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