4.

5: Diarrhea and Constipation

Dr. Sandejas |December 3, 2013
OUTLINE
I. Physiology of Diarrhea II. Diarrhea III. Acute Diarrhea IV. Chronic Diarrhea V. Constipation

MEDICINE
2nd

20132014

7&erflo' diarrhea (ay occur in nursing ho(e patients due to fecal i(paction that is readily detecta"le "y rectal e!a(ination. Careful hist'ry and physical e-aminati'n generally allo' these conditions to "e discri(inated fro( true diarrhea

Source: Dr. Sandejas ppt, Harissons e!t"oo# of $edicine BOLD emphasized by lecturer in his PPT

III.

$&UTE DI$%%HE$

I. PH !IOLO" O# DI$%%HE$
$. Neural &'ntr'l
Intrinsic and %!trinsic inner&ations 'hich (odulate (otor and secretory functions )arge capacitance and functional reser&e can partially co(pensate for e!cess fluid deli&ery to the colon caused intestinal a"sorpti&e or secretory disorders $igrating $otor Co(ple! *$$C+ clears non,digesti"le residue fro( the s(all intestine during fasting Irregular (i!ing contractions occur in the s(all intestine after ingestion Allo's ti(e for sal&age of fluids, electrolytes and nutrients Diarrhea or constipation (ay result fro( alteration in the reser&oir function of the pro!i(al colon or the propulsi&e function of the left colon Increased fre-uency of High A(plitude Propagated Contractions *HAPCs+ (ay result in diarrhea or urgency Colonic one is an i(portant cofactor in the colon.s capacitance *&olu(e acco((odation+ and sensation Colonic phasic and tonic contractility is (ediated initially "y the &agus ner&e in response to (echanical distention of the sto(ach and at least in part "y hor(ones, e.g., gastrin and serotonin. onic contraction of the pu"orectalis (uscle *a sling around the rectoanal junction+ is i(portant to (aintain continence During defecation, sacral parasy(pathetic ner&es rela! the pu"orectalis, facilitating the straightening of the rectoanal angle

B.

Intestinal #luid $bs'rpti'n and !ecreti'n

Infectious agents , 1 <3= of cases of acute diarrhea o often acco(panied "y &o(iting, fe&er, and a"do(inal pain. 7ther causes , the re(aining >3= o $edications o o!ic ingestions o Ische(ia o other conditions

&.

!mall(Intestinal )'tility

&$U!E! O# DI$%%HE$ $. In,ecti'us $*ents

<3= of cases of acute diarrhea often acco(panied "y +'mitin*. ,e+er, and abd'minal pain $ost are ac-uired "y ,ecal('ral transmissi'n o ingestion of food or 'ater conta(inated 'ith pathogens fro( hu(an or ani(al feces. In the i((unoco(petent person, the resident ,ecal micr',l'ra, containing 1?33 ta!ono(ically distinct species o rarely the source of diarrhea o (ay actually play a role in suppressing the gro'th of ingested pathogens. Distur"ances of flora "y antibi'tics can lead to diarrhea o "y reducing the digesti&e function o "y allo'ing the o&ergro'th of pathogens, such as &l'stridium di,,icile Acute infection 4 injury occurs 'hen the ingested agent '+er/helms the host.s (ucosal i((une and noni((une defenses 0*astric acid. di*esti+e enzymes. mucus. peristalsis 1 suppressi+e resident ,l'ra2 %sta"lished clinical associations 'ith specific enteropathogens (ay offer diagnostic clues. HI"H %I!3 "%OUP! ra&elers o 8early :3= of tourists to ende(ic regions of )atin A(erica, Africa, and Asia de&elop so,called tra&eler.s diarrhea Causes: enter't'-i*enic E. c'li or enter'a**re*ati+e E. coli as 'ell as to &ampyl'bacter. !hi*ella. $er'm'nas. n'r'+irus. &'r'na+irus and !alm'nella o Visitors to 6ussia (ay ha&e increased ris# of "iardia(ass'ciated diarrhea o Visitors to 8epal (ay ac-uire &ycl'sp'ra o Ca(pers, "ac#pac#ers, and s'i((ers in 'ilderness areas (ay "eco(e infected 'ith "iardia o Cruise ships (ay "e affected "y out"rea#s of gastroenteritis caused "y agents such as N'r/al4 +irus Consu(ers of certain foods o Diarrhea closely follo'ing food consu(ption at a picnic, "an-uet, or restaurant (ay suggest infection 'ith !alm'nella. &ampyl'bacter, or !hi*ella fro( chic#en o Enter'hem'rrha*ic E. c'li *7>?@:H@+ fro( undercoo#ed ha("urger o Bacillus cereus fro( fried rice o !taphyl'c'ccus aureus or !alm'nella fro( (ayonnaise or crea(s

