Constipation/Zenker diverticulum Flashcards

1
Q

Constipation

general

A

Infrequent, irregular, or difficult evacuation of the bowels
Common reason for seeking medical attention
Acute (≤ 12 weeks) or chronic (> 12 weeks) presentation
Occurs in 15% of adults and 1/3 of elderly patients
♀>♂

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2
Q

constipation

etiology

A

Primary (Idiopathic or Functional) constipation
Not attributed to any structural abnormalities or systemic disease; 3 subtypes

Secondary constipation
Caused by systemic disease, medications, or obstructing colonic lesions

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3
Q

constipation

common causes

A

Inadequate fiber or fluid intake
Poor bowel habits
Physical inactivity

Systemic disease/disorders
Hypothyroidism, hypercalcemia, paraplegia

Medications
Opioids, diuretics, iron

Structural abnormalities
Slow colonic transit
Normal colonic transit is ~35 hours

Primary mechanisms that cause constipation:
Altered stoolconsistency
Altered bowelmotility

bold = primary cause

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4
Q

defecation

Mechanism

A

Colonic mass movements/peristalsis move intestinal contents distally into the rectum
Rectal filling activates mechanoreceptors in the rectal wall causing awareness of the need to defecate
A small amount is allowed to pass through to the anal canal by an involuntary relaxation of the internal anal sphincter (rectoanal inhibitory reflex) → determine if the rectal contents is gaseous, solid, or liquid form
Abdominal muscles contract and a Valsalva maneuver is performed while simultaneously relaxing the external anal sphincter and puborectalis muscle (pressure gradient generated between the rectum and anal canal expels the feces)

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5
Q

Constipation

S/Sx

A

Infrequent bowel movements (< 3/week)
Hard stools
Excessive straining
Sense of incomplete evacuation
Bloating
Abdominal cramping or pain
Tenesmus
Overflow diarrhea

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6
Q
A

Bristol Stool Chart
Diagnostic medical tool designed to classify the form of human feces into seven categories

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7
Q

constipation

diagnosis and HPI

A

Based on a complete history and physical examination to include a digital rectal examination (DRE)

History
Stool frequency, consistency, and color
Length of time for a bowel movement
Use of laxatives or enemas
Review prescription medications

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8
Q

constipation

When is additional testing recomended?

A

Additional testing for:
Age >50 years
Severe constipation

Alarm symptoms:
Hematochezia
Weight loss
+ FOBT (fecal occult blood test)
Inadequate response to empiric therapy

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9
Q

Approach to Management

with red flag features

A

Order colonoscopy or flexible sigmoidoscopy and biopsy to rule out colorectal cancer

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10
Q

Approach to Management

without red flags

A

Assess for secondary causes of constipation
CBC with differential, serum electrolytes, calcium, glucose, and TSH
Review medications

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11
Q

approach to management

for constipation with inadequate response to empiric therapy

A

Anorectal manometry and a balloon expulsion test
or
Colonic transit study

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12
Q

anorectal manometry amd a balloon expulsion test

A

Measure pressures inside the rectum and anus and the ability of the pelvic muscles to expel stool from the rectum
Abnormal results → defecatory disorder

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13
Q

colonic transit studies

A

Patients swallow radiopaque markers, which are then tracked through the gastrointestinal tract using x-rays
Differentiate between slow and normal transit constipation
Normal transit constipation → a disorder of the gut-brain axis

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14
Q

constipation Tx

Dietary and lifestyle measures

A

Increase dietary fiber (20-35 g/day)
Regular exercise
Increase intake of water (2L/day if not on water restriction)
Decrease constipating agents, such as dairy products, coffee, tea, and alcohol

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15
Q

constipation Tx

Pharm

A

Discontinue medications linked to constipation

Pharmacotherapy
Laxatives: fiber, osmotic, or stimulant laxative

Suppositories

Stool surfactants: Colace, mineral oil

Enemas: warm water, sodium phosphate, milk of molasses

Acute purgative/clean bowel prep: polyethylene glycol (PEG), magnesium citrate
Opioid-receptor antagonists

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16
Q

complications

Anal fissures

A

Passage of hard, lumpy stools causes a tear in the anoderm
Leads topainful defecationand rectal bleeding

17
Q

complications of constipation

Hemorrhoids

A

Due to excessive straining with hard, lumpy stools
Leads to rectalpain, itching, and/or bleeding

18
Q

complications

Fecal incontinence

A

Chronic constipation → formation of ahard stool mass→ progressive distention of the anal sphincter complex → patient no longer feels urge to defecate
Soft or liquid stool begins to seep around the obstructing stoolmass, causingoverflow incontinence

19
Q

complications

other

A

Urinary retention
Syncope with straining

20
Q

complications

Rectal Fecal impaction
General and Sx/Tx

A

Common in the elderly
↑ rectal capacity and ↓ colonic motility
Firm often puttylike mass in the rectal vault on DRE; sometimes rocklike

Symptoms: rectal pain, tenesmus, overflow (paradoxic) diarrhea: watery fecal material leaking around the impacted stool

Treatment: enema and manual disimpaction

21
Q

complications

Bowel obstruction
Sx and imaging

A

Partial or complete
Symptoms: ↓ appetite, nausea and vomiting, abdominal pain and/or distention
Diagnosis: flat and upright abdomen x-ray or CT scan

22
Q

Zenker diverticulum

general

A

Acquired mucosal herniation that forms in the hypopharynx
Also known as pharyngoesophageal false diverticulum
Involves the mucosa and submucosal layers; NO muscular involvement
Rare condition
Seen in patients >40 years

23
Q

Zenker

Patho

A

Impaired relaxation of the cricopharyngeal muscle and as a result…

Pharyngeal muscles must contract more forcefully to propel food to the esophagus

↑ pressure in the hypopharynx
Herniation of the mucosa and submucosa through an area with muscle weakness creating a pouch-like structure outside the lumen of the esophagus

24
Q

Zenkers

most common location

A

Most common location is at the Killian’s triangle (between the thyropharyngeus and cricopharyngeus muscles)

25
Q

Zenker diverticulum

clin man

A

Retention of food particles and salivary secretions leading to:
Dysphagia – “high up dysphagia”
Regurgitation → aspiration
Sensation of food struck in the throat
Halitosis (bad breath)
Chronic cough
Weight loss
Visible lump in the neck (rare)

26
Q

Zenker

Dx

A

Barium swallow study
Diverticulum fills with contrast media
Allows for assessment of the size, location, and character of the mucosal lining

Upper endoscopy

27
Q

Zenker diverticulum

Tx

A

Lesions less than 2 cm rarely require treatment

Large, symptomatic diverticulum
Cricopharyngeal myotomy
Diverticulopexy