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Defaecation

Spinal reflex which can be modified voluntarily


In infants no voluntary control
Resting
o rectum empty
o External anal sphincter in a state of tonic contraction supplied by pudental nerve
o Internal anal sphincter tone - by sympathetic stimulation, by parasympathetic
stimulation
Distension of rectum with faeces
Increased rectal pressure (18mmHg)
Reflex relaxation of internal anal sphincter
Reflex contraction of external anal sphincter
Urge to defecate

Inappropriate Appropriate
Urge temporarily subsided External sphincter voluntarily open
Sphincter tone becomes normal Ab. Contraction + diaphragm
Voluntary defecation Intra abdominal pressure increased
Straining Rectal pressure up to 55mmHg
Contracts abdominal muscles Evacuation
Increased intra ab. Pressure
Pelvic floor lowered
Puborectalis relaxed
Decreased anorectal angle
Relaxation of ext. sphincter
Defecation

Constipation
A perception than a real entity, no single definition
Having two or more of the following for at least 12 weeks (Rome III criteria)
o Infrequent passage of stools (<3/week)
o Straining >25% of time
o Passage of hard stools
o Incomplete evacuation
o Sensation of anorectal blockage
o Manual maneouvers to facilitate at least 25% of defecations
Affects more than 20%, more common in women, non whites, children, elderly
Severe constipation almost exclusively in women
Absolute constipation inability to pass faeces and flatus
Assessment
o history (change in bowel habits, drug history, dietary history, past medical/surgical
history)
o Physical examinatoin
o Digital rectal examination
o rigid sigmoidoscopy (excludes colorectal cancer and narrowed segments due to
diverticular disease)
o barium enema
o colonoscopy
o exclude systemic disease by haemoglobin, ESR, thyroid function, calcium, blood
glucose, serum calcium, electrolytes, FBC, urinalysis
o Physiological tests for patients refractory to high fibre diet and laxatives and who
have no secondary cause
Ano-rectal manometry if defecatory disorder suspected
Balloon expulsion if defecatory disorder suspected
Defaecography if structural abnormality suspected
Colonic-transit tests initial test in patients without features that suggest a
defecatory disorder
Electromyography
Pathogenesis - multifactorial
Causes
o General
Pregnancy
Inadequate fibre intake
Little food intake
Immobility
o Metabolic/endocrine
Diabetes mellitus/ diabetes neuropathy
Hypercalcaemia smooth muscle hypotonicity, depressive effect on ANS,
dehydration
Hyperparathyroidism
Hypothyroidism
Porphyria
Hypokalaemia
Uraemia
Heavy metal poisoning -Pb
o Functional
Irritable bowel syndrome no anatomic abnormality
Idiopathic slow transit
o Drugs
Opiate
Antimuscarinics
Calcium channel blockers verapamil
Antidepressants -tricyclics
Iron
Anticonvulsants - Benzodiazepine, carbamazepine, chlorpromazine
Cholestryramine
Statins
Calcium containing antacids
o Neurological
Spinal cord lesions
Parkinsons disease
Multiple sclerosis
Autonomic neuropathy
o Psychological
Depression
Anorexia nervosa
Repressed urge to defecate
o GI disease
Intestinal obstruction and pseudo-obstruction
Colonic disease carcinoma, diverticular disease
Aganglionosis Hirschprungs disease, Chagas disease
Painful anal conditions anal fissure
Systemic sclerosis (scleroderma)
o Defecatory disorders
Rectal prolapse, mucosal prolapse intussusception and solitary rectal ulcer
syndrome
Large rectocele
Pelvic floor dyssynergia/anismus
Megarectum
In infantss consider Hirschsprung disease, anorectal abnormalities, hypothyroidism,
hypercalcaemia
In older children problems with toilet training
Types
o Normal transit
Most common
Stool traverses at normal rate, stool frequency normal, patients feel
constipated. (passage of hard stools, evacuation difficulties)
Complain of abdominal pain and bloating
Psychosocial stress
Some have increased rectal compliance, reduced rectal sensation
Typically responds to therapy with dietary fibre alone or with the addition of
osmotic laxative
o Defecatory disorders
Paradoxical contraction of puborectalis and external anal sphincter and
other muscles during straining (pelvic floor dyssnergia, anismus)
Identified using defecography by reduced descent of the perineum (<1 cm)
or reduced change in anorectal angle during stimulation of straining to
defecate
o Slow transit
Predominantly in young women with infrequent bowel movements (less
than once a week)
Starts at puberty with infrequent urge to defecate, bloating, pain and
discomfort.
Some have delayed emptying of proximal colon and others failure of meal-
stimualted colonic motility
Thought to be due to alteration in number of myenteric plexus neurons
expressing excitatory neurotransmitter substance, abnormalities in
inhibitory transmitters VIP, NO and reduction in number of interstitial cells
of Cajal
Mild disease managed with high fibre diet,
o Sometimes defecatory disorders with slow transit
Also divided as megacolon and non-megacolon (secondary to drugs or illness, primary
colonic problems)
Treatment
o Treat underlying cause.
o Reassurance, psychological support and stress management, make time for
defecation
o In normal and slow transit types, increase fibre and fluid content of food and
increase physical activity
o Laxatives for severe cases, check for laxative abuse
o For defecatory disorders surgery may be possible for anterior rectocele, internal
anal mucosal intussusception, total colectomy with ileorectal anastomosis is
preferred (complications SI obstruction, further surgery, constipation, diarrhoea,
incontinence), other surgeries are stoma creation and segmental resection
o Bio feedback therapy useful in rectal evacuation problems
o In pregnancy dietary and lifestyle change, bulk forming laxatives tried first.
Lactulose or Bisacodyl or senna can be tried.
Purgatives/Laxatives/Cathartics/Asperients/Evacuant
Usage not desired in children
Indications for purgatives
o If straining worsens patients conditions angina, bleeding from haemorrhoids
o Treatment for drug induced constipation
o Bowel clearance surgery, poisoning, radiological investigations
o Painful anal conditions haemorrhoids, fissures
o Expulsion of parasites after antihelminthic treatment
Habitual usage can lead to
o Atonic non functioning colon as whole bowel is emptied, it takes longer time to fill
the rectum, this can produce a vicious cycle in which he takes laxatives again for this
o Hypokalaemia due to NaCl loss in faeces leads to secretion of aldosterone, which
in turn causes NaCl retention in kidneys with more excretion of K. Can lead to
cardiac arrhythmias
Laxative Stool bulking agents Osmotic laxatives Faecal softners Stimulant laxatives
Example Dietary fibres
Bran residue when flour
made from cereals (25-50%
of fibre), bread or biscuits,
available as sachets
Ispaghula more palatable
than bran (Fibrogel)
Methylcellulose also has
faecal softening property
Sterculia (Normacol) -
available as granules
Magnesium salts avoid or reduce
dose in renal impairment
sulphate (Epsom salts) powerful
than hydroxide, act in 2-4 hours,
take with full glass of water before
breakfast,
citrate - takes 1 day to act
hydroxide (milk of magnesia) some
have liquid paraffin
Lactulose synthetic disachharide,
tolerance develops, used in hepatic
encephalopathy, fermented in gut
causing pain and distension
Macrogols (polyethylene glycols)
oral powder (movicol, idralax), not
fermented in gut
Liquid paraffin avoid
prolonged use as small
quantities can be absorbed,
contraindicated in children < 3
years
Arachis oil used in enemas to
soften impacted faeces in
elderly

