Constipation

CONSTIPATION Dr. SAO SIRA Associated staff physician Internal Medicine Training Program at SHCH

Contents 1. 2. 3. 4.

Definition Etiology Causes Types A-Constipation (functional) B-Constipation (organic) C-Classification

Definition  Constipation is a common symptoms, decrease in frequency of stools or difficulty in defecation. (more than three bowel movements per week)  Abdominal pain, distention and fecal impaction.  Hard stool.

Etiology  Diet issues  Inadequate water intake, inadequate fluid  Inadequate fiber intake, low fiber  Over use of coffee, tea or alcohol  Poor diet habit

 Lifestyle factors  Inactivity  Cheese  Post-op (fear of straining)  Psychological factor  Systemic endocrine or neurologic diseases

Etiology          

Al+ and Ca++ antacids Anticholinergics Antidepressants Antihistamines Antihypertensives(Calcium channel blockers) Diuretics Iron salts Chronic irritant laxatives Narcotics Iron supplements

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GI cancers Age (decreased neuro. Stim) Diverticular Dz Rectal stenosis Stroke Adhesions Strictures Hernia IBS (spastic colon)

Cause of depend on lesion Constipation may originate primarily from within the colon and rectum or externally:  Colon or rectum:  Left colon obstruction  Slow colonic motility, with history of chronic laxative abuse  Outlet obstruction (anatomical or functional)

Type of constipation

 Three types of constipation: A-Functional (>90%) B-Organic C-Classification

A-FUNCTIONAL CONSTIPATION

A-FUNCTIONAL CONSTIPATION Pathophysiology  Slow colonic transit  Problem with rectal muscle coordination  Problem with rectal sensation

Management  Education  Diet /Disimpaction  Maintenance Therapy  Weaning

Arch Ped Adol Med 1999 153(4):380-5

Education  Age appropriate discussion, drawings,

play to

explain the problem / treatment  Reassure : laxative risks / lack of dependence  Goal: improve compliance

Disimpaction techniques  High dose mineral oil orally  Enemas  Combination: enema, suppositories, oral laxatives  Insufficient evidence to recommend one method over 

another Digital disimpaction (rarely required)

Disimpaction: Enemas  Hypertonic NaPO4 pr /colyte flavored3-785 l/bottle for 3 L water . • 1-2oz/10kg (max 4.5oz) pr od / bid x 1-2d

– Complications: • Dehydration • Hyper Na, hyper PO4, hypo Ca, hypo K

– Contraindications: • Wt < 10kg • Intestinal obstruction • Cardiac / renal / electrolyte

B-Organic Constipation 

Bowel obstruction – Volvulus – Intussusception

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Trauma - Sexual abuse Extrinsic mass • ?Malignancy

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Perianal Streptococcal cellulitis Anal stenosis Fissure

 Neuro/muscular – – – – –

Spinal cord lesion Myotonic dystrophy CVA Scleroderma SLE

Constipation as a manifestation of systemic disorder  Hypothyroid  Diabetes Mellitus

Hypothyroid  Constipation is the commonest GI complaint in  

hypothyroid. The pathologic effect are caused by an alteration of motor function and possible infiltration of the GUT by myxedematous tissue. The basis electrical rhythm of the human duodenum decreases in hypothyroidism, and small bowel transit time is increased.

Diabetes Mellitus

 Studies of colonic myoelectrical and motor activity in diabetes patients with constipation showed some with mild constipation had a delayed colonic respond after a standard meal, whereas others with severe constipation had no increased activity after food.

Constipation as a manifestation of central nervous disease or the extrinsic nerve supply  Loss of conscious control  Parkinson’s disease.  Multiple sclerosis  Spinal cord lesion.

Loss of conscious control

 Reduction

in or absence of body perception as a result of cerebral handicap or dementia may leads to defecatory failure, possibly because of inattention.

Parkinson’s disease • GI dysfunction –constipation is well recognized in Parkinson’s dse. • Depletion of dopamine containing neurons in the central neurvous system is a basic deficit in this disorder.(gray matter), and cant’ inhibit involuntary movement of the affect person when at rest. • Patient fail to relax the striated muscles of the pelvic floor on defecation, which is a local manifestation of the extrapyramidal motor disorder effecting all skeletal muscle.

Multiple sclerosis 

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In all group of patient suffering from advanced multiple sclerosis with intermittent or chronic constipation, all had evidence of disease central to the lumbosacral spinal cord, and there was decrease compliance of the colon on infusion of fluid. No increase in motor activity is demonstrable after meals. Treatment-spontaneous remission and fluctuating symptoms make treatments difficult to evaluation-prednisolone 60mg to100mg tapered over 2- 3week . Drug for spasticity-baclofen 10- 20mg tid or qid. Multiple drug –Amitryptilline 25mg 75mg po at bed time.

