The document provides a comprehensive overview of constipation, including its definition, risk factors, common causes, and distinctions between functional constipation and irritable bowel syndrome (IBS). It elaborates on diagnostic criteria, necessary tests, and treatment strategies, particularly for chronic idiopathic constipation. Treatment options discussed include dietary measures, biofeedback therapy, and pharmacological interventions such as plecanatide.

1. FUNCTIONAL AND ORGANIC
CONSTIPATION
by
Dr Wael Ahmed Yousry
Prof .of Gastroenetrology and
Hepatology

2. Definition of constipation
Constipation is generally defined as infrequent and/or
unsatisfactory defecation fewer than 3 times per
week. Patients may define constipation as passing
hard stools or straining, incomplete or painful
defecation
Risk factors for constipation
The following factors can increase a person’s
likelihood of becoming constipated; however, these
do not need to be present for constipation to occur:
Female gender
Over 65 years of age
Low caloric intake (eating less food)
Greater number of medications used
Sedentary lifestyle (lack of exercise)
Ignoring the urge to defecate

3. •Medications
•Analgesics (opiates, tramadol, NSAIDs)
•Tricyclic antidepressants
•Anticholinergic agents
•Calcium channel blockers
•Anti-parkinsonian drugs (dopaminergic
agents)
•Antipsychotics (phenothiazine
derivatives)
•Antacids (calcium and aluminum)
•Calcium supplements
•Bile acid resins
•Iron supplements
•Antihistamines
•Diuretics (furosemide,
hydrochlorothiazide)
•Anticonvulsants
Common causes of constipation

4. •Endocrine and metabolic diseases
•Diabetes mellitus
•Hypothyroidism
•Hyperparathyroidism
•Chronic renal disease
•Neurologic disordersCerebrovascular disease and stroke
•Parkinson’s disease
•Multiple sclerosis
•Autonomic neuropathy
•Spinal cord lesions
•Dementia
•Myopathic disorders
•Amyloidosis
•Scleroderma
•OthersDepression
•General disability
•Poor mobility
•Colonic obstructing mass or stricture,…

5. what is functional constipation???

6. Functional GI Disorders, better defined as Disorders of
Gut-Brain Interaction,
No structural basis to explain its clinical features, our
understanding of these disorders adhere to a
biopsychosocial model.
Symptoms are generated based on a complex interaction
among factors such as
Microbial dysbiosis with
in the gut
Visceral
hypersensitivit
y
Altered
mucosal
immune
function
CNS
dysregulation of
gut signaling

7. Functional constipation is also
known as chronic idiopathic
constipation (CIC). It is
constipation that does not
have a physical (anatomical)
or physiological (hormonal or
other body chemistry) cause.
It may have a neurological,
psychological or
psychosomatic cause. A

8. Rome IV criteria define Functional Constipation as
including two or more of the following symptoms:
•(1) straining during >25% of defecations;
•(2) lumpy or hard stools in >25% of defecations;
•(3) sensation of incomplete evacuation in >25% of
defecations;
•(4) sensation of anorectal obstruction/blockage in
>25% of defecations;
•(5) manual maneuvers (e.g. digital evacuation,
support of the pelvic floor) in >25% of evacuations;
and
•(6) fewer than three spontaneous bowel
movements per week.

9. Furthermore, these criteria should be
fulfilled for the last 3 months and
symptom onset should have been at least 6
months prior to diagnosis.
-In addition, loose stools should be rarely
present in the absence of the use of
laxatives
- Abdominal pain and/or bloating may be
present, but these should not be
predominant symptoms
(i.e. Rome IV criteria for irritable bowel
syndrome (IBS) should not be met)

10. Diagnostic criteria for irritable bowel
syndrome (Rome IV)
-Recurrent abdominal pain(essential),
on average, at least 1 day per week in the last 3
months, associated with 2 or more of the
following criteria:
– Related to defecation
– Associated with a change in frequency of stool
– Associated with a change in form (appearance)
of stool
word discomfort
has been
removed
3days /month changed
Phrase Improved with
defecation removed

11. : Patient reports that abnormal bowel
movements are usually constipation (like
type 1 or 2 in the picture of Bristol Stool
Form Scale [BSFS]

12. So,,What similarities and differences
are there between irritable bowel
syndrome with constipation and
functional constipation?
The key difference between both lies
in the presence or absence of pain

13. constipation
• PAINFULL
• IBS-constipation
• PAINLESS
• Functional constipation