D.

Ile'c'l'nic !t'ra*e and !al+a*e

E.

&'l'nic )'tility and T'ne

#.

&'l'nic )'tility $,ter )eal In*esti'n

". De,ecati'n

II. DE#INITION O# DI$%%HE$

loosely defined as passage of a"nor(ally li-uid or unfor(ed stools at an increased fre-uency /or adults on a typical 0estern diet, stool 'eight 1233 g4d can generally "e considered diarrheal $ay "e further defined according to the D56A I78: o Acute if 9 2 'ee#s o Persistent if 2,: 'ee#s o Chronic if 1 : 'ee#s 2 Conditions to Differentiate fro( Diarrhea *usually stool 'eight 9233 g4d+ o Pseudodiarrhea, or the fre-uent passage of s(all &olu(es of stool, is often associated 'ith rectal urgency and acco(panies I;S or proctitis. o Fecal incontinence is the in&oluntary discharge of rectal contents and is (ost often caused "y neuro(uscular disorders or structural anorectal pro"le(s Diarrhea and urgency, especially if se&ere, (ay aggra&ate or cause incontinence o Pseud'diarrhea and ,ecal inc'ntinence occur at pre&alence rates co(para"le to or higher than that of chronic diarrhea

Page 5 of 6
Delgado M., Desabelle, Dimayacyac, Dimayuga, Dingco, Dizon

Delas Peas, Delgado G., Delgado M., Desabelle, Dimayacyac, Dimayuga, Dingco, Dizon

SUBJECT Med 4.5

o !alm'nella fro( eggs, +ibri' species, !alm'nella, or acute hepatitis $ fro( seafood, especially if ra'. the hem'lytic(uremic syndr'me high (ortality rate

B.

)edicati'ns
!ide e,,ects are pro"a"ly the (ost co((on noninfectious cause of acute diarrhea %tiology (ay "e suggested "y a temp'ral ass'ciati'n "et'een use and sy(pto( onset. o %!a(ples: Anti"iotics Cardiac antidysrhyth(ics Antihypertensi&es 8SAIDs Antidepressants Che(otherapeutic agents ;ronchodilators Antacids )a!ati&es Or*an'ph'sphate insecticides A(anita and other mushr''ms $rsenic Prefor(ed en&iron(ental to!ins in seafood such as &i*uatera *food"orne illness fro( eating certain reef fish 'hose flesh is conta(inated 'ith to!ins originally produced "y dinoflagellates+ such as Ca("ierdiscus to!icus 'hich li&e in tropical and su"tropical 'aters and sc'mbr'id *food"orne illness that results fro( eating spoiled, decayed fish+ Ische(ia or nonocclusi&e or nonocclusi&e ische(ic colitis o typically occurs in pers'ns 9:; years o presents as acute l'/er abd'minal pain preceding o 'atery bl''dy diarrhea generally results in acute in,lammat'ry chan*es in the sig(oid or left colon 'hile sparing the rectu(.

