1) The document discusses the physiology and types of constipation including normal transit, slow transit, and dyssynergic defecation. 2) It provides guidelines for evaluating patients with constipation through history, physical exam, and tests to identify organic causes or characterize colonic transit time. 3) Key tests discussed are abdominal x-ray, colonic transit studies using radiopaque markers or wireless motility capsule, and anorectal manometry to identify dyssynergic defecation.

1. APPROACH
TO
CONSTIPATION

2. Physiology of Defecation
■ Defecation is a spinal reflex.
■ Distension of the rectum → reflex contractions of its musculature → desire to
defecate
Internal
Smooth muscle
Sympathetic-Excitatory
Parasympathetic-Inhibitory
External
Skeletal muscle
Pudendal nerve

3. Rectal pressure Response
≥ 18 mm Hg Urge to defecate
≥ 55 mm Hg defecation
90-100
*Ganong, Guyton and Hall Physiology
Straining abdominal muscles puborectalis muscle relaxes pelvic floor descent
anorectal angle
straight
relaxation of the external anal sphincter
Defecation

4. *Guyton and Hall Physiology
1 2
3
4
5 6
Rectal nerve
endings
Spinal cord
colon
sigmoid
rectum
Parasympathetic
nerves
↑ Persistalsis
relaxed internal sphincter
defecation

5. CONSTIPATION
■ Very common clinical problem all over the world.
■ Serious impact on quality of life of the patients, financial burden.
■ It is said that 2.5 million individuals with constipation undergo evaluation annually.
■ ≥ $500 million is spent on laxatives each year.
■ The traditional definition of constipation has been ≤ 3 bowel movements per week.
■ ACG Task force defines it as “Unsatisfactory defecation characterized by infrequent
bowel movements/ difficult to pass stools/ both”.
■ Objectively defined by recent ROME IV criteria.

6. ■ These disorders should be thought of as existing on a continuum, rather than as in
isolation.

7. *Van Oudenhove et al Gastroenterology 2016;150:1355–1367
Biopsychosocial model for FGID

8. Criteria fulfilled for the last 3 months with symptom
onset at least 6 months prior to diagnosis.
Any 2 of the below
Loose stools rarely
present without
use of laxatives
Not meeting IBS
criteria
Straining
Lumpy/hard stools
Incomplete
evacuation
Sensation of
obstruction
Manual maneuvers
≤3 spontaneous
movements/week
25% of the
defecations
Patient might be passing stools daily and
can still have constipation

10. Epidemiology
■ The prevalence of constipation is estimated to be 14% based on a meta-analysis of
41 studies with over 261,000 subjects throughout the world.
STUDY SAMPLE SIZE CRITERIA FOR Dx Prevalence
Ghoshal et al. 2008 Complainants: 2785
Non-complainants: 4500
Self-perception 53%
Makharia et al 2011 4767 Self perception 11.6%
Rajput and Saini 2014 505 ROME II 16.8%
Self Perception 24.8%
Ghoshal , Singh 2017 2774 ROME III 2.4%
Indian studies
• Advanced age
• Female gender
• Low level of education
• Low level of physical
activity
• Low socioeconomic status
• Multiracial ethnicity
• Use of certain medications

11. Types
■ Functional – Most common type – 80%
■ Organic – 20 %
Anal stenosis
Intestinal stricture
Rectocele
Sigmoidocele
Colorectal cancer
Extrinsic compression
Diabetes mellitus
Heavy metals
Hypercalcemia
Hypokalemia
Hypothyroidism
Amyloidosis
Multiple sclerosis
Parkinsonism
dermatomyositis
Anti depressants,
Anti Parkinson
Vinca alkaloids
opioids
Diuretics
Iron

12. Functional constipation
Normal Transit Constipation
Slow Transit Constipation
Defecatory Disorders
Normal Transit
59%
Slow Transit
25%
Defecatory disorder
13%
Mixed
3%
Functional constipation

