Is this true?
This has become a common myth among nurses. The RCN guidelines state that ME is an acceptable nursing procedure, where other methods of bowel emptying have failed. It should be done after full assessment and by a trained individual, but the potential to do any harm is very slight. For some patients (for example, those with a low spinal cord injury) ME is likely to be the preferred method of bowel care and needed on a permanent basis. The National Patient Safety Agency has recommended that ME be made available to patients who need this in hospital and community settings.
Many of my older patients seem to need regular laxatives. Is this harmful and which is the best laxative?
There is no evidence that long-term laxative use is harmful, although many laxatives do become less effective with time. There is very limited evidence on which to base choice and no ‘best buy’, but it is logical to try a softener for hard stool and a stimulant for infrequent bowel actions. For many it is a case of trial and error to find the best. Many older people find laxatives make them fearful of faecal incontinence and some find a suppository or micro enema gives them better control. Always remember to try the simpler remedies (such as diet, fluid, exercise) before resorting to laxatives.
What is the difference between IBS and IBD?
These terms refer to very different disorders. Irritable bowel syndrome (IBS) is a disorder of gut motility and sensation. Patients typically complain of altered bowel habit (this may be constipation, diarrhoea or alternating), with abdominal pain and often bloating. Diagnosis is made by excluding gut pathology (usually endoscopy or imaging and blood tests). Treatment may include diet, antispasmodics and lifestyle advice, stress reduction and reassurance that there is no serious pathology. Inflammatory bowel disease (IBD) takes two main forms: ulcerative colitis and Crohn’s disease. Both involve inflammation of the gut: confined to the colon and rectum in UC; it may affect the whole gut in CD. Onset is usually in children or young adults. Treatment is with anti-inflammatory medication and more recently biological drugs.