Functional Constipation

ByM. Osama Shetta.

Professor of SurgeryAin Shams University

Definition

At least two of the following:- Less than three bowel motions/week.- Need in more than 25% of occasions to:

- To strain.- To manually evacuate- Passage of hard stool- Sense of incomplete evacuation

Definition(cont.)

- These symptoms need to be chronic.- All other aetiological causes of

constipation must be excluded specially the organic causes.

Aetiology of constipation I

DietaryEndocrine / MetabolicNeurological PsychogenicDrugs & poisonsGeneral causes

Drugs:opiatesanticholinergics.Iron therapy.antiacids

Aetiology of constipation II

- Organic obstruction- Functional constipation

Organic Obstruction

Functional Constipation

In terms of pathophysiology:- Slow gut transit(colonic inertia).- Rectal evacuatory dysfunction.- Combination of both.

Functional Constipation

Slow transitOutlet obstruction

–Rectocele–Rectal prolapse, intussusception–Anismus–Solitary rectal ulcer syndrome–Descending perineum syndrome

Slow transit + Outlet obstructionConstipating form of IBS

Functional Constipation

Consider it when–All other causes are excluded–Colon looks normal on barium

enema and colonoscopy–Rectoanal inhibitory reflex (RAIR)

is preserved–Colon is ganglionic

Evaluation & Management

Initial evaluation

Initial management

Secondary management

Secondary evaluation

Tertiary management

Aim of Initial Evaluation

Exclude organic obstruction

Initial Evaluation- History and examination- Anorectal examination

– Inspection (rest, strain, squeeze)–Palpation, check anal wink–PR (rest, strain squeeze) – Inspection of stools–Proctosigmoidoscopy

- Routine blood investigations- Colonoscopy + Barium enema- More tests or consultation if history and

examination are suspicious

Initial Management with Apparent cause

Treatment of the cause.

Initial ManagementNo Apparent Cause

Dietary manipulation– Increase fluid intake– Increase fiber in diet or by laxative

Regular exercise Advise Never to :

–Strain–Suppress desire–Use stimulant laxatives

Can use supposit., lactulose, bulk forming laxatives

Secondary Management

By Stimulant laxatives:

Aim of Secondary Evaluation

Document the presence and the type of functional constipation

Secondary Evaluation

Extensive lab. StudiesColonic transitPelvic floor tests (PFT)

–Manometry (press., sens., RAIR)–EMG–Defecography–Balloon expulsion test

Biopsy for ultrashort segment HirschsprungPsychological consultation

Categorization of Functional Constipation

Anorectal physiology testing

normal transit, abnormal PFT = PF dysfunction

abnormal transit, normal PFT = slow transit constip.

abnormal transit,abnormal PFT = slow transit &PF dysf.

normal transit,normal PFT = IBS

Intervention in functional constipation should be

considered only when medical treatment consistently failed to help the patient, constipation is

most intractable and the patient is thoroughly

investigated

Treatment

Rectocele– Surgical repair

– Biofeedback

Treatment

Slow transit constipation–Total colectomy–Segmental colectomy–Biofeedback

Treatment

Complete rectal prolapse–Rectopexy–Resection–Delorme

Treatment

Internal intussusception–Biofeedback–Rectopexy–Delorme–Rectopexy + Resection–Other extensive operations

Treatment

Solitary rectal ulcer–Biofeedback–Excision–Injection–Rectopexy

Treatment

Anismus–Biofeedback–Botulinum toxin

Treatment

Descending perineum–Biofeedback

Proper Management

Starts With Proper

Diagnosis

Surgical Aspects Of Constipation

by

Ahmed A. Abou-Zeid

Professor of SurgeryAin Shams University