Spinal cord lesion  Lesion above the sacral segment lead to an upper   

motor neuron disorder with severe constipation. Studies of colonic transit reveal delay that affects mainly the rectosigmoid colon. Abnormal colonic compliance occurs in patient with complete traumatic transection of the cord. No increase in motor activity is demonstrable after meals.

Constipation secondary to structural disorders of the colon, rectum anus and pelvic floor • • • • •

Obstruction Disorder of smooth muscle Neuropathy unknown causes. Rectocele. Weakness of the pelvic floor

Weakness of the pelvic floor

 A common reason for pelvic flood weakness is trauma or stretching during parturition.  In some cases, repeated and prolong straining during defecation appears to be the damaging factor.

Rectocle  In women, the anterior rectal wall at he anorectal junction is supported by the perineal body, but above this level it is unsupported, and the rectovaginal septum can bulge anteriorly to form a rectocele.

Neuropathy unknown causes  Severe acute neuropathies

that manifest with mainly obstruction symptoms, but not principally constipation, have been described.  Some time may be use long time of laxativecan cause of constipation.

Disorder of smooth muscle  Congenital

or acquired myopathy of the colon usually manifest with pseudoobstruction.

Obstruction  Anal atresia in infancy, anal stenosis developing in life or obstruction of the large intestine for any reason may manifest with constipation.

C-Constipation can classified as

 ACUTE  SUBACUTE  CHRONIC

Acute constipation  Mechanical bowel obstruction  Adynamic ileus (accompanies acute intra-abdominal    

disease) localized peritonitis, diverticulitis. Traumatic condition( eg head injuries, spinal fractures). May F/U general anesthesia. In bedridden patient. Many agent (Alcohol, bismuth salts, iron salts, cholestyramine, anticholinergics, opioids, many tranquilizer, and sedatives.

SUBACUTE

 The change of bowel habit persists for weeks or occurs intermittently with increasing frequency and /or severity – colonic tumor and other causes of partial obstruction should be suspected.  Underlying causes must be identified and treated.

CHRONIC The mechanism of the colon are deranged, sometime:  systemic disorders eg- debilitating infections, hypothyroidism, hypercalcemia, uremia or porphyria,  local neurogenic disorders eg IBS, megacolon idiopathic, secondary (colon dilatation anal, rectal stenosis, lesion of spinal cord, hypokalemia, hypothyrodism,)  neurologic disorders-parkinson’s disease, cerebral thrombosis, tumors injury of spinal cord.

Signs and Symptoms • • • • •

Dull headache Loss of appetite Lack of energy Feeling of fatigue Abdominal discomfort and distension • Bloating • Lower abdominal discomfort or pain • Lower back pain

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Blood in feces Nausea, vomiting acute abdominal pain 7-10 days duration Unresponsive to adequate laxative Rx

Investigations  Base on your clinical assessment  Urinalysis – R/O UTI b/c of potential urinary retention 20 impaction

 Abdominal plain film if you do not find an impaction

– ?bowel obstruction, ?toxic megacolon, ?volvulus, ? mass lesion

Complication       

Hemorrhoids Anal fissure Rectal prolapsus Stercoral ulcer fecal impaction Ischemic colitis Colonic volvulus

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Colonic perforation Fecal incontinence Urinary retension Cardiac, cerebrovascular dysfunction (syncope,arrythmias, angina).

Treatment nondrug

 Alterations in diet (fiber), fruits, enough liquids.  Increased fluid  Exercises (relaxation exercises of anal sphincters and muscle of pelvic floor  Stress management  Avoidance of constipating drugs

Treatment pharmacotherapy  Bisacodyl (Dulcolax  Senna (Senokot)  Castor Oil

 Polycarophil (Konsyl  

Fiber) Psyllium (Metamucil, others) Methylcellulose (Citrucel, Maltsupex)

SURGICAL TREATMENT  For severe chronic constipation  In colonic inertia –subtotal colectomy with ileorectal anastomosis.

•THANK YOU

Reference • • • •

HARRISON’S [email protected] [email protected] Clinical examination-Edited byJohn Mc Leod John Munto. • A guide to physical examination and history taking-Barbara Bates. • Gastrointestinal and liver diseasePathophysiopogy / Diagnosis /Management: Sleisenger &Fordtran’s.