Nama: Andi Dila Cantika Carmelia

Stambuk: 11020210036

SCENARIO 3 

A 35-year-old woman comes to the general practitioner with complaints of difficulty

in defecation that has been experienced since the last 6 months, usually every 5 days, very
hard. Recurrent abdominal pain, there are no nausea and vomiting. Weight loss ± 10 kg in the
last 6 months.

1. Explain the normal BAB mechanism

Stool formation

Stool Formation Process

Chyme mixes with digestive enzymes (such as bile and amylase) as it travels through the small
intestine. Segmentation (alternating contraction and relaxation of smooth muscle) agitates the
chyme to further break down food for digestion. When the chyme is churned, peristalsis stops
temporarily for absorption to occur.

Chyme travels slowly through the digestive tract to be absorbed. Much food and electrolytes are
absorbed in the small intestine. Enzymes from the pancreas (amylase) and bile from the gallbladder.
The intestines break down fats, proteins and carbohydrates into basic elements. Most of the food is
absorbed by the duodenum and

jejenum. The ileum absorbs some vitamins, iron and bile salts. If its function is disturbed, the
digestive process changes drastically. For example, inflammation, cesarean section, or obstruction
can impair peristalsis, reduce absorption areas,

or block the path of chyme. The absorbed chyme enters the large intestine at the caecum through
the ileocecal valve, where the circular muscle lining prevents regurgitation (food returns to the small
intestine).

Chyme is smooth when it enters the colon the water volume decreases. Colon consists of ascending,
transverse, descending, & sigmoid.

Colon has 4 functions namely absorption, protection, secretion, and elimination. Large amounts of
water and large amounts of sodium and chloride are absorbed by the liver. As food travels through
the colon, haustral contractions occur. These are the same as segmental contractions of the small
intestine, but longer, up to 5 minutes. Contraction

produce large sacs on the colonic wall which are areas for absorption. Water can be absorbed from
the colon within 24 hours, an average of 55mEq of sodium and 23mEq of chloride is absorbed each
day. the amount of water absorbed from the chyme depends on the speed of movement of the
colon. Chyme is usually soft, mass-like. If the speed of peristaltic contractions is fast (abnormal) it
means there is not enough time to absorb water and the stool becomes watery. If the peristaltic
contractions are slow, more water is absorbed and hard stools are formed, causing constipation.

The colon protects itself by secreting some mucous. Mucous is usually clear to opaque with a stringy
consistency. Mucous lubricates the colon, preventing trauma to the inner walls. Lubricant is
especially important near the distal part of the colon where it becomes dry and hard. The secretory
function of the colon helps in electrolyte balance. Bicarbonate is secreted for chloride exchange.
About 4-9 mEq of sodium is excreted daily

by the large intestine. Changes in colon function can cause electrolyte imbalances. Eventually the
colon removes waste products and gas (flatus). Flatus results from swallowing of air, diffusion

gas from the blood vessels into the intestine and the action of the bacteria on

non-absorbable carbohydrates. Fermentation of carbohydrates (such as cabbage and onions)

produces gas in the intestines which can stimulate peristalsis. Adults usually form 400-700 ml of
flatus every day. Every day, about 750 cc of chyme enters the colon from the ileum. In the colon, the
chime undergoes a process of absorption of water, sodium and chloride. This absorption is assisted
by intestinal peristalsis. Of the 750 cc of chyme, around 150-200 cc undergo a re-absorption process.
Chyme that is not reabsorbed becomes a semisolid form called faeces. In addition, in the digestive
tract there are many bacteria. These bacteria carry out fermentation of food substances that are not
digested. The fermentation process will produce gas released through the anus every day, which we
know as flatus. For example, carbohydrates when fermented will become hydrogen, carbon dioxide,
and methane gas. If there is a disturbance in the digestion of carbohydrates, there will be a lot of gas
formed during fermentation. As a result, a person will feel bloated. Protein, after experiencing the
process of fermentation bybacteria, will produce amino acids, indole, statole, and hydrogen sulfide.
Therefore, if there is interference with protein digestion, then flatus and fecesget really smelly.

a. Defecation Physiology

Defecation is the expulsion of feces from the anus and rectum. This is also called bowel movement.
The frequency of defecation varies from a few times a day to 2 or 3 times a week. The amount of
stool also varies from person to person. When peristaltic waves propel stool into the sigmoid colon
and rectum, sensory nerves in the rectum are stimulated and the individual becomes aware of the
need to defecate. Defecation is usually initiated by two defecation reflexes:

● Intrinsic defecation reflex

When stool enters the rectum, swelling of the rectal wall provides a signal that spreads through the
mesenteric plexus to initiate peristaltic waves in the descending colon, sigmoid colon, and in the
rectum. These waves push the stool toward the anus. As soon as the peristaltic waves approach the
anus, the internal anal sphincter does not close and if the external sphincter is calm, the stool comes
out.