13. NORMAL TRANSIT CONSTIPATION
■ Patients report that they have constipation, inspite of normal frequency.
■ Presence of hard stools or a perceived difficulty with evacuation.
■ Stool transit, stool frequency - within the normal range.
■ Bloating and abdominal pain.
■ May exhibit increased psychosocial distress.
■ Respond to therapy with dietary fibre ± osmotic laxative or enterokinetic.
■ Typically will not require a formal transit test.
NTC
IBS C

14. Slow transit constipation
■ Slow transport of stool across colon.
■ Infrequent bowel movements (<1 /week)
■ Young Women.
■ Colonic inertia - most severe end of the spectrum.
Colonic dysmotility
Colonic neuropathy
Neuro-hormonal cause
Methanogenic bacteria
Slow Transit
Constipation

15. Colonic dysmotility
■ Colonic motor activity has temporo-spatial variation
■ influenced by sleep, waking, meals , physical and emotional stressors, gender, aging.
■ STC- overall ↓ colonic motor activity.
■ Blunted Gastrocolonic response, no increase in activity after waking up.
■ ↓ frequency, amplitude and duration of HAPCs.

16. Colonic Neuropathy
■ Interstitial cells of cajal –evoke basic electrical rythms for intestinal movements,
■ Pacemaker cells for intestinal motility.
■ Pancolonic ↓ in the icc volume across the circular and longitudinal muscle layers and
submucosa,
■ ↓ myenteric ganglion cells
*GUT- BMJ

17. Neuro-hormonal
■ Women>Men. Possible Hormonal cause??
■ Low levels of ovarian and adrenal steroid hormones has been suggested (not confirmed)
■ Colectomy specimens from women with STC -- ↓ progesterone-dependent contractile G
proteins,
↑ inhibitory G proteins in constipated women.
Stimulation
of mucosa
Acetyl
choline
Substance P
NO,VIP
Descendin
g
inhibitory
Ascending
excitator
y
Myenteric
plexus
Mechanical,
5HT,CGRP
Relaxation of
circular
muscle
Peristaltic
contractions
Role of paracrine
neurotransmitters
↓ serotonin
↓ receptor
density
↓ function of the
serotonin reuptake
transporter
Impaired
ascending
contractions

18. Dyssynergic defecation
■ Inability to coordinate the abdominal, rectoanal, and pelvic floor muscles during defecation
■ Symptoms often begin in childhood.
Functional
constipatio
n
Abnormal
balloon
expulsion
test
Impaired
Rectal
evacuation
Abnormal
ARM/Anal
surface EMG
≥2 of
following
Criteria fulfilled for the last 3 months with symptom
onset at least 6 months prior to diagnosis.
STC DD
Am J Gastroenterol. 2008;103(3):692-698.

19. ■ spasm or inability to relax the external anal sphincter is NOT the sole mechanism.
■ Incoordination or dyssynergia of the muscles, impaired rectal sensation are the primary
causes.
■ Three phenotypes have been described
↑ Sphincter
pressure
Inadequate
propulsive
force
Mixed
phenotype
31%
29%
40%
childhood post pregnancy/trauma unknown cause
J Neurogastroenterol Motil, Vol. 22 No. 3
July, 2016

20. Approach to a patient of constipation
■ History
 Onset – whether it began in childhood
 Urge, frequency, need for straining, stool consistency, stool size, history of ignoring a call to
stool precipitating events, use of any maneuver to assist the defecation.
 Dietery history- Fiber and fluid intake, number of meals, Breakfast habits
 Significant past history: Obstetric and Surgical procedures.
• Weight loss
• Rectal bleeding
• Recent change in the caliber
of stool
• Abdominal pain
• Family history of colon
cancer
Be alert to manifestations of depression, such as insomnia, lack of
energy, loss of interest in life, loss of confidence, and a sense of
hopelessness.
In one study of dyssynergic defecation,22% had a history of sexual
abuse, 32% had physical abuse

21. 79%
71%
62%
57% 57% 54%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
straining Hard stools discomfort bloating infrequent bowel
movemnts
Feeling of incomplete
evacuation
Functional Organic Dyssynergic defecation
Long standing symptoms Recent onset Heaviness in perineum
No constitutional symptoms Loss of appetite Excess straining
No bleeding/mass Loss of weight Feeling of obstruction
No symptoms of obstruction Bleeding/mass Digital evacuation/support
of perineum
Family h/o colonic
Can History differentiate between types of
constipation?

