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MET2 > Defecation > Flashcards

Defecation Flashcards

1
Q

When does primitive gut tube develop?

After 2 weeks
After 3 weeks
After 4 weeks
After 5 weeks

A

When does primitive gut tube develop?

After 2 weeks
After 3 weeks
After 4 weeks
After 5 weeks

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2
Q

Microbrial colonisation of the infant is critical for what two things in the adult? [2]

A

Immune system
GI Development

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3
Q

Name the anal sphincters [2]
Which is voluntary / involuntary?

A

External Anal Sphincter (EAS): voluntary
Internal Anal Sphincter (IAS): involuntary and thickened muscle

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4
Q

Name the 3 levator ani muscles of the pelvic floor muscles

A

PPI

Puborectalis
Puboccygeus
Iliococcygeus

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5
Q

Which muscle is depicted?

Puborectalis
Pubcoccygeus
Iliococcygeus

A

Which muscle is depicted?

Puborectalis
Pubcoccygeus
Iliococcygeus

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6
Q

Which muscle is depicted?

Puborectalis
Pubcoccygeus
Iliococcygeus

A

Which muscle is depicted?

Puborectalis
Pubcoccygeus
Iliococcygeus

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7
Q

Which muscle is depicted?

Puborectalis
Pubcoccygeus
Iliococcygeus

A

Which muscle is depicted?

Puborectalis
Pubcoccygeus
Iliococcygeus

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8
Q

What is the role of the puborectalis?

A

Supports EAS and helps to create the anorectal angle

Surrounds tthe rectum, vagina and urethra

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9
Q

Which nerves provides the parasympathetic innervation to the rectum, anus, bladder and urethrea? [1]

What are the nerve roots? [1]

A

Pudendal nerve

S2-4

S2, 3, 4 keeps the Penis, Poo and Pee of the floor

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10
Q

The EAS is supplied by which nerve?
The IAS is innervated by which NS?
- What are sympathetic and parasympathetic nerve roots?

A

EAS: supplied by inferior branch of the pudendal nerve

IAS: Enteric NS
- Sympathetic: L1-L2 via hypogastric nerves (excitatory)
- Parasympathetic: S2-S4: pelvic nerves (inhibitory)

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11
Q

The inferior rectal nerves divides into which two terminal branches? (m v f)

A

M: Perineal nerve and dorsal nerve of the penis

F: Dorsal nerve of the clitoris

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11
Q

The inferior rectal nerves divides into which two terminal branches? (m v f)

A

M: Perineal nerve and dorsal nerve of the penis

F: Dorsal nerve of the clitoris

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12
Q

What factors do we rely on for continence? [5]

A

Anorectal angle
Stool consistency and colonic transit time
Rectal compliance
Rectal filling – sensation
Rectoanal inhibitory reflex (RAIR)

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13
Q

How does the anorectal angle work?

A

The tonic contraction produced by the puborectalis muscle, creates what is called a ‘flap valve’

Maintains the angle, whereby the anterior rectal wall is pushed downwards onto the anal canal when the intra-abdominal pressure during straining, laughing and coughing rises, thus stopping the passage of faeces into the anal canal

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14
Q

Stool consistency:

Ability of the rectum to retain stool is known as []?

Which two structures provide a mechanical barrier and retard progression of stool? [2]

A

Ability of the rectum to retain stool is known as reservoir continence

Lateral angulations in the sigmoid colon AND the valves of Houston provide a mechanical barrier and retard progression of stool.

It is the weight of the stool that tends to accentuate these angles and thus enhance their barrier effect

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15
Q

Which structure does this describe?

semi-lunar transverse folds of the rectal wall that protrude into the anal canal

A

valves of Houston

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16
Q

What is rectal compliance? [1]
Explain how rectal compliance helps continence [1]

A

Rectal compliance: the ability of the rectum to adapt to the imposed stretch is called

Extrinsic afferent neurones mediate the conscious sensation of urgency which is activated by mechanoreceptors.

Got to be full, have to know that it is full

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17
Q

Explain what the rectoanal inhibitory reflex (RAIR) is

A

RAIR: a relaxation response in the IAS following rectal distension. Increase in pressure causes the relaxation !

18
Q

Out of the EAS & IAS, which is responsible for greater anal resting pressure? [1]

Why is that clincically significant? [1]

A

IAS has higher resting pressures: causes incontinence to not occur

19
Q

Defaction involves the relaxation of which two muscles? [2]

A

EAS and puborectalis muscles

20
Q

Explain proper mechanism for defecation xx

A

Hold breath forcibly trying to exhaled: causes increase in abdo pressure & muscles of the the anterior abdo wall tense to funnel the pressure down to pelvis; Valsalva manoeuvre

Relaxation leads to stool enter lower rectum

21
Q

Explain proper mechanism for defecation xx

A

Hold breath forcibly trying to exhaled: causes increase in abdo pressure & muscles of the the anterior abdo wall tense to funnel the pressure down to pelvis; Valsalva manoeuvre)

Relaxation leads to stool enter lower rectum

22
Q

Explain how the closing reflex occurs

A

Last bolus of stool is passed and then the ‘closing reflex’ of the EAS is stimulated by the releases of traction.

Upon voiding, receptor adaptation in ampulla recti removes inhibitory drive to IAS - thus contraction of IAS

Voluntary contraction of EAS closes anus off.

Smooth muscles in sigmoid relax (enteric nervous system) re-establishing of reservoir function.

