Constipación + Fecaloma Flashcards
Constipación crónica. Prevalencia.
Highly prevalent ailment in Western society, afflicting from 15% to 20% of adults,of whom 33% are over the age of 60 years, with a notably female predominance.
CC. Definición.
Syndrome characterized by intestinal symptoms that require a high level of medical attention, in most cases, it is not life threatening or debilitating for the patient; however, it has a significant effect on quality of life, particularly in chronic cases.
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Other anatomical disorders that may alter intestinal transit should be excluded, mainly in cases of recent-onset or unexplained constipation, constipation with anal bleeding and/or unexplained weight loss, and altered intestinal habits in the elderly population.
CC. Clasificación.
→Primaria.
→Secundaria.
CC. Primaria.
→Entity in which the cause of constipation cannot be identified from the clinical history and physical examination.
→May be further classified as: normal transit constipation (NTC); slow transit constipation (STC), colonic inertia; outlet obstruction or pelvic floor dysfunction; and combined causes (slow transit constipation and pelvic floor dysfunction).
CC. Secundaria.
→Constipation for which the clinical assessment and workup identifies intestinal or extra-intestinal abnormalities, metabolic or hormonal factors and medications as responsible for the defecatory disturbances.
•Intestinal: tumors, diverticulitis, inflammatory strictures, ischemia, volvulus, endometriosis, postoperative strictures, anal fissure, thrombosed hemorrhoids, mucosal prolapse, ulcerative proctitis.
•Medication-induced: Antidepressants, antiepileptics, antihistamines, antispasmodics, anticholinergics, calcium channel blockers, calcium and iron supplements, and non-hormonal anti-inflammatories.
• Metabolic diseases: Hypothyroidism, hypoparathyroidism, hypercalcemia, hypokalemia, hypomagnesemia, diabetes mellitus, uremia, and heavy metal poisoning.
• Neuropathies: Medullar lesions or neoplasia, cerebrovascular disease, multiple sclerosis, autonomic neuropathy, and Parkinson’s disease.
• Myopathies: Amyloidosis and scleroderma.
• Other conditions: Chagas disease, cognitive impairment, immobility.
CC. Clinica.
→Criterios Roma IV.
→The medical history of patients with constipation should be analyzed along with fecal consistency, defecatory frequency, straining when defecating, digital maneuvers, sensation of incomplete evacuations, pain and abdominal discomfort, laxative use, surgical history, comorbidities, lifestyle, diet and occupation.
→Heces Bristol 1 (quizás 2). Diarios fecales ah.
→DRE + tacto vaginal.
→Identification of alarming features such as hematochezia, significant weight loss, a family history of cancer, anemia, anal bleeding and alterations in intestinal behavior that indicate the need for colonoscopy and/or radiological examination to rule out secondary causes of constipation.
Estudios.
→Fecal, radiological or endoscopic examinations in constipation without alarming features is not routinely
indicated.
→Blood tests: include a complete blood count, serological test for Chagas disease (for patients in endemic areas), serum calcium, thyroid, parathyroid and renal function tests, fasting blood glucose levels, and potassium and magnesium levels. These examinations should be ordered mainly in clinically suspicious cases and not as routine investigations.
→Barium enema: may be recommended to identify colorectal diseases (diverticular disease, neoplasia, and megacolon) although currently, the test is less frequently used.
→Manometría anorrectal.
→Videodefecografía con RMN o ECO.
→Tiempo de transito colónico (CTT). no outlet obstruction.
→Test de expulsión de balón (<2 min normal). outlet obstruction.
→Electromyography of the anal sphincter (EMG).
→Hydrogen breath test.
Control en casos sin mejoría.
A complementary workup to investigate constipation should be conducted 12 weeks after clinical treatment, in persistent cases or following a lack of success with dietary measures and functional readjustment.
Tratamiento Medico.
→25 a 30 gr/día de fibra soluble. →Mucha agua. →Ejercicio. →Evitar pujos y estar mucho rato en el inodoro. →Laxantes.
Tipos de laxantes.
→Estimulantes (senna, cascara buckthorn, bisacodyl,
sodium picosulfate and anthraquinone derivatives, acción: 6 a 12 hs) y osmóticos (PEG, Lactulosa).
→Formadores de materia fecal (psyllium, methylcellulose and polycarbophil).
→Prokinetic pharmaceuticals such as Tegaserod (a 5-HT4 agonist) and Prucalopride (a highly selective 5-HT4 receptor agonist, dosis: 2-4 mg) act to increase peristalsis, thereby accelerating gastrointestinal transit.
→ Probióticos (no hay evidencia).
→Enemas or suppositories may be used in select cases (e.g., those with psychogenic megacolon) or fecal impaction, in which the initial measures (fiber, fluids and laxatives) were ineffective.
→Transanal irrigation stimulates the rectum and hydrates the feces, allowing intestinal discharge. The use of these methods should be limited to brief periods, and the agents may be composed of sodium phosphate or vegetable oils.
→Other drugs stimulate the secretion of fluids by the intestine (Lubiprostone and Linaclotide), thereby increasing the fecal water content. Lubiprostone.
→Modulation of biliary acids: Elobixibat.
Tratamiento de disfunción pelviana (DD).
Biofeedback.
This approach is recommended for children over 6 years of age and adults. Biofeedback therapy with the aim of training patients to relax the pelvic floor during defecation is appropriately recommended for the treatment of patients with symptoms of pelvic dysfunction. Success 40 a 90%. Resultados inician en 6 semanas.
Cirugía.
→STC (refractaria): may benefit from subtotal colectomy with ileorectal anastomosis; full colectomy with ileorectal anastomosis.
→DD (outlet obstruction): the principal indications for the surgical treatment of constipation by obstructed defecation syndrome are rectocele, enterocele, sigmoidocele and prolapse with the appropriate surgical option assessed for each case individually.
