Gastroenterology- Constipation Flashcards by Boikhutso Sekgobela

What is constipation?

Constipation is a symptom, not a disease.

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What is the prevalence of constipation in different age groups?

All Ages: Approximately 16%
> 60 Years: Approximately 33%

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What are the symptoms that define constipation?

Infrequent Bowel Movements: Typically less than 3 per week.
Hard (and Lumpy) Stools.
Feeling of Incomplete Evacuation.
Excessive Straining.
Sense of Anorectal Blockage.
Abdominal Discomfort, Bloating, or Distension.

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What are the primary causes of constipation?

Chronic Idiopathic Constipation (CIC)
Pelvic Floor Dyssynergia
Slow Transit Constipation
Normal Transit Constipation
Irritable Bowel Syndrome with Predominant Constipation

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What are some secondary colonic causes of constipation?

Benign Stricture
Cancer
Anal Fissure
Rectocele
Proctitis
Primary Neuromuscular Disease (e.g., Hirschsprung’s Disease)

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What are some extra colonic causes of constipation?

Dietary Factors
Medications
Neurological Disorders
Psychiatric Conditions
Metabolic and Endocrine Disorders
Extrinsic Compression

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Neurogenic disorders that causes constipation

Peripheral
- Diabetes mellitus
- Autonomic neuropathy
- Hirshsprung disease
- Chagas disease
- Intestinal pseudoobstruction

Central
- Multiple sclerosis
- Spinal cord injury
- Parkinson disease

Irritable bowel syndrome
Drugs

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Non neurogenic disorders that causes constipation

Hypothyroidism
Hypokalemia
Anorexia nervosa
Pregnancy
Panhypopituitarism
Systemic sclerosis
Myotonic dystrophy

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Idiopathic causes of constipation

Normal colonic transit
-Slow transit constipation
-Dyssynergic defecation

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Drugs associated with constipation

Anticholinergics
- antihistamine
- antispasmodics
- antidepressants
-antipsychotics

Cation- contianing agents
- iron supplements
- aluminum (antacids, sucralfate)
- barium

Neurally active agents
- opiates
- antihypertensive
- ganglionic blockers
- vinca blockers
- calcium channel blockers
- 5HT3 antagonists

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History

Symptoms defining constipation
Alarm features/symptoms
Diet
Medication use
Physical activity
Surgical history
Sexual and physical abuse

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Physical examination

Signs of systemic disease

Abdominal examination
- Presence of faeces (left quadrant)
- Abdominal mass

Digital rectal examination

Normal examination common

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Digital rectal examination

Inspection of anus and surrounding area – fissures, etc
Testing of perineal sensation and ano-cutaneous reflex
Assess resting anal tone
Palpate for rectal masses, prostate in men
Squeeze manoeuvre – squeeze and hold my finger as long as possible
Push my finger out

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Exclude secondary features

Alarm features:
Abrupt/recent onset constipation
Iron deficiency anaemia/ haematochezia
Age > 50 years
Unexplained weight loss
+ve family history colon ca
+ve FOBT

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Investigations

FBC
Calcium
TSH
Glucose
Colonoscopy

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Primary/Functional constipation

Chronic idiopathic constipation
Irritable bowel syndrome

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What is Chronic Idiopathic Constipation (CIC)?

Chronic Idiopathic Constipation is a condition characterized by persistent constipation with no identifiable underlying cause. It is a diagnosis of exclusion.

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What are the features of Irritable Bowel Syndrome (IBS) with predominant constipation?

IBS with predominant constipation is characterized by abdominal pain or discomfort associated with constipation, along with changes in bowel habits. Patients may experience bloating and may not always have infrequent bowel movements.

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chronic idiopathic constipation

normal transit constipation
slow transit constipation
defecatory disorder

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What is normal transit constipation?

Normal transit constipation is characterized by bowel movements that occur at a normal frequency, but patients experience symptoms of constipation, such as hard stools and a feeling of incomplete evacuation. This type often involves difficulty with the defecation process despite normal colonic transit.

