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CONSTIPATION

Dr. SAO SIRA


Associated staff physician
Internal Medicine Training Program at SHCH
Contents

1. Definition
2. Etiology
3. Causes
4. Types
A-Constipation (functional)
B-Constipation (organic)
C-Classification
Definition
 Constipation is a common symptoms, decrease
in frequency of stools or difficulty in
defecation. (more than three bowel movements
per week)
 Abdominal pain, distention and fecal
impaction.
 Hard stool.
Etiology

 Diet issues
 Inadequate water intake, inadequate fluid
 Inadequate fiber intake, low fiber
 Over use of coffee, tea or alcohol
 Poor diet habit
 Lifestyle factors
 Inactivity
 Cheese
 Post-op (fear of straining)
 Psychological factor
 Systemic endocrine or neurologic diseases
Etiology

 Al+ and Ca++ antacids  GI cancers


 Anticholinergics  Age (decreased neuro. Stim)
 Antidepressants  Diverticular Dz
 Antihistamines  Rectal stenosis
 Antihypertensives(Calcium  Stroke
channel blockers)  Adhesions
 Diuretics  Strictures
 Iron salts  Hernia
 Chronic irritant laxatives  IBS (spastic colon)
 Narcotics
 Iron supplements
Cause of depend on lesion
Constipation may originate primarily from
within the colon and rectum or externally:
 Colon or rectum:
 Left colon obstruction
 Slow colonic motility, with history of chronic laxative
abuse
 Outlet obstruction (anatomical or functional)
Type of constipation

 Three types of constipation:


A-Functional (>90%)
B-Organic
C-Classification
A-FUNCTIONAL
CONSTIPATION
A-FUNCTIONAL CONSTIPATION
Pathophysiology
 Slow colonic transit
 Problem with rectal muscle coordination
 Problem with rectal sensation
Management

 Education
 Diet /Disimpaction
 Maintenance Therapy
 Weaning

Arch Ped Adol Med 1999 153(4):380-5


Education

 Age appropriate discussion, drawings, play to


explain the problem / treatment
 Reassure : laxative risks / lack of dependence
 Goal: improve compliance
Disimpaction techniques
 High dose mineral oil orally
 Enemas
 Combination: enema, suppositories, oral laxatives
 Insufficient evidence to recommend one method over
another
 Digital disimpaction (rarely required)
Disimpaction: Enemas
 Hypertonic NaPO4 pr /colyte flavored3-785
l/bottle for 3 L water .
• 1-2oz/10kg (max 4.5oz) pr od / bid x 1-2d
– Complications:
• Dehydration
• Hyper Na, hyper PO4, hypo Ca, hypo K
– Contraindications:
• Wt < 10kg
• Intestinal obstruction
• Cardiac / renal / electrolyte
B-Organic Constipation

 Bowel obstruction  Neuro/muscular


– Volvulus – Spinal cord lesion
– Intussusception – Myotonic dystrophy
 Trauma – CVA
- Sexual abuse – Scleroderma
– SLE
 Extrinsic mass
• ?Malignancy
 Perianal Streptococcal
cellulitis
 Anal stenosis
 Fissure
Constipation as a manifestation
of systemic disorder
 Hypothyroid
 Diabetes Mellitus
Hypothyroid
 Constipation is the commonest GI complaint in
hypothyroid.
 The pathologic effect are caused by an alteration of
motor function and possible infiltration of the GUT
by myxedematous tissue.
 The basis electrical rhythm of the human duodenum
decreases in hypothyroidism, and small bowel transit
time is increased.
Diabetes Mellitus

 Studies of colonic myoelectrical and motor


activity in diabetes patients with constipation
showed some with mild constipation had a
delayed colonic respond after a standard meal,
whereas others with severe constipation had
no increased activity after food.
Constipation as a manifestation of
central nervous disease or the extrinsic
nerve supply
 Loss of conscious control
 Parkinson’s disease.
 Multiple sclerosis
 Spinal cord lesion.
Loss of conscious control

 Reduction in or absence of body perception as


a result of cerebral handicap or dementia may
leads to defecatory failure, possibly because of
inattention.
Parkinson’s disease
• GI dysfunction –constipation is well recognized in
Parkinson’s dse.
• Depletion of dopamine containing neurons in the central
neurvous system is a basic deficit in this disorder.(gray
matter), and cant’ inhibit involuntary movement of the
affect person when at rest.
• Patient fail to relax the striated muscles of the pelvic floor on
defecation, which is a local manifestation of the
extrapyramidal motor disorder effecting all skeletal muscle.
Multiple sclerosis