● Parasympathetic defecation reflex

When nerve fibers in the rectum are stimulated, signals are transmitted to the spinal cord (sacral 2 –
4) and then back to the descending colon, sigmoid colon and rectum. These parasympathetic signals
increase peristaltic waves, relax the internal anal sphincter and enhance the intrinsic defecation
reflex. The individual anal sphincter sits on a toilet or bedpan, the external anal sphincter is relaxed
by itself. Expulsion of stool is assisted by contractions of the abdominal muscles and diaphragm
which increase abdominal pressure and by contraction of the levator ani muscle in the pelvic floor
which moves feces through the anal canal.
Normal defecation is facilitated by flexion of the thigh which increases pressure in the abdomen and
a sitting position which increases downward pressure on the rectum. If the defecation reflex is
neglected or if defecation is deliberately inhibited by contracting the external sphincter muscles, the
urge to repeat defecation can result in the rectum expanding to accommodate a collection of faeces.
Defecation is caused by a defecation reflex, one of which is an intrinsic reflex mediated by the local
enteric nervous system in the wall of the rectum. It can be explained that when feces enters the
rectum, distension of the rectal wall initiates afferent signals that spread through the myenteric
plexus to generate peristaltic waves in the descending colon, sigmoid and rectum, pushing the feces
toward the anus. As the peristaltic wave approaches the intestine, the internal anal sphincter is
relaxed by inhibitory signals from the myenteric plexus; if the external anal sphincter is also awake
and voluntarily relaxed at the same time, defecation occurs.

a. Fisiologi Defekasi Defekasi adalah pengeluaran feses

dari anus dan rektum. Hal ini juga disebut bowel
movement. Frekwensi defekasi pada setiap orang
sangat bervariasi dari beberapa kali perhari sampai
2 atau 3 kali perminggu. Banyaknya feses juga
bervariasi setiap orang. Ketika gelombang peristaltik
mendorong feses kedalam kolon sigmoid dan
rektum, saraf sensoris dalam rektum dirangsang dan
individu menjadi sadar terhadap kebutuhan untuk defekasi. Defekasi biasanya dimulai oleh
dua refleks defekasi yaitu
● Refleks defekasi instrinsik Ketika feses masuk kedalam rektum, pengembangan dinding
rektum memberi suatu signal yang menyebar melalui pleksus mesentrikus untuk memulai
gelombang peristaltik pada kolon desenden, kolon sigmoid, dan didalam rektum. Gelombang
ini menekan feses kearah anus. Begitu gelombang peristaltik mendekati anus, spingter anal
interna tidak menutup dan bila spingter eksternal tenang maka feses keluar.
● Refleks defekasi parasimpatis Ketika serat saraf dalam rektum dirangsang, signal
diteruskan ke spinal cord (sakral 2 – 4) dan kemudian kembali ke kolon desenden, kolon
sigmoid dan rektum. Sinyal – sinyal parasimpatis ini meningkatkan gelombang peristaltik,
melemaskan spingter anus internal dan meningkatkan refleks defekasi instrinsik. Spingter
anus individu duduk ditoilet atau bedpan, spingter anus eksternal tenang dengan
sendirinya.Pengeluaran feses dibantu oleh kontraksi otot-otot perut dan diaphragma yang
akan meningkatkan tekanan abdominal dan oleh kontraksi muskulus levator ani pada dasar
panggul yang menggerakkan feses melalui saluran anus

Sherwood L. Intruduction to Human Physiology. 9th ed US: Cengage Learning. 2015 - Hall E J. Guyton
and Hall Textbook of Medical Physiology. 13th ed. US: Saunders. 2016

