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Mission im ..poo ..sible
Dr. Naresh Bhat
Bangalore
Clinical approach
Is it constipation ? Are drugs or systemic disease responsible ? Are there alarm symptoms ? What is the cause of constipation ?
Clinical exam
Perineal and rectal exam essential
Labs
TSH Calcium
Management of evacuation disorders
STC Defecatory disorderNormal transit
Medications commonly used for constipation•Hyperosmolar agents
•Lactulose
•Sorbitol
•PEG
•Suppository
•Glycerin
•Bisacodyl
•Stimulant
•Senna
•Bisacodyl
•Fiber
•Saline laxative
•Milk of magnesia
•Lubricant
•Mineral oil
•Enemas
•Tap water
•Phosphate
•Soap water enema
Which one to use?
Constipation -classification
Normal transit Slow colonic transit Defecatory disorder
Modalities to evaluate
Transit study Anorectal manometry and balloon expulsion Defecography
Defecatory disorder …clues
Adequate urge Daily visits Prolonged ET Digital evac / Perineal pressure
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Basal (15.08:27)
Basal pressure
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64Basal (13.53:32)
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Balloon Expulsion (15.16:10)
Balloon Expulsion
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Balloon Expulsion# 1 (14.47:56)
Pelvic floor disorder
Abnormal ARM Abnormal BET/BDAbnormal ARM Abnormal BET/BD
Absent RAIR High RP, SP
Hirschsprung’s disease
AnismusAnal fissure
Abnormal anorectal anglePerineal descent
Constipation Due to Pelvic Floor Disorder
Anterior rectocele Non relaxing puborectalis
Biofeedback Therapy
Dyssynergic defecation: 40% of chronic constipation
Paradoxical anal contraction,
inadequate push effort,
incomplete anal relaxation,
altered rectal sensation
Overlap with delay in colonic transit in 2/3rds
Biofeedback Therapy
Neuromuscular training “operant conditioning” technique
Visual cues Toilet training – capitalise on intrinsic
physiological mechanisms, avoid certain maneuvers
Duration of sessions: 30-60 mins, 4-6 sessions reinforcement session Time consuming, labour intensive.
Efficacy of biofeedback in evacuation disorder
Author Year Mode % well
Bleijenberg 1988 Inpatient-home 70Weber 1988 Outpatient 18Lestar 1991 Outpatient 69Kawimbe 1991 Home 87Dahl 1991 Inpatient 78Wexner 1992 Outpatient 89Fleshman 1992 Outpatient 100
Dig Dis Sc 1993; 38: 1953-60
Our experience in biofeedback
110 patients in last 3 years- Defecatory disorder, fecal incontinence
80-85% patients had significant positive response
Role of surgery
• Hirschsprungs disease• Rectocele• Colonic inertia
Summary
All constipation are not IBS
Clinical history – exclude secondary causes
Defecatory disorders to be kept in mind
Anorectal manometry, transit study very useful
Significant overlap – use more than one test
Biofeedback therapy – treatment of choice in defecatory disorders
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206Balloon Expulsion (15.19:05)
Balloon expulsion
Check list
Hypothyroidism Parkinsons Diabetes
Parkinson drugs Antihistaminics Anti histaminics