Constipation & Chronic Diarrhea Flashcards
What is Constipation
Rome IV Criteria
Bristol Stool Form Scale
- constipation is subective….
Rome IV Criteria : Constipation
- symptoms present for > 3months and began > 6 months before the dx.
- 2 + of the following…
1. more then 25% of defication = straining
2. more thatn 25% of defication has lumpy or hard stools
3. leaves pt. with incompletel sensation
4. feelings of obstruction
5. needing manuveurs to facilitate the process
6. fewer than 3 BM spontaneously during the week
7. loose stool nots happening without laxitives
pt does NOT meet IBS criteria
Bristol Stool Form Scale
Tpye 1: seperate hard lumps: rabbit poop
Type 2: sausage shaped but lumpy
Tpye 3: sausage with cracks on surface
Type 4: sausage snake and smooth
3 and 4 are normal
type 5: soft blobs with clear edges (lack of fiber)
Type 6: fluffy with edges and mushy
Type 7L watery , no solid
History Taking for Constipation
Red Flag symptoms
PE for constipation
History Taking
- define nature and duration of teh constipation
- try to idetnify secondary sourse (ROS)
- medical history
- diet, travel, recent sickness/surgery, psychosocial
Red Flags
- hematochezia (bright red blood stool)
- weight loss
- fam. hx. of colon cancer or IBD
- anemia
- Postive fecal occult blood test
- acute onset in elderly
PE: Rectal Exam
- fissures
- hemorrhoids
- anal opening
- feeling: masses, stool, strictures, tenderness
- sphincter tone
Causes of Chronic Constipation
Causes
1. Neurogenic: DM, neuropahty, cahgas, hirschprung, MS, spinal cord injurt, parkinsons
2. IBS
3. hypothyroid
4. hypokalemia
5. anorexia nervosa
6. pergnancy
7. sclerosis
8. slow colonic transit
9. idopathic
Medications
- anticholenergics
- antidepressants
- iron suppls.
- barim
- opiates!!!
- atnihypertensives
- CCBs
- 5HT antagonists (seritonin speeds up GI)
Work Up and Diagnosis of Constipation
colonscopy
sigmoidoscopy
colonic transit
Tests
- anorectal manometry: measure pressures
- balloon expulsion test: see if they can expel balloon
- +/- MRI or Xray : to see if it moves through
Labs
- CBC
- BMP
- FOBT
- thyroid
- radiography (xray)
- endoscopy
Colonscopy:
- visualize entire colon and to the terminal ileum
- expensive
- risky
- complications: under anesthesia, performation, hemorrhage
Sigmoidoscopy:
- visulaize and bx. to the sigmoid colon only
- enough to dx. usually
- cheaper, less risk
- still can perf the colon
Colonic Transit Study: helpful with those with infrequent stools
- helps understand normal from impaired transit time
- CCT: swallow radioactive capsules and track process through the gut
- normal: 20-56 hours: 4-5 days to clear; see < 20% of the rings at 5 days is normal
- Colonic inertia: delayed passage in proximal colon; normal defication or normal resting oclon, but no increase in movement when meals are happening
can signal nerve issues = surgery
outlet delay: marker move through colon okay, but stop in the rectum
- seen in hisrschsprungs disease, megarectuam
- treatm with suppositories or botx
Anorectal and Pelvic Floor Tests in Constipation
peliv floor dysfunction: inability to evaculate, rectal fullness, pain, digital impaction or pressure inside vaginal canal
- test: have patient strain to expel the finger during DRE
Assessment of the puborectalis muscle
- when sitting: should be pulling on rectum to inhibit defication
- when squatting: relaxes to allow rectum to straighten
Management of Constipation
- fiber
- laxitive classes
1: patient education & identification of the underlying condtion
then…
1. changes in diet and behaviors (increase fiber, fluid and activity)
2. bulk forming laxitives
3. enemas or non bulk laxitives
4. osmotic laxitives
5. stimulant laxitives
Fiber
- bulks stool : want 20-35g daily
- raw bran with water
- blatoing and distension possible
Bulk Forming Laxitives
Bulk Forming Laxitives
- Psyllium, methylcellulose, calcium polycarbphil, wheat dextrain (OTCs)
- absorbs water and increase fectal mass
- softens stool to pass and increase frequency
Surfactant
Surfactnat: a stool softener
- Docusate Sodium
- stool softener: lowers surface tensions of stool: increases water into stool
- cheap, less effective
Osmotic Agents
Osmotic Agents
- polyethylene glycol, nonabsorbale sugar, saline laxitives
- cause intestinal water secretion
- increase the frequency of stools
- caution in renal and cardaic pts.: electrolyte abnormalities
- saline laxitives: MOM, mag citrate
Stimulant Laxitives
Stimulant laxitives
- biscodyl, senna, sodium picosulfate
- alteres electrolyte transport in teh mucosa
- increases intestinal motility
- chronic use: hypokalemia, protein loss and salt overload
- cramping side effect
Management of Refractory Constipation
Suppositories
- liquify the stool; indicated for dysfunction defication
Disimpaction
- manual fragmentation; mineral oil enema
Biofeedback
- can correct pelvic floor isses of sphincters
Botox
- into pubisrectalis
Criteria for a Colectomy procedure in the frame of constipation
- chronic, severe disabling symptoms
- slow colonic transit (through the studies)
- no intestinal obstrution
- no peliv floor issues
- no abdominal pain
good for hirschsprungs disease
Chronic Diarrhea
- definition
- Etiology
- history specifics
Definition = a decrease in fecal consistency lasting for 4+ weeks
Etiology
- secretory diarrhea
- osmotic diarrhea
- inflammatory diarrhea
- fatty diarrhea (steatorrhea)
- dysmotility diarrhea
- factitial diarrhea
History Specifics
- onsetn, pattern, duration and timing
- travel? sickness?
- type of stools, pain
- hisotry of IBS/IBD
- family history of cancers
- assocaited symptoms
- medications
Chronic Diarrhea
Work up
Labs
- CBC
- ESR, CRP
- TSH
- electrolytes
- hepatic function
- protein and albumin
- FOBT
- stool culutres
- celiac testing
- endoscopt: bx.
Stool Analysis
- lax. screen
- fat
- WBC
- pH
- blood
- osmotic gap
- electrlytes
- weight
Secretory Diarrhea
etiology
symptoms
treatment
due to abnormal fluid and electrolyte balance
Symptoms
- LARGE VOLUME, watery diarrhea ( > 1 liter daily)
- painless diarrhea day and night
Causes
- medications (MC)
- bowel secetion, disease of mucosa
- fistula
- hormones (tumors!)
- congential defects
Diagnosis
- exclude structural disease via imagin, endoscopy & biopsy
Treatment
- bile-acid binder