1. Kebiasaan buang air besar (BAB) yang tidak teratur

Salah satu penyebab yang paling sering menyebabkan konstipasi adalah kebiasaan bab yang tidak
teratur. Refleks defekasi yagn normal dihambat atau diabaikan, refleks refleks ini terkondisi untuk
menjadi semakin melemah. Ketika kebiasaan diabaikan, keinginan untuk defekasi habis. Anak pada
masa bermain bisa mengabaikan refleks refleks ini ; orang dewasa mengabaikannya karena tekanan
waktu dan pekerjaan. Klien yang dirawat inap bisa menekan keinginan buang air besar karena malu
menggunakan bedpan atau karena proses defekasi yang sangat tidak nyaman. Perubahan rutinitas
dan diet juga dapat berperan dalam konstipasi. Jalan terbaik untuk menghindari konstipasi adalah
membiasakan b.a.b teratur dalam kehidupan.

2. Penggunaan laxative yang berlebihan

Laxative sering digunakan untuk menghilangkan ketidakteraturan buang air besar. Penggunaan
laxative yang berlebihan mempunyai efek yang sama dengan mengabaikan keinginan b.a.b – refleks
pada proses defekasi yang alami dihambat. Kebiasaan pengguna laxative bahkan

memerlukan dosis yang lebih besar dan kuat, sejak mereka mengalami efek yang semakin berkurang
dengan penggunaan yang terus menerus (toleransi obat).

3. Peningkatan stres psikologi menghambat kerja peristaltic usus

Emosi yang kuat diperkirakan menyebabkan konstipasi dengan menghambat gerak peristaltik usus
melalui kerja dari epinefrin dan sistem syaraf simpatis. Stres juga dapat menyebabkan usus spastik
(spastik/konstipasi hipertonik atau iritasi colon). Yang berhubungan dengan konstipasi tipe ini adalah
kram pada abdominal, meningkatnya

jumlah mukus dan periode bertukar-tukarnya antara diare dan konstipasi.

4. Ketidaksesuaian diet

Makanan lunak dan rendah serat yang berkurang pada feses sehingga menghasilkan produk sisa
yang tidak cukup untuk merangsang refleks pada proses defekasi. Makan rendah serat seperti;
beras, telur dan daging segar bergerak lebih lambat di saluran cerna. Meningkatnya asupan cairan
dengan makanan seperti itu meningkatkan pergerakan makanan tersebut.

5. Obat-obatan

Banyak obat menyebabkan efek samping kponstipasi. Beberapa di antaranya seperti ; morfiin,
codein, sama halnya dengan obat-obatan adrenergik dan antikolinergik, melambatkan pergerakan
dari colon melalui kerja mereka pada sistem syaraf pusat. Kemudian, menyebabkan konstipasi yang
lainnya seperti: zat besi, mempunyai efek menciutkan dan kerja yang lebih secara lokal pada mukosa
usus untuk menyebabkan konstipasi. Zat besi juga mempunyai efek mengiritasi dan dapat
menyebabkan diare pada sebagian orang.

6. Latihan yang tidak cukup

Pada klien yang pada waktu yang lama otot secara umum melemah, termasuk otot abdomen,
diafragma, dasar pelvik, yang digunakan pada proses defekasi. Secara tidak langsung kurangnya
latihan dihubungkan dengan kurangnya nafsu makan dan kemungkinan kurangnya jumlah serat,
yang penting untuk merangsang refleks pada proses defekasi.

7. Umur tonus spinchter

Otot semakin melemah dan melemahnya tonus spinkter yang terjadi pada orang tua turut berperan
menyebabkan defekasi.

8. Proses penyakit

Beberapa penyakit pada usus dapat menyebabkan konstipasi, beberapa di antaranya obstruksi usus,
nyeri ketika defekasi berhubungan dengan hemorhoid, yang membuat orang menghindari defekasi;
paralisis, yang menghambat kemapuan klien untuk buang air besar; terjadinya peradangan pelvik
yang menghasilkan paralisis atau atoni pada usus. Konstipasi bisa jadi beresiko pada klien, regangan
ketika b.a.b dapat menyebabkan stres pada abdomen atau luka pada perineum (post operasi).
Ruptur merusak mereka jika tekanan cukup besar. Ditambah lagi peregangan sering bersamaan
dengan tertahannya napas. Gerakan ini dapat menciptakan masalah yagn serius pada orang dengan
sakit jantung, trauma otak, atau penyakit pada pernapasan. Tertahannya napas meningkatkan
tekanan intratorakan dan intrakranial. Pada beberapa tingkatan, tingkatan ini dapat dikurangi jika
seseorang mengeluarkan napas melalui mulut ketika regangan terjadi. Bagaimanapun, menghindari
regangan merupakan pencegahan yang terbaik