 In all group of patient suffering from advanced multiple


sclerosis with intermittent or chronic constipation, all had
evidence of disease central to the lumbosacral spinal cord, and
there was decrease compliance of the colon on infusion of
fluid. No increase in motor activity is demonstrable after
meals.
 Treatment-spontaneous remission and fluctuating symptoms
make treatments difficult to evaluation-prednisolone 60mg
to100mg tapered over 2- 3week .
 Drug for spasticity-baclofen 10- 20mg tid or qid.
 Multiple drug –Amitryptilline 25mg 75mg po at bed time.
Spinal cord lesion
 Lesion above the sacral segment lead to an upper
motor neuron disorder with severe constipation.
 Studies of colonic transit reveal delay that affects
mainly the rectosigmoid colon.
 Abnormal colonic compliance occurs in patient with
complete traumatic transection of the cord.
 No increase in motor activity is demonstrable after
meals.
Constipation secondary to structural
disorders of the colon, rectum anus and
pelvic floor
• Obstruction
• Disorder of smooth muscle
• Neuropathy unknown causes.
• Rectocele.
• Weakness of the pelvic floor
Weakness of the pelvic floor

 A common reason for pelvic flood weakness is


trauma or stretching during parturition.
 In some cases, repeated and prolong straining
during defecation appears to be the damaging
factor.
Rectocle

 In women, the anterior rectal wall at he


anorectal junction is supported by the perineal
body, but above this level it is unsupported,
and the rectovaginal septum can bulge
anteriorly to form a rectocele.
Neuropathy unknown causes
 Severe acute neuropathies that manifest with
mainly obstruction symptoms, but not
principally constipation, have been described.
 Some time may be use long time of laxative-
can cause of constipation.
Disorder of smooth muscle
 Congenitalor acquired myopathy of the colon
usually manifest with pseudoobstruction.
Obstruction
 Anal atresia in infancy, anal stenosis
developing in life or obstruction of the large
intestine for any reason may manifest with
constipation.
C-Constipation can classified as

 ACUTE
 SUBACUTE
 CHRONIC
Acute constipation

 Mechanical bowel obstruction


 Adynamic ileus (accompanies acute intra-abdominal
disease) localized peritonitis, diverticulitis.
 Traumatic condition( eg head injuries, spinal fractures).
 May F/U general anesthesia.
 In bedridden patient.
 Many agent (Alcohol, bismuth salts, iron salts,
cholestyramine, anticholinergics, opioids, many
tranquilizer, and sedatives.
SUBACUTE

 The change of bowel habit persists for weeks


or occurs intermittently with increasing
frequency and /or severity – colonic tumor and
other causes of partial obstruction should be
suspected.
 Underlying causes must be identified and
treated.
CHRONIC

The mechanism of the colon are deranged, sometime:


 systemic disorders eg- debilitating infections,
hypothyroidism, hypercalcemia, uremia or porphyria,
 local neurogenic disorders eg IBS, megacolon
idiopathic, secondary (colon dilatation anal, rectal
stenosis, lesion of spinal cord, hypokalemia,
hypothyrodism,)
 neurologic disorders-parkinson’s disease, cerebral
thrombosis, tumors injury of spinal cord.
Signs and Symptoms
• Dull headache • Blood in feces
• Loss of appetite
• Nausea, vomiting
• Lack of energy
• Feeling of fatigue • acute abdominal pain
• Abdominal discomfort and • 7-10 days duration
distension
• Unresponsive to
• Bloating
• Lower abdominal
adequate laxative Rx
discomfort or pain
• Lower back pain
Investigations
 Base on your clinical assessment

 Urinalysis – R/O UTI b/c of potential urinary


retention 20 impaction

 Abdominal plain film if you do not find an


impaction
– ?bowel obstruction, ?toxic megacolon, ?volvulus, ?
mass lesion
Complication
 Hemorrhoids
 Anal fissure  Colonic perforation
 Rectal prolapsus  Fecal incontinence
 Stercoral ulcer  Urinary retension
 fecal impaction  Cardiac, cerebrovascular
dysfunction
 Ischemic colitis
(syncope,arrythmias,
 Colonic volvulus angina).
Treatment nondrug

 Alterations in diet (fiber), fruits, enough


liquids.
 Increased fluid
 Exercises (relaxation exercises of anal
sphincters and muscle of pelvic floor
 Stress management
 Avoidance of constipating drugs
Treatment pharmacotherapy
 Bisacodyl (Dulcolax  Polycarophil (Konsyl
 Senna (Senokot) Fiber)
 Castor Oil  Psyllium (Metamucil,
others)
 Methylcellulose
(Citrucel, Maltsupex)
SURGICAL TREATMENT
 For severe chronic constipation
 In colonic inertia –subtotal colectomy with
ileorectal anastomosis.
•THANK YOU
Reference
• HARRISON’S
• Google@.com
• Yahoo@.com
• Clinical examination-Edited byJohn Mc Leod
John Munto.
• A guide to physical examination and history
taking-Barbara Bates.
• Gastrointestinal and liver disease-
Pathophysiopogy / Diagnosis /Management:
Sleisenger &Fordtran’s.