Chronic constipation is defined as symptoms lasting at least 3 months. Diagnosis involves assessing stool frequency and form, straining, incomplete evacuation, manual maneuvers, and excluding other causes. Tests evaluate anorectal physiology including balloon expulsion, manometry, defecography and transit studies. Treatment involves lifestyle changes, biofeedback, prucalopride, surgery for severe cases. Indian definitions differ based on stool characteristics and transit times.

1. CHRONIC CONSTIPATION
MEDICAL perspective

2. DEFINITION …….
⚫ Chronic constipation 🡪symptoms duration for
atleast 3months
⚫CLINICALLY🡪 whether or not related to IBS
⚫PATHOPHYSIOLOGICALLY🡪slow transit, normal
transit or defecatory disorders

3. .
⚫Rome IV diagnostic criteria
⚫ ........ present for at least 3 months with symptom onset at least 6
months prior to diagnosis.
1)Presence of ≥2 of the following symptoms: (symptom 1-4 should be in >25%
of defecations)
✔ Lumpy or hard stools (Bristol Stool Form Scale 1–2) ...west
✔ Straining during defecation
✔ Sensation of incomplete evacuation
✔ Sensation of anorectal obstruction/blockage
✔ Manual maneuvers to facilitate defecation
(digital manipulations, pelvic floor support)
✔ <3 spontaneous bowel movements per week(2)
2) Loose stools rarely present without the use of laxatives
3) Insufficient criteria for irritable bowel syndrome(indians may have
coexisting)

4. The Bristol Stool Scale …….
Stool consistency - better predictor gut transit time
In Indians Bristol type III also
constipation
Indian J Gastroenterology

5. Indian scenario….
⮚ Stool frequency higher, softer stools(bristol3) and higher stool
weight as compared to west.
⮚ Defined more by stool form and pts perception than frequency.
⮚ Functional constipation >IBS-C (bcoz less pain more bloating)
⮚ Colon transit study, method and interpretation is different from
west(ghoshal protocol later)

6. PART ONE-PRIMARY HEALTH
CARE LEVEL
CLINICAL APPROACH TO CHRONIC
CONSTIPATION…

7. PART 2-TERTIARY CARE
LEVEL

9. Approach To Constipation
History –
1 warning symptoms or signs— (colonoscopy
indicated) ----without red flag signs…output same as
asymptomatic screen for cx
⚫unintentional weight loss,
⚫rectal bleeding(occult or overt)
⚫ recent change in the caliber of stool,
⚫severe abdominal pain,
⚫family history of colon cancer
2) any h/o drugs, metabolic disease , neuro phychiatric
disorders disease

10. ✔ Bristol stool type (over the last 2 weeks)
✔ Symptoms suggestive of fecal evacuation disorder
Prolonged (>30 min) and excessive straining
Infrequent defecation (<3 per week)
Manual evacuation, need of perineal and vaginal pressure to
assist defecation
✔ Obstetric history
✔ Urge to evacuate
✔ Abdominal pain, bloating
✔ Toilet type (Indian vs. Western) and any recent change
✔ Dietary history (vegetarian vs. non-vegetarian), dietary fiber, water intake
✔ Physical exercise
✔ Pain during defecation
✔ Physical examination/DRE

11. PART 2

12. Tests to Assess the Physiology of Defecation
⮚Balloon expulsion test
⮚ Anorectal manometry
⮚ Defecography,
⮚ Electromyography (EMG)

13. 1 Balloon Expulsion Test

14. Balloon expulsion test
⚫Simple screening test for FED
⚫ 50ml (or until rectal sensation) water filled balloon
> 2min to evacuate FED
or >250g hanging wt added to evacuate ballon.
1) sensitivity …88% ,specificity…89%, PPV 67%,
NPV..97%. Normal BET might exclude a defecatory
disorder.
2) Mingues etal Gastroenterology 2004

16. 2 Normal anorectal manometry

17. Anorectal Manometry components
❖ ANAL SPHINCTER FUNCTIONS(Resting pressures , squeeze pressures of
the anal sphincters,functional length of anal canal)
❖ RECTOANAL REFLEX ACTIVITY…..Presence or absence of relaxation of
the anal sphincter during balloon distention of the rectum (rectoanal
inhibitory reflex and recto anal contractile reflex).
❖ ABILITY OF THE ANAL SPHINCTER TO RELAX DURING STRAINING
❖ RECTAL SENSATION(BIOFEEDBACK HELPFUL)
❖ RECTAL COMPLIANCE(checks capacity and distensibilty of rectum)
❖ Balloon expulsion test(already described)
Absence of Rectoanal inhibitory reflex raises the
possibility of Hirschsprung’s disease.

