CONSTIPATION

CONSTIPATION

Dr. M Baghbanian

Gastroenterologist

Shaheed Sadoughi university of medical scinces

Yazd - 2012

What is the normal defication frequency?

2 _ 3 time/week

introduction

Dry & hard stool Evacuation is difficult & infrequent Excessive straining (dyschezia) 1/8 of people taking laxatives at least once

each month.

Pathophysiology:

1. Slow transit

2. Functional outlet obstruction

INTRODUCTION

Constipation is the most common digestive complaint in the general population.

Medication costs of many hundreds of million dollars.

Prevalence of constipation

20 percent

• 2-27% of the population

depending in part upon the criteria

used to define it.

•

Prevalence of chronic functional constipation in IRAN

32.9( ROME II-defined )

9.6 ( % self-reported.) Adibi p and et al isfahan Alzahra.H.)Dig Dis Sci 2007(

In female constipation ) passage of stools Two times per week or less ( 9.6 % in the 40-69 year 20.5 % in the over 70- year Massarat and et al DDRC Shariati .H ) Archive of Iranian Medicine Vol 5 No 2 ,2002 (

Classification & causes

Secondary :

1. Endo. & metabolic

2. Neurologic dis.

3. Rectoanal dis.

4. Iatrogenic dis.

5. Dietary factors

Idiopathic dis.

1. Colonic inertia

2. Functional outlet obstruction

Functional constipation

Should be considered

only after other

diseases )systemic or

organic have

been excluded.

Chronic Functional Constipation Subtypes

Slow-transit Constipation

Pelvic floor

dyssynergia

IBS with

constipationIBS 58% Dyssynergic

59%

Slow transit 47 %

Obstructed defecation Dyssynergia or Anismus

paradoxical contraction or inadequate relaxation of the pelvic Floor muscles during attempted defecation.

Evaluation & management

History & rectal exam fibre therapy)unless alarm symptoms(.

1. 20-40 gr/day dietary fibre2. 10-20 gr/day psyllium

Sigmoidoscopy,barium enema,

defaecography,anal manometry,

colon marker transit study

Physiologic tests of Colonic motor function

Syringe

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Syringe 100 ml

1- 2”

3- 5”

50 ml

Summery

Chronic Constipation

Supplemental trial fiber25 g for 2 weeks

5 - day Colonic transitAnorectal manometry with

Balloon expultion test

Normal transit Normal Pelvic floor

function

Prolonged transitNormal pelvic floor

function

Slow-transitConstipation

IBS with Constipation

Abdominal pain+

Functional Constipation

Normal transitAbnormal pelvicFloor function

Pelvic Floordyssynergia

Abdominal pain -

Diagnostic strategy for constipation

Classification of drugs:

Bulking or hydrophilic

Osmotic agents

1. Ions

2. Disaccharides,sugar

3. Glycerin

4. Polyethylen glycol

Lubricating agent

Neuromuscular agents

1. Cholinergic agonists

2. 5-HT4 agonists

3. Prostaglandin agonist

4. Colchicine Stimulant laxatives

1. Surface-active agents

2. Diphenylmethane drivat.

3. Ricinoleic acid

4. Anthraquinones

Guidelines

Mild complaints1. Dietary fibre 2. Medicinal fibre Severe or acute constipation1. Osmotic agents2. Stimulant laxatives More chronic:1. larger doses of osmotic agents2. Misoprostol,bethanechol,colchicin

Guidelines Cont.

Dyschezia :

1. Moderate dose of osmotic laxatives

2. Mineral oil

3. Enema If dyschezia is the major

problem,fibre should be avoided .

Constipation in pregnancy

Fibre Lactulose

Castor oil may initiate premature labour.

Outlet obstruction constipation

Biofeedback therapy Surgery Pharmacological therapy Comb.)biofeedback+osmotic agents( Comb.NSAIDs+ skeletal muscle relax. Injection of botulinum toxin into the

pelvic floor or anal sphincter

surgery

Intrarectal intussusception Entrocele Refractory mechanical or functional

outlet problems)fecal diversion( Refractory slow-transit )subtotal

colectomy+ileorectal anastomosis( Patients with psychological problems do

not respond to surgery

Diagnostic algorithm for refractory constipation



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CONSTIPATION