Constipation Flashcards
_____is the difficult passage of small hard
stools
Constipation
ROME Criteria for constipation
duration:
to be positive, fulfill?
12 weeks
> 2
ROME III Criteria
• infrequent passage of stools 25% of time
• sensation of incomplete evacuation >25% of time
• use of manual manoeuvres >25% of time
• sensation of ________
>25% of time
3/week
straining
anorectal obstruction/blockage
emphasis should be on the
_______rather than on the frequency
of defecation;
consistency of the stool
Constipation from infancy may be due to
_____
Hirschsprung disorder
______is the single most important factor in
preventing constipation
Diet
Unusually shaped stools (small pellets or ribbonlike)
suggest _____
irritable bowel syndrome
The ________ is far superior to the
rigid sigmoidoscope in investigation of the lower
bowel
flexible sigmoidoscope
MC cause of constipation
The commonest is ‘idiopathic’ constipation where
there is no structural or systemic disease. This is also
referred to as ‘functional’ constipation
Alarm Sx for constipation
- Recent constipation in >40 years of age
- Rectal bleeding
- Family history of cancer
In the Mx of constipation,
Ensure that the anthraquinone group of
laxatives, including_____, is never used
long term because they cause melanosis coli and
associated megacolon
‘Ford pills’
Three of the primary masquerades
are important causes of constipation, namely
______
drugs, depression and hypothyroidism
These drugs may be associated with
constipation, especially codeine and its derivatives,
___, ____ and ______
antidepressants, aluminium and calcium antacids
The metabolic causes of constipation include
1
2
3
hypothyroidism, hypercalcaemia and porphyria
Diabetes rarely can be associated with constipation
when an _______ can lead to
alternating bouts of constipation and diarrhoea.
autonomic neuropathy
Constipation may be a manifestation of an underlying
functional problem and psychiatric disorder, such
as
1
2
3
4
depression, anorexia nervosa, schizophrenia or
drug abuse
It is worth noting that 60% of polyps and
cancers will occur in the _______
and diverticular disorder should be evident with the
flexible sigmoidoscope
first 60 cm of the bowel
The presence of _____is an important
sign—it may give a pointer to the duration of the
constipation and the consequent chronic intake
(perhaps denied) of anthraquinone laxatives
melanosis coli
Labs for constipation work-up. What blood chem?
— thyroid function tests
— serum calcium
— serum potassium
— carcinoembryonic antigen (a tumour marker)
Radiological findings — CT colonography (virtual colonography) —\_\_\_\_\_\_\_\_\_ (especially for primary colonic disease, e.g. megacolon) — \_\_\_\_\_\_\_\_, using radio-opaque shapes taken orally and checking progress by abdominal X-ray or stool collection
double contrast barium enema
bowel transit studies
Physiological tests:
— \_\_\_\_\_\_\_\_—test anal tone — rectal sensation and compliance, using an \_\_\_\_\_\_\_\_\_ — \_\_\_\_\_\_\_\_\_, to determine disorders of defecation — Rectal biopsy, to determine \_\_\_\_\_\_
anal manometry
inflatable rectal balloon
dynamic proctography
aganglionia
__________or faecal incontinence is the
inappropriate passage of normal stool
encopresis
constipation is difficulty or delay in passing the
stool with incomplete emptying of the rectum:
this can present as _______, due to faecal retention
with overflow of liquid faeces (paradoxical
diarrhoea)
soiling
consider if stool hard and associated with pain or
bleedin
Anal fissure in infants
It is best to classify idiopathic constipation into three
subgroups:
1
2
3
1 simple constipation
2 slow transit constipation
3 normal transit constipation (irritable bowel
syndrome)
______or lazy bowel, is the term used to
describe a rectum that has become unresponsive
to faecal content, and this usually follows repeated
ignoring of calls to defecate
Dyschezia,
Pharma Tx of constipation
An appropriate choice would be one of the
hydrophilic bulk-forming agents such as ____
ispaghula or
psyllium.