I((unodeficient persons o >o i((unodeficiency *e.g., IgA deficiency A chronic granulo(atous disease+ o 2o i((unodeficiency states *e.g., AIDS, senescence, phar(acologic suppression+ o AIDS patients Co((on enteric pathogens often cause a m're se+ere 1 pr'tracted diarrheal illness Agents trans(itted &enereally per rectu( *e.g., Neisseria *'n'rrh'eae. Trep'nema pallidum. &hlamydia+ (ay contri"ute to proctocolitis. o Persons 'ith he(ochro(atosis prone to in&asi&e enteric infections 'ith 7ibri' species and ersinia infections and should a&oid ra' fish. o 7pportunistic infections )yc'bacterium species, certain &iruses *cyt'me*al'+irus. aden'+irus, and herpes simple-+ and protoBoa *&rypt'sp'ridium. Is'sp'ra belli. )icr'sp'rida. and Blast'cystis h'minis+ (ay also play a role Daycare attendees and their fa(ily (e("ers o Shigella o Ciardia o Cryptosporidiu( o 6ota&irus InstitutionaliBed persons o In,ecti'us diarrhea is one of the (ost fre-uent categories of nosoco(ial infections in (any hospitals and long,ter( care facilities o the causes are a &ariety of (icroorganis(s "ut (ost co((only &. di,,icile o &LINI&$L P%E!ENT$TION o!in Producers *ingestion of pre(,'rmed t'-ins and enter't'-in pr'ducin* bacteria o Pr',use /atery diarrhea 2o to s(all "o'el hypersecretion occurs o Diarrhea associated 'ith mar4ed +'mitin* and minimal 'r n' ,e+er (ay occur a"ruptly 'ithin a fe' hours after ingestion %nteroadherent pathogens o Pr',use /atery diarrhea 2o to s(all "o'el hypersecretion occurs o 7'mitin* is usually less o $bd'minal crampin* or bl'atin* is greater o #e+er is higher Cytoto!in,producing A In&asi&e (icroorganis(s o 5sually produce hi*h ,e+er and abd'minal pain In&asi&e "acteria A %nta(oe"a histolytica o often cause "loody diarrhea *referred to as dysentery+ o ersinia in&ades the ter(inal ileal and pro!i(al colon (ucosa and (ay cause especially se&ere a"do(inal pain 'ith tenderness (i(ic#ing acute appendicitis ! !TE)I& )$NI#E!T$TION! $!!O&I$TED 8ITH IN#E&TIOU! DI$%%HE$ 6eiter.s syndro(e o Sal(onella, Ca(pylo"acter, Shigella, Dersinia Arthritis 5rethritis Conjuncti&itis %nterohe(orrhagic %. coli *7>?@:H@+ A Shigella can lead to

&.

T'-ins

D.

Ischemia

$PP%O$&H TO P$TIENT

Figure 1. Algorithm for the management of acute diarrhea he decision to e&aluate acute diarrhea depends on its

Page < of 6

SUBJECT Med 4.5

se+erity and durati'n and on +ari'us h'st ,act'rs $ost episodes of acute diarrhea are mild and sel,(limited o does not justify the cost and potential (or"idity of diagnostic or phar(acologic inter&entions In (oderate to se&erely ill patients 'ith ,ebrile dysentery Enter'pathic &irculati'n ', Bile
;ile is rea"sor"ed in the ileu(. A"sent ileu( K ;ile NOT rea"sor"ed ;ile acids ha&e an os(otic effect. Conse-uently, 'ater gets dra'n into the CI tractDiarrhea

