Constipation Flashcards
Constipation Definition
- Fewer than three bowel movements per week
- hard stools requiring excessive straining to pass
- and/ or sensation of incomplete emptying after defecation.
Constipation Classified as
- Functional (primary)
slow-transit constipation (colonic dysmotility)
normal transit constipation
obstructed defecation syndrome
(pelvic floor dysfunction, rectal hyposensitivity, organ prolapse, internal intussusception). - Secondary chronic constipation
related to medications and/ or medical conditions (neurologic or endocrine problems, irritable bowel syndrome)
Infrequent hard stools refer more to cases of
colonic dysmotility
incomplete evacuation and straining
pelvic floor dysfunction and obstructed defecation syndrome
Abdominal pain that alleviates after defecations
may indicate irritable bowel syndrome
Investigations
Colonoscopy
> Rule out masses or strictures
Labs
> rule out Thyroid , parathyroid, DM and others
Sitz Marker Study (Radiopaque Marker Study)
A normal test
> day 5, at least 80% of the markers have passed.
- In cases when more than 20% of the markers are still observed in the colon > abnormal.
- Slow-transit constipation > markers are distributed throughout the colon
- retained markers in the rectosigmoid colon > obstructed defecation.
Defecography
used to rule out associated pathologies such as
rectoceles or intussusceptions and nonrelaxing puborectalis
Anorectal Physiology Testing
ARM :
- measuring resting and squeeze pressures
- rectal volume sensation
- rectoanal inhibitory reflex
- balloon expulsion
electromyography (EMG)
- evaluating proper puborectalis contraction and relaxation.
First Line Tx
- first line of treatment
patient education
diet modifications
increase fiber and water intake
Behavioral education > toilet habits (straining, time spent sitting on the toilet, etc.).
Then > Osmotic laxatives
(polyethylene glycol, magnesium hydroxide, and lactulose)
Short-term use of stimulant laxatives (bisacodyl) is recommended.
Newer alternatives such as
lubiprostone and linaclotide should be reserved for cases when fiber and water intake is adequate and osmotic and stimulant laxatives have failed.
constipation due to pelvic floor dyssynergia.
Biofeedback therapy
Algorithm of the management of constipation.
see
Colonic dysmotility + nonoperative measures have failed
Total abdominal colectomy with creation of an ileorectal anastomosis (TAC-IRA) > the procedure of choice
Things to do before Surgery
- Upper gastrointestinal dysmotility problems must be ruled out (Decrease Recurrence)
- Evaluation of the anal sphincter > ARM testing
when physical exam > low sphincter tone or poor squeeze effort (Decrease Diarrhea and incontinence)
Colonic slow-transit constipation, ARM testing may identify an additional component of pelvic floor dysfunction.
Treated with biofeedback before subtotal colectomy (TAC-IRA) > High rates of Constipation
if rectal intussusception or a rectocele/ enterocele is identified on defecography
Repair of the outlet obstruction may be necessary before or at the same time of TAC-IRA.
anastomosis should satisfy the principles of
being free of tension
well vascularized
with a confirmed negative leak test.
Division of the bowel is performed with a laparoscopic linear stapler at the level of
the terminal ileum proximally and at the conversion of the taenia at the rectosigmoid junction.
other surgical options, what is the benefit ?
side-to-side cecorectal anastomosis
and
antiperistaltic cecorectal anastomosis with subtotal colectomy.
The benefit of a subtotal total colectomy with cecorectal anastomosis (Jinling procedure) is the resolution of the obstructive defecation symptoms with less likelihood of consequence diarrhea due to preservation of the ileocecal valve
Most patients undergoing IPAA have undergone an abdominal TAC-IRA and present with
recurrent symptoms of constipation.
IPAA will not be first line
When to do Diverting Ileostomy
- Reserved as a last resort in patients in whom all other alternatives have failed (up to 25% of cases),
- Those with associated fecal incontinence
- or those deemed poor surgical candidates
Preferred for :
- Colonic slow-transit constipation.
- It allows symptomatic relief while offering information about the function of the upper gastrointestinal tract.
- helpful in cases such as global gastrointestinal dysmotility disorders.
Indications for Rectocele Repair
only large (> 4 cm) symptomatic rectoceles
or those in which nonoperative treatments have failed are offered surgical repair.
What is Rectoceles
the result of an abnormal rectovaginal fascia, typically caused by obstetric trauma.
Which method of repair is Better
- The authors prefer transvaginal repair
> simple technique
better access to the endopelvic fascia and levator muscle
fewer complications such as infection and fistula formation because it does not violate the rectal mucosa.
Colostomy Creation
outlet obstruction constipation who are not compliant or have failed nonoperative therapy, or those are not candidates for other available treatment options, a colostomy can be considered.
If workup reveals a normal colonic transit, a descending colostomy is generally a good alternative with much less morbidity than ileostomies.
ADULT HIRSCHSPRUNG’S DISEASE
- adult patients with constipation symptoms since childhood
- poor or no response to treatment,
- Hirschsprung’s disease > caused by the congenital absence of submucosal and myenteric ganglion cells
- confirmed by biopsy of the affected bowel segment.
what findings during ARM is pathognomoni for it ?
- absent rectoanal inhibitory reflex
surgically managed with :
Duhamel’s, Swenson’s, myectomy, Soave’s, and low anterior resection.