14. Causes of functional
constipation

15. -Anismus (spastic pelvic floor)
-Descending perineum syndrome
-inability or unwillingness to control the
external anal sphincter, which normally
is under voluntary control
-A poor diet
-An unwillingness to defecate
-Nervous reactions, including prolonged
and/or chronic stress and anxiety, that
close the internal anal sphincter, a
muscle that is not under voluntary
control
-Deeper psychosomatic disorders which
sometimes affect digestion and the

16. How many pathophysiological
types of functional constipation
(with or without irritable bowel
syndrome) are there?

17. FC is classified according to the pathophysiological
mechanism involved in three catergories :
1. Patients with functional defecatory disorders (impaired rectal
emptying from inadequate rectal propulsion or abnormal relaxation in
the striated muscle responsible for opening the anal canal (relaxation
deficiency, paradoxical contraction or dyssynergic defecation) may be
detected. Both dysfunctions may be associated and often result in
diminished rectal sensitivity (hyposensitivity), structural pelvic floor
defects (excessive perineal descent, rectocele, enterocele,
intussusception, etc.)
2. Patients with slow colonic transit (SCT), where the time it takes the
intestinal material to pass through the colon is longer than normal.
3. Patients with normal colonic transit (NCT).

18. What diagnostic tests are needed
for the diagnosis of constipation-
predominant irritable bowel
syndrome and of functional
constipation?

19. Alarm criteria that should prompt diagnostic
testing to rule out organicity
Personal or family history of colorectal cancer, intestinal
polyposis, inflammatory bowel disease.
Symptom onset from 50 years of age on.
Recent changes in bowel movement habit.
-Presence of signs and symptoms that may suggest
organicity:
-Nocturnal symptoms
-Fever
-Anemia
-Unintended weight loss that cannot be explained by
other causes -Fecal blood
-Severe abdominal pain
-Physical exam with palpable abdominal mass,
visceromegalies, or abnormal digital rectal examination

20. 1- Anorectal manometry
2-high resolution manometry
3-high definition manometry
4- Balloon expulsion test
5-Defecography and MR proctography
6-colonic transit assessment

23. How to assess colon
transit time

30. Balloon expulsion test

31. Anorectal manometry

33. DEFECOGRAPHY

42. Spastic pelvic floor $

43. descending perineal syndrome

45. Treatment:
The treatment of a patient with
dyssynergic defecation consists of:
1-Standard treatment for constipation
2-Specific treatment i.e. neuromuscular
training or biofeedback therapy
3-Other measures include botulinum
toxin injection, myomectomy or
ileostomy

50. Plecanatide(brandname Trulance),
is a drug approved in January 2017
by the FDA for the treatment of
chronic idiopathic constipation
(CIC). Plecanatide is an agonist of
guanylate cyclase-C. Plecanatide
decreases intestinal transit time and
increase fluid through a buildup of
cGMP
Dose: 3 mg taken orally once daily

51. Biofeedback therapy
1-Timed toilet training: consists of
educating the patient to attempt a
bowel movement at least twice a day,
usually 30 minutes after meals and to
strain for no more than 5 minutes.
During attempted defecation, they
must be instructed to push at a level
of 5 to 7, assuming level 10 as their
maximum effort of straining

52. They should be encouraged to stress on intrinsic
physiologic mechanisms that stimulate the colon,
such as after waking and after a meal ,
It is important to emphasize that stool impaction
should be prevented at all costs.
Patients should be advised to refrain from manual
maneuvers such as digital disimpaction of stools.
Enemas should be generally discouraged although
during the initial stages of training or if
biofeedback therapy is pending this may be
permitted along with use of glycerin or bisacodyl
suppositories

53. 2-Diaphragmatic breathing
excercises

54. To facilitate the training, ideally the subject should be seated
on a commode with the manometry probe in situ. After
correcting the patient’s posture (for example, keeping the legs
apart as opposed to keeping them together) and the sitting
angle at which he/she will attempt the defecation maneuver,
i.e. leaning forward, the subject is asked to take a good
diaphragmatic breath and to push and bear down as if to
defecate .
The subject is encouraged to watch the
monitor while performing this maneuver.
The subject’s posture and breathing techniques are
continuously monitored and corrected.
The visual display of the pressure changes in the rectum
and anal canal on the monitor provides instant feedback
to the subject regarding their performance and helps
them to understand and learn quickly. At least 10-15
maneuvers are performed.

55. Thank
you