1. Irregular bowel habits (BAB).

One of the most common causes of constipation is irregular bowel habits. The normal defecation
reflex is inhibited or ignored, this reflex is conditioned to become progressively weaker. When the
habit is abandoned, the desire for defecation is exhausted. Children during play can ignore these
reflexes; adults neglect them due to time and work pressure. Clients who are hospitalized may
suppress the urge to defecate because they are embarrassed to use a bedpan or because the
defecation process is very uncomfortable. Changes in routine and diet can also play a role in
constipation. The best way to avoid constipation is to get b.a.b regular in your life.

2. Excessive use of laxatives

Laxatives are often used to relieve irregular bowel movements. Excessive use of laxatives has the
same effect as ignoring the urge to b.a.b - the reflex to the natural process of defecation is inhibited.
Even laxative user habits

require larger and stronger doses, since they experience diminishing effects with continued use
(drug tolerance).

3. Increased psychological stress

Strong emotions are thought to cause constipation by inhibiting intestinal peristalsis through the
action of epinephrine and the sympathetic nervous system. Stress can also cause spastic bowel
(spastic/hypertonic constipation or colon irritation). Associated with this type of constipation are
abdominal cramps, increasing

amount of mucus and periods of alternating between diarrhea and constipation.

4. Inadequate diet

Soft, low-fiber foods are reduced in the stool resulting in insufficient waste products to stimulate the
reflex in the defecation process. Eat low fiber such as; rice, eggs and fresh meat move more slowly in
the digestive tract. Increased fluid intake with such foods increases the movement of those foods.

5. Drugs

Many drugs cause constipation as a side effect. Some of them are like; Morphine, codeine, as well as
adrenergic and anticholinergic drugs, slow the movement of the colon through their action on the
central nervous system. Then, other causes of constipation such as: iron, has a shrinking effect and
acts more locally on the intestinal mucosa to cause constipation. Iron also has an irritating effect and
can cause diarrhea in some people.

6. Not enough exercise

In clients who for a long time the muscles are generally weakened, including the abdominal muscles,
diaphragm, pelvic floor, which are used in the process of defecation. Indirectly, lack of exercise is
associated with a lack of appetite and possibly a lack of fiber, which is important for stimulating the
reflex in the process of defecation.

7. Age

Muscles are getting weaker and the weakened sphincter tone that occurs in the elderly also
contributes to causing defecation.

8. Disease process

Several diseases of the intestine can cause constipation, some of which are intestinal obstruction,
pain when defecating associated with hemorrhoids, which makes people avoid defecation; paralysis,
which hinders the client's ability to defecate; Pelvic inflammation results in paralysis or atony of the
intestine. Constipation can be at risk for the client, strain when b.a.b can cause stress on the
abdomen or injury to the perineum (post surgery). Rupture destroys them if the pressure is great
enough. Plus stretching often coincides with holding your breath. These movements can create
serious problems in people with heart disease, brain trauma, or respiratory diseases. Retention of
breath increases intrathoracic and intracranial pressure. To some extent, this level can be reduced if
a person exhales through the mouth when a stretch occurs. However, avoiding strain is the best
prevention
Proses pembentukan feses

Formation Process

Stool

1. the first one, Chyme is mixed with digestive enzymes (bile & amylase) then a segmentation
process occurs
2. Then the haustral contractions occur which result in colonic absorption
3. then the stool collects in the Sigmoid (solid)

Setiawan, GW. 2015. Saluran Pencernaan Manusia. Sumatera Utara: USU. repository.usu.ac.i

1. anus closed

rectal ampulla

kohlraucsh fold

contraxed

puborectal muscles

circular musdes

relaxed

2. urge to defecate

strecth receptors

3. defecation

abdominal pressure

contracted

puborectal muscles relaxed

rectum shortens
1. anus tertutup

ampula rektal

lipatan kohlraucsh

kontradiksi

otot puborektal

musdes melingkar

santai

2. dorongan untuk buang air besar

reseptor strecth

3. buang air besar

tekanan perut

dikontrak
otot puborektal rileks

rektum menjadi lebih pendek