22. Examination
■ Complete General Physical examination along with neurologic assessment to screen for organic
cause
■ Abdominal examination, for distention, hard feces, presence of mass per abdomen.
■ One thing that is very important and is very commonly not performed!??

23. sensitivity and specificity of DRE were75% sensitive
and 87% specific for identifying dyssynergia. PPV was
97%.
paradoxical contraction of the external anal
sphincter and puborectalis muscles with
fingertip being displaced anteriorly during
attempted defecation, suggesting dyssynergic
defecation
*The American Journal of Gastroenterology

24. Investigations
■ Young patients without alarm features can be treated empirically after thorough history taking
and DRE.
■ Patients with alarm features- mandate work up.
■ Tests for systemic diseases-
 ESR,
 CBC,
 Biochemistry profile,
 FBS/PPBS/HBA1C
 Thyroid function tests
To exclude
systemic/structural
disease
To detect underlying cause
if patient is unresponsive to
simple treatment

25. Tests for structural diseases
 Plain X ray Abdomen
- to complement clinical history and physical examination
- Identifies excessive amount of stool in the colon
- Not recommended if no alarm features
 Barium enema
- To identify redundant sigmoid colon, megacolon, megarectum, stenosis, extrinsic compression
intraluminal masses.
- Not recommended if no alarm features
C
C

26. Endoscopic procedures
In younger patients, a flexible sigmoidoscopy may be sufficient.
scop
y
Bleedin
g
Age≥ 50
Weight
loss
Obstructiv
e
symptoms
Recent
onset
symptoms
IDA
Recent
change
in stool
calibre
*ACG Taskforce
recommendation

27. Tests for functional constipation
Colonic Transit studies-- The American and European Neurogastroenterology and Motility Societies
recommend 3 methods for assessing colonic transit time.
radiopaque
markers
wireless
motility
capsule
scintigraphy
20% or more
retention of
markers
X rays taken after
120 hours
Single capsule
swallowed on day
1
STC

28. If the markers are retained
exclusively in the sigmoid
colon and rectum, the patient
may have a defecatory
disorder.
Ghoshal's protocol
20 radio-opaque markers filled in capsules administered at 0, 12, and 24 h, and then abdominal
radiographs obtained at 36 and 60 h is found useful.
Retention of ≥ 30 radio-opaque markers at 36 h (sensitivity 90%, specificity 82%) and ≥ 14 markers
at 60 h (sensitivity 95%, specificity 100%) is quite accurate to detect slow colon transit.

29. The wireless motility capsule is ingested following a standardized meal
and 50 mL of water
Patients wear a data receiver on their waists for 5 days, or until the
capsule is passed.
After the passage of capsule,the data is analysed to assess the transit
time.
↑ 𝑇𝑒𝑚𝑝 ↓pH
↑ 𝑝𝐻 ↓Tem
p
Gastri
c
Transit
Small
bowel
Transit
Coloni
c
Transit
J Neurogastroenterol Motil, 2014 Apr; 20(2): 265–270
Wireless motility capsule
2-5 hr 2-6 hr 10-59 hr

30. Scintigraphy
■ Scintigraphy transit tests involve the ingestion of radioactive isotopes.
■ There are 2 methods for the delivery of markers in clinical uses: 111In-DTPA labeled water
consumed in a standard solid-liquid meal, 111In activated charcoal slurry contained in a
capsule.
■ Anterior and posterior images of the colon are obtained using a gamma camera at specified
times over 2 to 3 days following ingestion of the meal.
■ Results are expressed as geometric center(GC). It is a Single figure that indicates the region
where the median of the radioactivity lies.
■ A GC of 1 would indicate that activity is mostly in region 1 (cecum and ascending colon), and a
GC of 5 would indicate that most of the activity is in region 5 (feces).
■ Normal values GC : 1.6–3.8 at 24 h and 3.0– 4.8 at 48 h.
■ Slow colon transit is defined as a GC less than these reference values at 24 and 48 h.
■ A low GC is considered slow transit, high GC center is considered accelerated transit.
*THE JOURNAL OF NUCLEAR MEDICINE • vol. 54 • no. 11 • november 2013

31. *Evaluation of gastrointestinal transit in clinical practice: position paper of the
American and European Neurogastroenterology and Motility Societies, Rao et
al 2010

32. Anorectal manometry

34. The patient can generate an adequate
pushing force, (rise in intra abdominal
pressure) along with a paradoxical
increase in anal sphincter pressure .

