The document discusses the evaluation and management of constipation. It outlines the clinical approach which includes determining if it is constipation, identifying potential causes like drugs or disease, and checking for alarm symptoms. Evaluation involves examination, labs like TSH and calcium, and tests like anorectal manometry and balloon expulsion tests to classify constipation and identify defecatory disorders. Biofeedback therapy is described as the treatment of choice for defecatory disorders by training muscles through visual cues. Surgery may be considered for issues like rectocele or Hirschsprung's disease.

1. Mission im ..poo ..sible
Dr. Naresh Bhat
Bangalore

3. Clinical approach
 Is it constipation ?
 Are drugs or systemic disease responsible ?
 Are there alarm symptoms ?
 What is the cause of constipation ?

6. Clinical exam
 Perineal and rectal exam essential

7. Labs
 TSH
 Calcium

9. Management of evacuation
disorders
STC Defecatory disorderNormal transit

14. 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?

15. Constipation -classification
 Normal transit
 Slow colonic transit
 Defecatory disorder

16. Modalities to evaluate
 Transit study
 Anorectal manometry and balloon expulsion
 Defecography

18. 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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Basal (13.53:32)

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Balloon Expulsion (15.16:10)
Balloon Expulsion
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Balloon Expulsion# 1 (14.47:56)

21. Pelvic floor disorder
Abnormal ARM Abnormal BET/BDAbnormal ARM Abnormal BET/BD
Absent RAIR High RP, SP
Hirschsprung’s
disease
Anismus
Anal fissure
Abnormal anorectal angle
Perineal descent
Constipation Due to Pelvic Floor Disorder

22. Anterior rectocele Non relaxing puborectalis

24. 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

25. 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.

26. Efficacy of biofeedback in evacuation disorder
Author Year Mode % well
Bleijenberg 1988 Inpatient-home 70
Weber 1988 Outpatient 18
Lestar 1991 Outpatient 69
Kawimbe 1991 Home 87
Dahl 1991 Inpatient 78
Wexner 1992 Outpatient 89
Fleshman 1992 Outpatient 100
Dig Dis Sc 1993; 38: 1953-60

27. Our experience in biofeedback
110 patients in last 3 years
- Defecatory disorder, fecal incontinence
80-85% patients had significant positive
response

28. Role of surgery
• Hirschsprungs disease
• Rectocele
• Colonic inertia

30. 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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Balloon Expulsion (15.19:05)
Balloon expulsion

34. Check list
 Hypothyroidism
 Parkinsons
 Diabetes
 Parkinson drugs
 Antihistaminics
 Anti histaminics