What to avoid in the tx of constipation
Avoid stimulant laxatives except for short
sharp treatments.
Stimulant (irritant) laxatives examples
Sodium picosulfate
Anthraquinones: senna (Senokot/Sennetabs), senna with
dried fruits (Nu-Lax), sennosides A and B; cascara
Frangula bark (in Normacol Plus)
Castor oil
Triphenylmethanes: bisacodyl (e.g. Dulcolax); picsulfate
CX of fecal impaction
Complications include spurious
diarrhoea, faecal incontinence, bowel obstruction,
urinary incontinence or retention
Tx of fecal impaction
Treat with oral or osmotic
laxatives (e.g. 8 sachets of macrogol 3350 for 3 days
with or without rectal suppositories) or enema e.g.
Fleet Enema, Microlax.
• Commonest GIT malignancy
• Second most common cause of death from cancer
in Western society
• Generally men over 50 years (90% of all cases)
Colorectal cancer
Prognosis of colon CA
Good prognosis if diagnosed early
location of Colon CA
Two-thirds in descending colon and rectum
RF for colon CA
• Ulcerative colitis (long-standing)
• Familial: familial adenomatous polyposis (FAP),
hereditary non-polyposis colorectal cancer
• Colonic adenomata
• Decreased dietary fibre
Why is DRE impt in rectal CA
this is appropriate because
many cancers are found in the lowest 12 cm and
most can be reached by the examining finger
Cx of rectal CA in the rectum
If obstructing, there is a risk of rupture of the caecum.
Spread of colon CA
- Lymphatics → _______
- Direct → _________
- Blood → ______
epigastric and para-aortic nodes
peritoneum
portal circulation
Dx of choice for colon CA
CT colonography (investigation of choice)
Serum_____is not useful for diagnosis but is
useful for monitoring response to treatment
CEA level
_____ (if available) is useful for follow-up
PET scanning
If FOBT is positive—investigate by ____ or ____
colonoscopy
or by flexible sigmoidoscopy
An FOBT every_____ years is now recommended for all
people from 50 years
2
Colonoscopy recommendation for moderate risk COlon CA
• Moderate risk: every five years from 50 years or
10 years younger than when a family member
presented
Colonoscopy reco for high risk
• High risk: guided by clinical genetics team but as
a rule yearly or 2 yearly commencing at 25 years,
and every 12 months from 12–15 years of age if a
strong family history of FAP.
Criteria used for colorectal CA
Modified Dukes’ classification of colorectal
cancer
What is Modified Dukes’ classification of colorectal
cancer
A
B
C
D
A: Cancer limited to mucosa and submucosa
B. Cancer extends into muscularis or serosa
C. Cancer involves regional lymph nodes
D. Distant metastases (e.g. liver
5 year SR of diff stages of colon CA
A
B
C
D
88
70
43
7
ff up pts with colon CA
- CEA antigen
- colonoscopy
- abdominal imaging: ultrasound or CT scan of liver
DRE of Hirschprung
Rectal examination—narrow or normal rectum
Dx of Hirschprung
Abdominal X-ray/barium enema—_____
distended
colon full of faeces to narrow rectum
Dx of Hirschprung
Absent rectoanal reflex on ______
anal manometry
Tx of Hirschprung
Resect narrow segment after preliminary colostomy
• In older children and adults • Mainly due to bad habit • Can be caused by: — chronic laxative abuse — milder form of Hirschsprung disorder — Chagas disease (Latin America) 2 — hypothyroidism (cretinism) — systemic sclerosis
Acquired megacolon
DRE of acquired megacolon
Rectal examination—dilate loaded rectum, lax
sphincter
First-line treatment of functional constipation
(unresponsive to simple measures) is _______. An _______ is good second-line
therapy.
a bulking agent
osmotic laxative
Beware of ______ causing constipation in
the elderly patient on diuretic treatment
hypokalaemia
