Approach to Constipation

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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 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
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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