e!.+ &'l'n'sc'py for acute diarrhea Indications for e&aluation o Profuse diarrhea 'ith dehydration o Crossly "loody stools o /e&er EF.?G C o Duration 1 :F h 'ithout i(pro&e(ent o 6ecent anti"iotic use o 8e' co((unity out"rea#s o Diarrhea '4 se&ere a"do(inal pain in patients 1?3 years, and elderly *@3 years+ or i((unoco(pro(ised patients. In so(e cases of m'derately se+ere ,ebrile diarrhea associated 'ith fecal leu#ocytes or 'ith gross "lood o a diagnostic e&aluation (ight "e a&oided o empirical antibi'tic trial (ay "e considered )icr'bi'l'*ic analysis of the stool is the cornerstone of diagnosis in those suspected of se&ere acute infectious diarrhea is 0or#up includes: o cultures for bacterial A +iral path'*ens o Direct inspection for '+a A parasites o Immun'assays for certain bacterial t'-ins *C. difficile+ for +iral anti*ens *rota&irus+ for pr't'z'al anti*ens *Ciardia, %. histolytica+ Persistent diarrhea is co((only due to Ciardia Additional causati&e organis(s for persistent diarrhea include: o &. di,,icile o E. hist'lytica o &rypt'sp'ridium o &ampyl'bacter If stool studies are unre&ealing o /le!i"le sig(oidoscopy 'ith "iopsies o 5pper endoscopy 'ith duodenal aspirates and "iopsies In patients 'ith uncharacteriBed persistent diarrhea o /le!i"le sig(oidoscopy: e!clude I;D o Colonoscopy: initial approach in patients 'ith suspected non,infectious acute diarrhea due to ischemic c'litis. di+erticulitis 'r partial b'/el 'bstructi'n o A"do(inal C scanning *or other i(aging approaches+
T%E$T)ENT

e(piric treat(ent 'ithout diagnostic e&aluation using a -uinolone is an option o &ipr',l'-acin *?33 (g "id for EH? d+. %(pirical treat(ent for suspected "iardiasis o )etr'nidaz'le 2?3 (g IID for @ days Selection of anti"iotics and dosage regi(ens are other'ise dictated "y o specific pathogens o geographic patterns of resistance and conditions found $ntibi'tic c'+era*e is indicated 'hether or not a causati&e organis( is found o Immun'c'mpr'mised patients o Patients 'ith mechanical heart +al+es o Patients 'ith recent +ascular *ra,ts o Elderly $ntibi'tic pr'phyla-is is indicated if o patients tra+elin* t' hi*h(ris4 c'untries in 'ho( the li#elihood or seriousness of ac-uired diarrhea 'ould "e especially high, o includes: I((unoco(pro(ised patients patients 'ith I;D patients 'ith he(ochro(atosis patients 'ith gastric achlorhydria. &ipr',l'-acin *in&asi&e disease+ or %i,a-imin *unco(plicated tra&elers disease+ (ay reduce "acterial diarrhea in tra&elers "y <3= During an out"rea# of diarrheal illness o alert the pu"lic health authorities pro(ptly o (ay reduce the ulti(ate siBe of the affected population.

I7.

&H%ONI& DI$%%HE$

#ecal Osm'tic "ap A lot of ingested su"stances ha&e os(otic potential. If a solute cannot "e a"sor"ed, it 'ill pro(ote the flo' of 'ater fro( inside the CI tract into the lu(en. $ore fluid dra'n into the CI tract 'ill aggra&ate the diarrhea In secret'ry diarrhea@ there is NO in*esti'n A n' malabs'rbed

/luid replace(ent alone (ay suffice for mild cases 7ral sugar,electrolyte solutions *sport drin#s or designed for(ulations+ should "e instituted pro(ptly 'ith se+ere diarrhea to li(it dehydration Profoundly dehydrated patients, esp. infants A elderly pts, re-uire IV rehydration. In (oderately se&ere n'n,ebrile and n'nbl''dy diarrhea anti(otility A antisecretory agents *e.g. lopera(ide+ Such agents should "e a&oided 'ith ,ebrile dysentery, 'hich (ay "e e!acer"ated or prolonged "y the(. ;is(uth su"salicylate (ay reduce sy(pto(s of &o(iting A diarrhea "ut sh'uld NOT be used t' treat immun'c'mpr'mised patients /=renal impairment ris# of "is(uth encephalopathy. >udici'us use ', antibi'tics is appropriate in selected instances of acute diarrhea and (ay reduce its se&erity and duration

Diarrhea lasting 1 : 'ee#s 'arrants e&aluation to e!clude serious underlying pathology *e.g. diarrhea due to colon cancer+ $ost causes are non,infectious, in contrast to acute diarrhea Classification "y pathophysiologic (echanis( facilitates a rational approach to (anage(ent

$.