What is slow transit constipation?

Slow transit constipation is characterized by infrequent bowel movements (typically less than three per week) due to delayed movement of stool through the colon. Patients may experience significant straining and hard stools, and this type often requires further evaluation to determine underlying causes.

What is a defecatory disorder in the context of chronic idiopathic constipation?

A defecatory disorder refers to difficulty in the act of defecation, often due to pelvic floor dysfunction or coordination issues during bowel movements. Patients may experience excessive straining, a sense of anorectal blockage, and may benefit from pelvic floor therapy or biofeedback.

What dietary changes can help manage functional constipation?

Increase Fiber Intake: Aim for 25-30 grams of fiber daily from fruits, vegetables, whole grains, and legumes.

Stay Hydrated: Drink plenty of fluids, ideally 1.5-2 liters per day, to help soften stool.

What are some lifestyle modifications for treating functional constipation?

Regular Exercise: Engage in physical activity for at least 30 minutes most days to promote bowel motility.

Establish a Routine: Set a regular time for bowel movements, especially after meals, to encourage a natural urge.

hat pharmacological treatments are commonly used for functional constipation?

Laxatives: Bulk-forming Laxatives (e.g., psyllium, methylcellulose) Osmotic Laxatives (e.g., polyethylene glycol, lactulose, sorbitol, slaine laxatives) Stimulant Laxatives (e.g., bisacodyl, senna) for occasional use. Prescription Medications: Prokinetic Agents (e.g., prucalopride) Secretagogues (e.g., linaclotide, plecanatide) for chronic cases.

What is anorectal manometry used for?

Anorectal manometry measures the pressure and function of the anal sphincter and rectum, assessing the coordination of pelvic floor muscles during defecation and identifying potential disorders contributing to constipation.

What does the balloon expulsion test evaluate?

The balloon expulsion test assesses the ability of the patient to expel a balloon filled with water from the rectum. It helps determine if there is a defecatory disorder, indicating issues with pelvic floor function or coordination.

What results might indicate a defecatory disorder during these tests?

Results indicating a defecatory disorder may include: Inadequate pressure during straining in anorectal manometry. Inability to expel the balloon within a normal time frame during the balloon expulsion test.

Treatment for Evacuation disorder/pelvic floor dyssynergia

Biofeedback Psychological support Diet/lifestyle/fibre Traditional laxatives

What is a colonic transit study?

A colonic transit study is a diagnostic test used to evaluate how well and how quickly stool moves through the colon, helping to identify causes of constipation.

How is a colonic transit study typically performed?

Patients ingest a radiopaque marker (usually in capsule form) or a special dye, and follow-up X-rays or scans are taken over a period (usually 1-5 days) to track the passage of the markers through the colon.

What are the potential findings of a colonic transit study?

Normal Transit: Markers move through the colon within the expected timeframe. Slow Transit: Delayed movement of markers, indicating slow colonic motility. Rapid Transit: Markers pass through too quickly, possibly indicating a functional issue.

Treatment for normal or slow colonic transit

Diet/fibre/lifestyle Traditional laxatives Psychological support Newer agents eg Lubiprostone, Linaclotide Remember IBS-C fits into category of normal transit constipation and may require additional specific treatment Surgery - colectomy

Which of the following is a metabolic cause of constipation? A. Anal fissure B. Parkinson’s Disease C. Hypokalaemia D. Hypernatremia

C. Hypokalaemia

A 30-year old woman presents with abdominal pain that is associated with alternating diarrhoea and constipation. Which of the following symptom is the least consistent with irritable bowel syndrome? A. Abdominal bloating B. Waking at night with abdominal pain C. Faecal urgency D. Feeling of incomplete stool evacuation