Bisacodyl - in geriatric patients,
tablets (duclolax) and
suppositories, suppository can
cause local irritation
Sodium picosulfate capsules
and elixir available
Glycerol suppository,
moistened in water before use
Senna Tablets, granules and
syrup available, contains
sennoside as active ingredient
Castor oil powerful irritant
action, can even start labour
Docusate Na also has faecal
softening effect, acts in 1-2 days
Mechanism
of action
Increase volume and lower
the viscosity of intestinal
contents soft bulky stool
normal reflex bowel
activity
Little absorption increase bulk
and reduce viscosity fluid stool
Lowers surface tension of fluids
in bowel more water remain
in faeces softens faeces
Some have bowel stimulant
properties
Stimulates sensory endings in
colon by direct action from
lumen increases intestinal
motility
Treatment of
choice
Constipation in elderly
anal fissure
haemorrhoids
patients with colostomy
Preferred in pregnancy
Clear colon for diagnostic
procedures or surgery
Painful anal conditions
Anal fissures
Haemorrhoids
Bowel preparation for
radiological and endoscopic
procedures
Cautions Avoid taking in night (as they
swell in contact with liquid)
Take with liberal quantities
of fluid (at least 2L) to avoid
intestinal obstruction
Maintain adequate fluid intake Cause abdominal cramps,
caution in pregnancy,
Avoid in children
If used excessive can cause
diarrhoea
Contra-
indications
Difficulty in swallowing,
intestinal obstruction,
colonic atony, faecal
impaction
Acute gastrointestinal conditions Acute surgical abdominal
conditions, acute inflammatory
bowel disease, severe
dehydration
Dietary Fibre / Non-starch polysaccharides
Types Soluble Insoluble
Examples Pectins, guar, isphagula Cellulose, hemicellulose, lignin
Viscosity of gut contents high less
Digestion in small bowel more less
Laxative strength Less more