23
Q

How do you take Hx for constipation? [8]

A
  • stool frequency and consistency (Bristol Scale)
  • need to strain or digitally extract stool – defecatory disorder
  • Any clear precipitants to onset? abdominal/pelvic surgery; childbirth or emotional trauma
  • Faecal impaction and faecal soiling: suggest idiopathic megacolon
  • Comorbid medical history: e.g. thyroid disease, diabetes; renal impairment; neurogenic conditions
  • Drug history: e.g. opiates
  • Dietary history: meal frequency and fibre intake
  • Toilet behaviour – sitting properly, routine
24
Q
  • Whats an alarm symptoms for history taking of Ptx with regards to metabolic disoders? [4] * !!!
A
  • Blood in stool
  • Loss of weight
  • Family Hx of colon cancer
  • Rectal bleeding
  • Recent onset of symptoms
25
Q

What is the definition of constipation?

A

purely symptomatic – not at diagnosis

infrequent stools (more than 3 per week) OR

passage of hard stools (less than 25% of the time) OR

a sensation of incomplete evacuation (>25% of the time) or

26
Q

What is primary constipation? [1]

Name 3 types of primary constipation [3]

A

Primary constipation: no identifiable organic cause include:

  • normal transitconstipation: due to inadequate calorie, fibre, or water intake, difficulty with defecation and hard stools, overlap with IBS-C since pain and bloating are common.
  • slow transitconstipation: infrequency and slow movement of stool
    due to bloating, abdominal pain and infrequent urge to defecate

- pelvic floor dyssynergia.

27
Q

Explain dyssynergia

A

Can’t coordinate sphincters and pelvic floor muscles (stomach should push OUT not in) to expel faeces

27
Q

Explain dyssynergia

A

Can’t coordinate sphincters and pelvic floor muscles (stomach should push OUT not in) to expel faeces

28
Q

What is rectal intussusception?

What is rectal prolapse?

A

Rectoanal intussusception: is an invagination of the rectal wall into the lumen of the rectum.

Rectal prolapse: occurs when your rectum, part of your large intestine, slips down inside your anus

29
Q

How are you meant to sit on the loo xx

A

Squat, not sit !

30 degree posture

30
Q

FYI: causes of secondary constipation

A

Secondary - often multifactorial
Most common (underlined)

Endocrine: Diabetes; Hypothyroidism;

Hyperparathyroidism; glucagonoma

Neurological: spinal injury;

Parkinson’s disease; MS, autonomic neuropathy;

Psychogenic: affective disorders; eating disorders; dementia or learning difficulty

Metabolic: Hypercalcaemia; uraemia; hypokalaemia; amyloidosis; lead poisoning.

Colonic: tumour; diverticular disease stricture; ischaemia

Anal: Fissure; polyp; tumour

Physiological: pregnancy; old age

Drugs (prolong transit): opiates; anticholinergics; anticonvulsants; tricyclic antidepressants; antacids (aluminium and calcium containing one); NSAIDs; iron; antihypertensive.

31
Q

Name external and internal signs of fecal incontinence (FI)

A

External:
* visible soiling; excoriation (scars/defects)

Internal:
* organic disease (piles, fissures, fistula, tumour);
* defects; tone; squeeze; pelvic floor dysnergia;
* rectocele/intussusception (internal prolapse)

32
Q

Passive incontinence is caused by structural lesion to which muscle? [1]

Urge incontienence is caused structural lesion to which muscle? [1]

A

Passive incontinence is caused by structural lesion to which muscle: IAS

Urge incontienence is caused structural lesion to which muscle: EAS

33
Q

What type of imaging is this? [1]

A

Endo-anal ultrasound

34
Q

Which of the following is the EAS?

A
B
C
D
E

A

Which of the following is the EAS?

A
B
C
D
E

35
Q

Which of the following is the IAS?

A
B
C
D
E

A

Which of the following is the IAS?

A
B
C
D
E

36
Q

When do you perform endo-anal ultrasound?

A

Structure
* obstetric sphincter tear
* latrogenic sphincter tear
* radiation damage
* congenital malformations

Function
* pudendal neuropathy

37
Q

What does High Resolution Anorectal Manometry measure / ID?

A

Pressure / time graphs of sphincter or rectum

Sphincter function: Resting pressure, Squeeze pressure, Endurance Squeeze, Rectoanal inhibitory reflex (RAIR)

Rectal sensation:
* hypersensitivity (associated with faecal incontinence)
* hyposensitivity (associated with constipation)

38
Q

What is a hypersenstive rectum? [1]
What is a hyposenstive rectum? [1]

A

What is a hypersenstive rectum? [1]
* Reduced sensory threshold to volumetric rectal distension
* associated with urge FI

What is a hyposenstive rectum? [1]
* Increased sensory threshold to volumetric rectal distension
* Associated with evacuation difficulties;
functional disorders, constipation

39
Q

Whats a Barium / MRI proctogram?

A

will be asked to lie on your side on the x-ray table whilst barium paste is introduced into your rectum via a small tube. can visualise rectum and colon

40
Q

What is important to note when investigating constipation?

A
41
Q

How should you manage constipation?

A
  1. Diet / toilet behaviour
  2. Laxatives
  3. Biofeedback (someone teaches you how to push properly)
  4. Botox: relaxes sphincter muscle
  5. Anal irrigation
  6. Neuromodulation
  7. Stoma

MET2 (52 decks)

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