Constipation

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Constipation

  1. 1. constipation
  2. 2. • • • • • Definition Pathophysiology symptoms Causes Treatment
  3. 3. • affects approximately 2% of the population in the U.S. • Women and the elderly are more commonly affected. • Though not usually serious, can be a concern
  4. 4. • It is a symptom not a disease
  5. 5. • Rome III criteria for constipation
  6. 6. Definition Rome III criteria for constipation if you have 2 or > of the following for at least 3 months: • Fewer than 3 bowel movements / week • Straining • Lumpy or hard stools • Sensation of anorectal obstruction • Sensation of incomplete defecation • Manual maneuvering required to defecate
  7. 7. S&S Asymptomatic or have 1 of the following/ • Abdominal bloating • Pain on defecation • Rectal bleeding • Spurious diarrhea • Low back pain
  8. 8. Severe if/ • Feeling of incomplete evacuation • Digital extraction • Tenesmus • Enema retention
  9. 9. • Rectal bleeding • Abdominal pain (suggestive of possible irritable bowel syndrome [IBS] with constipation [IBS-C]) • Inability to pass flatus • Vomiting • Unexplained weight loss
  10. 10. Hx & Ex • • • • • • • onset bowel habit Fluid intake Activity exercise! Other disease,DM,HYPOTHYRIODISM Medication Mental assessment
  11. 11. ex • no benefit in determining etiology or deciding on treatment • Abdomen ,mass,distention • Pelvis, hernia • Anorectal ex,fissure,piles,prolapse
  12. 12. complication • acute or chronic hemorrhoidal disease • hypotonic laxative colon • Anal fissure • pelvic floor damage in women • solitary rectal ulcers • Fecal impaction • Bowel obstruction • • • • • • • • Megacolon Volvulus Rectal prolapse Urinary retention Syncope Fistula in ano Fecal incontinence Stercoral ulceration/perforation
  13. 13. Cauese
  14. 14. causes • • • • • • • Psychological causes Diabetes mellitus Hyperparathyroidism Hypothyroidism Uremia Lead poisoning Neuropathy • • • • • • Parkinson disease Multiple sclerosis Spinal cord injuries Scleroderma Lupus Amyloidosis
  15. 15. ddx • • • • • • • • • • Abdominal Hernias Anxiety Disorders Appendicitis Chagas Disease (American Trypanosomiasis) Colon Cancer, Adenocarcinoma Colonic Obstruction Crohn Disease Depression Diverticulitis Hypopituitarism (Panhypopituitarism) • • • • • • • • • • • Hypothyroidism Ileus Intestinal Motility Disorders Intestinal Pseudo-obstruction: Surgical Perspective Intra-abdominal Sepsis Irritable Bowel Syndrome Large Bowel Obstruction Megacolon, Toxic Multiple Endocrine Neoplasia, Type 2 Ogilvie Syndrome
  16. 16. pathophysio
  17. 17. investigation • • • • • • Outpatient 3-6 m Lab ? Image study , sepsis endoscopy Acute or chronic Age? Consider sigmoidoscopy, colonoscopy, or bariumenema for colorectal cancer screening in patients older than 50 years.
  18. 18. • • • • • • • • • X-ray ct Lower gastrointestinal (GI) endoscopy Barium or Gastrografin Study colonic transit study defecography anorectal manometry surface anal electromyography (EMG) balloonexpulsion
  19. 19. • • • • Cbc anaemia Fecal occult blood Thyroid function Serum chemistry
  20. 20. • • • • • Foods to Relieve Constipation 1. Prunes 2. Beans 3. Kiwi 4. Rye Bread 5. Pears
  21. 21. • • • • • • Foods That Can Cause Constipation 1. Chocolate 2. Dairy Products 3. Red Meat 4. Bananas 5. Caffeine
  22. 22. Treatment • Medical care • should focus on dietary change and exercise rather than laxatives, enemas, and suppositories • To avoid the laxative colon • Exercise • stimulate bowel motility
  23. 23. • Once acute constipation has resolved and the associated medical or surgical conditions have been ruled out, additional inpatient care is rarely indicated.
  24. 24. • • • • • • • • • • • • The following factors may warrant a transfer: Uncertain diagnosis Evidence of intra-abdominal catastrophe Acute abdominal pain Fever Lower gastrointestinal (GI) bleeding Chills Instability of vital signs Absence of bowel sounds Acute recent change in bowel habits Unsuccessful or inadequate treatment offered at the local facility
  25. 25. Dietary Measures • Increased fiber intake • Increased fluid intake