!ecret'ry
due to derange(ents in fluid and electrolyte transport across the enterocolonic (ucosa characteriBed "y 'atery, large,&olu(e fecal outputs that are typically painless 1 persist /ith ,astin* 8o (ala"sor"ed solute stool os(olality is accounted for "y nor(al endogenous electrolytes 'ith no fecal osmotic gap Causes: o Side effects fro( regular ingestion of drugs and to!ins Ha"itual use of sti(ulant la!ati&es: senna, cascara, bisacodyl, ricinoleic acid (castor oil)-seen in long ter( use Chronic ethanol consu(ption enterocyte injury 'ith i(paired 8aJ A

Page ? of 6

SUBJECT Med 4.5

'ater a"sorption Chronic ingestion of certain to!ins *arsenic+ Persistent "acterial infections (ay "e associated 'ith a secretory,type diarrhea ;o'el 6esection, $ucosal Disease, or %nterocolic /istula Inadequate surface for reabsorption of secreted fluids and electrolytes due to a shorter "o'el. ends to /'rsen /ith eatin*, peristalsis occurs 'hich aggra&ates the diarrhea In Crohn s ileitis or resection of 9>33 c( of ter(inal ileu(, dihydro!y "ile acids (ay escape a"sorption sti(ulate colonic secretion cholorrheic diarrhea) Idiopathic secretory diarrhea, in 'hich "ile acids are functionally (ala"sor"ed fro( a nor(al,appearing ter(inal ileu(. !artial bo"el obstruction, ostomy stricture, or fecal impaction (ay parado!ically lead to increased fecal output due to fluid hypersecretion Hor(ones *Sir said this part 'ill (ost li#ely 87 co(e out in the e!a( e!cept CAS 6I87$A+ #etastatic g.i. carcinoid tumors or, rarely, 1o bronchial carcinoids (ay produce 'atery diarrhea alone or as part of the carcinoid syndro(e 6elease of potent intestinal secretagogues *serotonin, histamine, prostaglandins $ %arious &inins+ diarrhea Gastrinoma (neur'end'crine tum'rs2 diarrhea 'ccurs in up t' 5=? ', cases. L'/ pH pancreatic enzyme inacti+ati'n ,at maldi*esti'n diarrhea he 0atery Diarrhea Hypo#ale(ia Achlorhydria *0DHA syndro(e+ *pancreatic cholera) 2o non,cell pancreatic adeno(a *'I!oma) $assi&e secretory diarrhea "ith stool %olumes () *+day #edullary carcinoma of the thyroid (ay present 'ith 'atery diarrhea caused "y calcitonin, other secretory peptides, or prostaglandins Congenital Defects in Ion A"sorption Defects in specific carriers associated 'ith ion a"sorption cause "atery diarrhea from birth Congenital chloridorrhea: defecti&e Cl4HC7EH e!change 'ith al#alosis and defecti&e 8aJ4HJ e!change 'ith acidosis Addison s disease, (ay "e associated 'ith 'atery diarrhea and s#in hyperpig(entation. *a-ati%es (ay induce os(otic diarrhea typified "y a stool os(otic gap *1?3 (os(ol4)+ seru( os(olarity , typically 2<3 (os(ol4#g (easure(ent of fecal os(olarity is no longer reco((ended Car"ohydrate $ala"sorption ac-uired or congenital defects in "rush, "order disaccharidases and other enBy(es leads to os(otic diarrhea 'ith a lo' pH 7ne of the (ost co((on causes of Lactase De,iciency
CI tract no longer is a"le to "rea# do'n lactose. As a result, "acteria end up "rea#ing do'n the (il# products

chronic diarrhea in adults is lactase deficiency $ost patients a&oid (il# products 'ithout re-uiring treat(ent 'ith enBy(e suppl. .orbitol *s'eeteners+, *actulose, or Fructose are fre-uently (ala"sor"ed diarrhea

&.