B. Waking at night with abdominal pain

A 24-year old woman presents complaining of intermittent constipation and diarrhoea for the past six-months. She reports no weight-loss but does complain of increased bloating and abdominal pain particularly around her menses. What is the most likely diagnosis? A. Constipation causing over-flow diarrhoea B. Coeliac disease C. Irritable bowel syndrome D. Lactose intolerance

C. Irritable bowel syndrome

A 54- year old man presents complaining of three-month history of constipation and poor appetite. He is concerned as his father was recently diagnosed with colon cancer. On examination he has a pulse rate of 58 beats per minute, a blood pressure of 124/62mmHg and is aypyrexial. Of note he has extremely dry skin and delayed tendon reflexes. The rest of his examination is normal. What is the most likely cause for his constipation? A. Hypothyroidism B. Rectocele C. Colon cancer D. Pelvic floor dyssynergia

A. Hypothyroidism

Which of the following drugs is NOT commonly associated with constipation? Which of the following drugs is NOT commonly associated with constipation? A. Metformin B. Calcium channel blockers C. Fe supplements D. Morphine B. Calcium channel blockers C. Fe supplements D. Morphine

A. Metformin

A 65-year old woman with a background history of hypertension presents complaining of a six-month history of constipation. She reports needing to strain on defaecation with a poor response to laxatives. She denies any abdominal pain. Six weeks ago, she had baseline bloods and a colonoscopy, which were both normal. What is the most likely diagnosis? A. Functional constipation B. Haemorrhoids C. Parkinson’s disease D. Irritable bowel syndrome

A. Functional constipation

Which of these is NOT a cause of primary constipation? A. Normal transit constipation B. Pelvic floor dyssynergia C. Slow transit constipation D. Extrinsic compression

D. Extrinsic compression

A 54-year old man presents complaining of a three- week history of constipation associated with weight-loss. On examination he has pallor. His full blood count is as follows: Haemoglobin: 7.5 (13 – 17 g/dL) Mean cell volume: 70 (83.1 - 101.6 FL) Mean cell haemoglobin: 24 (27.8 - 34.8 pg.) White cell count: 4.5 (3.92 - 10.4 x 109/L) What is the most appropriate next step? A. Colonoscopy B. Thyroid-stimulating hormone C. Trial of laxatives D. Anal manometry

A. Colonoscopy

Which of these are is NOT a defining symptom of constipation? A. Infrequent bowel movements (typically < 3 per week) B. Hard (and lumpy) stools C. Feeling of incomplete evacuation, excessive straining D. Blood mixed with stool

D. Blood mixed with stool

Which of the following is an exclusion criterion for the diagnosis of Irritable Bowel Syndrome (IBS)? A. Positive test for fecal occult blood B. Change in frequency of stool C. Change in consistency of stool D. Recurrent abdominal pain

A. Positive test for fecal occult blood

Which of the following are NOT red flags in a patient complaining of constipation? A. Family history colon cancer B. Hypertension C. Iron-deficiency anaemia D. Unexplained loss of weight

B. Hypertension

A 64-year old man known with multiple myeloma presents complaining of constipation. He is currently receiving chemotherapy and is on a bisphosphonate. His most recent blood results are as follows Total protein: 92 (60 – 80 g/L) Albumin: 31 (32 - 50 g/L) Calcium: 2.95 (2.05 - 2.55 mmol/L) Haemoglobin: 7 (13 - 17) What is the most likely cause for the constipation? A. Multiple myeloma B. Anaemia C. Hypercalcemia D. Side effect of chemotherapy

C. Hypercalcemia

Which of the following is a stimulant laxative? A. Lactulose B. Sorbitol C. Magnesium Sulphate D. Senna

D. Senna

Which of the following would be your first step of treating a patient with functional constipation? A. Dietary advice and fibre, and simple laxatives B. Anal manometry C. Colectomy D. Defecogram

A. Dietary advice and fibre, and simple laxatives

Which of the following tests would you do first if the patient has failed to respond to first line of treatment for constipation? A. Defecogram B. Wireless video capsule C. Anal manometry D. Colon transit study

C. Anal manometry