18. Dyssynergic defecation

19. 3 Defecography
.....(Evacuation/voiding proctography)
Shows rate and completeness of rectal emptying, anorectal angle and
amount of perineal descent and identifies structural abnormalities (e.g.,
large rectocele, internal mucosal prolapse, intussusception)
but …… Identified anatomical abnormalites are not
always functionally relevent

21. Rectal opacification….
250 to 300ml of thick
barium paste in left
lateral position
🡪 then fluoroscopic
table tilted to vertical
position.

22. ⚫ MR defecography better than barium ? ?
⚫No radiation exposure, image quality
better,imaging of surrounding structures but less
physiological( supine film in MRI).
⚫Both equally good

24. ⚫EMG
❖ EMG of external anal sphincter and pubo rectalis
indicated.
❖
❖ Spinal cord or cauda equina lesion, bilateral or
unilateral dysfunction of the external anal sphincter

26. What these tests signify….
Defecatory disorder…….

27. Rome III Criteria for Functional Defecation
Disorders(3month in last 6 months )
⚫During repeated attempts to defecate, the patient must
have at least 2 of the following:
⮚ Evidence of impaired evacuation, based on balloon expulsion test or
imaging
⮚ In appropriate contraction of pelvic floor muscles (i.e., anal sphincter
or puborectalis) or <20% relaxation of basal resting sphincter pressure
by manometry, imaging, or EMG
⮚ Inadequate propulsive forces assessed by manometry or imaging

29. ⚫4 ...Colon transit time Measurement
......(slow transit vs normal transit
constipation)
⮚ Radiopaque markers (radiation exposure)
⮚ Wireless motility capsule
⮚ Colonic transit scintigraphy(minimal radiation ,
more physiological assessment)

30. Radiopaque markers
✔ after the patient ingests plastic beads or rings,
and counting the number of retained markers.
✔Mean colon transit time - 30 to 40 hrs (max72
hrs ) in normal person (not applicable to
indians…ghoshal protocol)
✔ If the markers are retained exclusively in the
sigmoid colon and rectum🡪 defecatory disorder.

31. ⚫Wire less Motility Capsule
❖ NO RADIATION
❖ In addition …….
❖ MEASURES GASTRIC EMPTYING,
SMALL BOWEL TRANSIT, AND COLONIC
TRANSIT TIMES
Normal colonic transit time using the wireless motility capsule is
...............................................................................................10 to 59 hr
Delayed gastric emptying....>5hr duration.....
small bowel emptying>6hr in small bowel
colonic transit considered > 44 hours in men and
> 59 hours in women.

33. ⚫Colonic Transit Scintigraphy
Using a gamma camera at specified times after ingestion of a labeled meal
(In DTPA-labeled water with standard 99mTc egg sandwich) gastric,
small bowel , colon transit time.
Capsule (In-labeled activated charcoal particles) - measurement of
only colonic transit.

35. In slow transit …myopathic vs
neuropathic
⚫Colonic manometry studies
⚫Myopathy no role of prokinetics.

36. Treatment ……

37. Management

38. Biofeedback therapy……(helps in upto 2/3 of
cases of dysynergic disorder cases
⚫ Behavioural modification in defecatory dysfunction syndromes.
⚫ Patient watches the EMG recording and sphincter pressure responses
during attempted expulsion of apparatus and is asked to modify
inappropriate responses through trial and error.
⚫ Helpful in dyssynergic defecation and slow transit constipation only if
it is associated with dyssynergic defecation.

39. Indian experience ….
⚫Study from mumbai…. 70% of 20 pts ..improved after
4 sessions
⚫Study from lucknow…62% had improvement in
symptoms at 1 month of follow up.

40. Prucalopride …..
⚫5HT4 prokinetic agent .
⚫Dose 1-4mg.
⚫Safe in age 65 or more
⚫Improvement in quality of life maintained upto
18months of follow up.

41. Misc approaches…(not validated)
⚫I.M Botox in puborectalis (spastic pelvic floor
dysfunction--- here also biofeedback is a better
option)
⚫Complementary alternative medicine….. Acupuncture
& pro/prebiotics(bifidobacter &
fructooligosaccharides)
⚫Sacral nerve stimulation….. In severe constipation.

42. When to go for surgery ?

43. Summary ….
⚫Colonoscopy …..indicated in red flag signs , age >50
⚫BET, ARM ist line 🡪defecography 🡪transit studies
⚫Western defnition can be applied to indian
population in toto….there are imp differences.
⚫BET …97% NPV
⚫Interpretation of colon transit is also different

44. Acknowledgement ….
⚫
⚫DR ARUN KARYAMPUDI(consultant
gastroenterology)