Chronic constipation is a worldwide problem that can be primary or secondary. It involves two or more symptoms including difficult stool passage, decreased stool frequency of less than three times per week, and a sensation of incomplete evacuation or straining. The causes of constipation are complex and multifaceted. Treatment involves dietary changes with increased fluids and fiber intake, fiber supplements, laxatives, prokinetics, pelvic floor rehabilitation, sacral nerve stimulation or anorectal surgery depending on the severity and underlying cause. Complications can include hemorrhoids, anal fissures, rectal bleeding and impaction.

1. Approach to Constipation
ANWER GHANI
FIBMS
IRAQ

2. .
 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.

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

4.  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 >3 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.

10. 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-pelvic_x0002_abdominal or obstetric-
gynecological surgery.

11.  Red flags

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

13. 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).

14.  +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)

15. Rx
 ,

16. .
 many patients will benefit from abolishing or reducing
medications that cause constipation.

17. .
 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.

18. .
 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.


19. .
 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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 ,

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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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23. Laxative use
 .

24. Other therapeutic options
 - pelvic floor rehabilitation
 -sacral nerve stimulation
 -anorectal surgery

25. Other tests
 colpo-cysto_x0002_entero-defecography
 magnetic resonance (MR) defecography
 dynamic transperineal ultrasonography (DTP-US)

26. .
 Colonic and/or gastrojejunal manometry should be
performed in patients with serious slow-transit
constipation

27. 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)

28.  Complications of Constipation
 Hemorrhoids
 Anal fissures
 Rectal bleeding
 Fecal incontinence
 Fecaloma
 Pelvic organ prolapse
 Fecal impaction
 Bowel obstruction
 Bowel perforation
 Stercoral peritonitis