!teat'rrheal
Creasy, foul,s(elling, difficult,to,flush diarrhea associated 'ith 'eight loss A nutritional deficiencies due to conco(itant (ala"sorption of a(ino acids and &ita(ins Fat #alabsorption 7s(otic effects of fatty acids increased fecal output Steatorrhea is defined as stool fat 1 @ gra(s of stool fat4day Acco(panied "y pain, fe&er, "leeding or other (anifestations of infla((ation >. 2. E. :. $echanis(s: %!udation /at (ala"sorption Disruption of fluid4electrolyte a"sorption Hypersecretion or hyper(otility fro( release of cyto#ines and other infla((atory (ediators On st''l analysis: presence of leu#ocytes or leu#ocyte, deri&ed proteins *calpr'tectin+ 0ith se&ere infla((ation, e!udati&e protein loss can lead to anasarca >. $nasarca@ %de(a all o&erL *Dr. Sandejas, 23>E+ Any (iddle,aged or older person 'ith chronic infla((atory, type diarrhea, especially 'ith "lood o $ust e!clude a colorectal tu(or 6apid transit (ay acco(pany (any diarrheas as a 2 o pheno(enon Pri(ary dys(otility is an unusual etiology of true diarrhea Stool features often suggest a secretory diarrhea, "ut (ild steatorrhea of up to >: g of fat per day can "e produced "y (aldigestion fro( rapid transit alone. Hyperthyroidis(, carcinoid syndro(e, and certain drugs *e.g., prostaglandins, pro#inetic agents+ (ay produce hyper(otility 'ith resultant diarrhea. Primary +isceral neur'my'pathies or idi'pathic acBuired intestinal pseud''bstructi'n (ay lead to stasis 'ith secondary "acterial o&ergro'th causing diarrhea. Diabetic diarrhea (ay occur in part "ecause of intestinal dys(otility. he e!ceedingly co((on irritable b'/el syndr'me *>3= point pre&alence, >H2= per year incidence+ is characteriBed "y distur"ed intestinal and colonic (otor and sensory responses to &arious sti(uli. Sy(pto(s of stool fre-uency typically cease at night, alternate 'ith periods of constipation, are acco(panied "y a"do(inal

D.

In,lammat'ry

E.

Dysm'tility

B.

Osm'tic
Ingestion of poorly a"sor"a"le os(otically acti&e solutes 'hich dra's fluid into the lu(en and o&er'hel(s the rea"sorpti&e capacity of the colon /ecal 'ater output increases in proportion to such a solute load &eases /ith ,astin* or 'ith discontinuation of the causati&e agent Causes: o 7s(otic )a!ati&es #agnesium-containing antacids Health supplements

Page C of 6

SUBJECT Med 4.5

pain relie&ed 'ith defecation, and rarely result in 'eight loss or true diarrhea. 5se of glucocorticoids or other anti infla((atory agents for idiopathic I;Ds 5se of cholestyra(ine for ileal "ile acid (ala"sorption Proton pu(p inhi"itors *e.g. 7(epraBole+ to suppress the gastric hypersecretion of gastrino(as

#.

#actitial
Accounts for up to >?= of une!plained diarrheas referred to tertiary care centers. )unchausen syndr'me o Patients 'ho resort to deception or self,injury for secondary gain *e.g. hose 'ho drin# lactacyd to /0 .IC1, 2para maa"a sa &anila3, attention to"ards them+ 0ating disorders, so(e patients co&ertly self,ad(inister la!ati&es alone or in co("ination 'ith other (edications or surreptitiously add 'ater or urine to stool sent for analysis. Conta(ination of the stool 'ith 'ater or urine is suggested "y &ery lo' or high stool os(olarity, respecti&ely ypically 'o(en 'ith histories of psychiatric illness and disproportionately fro( careers in health care Patients (ay "enefit fro( psychiatric counseling 'hen they ac#no'ledge their "eha&ior. Hypotension and hypo#ale(ia are co((on co,presenting features.

