CONSTIPATION

AHMAD AMINUDDIN

CONSTIPATION

CONSTIPATION IS A COMMON COMPLAI IN CLINICAL PRACTICE AND USUALLY REFERS TO PERSISTENT, DIFFICULT, INFREQUEN OR SEEMINGLY INCOMPLETE DEFECATION

CONSIDERATION
MOST PATIENT HAVE AT LEAST THREE BOWEL MOVEMENT PER WEEK, EXCESSIVE STRAINING, HARD STOOLS, LOWER ABDOMINAL FULLNESS AND A SENSE OF INCOMPLETE EVACUATION. PSYCHOSOCIAL FACTORS CONSTIPATION OR DIFFICULTY WITH DEFECATION

CAUSES

PATHOPHYSIOLOGICALLY, CHRONIC CONSTIPATION GENERALLY RESULT FROM INADEQUATE FIBER INTAKE OR FROM DISORDERED COLONIC TRANSIT OR ANORECTAL FUNCTION AS A RESULT OF A NEUROGASTROENTERO- LOGIC DISTURBANCE, CERTAIN DRUGS OR IN ASSOCIATION WITH A LARGE NUMBER OF SYSTEMIC DISEASES THAT AFFECT THE GASTROINTESTINAL TRACT

CAUSES OF CONSTIPATION

RECENT ONSET - Colonic obstruction - Neoplasm - Stricture ; ischemic, diverticular, inflamatory. - Anal sphincter spasm - Anal fissure. - Painful hemorrhoids. - Medication

CAUSES OF CONSTIPATION

CHRONIC - Irritable bowel syndrome - Constipation predominat, alternating. - Medication - Ca blockers, antidepressants. - Colonic pseudo-obstruction - Slow colonic constipation, megacolon. - Disorders of rectal evacuation - Pelvic floor dysfuction, anismus, descending perineum syndrome, rectal mucosal prolapse

CAUSES OF CONSTIPATION

CHRONIC - Endocrinopathies - hypothyroidism, hypercalcemia, and pregnancy. - Psychiatric disorders - depression, eating disorders and drugs. - Neurologic diseases - Parkinsonism, multiple sclerosis, spinal cord injury. - Generalized muscle disese - progresive systemic sclerosis.

APPROACH TO THE PAIENT

A CAREFUL HISTORY EXPLORE THE PATIENT S SYMPTOM AND CONFIRM WETHER HE OR SHE IS INDEED CONSTIPATED; - FREQUENCY. - CONSISTENCY. - EXCESSIVE STRAINING. - PROLONGED DEFECATION TIME. - NEED TO SUPPORT THE PERINEUM OR DIGITATE THE ANORECTUM.

PHYSICAL EXAMINATION

DIGITAL RECTAL EXAMINATION -anal sphincter, rectocele,rectal prolapse or perineal descent during straining. SIGMOIDOSCOPY PLUS BARIUM ENEMA OR COLONOSCOPY ALONE. - rectal bleeding or anemia with constipation. COLONIC RADIOGRAPH LABORATORY STUDY - complete blood count - serum electrolytes - calcium - glucosa - TSH.

INVESTIGATION OF SEVERE CONSTIPATION

NORMAL COLONIC TRANSIT TIME IS APPROXIMATELY 35 HOURS, MORE THAN 72 HOURS IS SIGNIFICANTLY ABNORMAL. MEASUREMENT OF COLONIC TRANSIT - RADIOPAQUE MARKER TRANSIT TEST - RADIOSCINTIGRAPHY WITH A DELAYED- RELEASE CAPSULE CONTAINING RADIO-LABELLED PARTICLES.

INVESTIGATION OF SEVERE CONSTIPATION

ANORECTAL AND PELVIC FLOOR TEST - PELVIC FLOOR DYSFUNCTION - inability to evacuate the rectum. - rectal pain. - the need to extract stool from the rectum digitally. - application of pressure on the posterior wall of the vagina. - support the perineum during straining. - excessive straining. - DIGITAL RECTAL EXAMINATION

INVESTIGATION OF SEVERE CONSTIPATION

ANORECTAL AND PELVIC FLOOR TEST - DIGITAL RECTAL EXAMINATION motion of the puborectalis muscle posteriorly during straining indicate proper coordination of the pelvic floor and puborectalis. - MEASUREMENT OF PERINEAL DESCENT

INVESTIGATION ..

ANORECTAL AND PELVIC FLOOR TEST - MEASUREMENT OF PERINEAL DESCENT - patient in the left decubitus position. - watching the perineum to assess; - pacuity or lack of descent < 1,5 cm is pelvic floor dysfunction. - perineal balloning during strain relative to bony landmark, > 4 cm suggesting excessive perineal descent.

ANORECTAL ND PELVIC FLOOR TEST

THE BALLON EXPULSION TEST - URINARY CATHETER IS PLACED IN THE RECTUM. - THE BALLON IS INFLATED TO 50 ml WITH WATER. - WHETHER THE PATIENT CAN EXPEL IT ; - seated on toilet. - lateral left decubitus.

ANORECTAL AND PELVIC FLOOR TEST.

DEFECOGRAPHY - A DYNAMIC BARIUM ENEMA INCLUDING LATERAL VIEWS OBTAINED DURING BARIUM EXPULSION REVEAL - RECTOANAL ANGLE. - ANATOMIC DEFECTS OF THE RECTUM. - ENTEROCELES OR RECTOCELES.

TREATMENT OF CHRONIC CONSTIPATION

DIETARY AND LIFE STYLE MEASURES - Adverse psychosocial issies should be identified should be instructed in ; - normal defecatory function. - optimal toileting habits. - Proper dietary fiber intake should be emphasized. Fiber is most likely to benefit patient with normal colonic transit. - Regular exercise.

TREATMENT OF CHRONIC CONSTIPATION

LAXATIVE 1. OSMOTIC LACXATIVES Magnesium hydroxide - 15 30 ml orally, once or twice daily - onset of action 6 24 hours. Lactulose or 70% sorbitol - 15 60 ml orally once to three time daily - onset of action 6 48 hours. Polyethylene glycol - 17 g in 8 oz liquid, once or twice daily - onset of action 6 24 hours 2. STIMULANT LAXATIVES

TREATMENT OF CHRONIC CONSTIPATION

2. STIMULANT LAXATIVES - Stimulate fluid secretion and colonic contraction, resulting in a bowel movement within 6 12 hours after oral ingestion or 15 60 minutes after rectal administration. - Oral agents are usually administered once daily of bedtime.

STIMULANT LAXATIVE

BISACODYL 5 20 mg orally, onset of action 6 -8 hours. BISACODYL 10 mg per rectum, onset of action 1 hour. CASCARA 4 8 ml or 2 tablets, onset of action 8 12 hrs SENNA 8,6 17,2 mg orally, onset of action 8 -12 hrs