Approach to Constipation

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Approach to Constipation

• ANWER GHANI
• FIBMS
• IRAQ

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• Chronic constipation is a worldwide problem.
• It can be either primary or secondary.
• It is often, erroneously, considered as a single
  disease but it is a complex and multifaceted
  syndrome.

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The criteria for constipation includes two or
more of the following symptoms
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Definitions

• Constipation
• Derived from latin constipare (to crowd together)
• Difficult stool passage ( Sensation of incomplete
  evacuation, Straining at stool)
• Decreased stool frequency ( Normal frequency
  difficult to define, 95 of people pass gt3 stools
  per week)
• Therefore, 3 or less stools per week is defined
  as Constipation

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• The term primary constipation itself hides
  different conditions, such as irritable bowel
  syndrome with constipation (IBS-C), functional
  constipation, functional defecation disorders,
  and rectal hyposensitivity.

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Hx

• History can identify alarm symptoms, such as
  weight loss, bloody stools, anemia, or a family
  history of colon cancer.
• History can identify conditions potentially
  associated with constipation, such as dietary
  mistakes, low physical activity the use of
  constipating drugs, metabolic, psychiatric, or
  neurological diseases and previous
  perineal-pelvicabdominal or obstetric-gynecologic
  al surgery.

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Red flags

• ,

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• In case of alarm symptoms/signs, colonoscopy is
  recommended.

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Ex

• The examination can detect a possible
  gastrointestinal mass.
• Examination should include inspection of the
  anorectal region and exploration of the rectum.
• A digital rectal examination should detect any
  signs of organic disease or obstructed defecation
  (rectal masses, fecal impaction, stricture,
  rectal intussusception, or rectocele).

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• ve alarm s? colonscoppy. (abno Ve ? Rx, Abno
  -ve ? Chronic C)
• -ve alarm s?drugs Hx (ve drug Hx ? stop drugs,
• -ve drug Hx ? chronic c)

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Rx

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• many patients will benefit from abolishing or
  reducing medications that cause constipation.

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• many patients will benefit from recommending
  changes in lifestyle and diet with correct fluid
  (at least 1.5 l/day) and fiber (25 mg/day)
  intake.

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• Increased intake of whole fruits and vegetables
  significantly reduced fecal transit time by 14 h
  and increased the number of daily bowel movements
  by 0.4 and daily wet fecal weight by 118 g
  compared to 100 fruit and vegetable juices.

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• If diet management is not sufficient, it is
  mandatory to move to a second step encompassing
  the use of fiber supplementations and osmotic
  laxatives.

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• If osmotic laxatives are ineffective, it is
  possible to use
• -stimulant or softening laxatives then
• -prokinetics or prosecretory agents.
• In this subset of patients, further tests such
  as anorectal manometry and/or entero-defecography
  and/or colonic transit time are advisable.

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Laxative use

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Other therapeutic options

• - pelvic floor rehabilitation
• -sacral nerve stimulation
• -anorectal surgery

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Other tests

• colpo-cystoentero-defecography
• magnetic resonance (MR) defecography
• dynamic transperineal ultrasonography (DTP-US)

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• Colonic and/or gastrojejunal manometry should be
  performed in patients with serious slow-transit
  constipation

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Approach to Rx of Chronic C

• Diet (fluid and fibers)
• No resp ? suppl fibers
• No resp ? bulck laxative , Osmotic laxa
• No resp ? stimulant or softening laxat
• No resp ? Prokinetics (prucalopride),
  Prosecretory (linaclotide, lubiprostone)
• No resp ?Pelvic floor rehabilitation.
• No resp ? Sacral nerve stimulation, Anorectal
  surgery, Colectomy
• (after performing colonic and gastrojejejunal
  manometry)

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Complications of Constipation

• Hemorrhoids
• Anal fissures
• Rectal bleeding
• Fecal incontinence
• Fecaloma
• Pelvic organ prolapse
• Fecal impaction
• Bowel obstruction
• Bowel perforation
• Stercoral peritonitis