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Year 3 > Constipation (GI) > Flashcards

Constipation (GI) Flashcards

1
Q

What is chronic constipation?

A

Polysymptomatic heterogeneous disorder

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2
Q

Define constipation.

A

Defecation that is unsatisfactory characterised by:

  • infrequent stools
  • difficult stool passage (straining/discomfort)
  • infrequent and/or difficult defecation (seemingly incomplete)
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3
Q

What is the difference between primary and secondary constipation?

A
  • primary constipation - disordered regulation of colonic and anorectal neuromuscular function + brain-gut neuro-enteric function
    • issues with the gut itself
  • secondary constipation - metabolic disturbances, medicines, neurological disorders, spinal cord lesions, primary diseases of the colon e.g. cancer
    • due to other conditions/exogeneous substances
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4
Q

What are some types of primary constipation? (3)

A
  • slow-transit constipation: inadequate defecatory propulsion caused by primary dysfunction of colonic smooth muscle (myopathy) and/or its innervation (neuropathy)
  • dyssynergic defecation: paradoxical contraction/inadequate relaxation of the pelvic floor muscles during attempted defecation, e.g. due to faulty toilet training, behavioural problems, or parent-child conflicts
  • irritable bowel syndrome-constipation: altered autonomic regulation, release of NTs e.g. serotonin or altered functions of gut receptors
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5
Q

What is rectocele?

A

Associated with constipation - prolapse where the supportive wall of tissue between the rectum and vaginal wall weakens

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6
Q

Which gender is constipation more common in?

A

F > M

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7
Q

What is primary constipation caused by?

A

Most commonly due to poor diet (lack of fibre) or dehydration and insufficient exercise

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8
Q

What is secondary constipation caused by? (8)

A
  • colorectal cancer
  • bowel obstruction
  • diverticulosis
  • diverticulitis
  • haemorrhoids
  • IBS
  • hypothyroidism
  • drug-induced (opioids) etc
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9
Q

What is the main clinical feature of constipation?

A

Passage of infrequent hard stools

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10
Q

What are the key diagnostic/clinical features of constipation? (5)

A
  • infrequent stools
  • difficult defecation
  • tenesmus - sense of incomplete evacuation
  • excessive straining
  • hard stools
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11
Q

What clinical features might be seen on examination of constipation?

A
  • abdominal mass (RLQ/LLQ) on palpation - may indicate secondary cause
  • anorectal lesions/abnormalities on DRE
  • relaxation of the external anal sphincter and/or puborectalis muscle, together with perineal descent on defecation manouevre - abnormal may suggest evacuation disorder e.g. dyssynergic defecation
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12
Q

What are some risk factors for constipation?

A
  • female
  • age>65
  • African ancestry
  • lower socioeconomic status
  • Fx
  • sedentary lifestyle
  • low fibre intake, inadequate calories/fluid (hardens stool, reduces transit)
  • surgical procedures + childbirth
  • medications - opiates, calcium channel blockers, TCAs (co-codamol commonly causes constipation as side effect)
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13
Q

What problem with the urinary system can constipation cause?

A

Outflow obstruction and trigger episodes of urinary retention in patients with enlarged prostates

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14
Q

What examinations do we conduct for constipation?

A
  • abdominal examination
  • digital rectal examination
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15
Q

What main investigation do we do for constipation?

A

Anal manometry to evaluate constipation or functional anorectal pain

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16
Q

What 1st line investigations are done for constipation?

A
  • microbiology: stool sample, quantitative faecal immunochemical test
  • bloods: FBC, TFTs, U&Es, blood glucose
  • imaging: abdominal x-ray
  • special tests: barium enema
17
Q

What does FBC show for constipation?

A

Secondary cause e.g. iron deficiency anaemia

18
Q

What can TFTs show for constipation?

A

Hypothyroidism

19
Q

What could abdominal x-ray show for constipation?

A

Rectal masses, faecal impaction

20
Q

What can barium enema show for constipation?

A
  • barium inserted via tube into intestine –> fluoresces on x-ray –> visualise structure of colon
  • faecal impaction, rectal masses
21
Q

What red flags could prompt further investigation (e.g. colonoscopy) for constipation? (9)

A
  • blood in stool
  • significant unexplained weight loss
  • Fx of colorectal carcinoma, IBD
  • iron deficiency anaemia
  • palpable abdominal mass
  • rectal prolapse
  • sudden onset of new change in bowel habit
  • persistent constipation despite treatment
  • reduced stool calibre
22
Q

What are some differential diagnoses for constipation?

A
  • anal fissure - rectal pain, bleeding, excessive straining
  • medicine-induced constipation - opiates, CCBs, antipsychotics
  • hypercalcaemia
  • hypothyroidism
  • diabetes mellitus
  • spinal cord lesion
  • colonic stricture
  • colon cancer
  • Parkinson’s
  • dehydration
23
Q

What lifestyle changes do we recommend for constipation? (3)

A
  • high fibre diet
  • increase fluid and caloric intake
  • exercise
24
Q

What medications can we give for constipation and what types are there?

A
  • bulk laxatives & stool softeners - preferred (bulk laxatives produce gas, stool softeners = bitter taste, nausea, diarrhoea, cramping)
  • osmotic laxatives e.g. lactulose, polyethene glycol compounds, magnesium containing laxatives (–> bloating, diarrhoea, pain, flatulence, N&V)
  • stimulant laxatives e.g. senna, bisacodyl - if persistent symptoms after 6wk osmotic laxatives
  • prunes - natural alternative to laxatives
25
Q

How do we treat opioid-induced constipation?

A
  • 1st line: review opioid use + osmotic/stimulant laxative
  • 2nd line: peripherally acting mu-opioid receptor antagonist (e.g. methylnaltrexone)
  • 3rd line: lubiprostone
26
Q

How do we treat not opioid-induced constipation with symptoms <3 months?

A
  • 1st line - treatment of any identified underlying cause
  • consider bulk/fruit-based laxatives and/or stool softener
27
Q

How do we treat not opioid-induced constipation with symptoms >3 months?

A
  • 1st line - treatment of any identified underlying cause
  • 2nd line - osmotic and/or stimulant laxative
  • 3rd line - guanylate cyclase-C agonist/lubiprostone/prucalopride/vibrating capsule
28
Q

How do we treat dyssnergic defecation constipation?

A

Biofeedback

29
Q

What are some complications of constipation?

A
  • anal fissure (forceful expulsion of hard stool = trauma and injury)
  • haemorrhoids (excessive straining –> damage)
  • faecal impaction
  • rectocele (anterior bulging of rectal wall towards vagina)
  • faecal seepage
  • overflow diarrhoea
  • acute urinary retention
30
Q

What is the prognosis of constipation like?

A

Medical therapy is fairly effective in relieving constipation symptoms

Year 3 (22 decks)

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