Constipation 🚽

Question 1

What are the causes of constipation?

Answer 1

Causes:
1. Low fiber diet: Most common

2. sedentary lifestyle
3. lumen : obstruction as polyps, cancer, fissure, hemorrhoids
4. colonic motility: can be inhibited by hypothyroidism,hypokalemia, HYPERcalcemia ,scleroderma,DM, MS, Parkinson’s, paraplegia also medications as CCB ( verapamil) narcotics, anticholinergics
5. nerve or muscle defect
6. Neurologic disorder : Parkinson’s, MS, paraplegia, pelvic surgery, DM, IBS, colonic mass, hirschbrung disease
7. medication : CCB, anticholinergic as ( tricyclics antidepressant) opiates, antacids, clonidine, ferrous sulfate diuretic, laxatives abuse, levodopa
8. metabolic abnormalities : hypothyroidism, hypokalemia, hypercalcemia, amyloidosis, scleroderma, pregnancy
9. IBS
10. congenital disorder like hirschsprung disease
11. rectal ; fissure, hemmoroids etc.

Question 2

How to diagnose the cause for constipation

Answer 2

In young ptn with reasonable explanation from H & Examination management is done without further testing.

lab test include : CBC , electrolytes, TSH, calcium level ,

• Abd. X-rays are of limited values unless obstruction or fecal impaction is suspected
• flexible sigmoidoscopy + barium enema or colonoscopy used to detect stricture,masses ect.
• full colonoscopy only needed in cancer suspensions
• Anoscopy for fissure and internal hemmoroids

Question 3

How to treat constipation?

Answer 3

TTT💊
1. Should increase water & fiber intake

2. Toilet Training 10-15 min.
3. if the above failed you can give medication
   💊💊💊
   * Bulk agents : side effects; bloating , impaction above stricture
4. Psyllium ( Metamucil)
5. methylcellulose ( citrucel )
6. calcium polycarbophil ( fiberCon)

• Softeners
  1. Docusate sodium ( Colace ) 1-2 capsules / side effects; skin rash , hepatotoxicity
• Stimulants : Chronic use may cause melanosis coli and constipation
  1. ( Dulcolax ) bisacodyl / side effects: gastric or rectal irritation
  2. senna ( senokot ) ➡️ Degeneration of myoneural plexuses
  3. casanthranol ( peri- colace) 1-2 tablet ➡️ Same
• Osmotic :
  1. lactulose ( cephulac ) ➡️ bloating
  2. magnesium contraindicated in RENAL FAILURE
  3. sorbitol 70% ➡️ bloating

Enemas & suppository;
Warm water enema works best for bedridden ptn, stool impaction, sever idiopathic constipation , surgery,

Question 4

What’s Hirschsprung disease?

Answer 4

Absence of ganglion cells in bowel wall ( beginning at internal anal sphincter and extending variably proximally )

• diagnosis;
  Do CT to exclude masses and to confirm dilation in blowel
  rectal manometry ( not used nowadays) , rectal suction biopsy is definitive
  💊

Do fecal impaction for quick relief , NPO and attach NGT and
Surgical ( most with temporary colostomy and wait 6-12 month for definitive correction ) most achieve continence

Complications; enterocolitis

Question 5

What is the most common cause of lower GI bleeding in ptn > 40 years?

Answer 5

Diverticular disease

Question 6

How to diagnose Diverticular disease?

Answer 6

1. History
2. CBC shows
3. CT scan in diverticulitis will show inflammation or abscess
4. Colonoscopy for definitive diagnosis ( avoid it in ptn with early diverticulitis because of risk of perforation)