%(pirical 0hen specific cause of (echanis( of chronic diarrhea e&ades diagnosis

$ild opiates *e.g. dipheno!ylate or lopera(ide+ for (ild or (oderate 'atery diarrhea Codeine or tincture of opiu( for more severe diarrhea Clonidine for control of dia"etic diarrhea 6eplace(ent of fat,solu"le &ita(ins (ay also "e necessary in patients 'ith chronic steatorrhea /or all patients 'ith chronic diarrhea o o /luid and electrolyte repletion 6eplace(ent of fat,solu"le &ita(ins (ay also "e necessary in patients 'ith chronic steatorrhea

T%E$T)ENT

7. &ON!TIP$TION
Chronic constipation generally results fro( inade-uate fi"er or fluid inta#e or fro( disordered colonic transit or anorectal function Patients 'ith Se&ere4 Intracta"le Constipations includes:

Figure 4. Initial #anagement based on symptoms or features

o o o

those who do not benefit from simp e meas!res those who re"!ire on#$term treatment with potent a%ati&es those with attendant ris' of de&e opin# a%ati&e ab!se

&$U!E!

Figure ). 0%aluations based on findings from a limited age appropriate screen for organic disease reat(ent of chronic diarrhea depends on the specific etiology o Curati&e o Surgical resection of colorectal cancer Anti"iotic ad(inistration for 0hipples disease Discontinuation of a drug

Suppressi&e %li(ination of dietary lactose for lactase deficiency %li(ination of gluten for celiac sprue

Page : of 6

SUBJECT Med 4.5

Figure 5. Causes of Constipation suggesting an e&acuation disorder *J+ 0eight loss, rectal "leeding, or ane(ia 'ith constipation in p!s 1:3 years fle!i"le sig(oidoscopy J "ariu( ene(a colonoscopy Colonoscopy allo's for "iopsy of lesions, polypecto(y, or dilatation of strictures ;ariu( ene(a less costly identifies colonic dilatation,(ucosal lesions or strictures $elanosis coli indicates a"use of anthra-uinone la!ati&es such as cascara 'r senna $egacolon or cathartic colon (ay also "e detected "y colonic radiographs !erum &aDD. 3D. and T!H le+els 'ill identify rare patients 'ith (eta"olic disorders. If constipation doesnt not respond to fi"er alone use an osmotic la-ati%e )actulose Sor"itol Polyethylene glycol After "rea#fast, a distraction-free >?H23 (in on the toilet 'ithout straining is encouraged *J+ 'ea#ness of the pel&ic floor or injury to the pudendal ner&e o"structed defecation fro( descending perineu( syndro(e se&eral years later Patients 'ith se&ere or intracta"le constipation re-uire long,ter( treat(ent 'ith potent la!ati&es *'ith the attendant ris# of de&eloping la!ati&e a"use syndro(e+ should ha&e further in&estigation

$PP%O$&H TO P$TIENT

o o

o o o o

o o o

Figure 5. Approach to Patient with Constipation Hist'ry: %&aluate the patient.s sy(pto(s Confir( if patient is indeed constipated "ased on fre-uency *e.g. 9 than E "o'el (o&e(ents4'ee#+ consistency *lu(py4hard+ e!cessi&e straining prolonged defecation ti(e need to support the perineu( or digitate the anorectu(. o In 1<3= of cases, no underlying cause *e.g., cancer, depression, or hypothyroidis(+ o Constipation responds to a(ple hydration, e!ercise, and supple(entation of dietary fi"er *>?H2? g4d+ o %&aluate the diet 1 medicati'n hist'ry and any psych's'cial issues P.%. and a rectal e!a(ination o e!clude fecal i(paction and (ost of the i(portant diseases that present 'ith constipation o o