35. Patient is unable to generate an adequate
pushing force (no increase in intrarectal
pressure) but can exhibit a paradoxical anal
contraction.

36. The patient can generate an adequate
pushing force but, either has absent or
incomplete (<20%) sphincter relaxation (i.E.
No decrease in anal sphincter pressure) .

37. The patient is unable to generate an
adequate pushing force and demonstrates an
absent or incomplete anal sphincter
relaxation

38. Balloon expulsion test
■ a 4 cm long balloon filled with 50 mL of warm water is placed in the rectum.
■ After placement, the patient is given privacy and asked to expel the balloon.
■ A stop watch is provided to assess the time required for expulsion
■ Useful as Screening test for Dyssynergic defecation.
■ Sensitivity- 50% Specificity- 80-90%

39. Defecography
■ Barium defecography- 150 mL barium paste into the patient’s rectum--having the subject
squeeze, cough, and expel the barium.
• radiation exposure
• embarrassment
• limited availability
• interobserver bias
• inconsistent
methodology

40. Indian J Radiol Imaging. 2013 Jan-Mar; 23(1): 92–96.

41. MR
defecography
■ No preparation
needed.
■ Rectal instillation
of Ultrasound
jelly.
■ Wears adult
diaper
■ Patient in supine
position
■ Dynamic T2
Images are taken.
■ 4 Phases.
■ Clear instructions
before sending
patient on to MRI
machine

42. Multiple test positivity including balloon expulsion test, anorectal manometry,
and defecography has better accuracy than a single test for diagnosis of FED.

43. History, Physical exam
Baseline evaluation
Inadequate response
To Therapeutic trial
Anorectal Manometry
Balloon Expulsion Test
Normal Abnormal
Inconclusive
Colonic Transit Defecography
Defecatory
Disorder
Algorithm for chronic
constipation
AGA.,GASTROENTEROLOGY
Vol. 144, No. 1,PAGE 214

44. Colonic Transit
Defecatory
Disorder
Defecography
Normal
Slow Abnormal
Normal
Slow Transit
Constipation
Normal Transit
constipation
Algorithm for chronic constipation
AGA.,GASTROENTEROLOGY Vol. 144, No. 1,PAGE 214

45. Use of technology
Mobile app – constipation diary

46. lwc liu. chronic constipation: current treatment options.
can J gastroenterol 2011;25(suppl B):22B-28B.

47. Treatment
“Initial treatment of CC should include lifestyle modification and osmotic laxatives”
Timed toilet training
Dietery fibers
Position of defecation
Physical activity
Water intake
Squatting
1.5-2L
Attempt for 5 min,30-60 min after
meal, twice a day

48. fibre
s
Dietery fibres
Agent Dose remarks
Psyllium 4-6g/day Natural,Can cause IgE mediated reaction
Methyl
cellulose
4-6g/day synthetic
Polycarbophil 4-6g/day synthetic
Fiber supplement should be avoided if the patient is already on high fiber diet
and/or abdominal bloating is a prominent symptom
Slow Transit Constipation, Dyssynergic defecation-
Recommended dosage – 25-30g/day of soluble fibres – start at 12g/day, slowly increase.
(Oats,nuts,barley,beans,lentils,fruits).
The benefits of added fiber are not evident for days to weeks. Generous fluid intake along with fiber
supplementation.
If patients fail to respond to a dietary fiber trial, slow transit constipation and/or a defecatory disorder
could be suspected.
If results of therapy are inadequate, commercially packaged fiber supplements should be tried.