  26. 26. • Increased fiber intake • Dietary fiber is available in diverse natural sources, such as fruits, vegetables, and cereals. Ingestion of natural fiber sources is nutritionally superior to supplementation with purified fiber • started at a low subtherapeutic dose • are not laxatives • prescribing a fiber supplement, such as wheat, psyllium, or methylcellulose, is often useful.
  27. 27. • Increased fluid intake • drink at least 8 glasses of water daily • decrease consumption of • coffee, tea, and alcohol ? Diuretic effect
  28. 28. Pharmacologic Therapy Medications to treat constipation include • bulk-forming agents (fibers) • emollient stool softeners • rapidly acting lubricants • prokinetics • laxatives • osmotic agents • prosecretory drugs.
  29. 29. bulk-forming agents (fibers) • • • • long-term treatment best and least expensive Psyllium (Metamucil Methylcellulose (Citrucel)
  30. 30. emollient stool softeners • easier to use, but they lose their effectiveness with long-term administration • Short term • Docusate • stimulants increase peristaltic activity in the gastrointestinal (GI) system.
  31. 31. lubricants • Mineral oil • acute or subacute management of constipation • works within 8 hours. • Long-term use is accompanied by concerns about lipid pneumonia, lymphoid hyperplasia, and foreign body reactions.
  32. 32. Saline laxatives • Magnesium hydroxide • Magnesium citrate (Citroma) • Magnesium sulfate • acute treatment of constipation in the absence of bowel obstruction. • osmotic retention of fluid, which distends the colon and increases peristaltic activity; it also promotes emptying of the bowel.
  33. 33. Osmotic agents • useful for long-term treatment of constipated patients with slow colonic transit who are refractory to dietary fiber supplementation. • Lactulose • Sorbitol • Polyethylene glycol solution bowel preparation
  34. 34. prokinetics • a prokinetic selective 5-hydroxytryptamine-4 (5-HT4) receptor antagonist that stimulates colonic motility and decreases transit time. • Tegaserod • irritable bowel syndrome (IBS) with constipation (IBS-C) or chronic idiopathic constipation (CIC) in women younger than 55 years
  35. 35. prosecretory drugs • lubiprostone & linaclotide • which stimulate intestinal fluid secretion by acting on the intestinal epithelial chloride channel and the guanylate cyclase receptor • chronic idiopathic constipation • Irritable bowel syndrome • Lubiprostone is also approved for opioid-induced constipation in patients with chronic, noncancer pain.
  36. 36. Stimulant laxatives • commonly employed to treat acute constipation and are the most common class of laxatives used over the long term by individuals taking over the counter products. • Senna acting directly on the intestinal mucosa or nerve plexus, action 8-12 hours Bisacodyl • Cascara sagrada • • Castor oil • •
  37. 37. Surgical intervention • large bowel obstruction, volvulus, or intraabdominal infection or ischemia • hemorrhoidal thrombosis. • rectal outlet obstruction (eg, rectocele, rectal prolapse, internal rectal intussusception) or in patients with a hypomotile (laxative) colon who are refractory to medical treatment.
  38. 38. Consultations • large bowel obstruction or colonic ileus secondary to an acute intra-abdominal process is suspected. • anorectal complications of constipation or for surgical correction of the underlying cause. Symptomatic hemorrhoids and anal fissures represent complications of constipation until proven otherwise. • Acute hemorrhoidal thrombosis
  39. 39. Long term monitoring After resolves in a patient who was acutely constipated, outpatient care requires the following measures: • Confirming that the patient is not chronically constipated • Ruling out colorectal pathology
  40. 40. Long term monitoring For a patient who is chronically constipated, outpatient care may include the following: • Colonic imaging or endoscopic visualization • Dietary management • If these measures fail in a compliant patient, further evaluation

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