Sir said this part 'ill (ost li#ely 87 co(e out in the e!a( )easurement ', &'l'nic Transit 6adiopa-ue (ar#er transit: (ar#ers are ingested: an a"do(inal flat fil( ta#en ? days later should indicate passage of F3= of the (ar#ers out of the colon 'ithout the use of la!ati&es or ene(as. 6adioscintigraphy 'ith delayed,release capsule:, contains radiola"eled particles to nonin&asi&ely characteriBe nor(al, accelerated, or delayed colonic function o&er 2:H:F h 'ith lo' radiation e!posure. $n'rectal and Pel+ic #l''r Tests Straining: During D6%, ha&e the patient strain to e!pel the inde! finger. $otion of the pu"orectalis posteriorly during straining indicates proper coordination of the pel&ic floor (uscles. ;alloon e!pulsion test: A "alloon,tipped urinary catheter is placed and inflated 'ith ?3 () of 'ater. 8or(ally, a patient can e!pel it 'hile seated on a toilet or in the left lateral decu"itus position. Anorectal (ano(etry: in patients 'ith se&ere constipation, an e!cessi&ely high resting *1F3 ((Hg+ or s-ueeBe anal sphincter tone (ay "e found suggesting anis(us *anal sphincter spas(+. Defecography: "ariu( ene(a re&eals Msoft a"nor(alitiesN i.e. rectoanal angle, anato(ic defects of the rectu( li#e internal (ucosal prolapse, and enteroceles or rectoceles.

T%E$T)ENT
7nce cause of constipation is #no'n treat(ent decision Slo',transit constipation aggressi&e (edical 4 surgical treat(ent Anis(us or pel&ic floor dysfunction "iofeed"ac# (anage(ent 7nly OP3= of patients 'ith se&ere constipation are found to

high anal sphincter tone (ay indicate features

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SUBJECT Med 4.5

ha&e such a physiologic disorder o ?3= 'ith colonic transit delay o ?3= 'ith e&acuation disorder Patients 'ith spinal cord injuries or other neurologic disorders re-uire a dedicated "o'el regi(e that often includes o rectal sti(ulation o ene(a therapy o la!ati&e therapy Patients 'ith slo',transit constipation o ;ul# la!ati&es: #IBE% o 7s(otic la!ati&es: P! LLIU) o Pro#inetic agents: )IL3 O# )$"NE!I$ o Secretory A sti(ulant la!ati&es: POL ETH LENE "L &OL. LUBIP%O!TONE. BI!$&OD L 8e'er treat(ent ai(ed at enhancing (otility and secretion o constipation,predo(inant I;S in fe(ales or se&ere constipation Surgical reat(ent o )aparoscopic colecto(y '4 ileorectosto(yfor treat(ent failures 'ith docu(ented slo',transit constipation *unassociated 'ith o"structed defecation+ , not an option if 'ith continued e&idence of an e&acuation disorder4generaliBed CI dys(otility he decision to resort to surgery is facilitated in the presence of (egacolon and (egarectu( o he co(plications after surgery include s(all,"o'el o"struction *>>=+ and fecal soiling o /re-uency of defecation is EHF per day *first year post op+ >HE per day *second year post op+ Patients 'ith co("ined e&acuation A transit 4 (otility disorder o Pel+ic ,l''r retrainin* 0bi',eedbac4 and muscle rela-ati'n2 o Psych'l'*ical c'unselin* o Dietetic ad+ice if colonic transit studies do not nor(aliBe A sy(pto(s are intracta"le colecto(y or ileorectoso(y Patients 'ith pel&ic floor dysfunction alone o Bi',eedbac4 trainin* has a @3HF3= success rate (easured "y the ac-uisition of co(forta"le stool ha"its o Surgical (anage(ent *internal anal sphincter or pu"orectalis (uscle di&ision+ (ini(al success a"andoned.

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