49. Osmotic laxatives Lactulose 15-30ml OD/BD Cramps,flatulance
PEG 17-34g OD/BD Incontinence
Milk of Magnesia 15-30ml OD/BD hypermagnesemia
Stimulant laxatives Bisacodyl 5-10 mg H.S. Incontinence,cramps
Sod Picosulfate 5-15 mg H.S
Senna(anthraquinone) 1-2 7.5-mg Psudomelanosis coli
Stool Softners Docusate sodium 100mg bd
Enemas Phosphate enema
Mineral oil enema
Soapsuds enema
Rectal mucosa damage,
hyperphosphatemia,ele
ctrolyte abnormalities
Chloride channel
activator
Lubipristone 8-24𝜇g/day Nausea,headache,d
iarrhea
Guanyl cyclase C
agonist
Linaclotide 72-145𝜇g/day
diarrhea
Plecanatide 3mg OD
5HT4 agonist Tegaserod
Prucalopride
2-6mg BD
2mg OD
Cardiovascular
Headaches,nausea

50. Prucalopride, a full 5-HT 4 agonist -- benzofuran derivative -- accelerates colonic transit.
no cardiovascular side effects have been observed to date with prucalopride.
Possible future agents-
Chenodeoxycholate
Elobixibat
Velusetrag
Rifaximin*
*Intestinal research Journal,2015 Oct
Lubiprostone Linaclotide
Not recommended in <18years age.

51. Yvonne Tse et al. Canadian Journal of Gastroenterology and Hepatology / 2017 / Article

52. Biofeedback therapy
■ Principle - any behavior- such as eating or a simple task such as muscle
contraction,when reinforced, its likelihood of being repeated and perfected
increases several fold.
Correct
dyssynergia/incoordination of
muscles
Enhance rectal
sensory perception

54. Rectoanal coordination
■ Subject is supine/seated on commode with manometry probe in situ.
■ Asked to take a good diaphragmatic breath and to push as if to defecate.
Encouraged to watch the monitor.
■ Visual display of the pressure changes in the rectum
and anal canal on the monitor. 10-15 maneuvers are performed.
■ Balloon distended in rectum with 60cc air
■ Subject is asked to attempt defecation while watching the monitor.5-10 attempts
Simulated defecation training –
To teach the subject to expel an artificial stool in the laboratory using the correct technique.
■ 50ml of water filled balloon in rectum/artificial stool--- ask the patient to expel -– he is taught
how to relax the pelvic floor, co-ordinate breathing cycles with the attempt.

55. Enhance rectal perception
■ progressively inflate the rectal balloon until the subject experiences an urge to defecate.
■ Deflate and repeat the same step 2-3 times.
■ Then with each inflation, balloon volume is decreased by 10%
■ subject is encouraged to observe the monitor and to note the pressure changes and pay close
attention to the sensation in their rectum.
■ If patient fails to percieve a particular volume, deflate and again inflate with same volume or
to previously perceived volume.
■ By the end of each session, newer thresholds for rectal perception are established.
■ Number of sessions- customised.
■ Every session-1hr, one session every 2 weeks.Avg 4-6 sessions.
■ Reinforcement after 1.5 months,3,6,12 months

56. 81%
79%
70%
64%
66%
68%
70%
72%
74%
76%
78%
80%
82%
Chiaroni etal Rao et al heyman et al
Response to Biofeedback therapy

57. Surgical therapy
subtotal colectomy with an ileorectal anastomosis.
Defecatory Disorders
The stapled transanal rectal resection (STARR) procedure has been used with some success,
especially for rectocele and intussusception.
Slow
Transit
No PFD
No Pseudo
obstruction
Pain is not a
prominent
symptom
Refractory

58. Take Home message
■ Thorough history taking is a keystone in constipation.
■ Bristol stool chart is a very useful tool.
■ Red flag signs should mandate relevant work up.
■ Rectal Examination is a must in patients of constipation.
■ Initial treatment of choice is lifestyle and dietary modifications.
■ High Fiber diet will not be helpful in PFD.
■ Biofeedback therapy is the treatment of choice for pelvic floor dyssynergia.

59. Thank you