Bowel Cleansing Solutions
Indications - Before colonic surgery, colonoscopy or other procedures of the bowel to ensure
bowel is free of solids
Cautions pregnancy, renal impairment, ulcerative colitis
Other oral drugs should not be taken one hour before or after administration
Side effects nausea and bloating, abdominal cramps
Preparations citramag (magnesium citrate), Klean-prep (macrogol)
Faecal Incontinence
Defined as either the involuntary passage or the inability to control the discharge of faecal
matter through the anus
Occurs when intrarectal pressure exceeds intraanal pressure
Prevalence increases with age and common in women, elderly and residents of nursing
homes
Mechanisms preventing incontinence
o Internal and external anal sphincters
o Anal mucosal folds and cushions
o puborectalis
3 clinical subtypes
o Passive incontinence involuntary discharge of stool or gas without awareness
o Urge incontinence discharge of fecal matter in spite of active attempts to retain
bowel contents
o Faecal seepage leakage of stool following otherwise normal evacuation
Causes embarrassment, loss of self-esteem, social isolation and diminished quality of life
Pathogenesis often multifactorial. Anal sphincter disruption or weakness, pudental
neuropathy, impaired anorectal sensation, impaired rectal accommodation, or incomplete
evacuation may all contribute. These changes may be a consequence of local, anatomical or
systemic disorders.
Causes
o Congenital imperforate anus
o Anal sphincter dysfunction
Structural damage surgery (anorectal, vaginal hysterectomy), obstetric
injury during childbirth, trauma, radiation, perianal Crohns disease
Pudental nerve damage childbirth (forceps delivery, prolonged second
stage of labour, large birth weight, occipito-posterior presentation)
Perineal descent prolonged straining at stool
o Rectal prolapse
o Faecal impaction with spurious overflow or incomplete evacuation in elderly and
children
o Severe diarrhoea ulcerative colitis, functional diarrhoea, irritable bowel syndrome
o Neurological and psychological disorders spinal trauma (S2-S4), spina bifida,
stroke, multiple sclerosis, diabetes mellitus (with autonomic involvement),
dementia, psychological illness, brain tumours, cauda equina lesions, toxic
neuropathy from alcohol
o Skeletal muscle disorders affecting external anal sphincter and puborectalis
muscular dystrophy, myasthenia gravis
History
o Onset/precipitating events
o Duration, severity, timing
o Stool consistency, urgency
o Coexisting problems/ surgery/ urinary incontinence/ back injury
o Ability to differentiate from flatus and formed stool
o Obstetric history
o Dietary history
o Drugs, caffeine
o Clinical subtype
o Severity (major passage of normal consistency stools, minor passage of flatus or
liquid stool)
o Faecal impaction
Examination
o Detailed physical and neurological exam of back and lower limbs
o Perineal inspection faecal matter, prolapsed haemorrhoids, dermatitis, scars, skin
excoriation, absence of perianal creases, gaping anus
o Digital rectal examination resting sphincter tone, length of anal canal, puborectalis
sling, anorectal angle, perineal muscles, elevation of perineum during voluntary
squeeze, rectocoele
o Perianal sensation and anocutaneous reflex
Investigations
o Lower GI endoscopy to exclude colonic mucosal inflammation, rectal mass or
stricture
o Stool tests infections, infestations
o Biochemistry thyroid function, diabetes
o Anorectal physiology
Anorectal manometry sphincter pressure (resting and voluntary), rectal
sensation, rectoanal reflexes
Sensory testing with rectal balloon distension sensory responses and rectal
compliance
o Imaging
Pelvic MRI for anal sphincteric damage
Endoanal US for anal sphincteric damage, scarring and loss of muscle
tissue
Defecography uses fluoroscopy, for rectal prolapse and poor evacuation
o Balloon expulsion test identifies impaired evacuation in faecal seepage and
impaction and overflow
o Pudental nerve terminal motor latency prior to anal sphincter repair and predicts
outcome, muscle injury or nerve injury can be relatively separated ?
o Saline infusion test to evaluate faecal incontinence, assessing clinical improvement
after therapy
Management to improve quality of life and restore continence
o Treat underlying cause
o Supportive measures
Avoiding offending foods
Ritualizing bowel habit
Improving anal skin hygiene immediate cleansing after soiling, changing
undergarments, barrier creams like zinc oxide and calamine lotion
Instituting lifestyle changes reducing caffeine or fibre, lactose, fructose
intake
o Specific therapy
Pharmacological therapy loperamide or atropine produce modest
improvement. Loperamide reduced frequency of incontinence, improve
stool urgency, increase colonic transit time, increase anal resting pressure
and reduce stool weight. Also codeine, oestrogen replacement therapy,
amitriptyline,
Biofeedback therapy safe and effective, uses operant conditioning, tries to
improve strength of anal sphincters, coordination of defecatory mechanism,
enhance anorectal sensation.
Plugs, sphincter bulkers (collagen, silicone), and ancillary therapy
Surgery
Sphincteroplasty
Anterior repair
Gracilis muscle transposition with implanted pacemaker
Artificial bowel sphincter
Sacral nerve stimulation
colostomy