Date post: | 03-Jun-2015 |
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Health & Medicine |
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Functional Constipation
ByM. Osama Shetta.
Professor of SurgeryAin Shams University
Definition
At least two of the following:- Less than three bowel motions/week.- Need in more than 25% of occasions to:
- To strain.- To manually evacuate- Passage of hard stool- Sense of incomplete evacuation
Definition(cont.)
- These symptoms need to be chronic.- All other aetiological causes of
constipation must be excluded specially the organic causes.
Aetiology of constipation I
DietaryEndocrine / MetabolicNeurological PsychogenicDrugs & poisonsGeneral causes
Drugs:opiatesanticholinergics.Iron therapy.antiacids
Aetiology of constipation II
- Organic obstruction- Functional constipation
Organic Obstruction
Functional Constipation
In terms of pathophysiology:- Slow gut transit(colonic inertia).- Rectal evacuatory dysfunction.- Combination of both.
Functional Constipation
Slow transitOutlet obstruction
–Rectocele–Rectal prolapse, intussusception–Anismus–Solitary rectal ulcer syndrome–Descending perineum syndrome
Slow transit + Outlet obstructionConstipating form of IBS
Functional Constipation
Consider it when–All other causes are excluded–Colon looks normal on barium
enema and colonoscopy–Rectoanal inhibitory reflex (RAIR)
is preserved–Colon is ganglionic
Evaluation & Management
Initial evaluation
Initial management
Secondary management
Secondary evaluation
Tertiary management
Aim of Initial Evaluation
Exclude organic obstruction
Initial Evaluation- History and examination- Anorectal examination
– Inspection (rest, strain, squeeze)–Palpation, check anal wink–PR (rest, strain squeeze) – Inspection of stools–Proctosigmoidoscopy
- Routine blood investigations- Colonoscopy + Barium enema- More tests or consultation if history and
examination are suspicious
Initial Management with Apparent cause
Treatment of the cause.
Initial ManagementNo Apparent Cause
Dietary manipulation– Increase fluid intake– Increase fiber in diet or by laxative
Regular exercise Advise Never to :
–Strain–Suppress desire–Use stimulant laxatives
Can use supposit., lactulose, bulk forming laxatives
Secondary Management
By Stimulant laxatives:
Aim of Secondary Evaluation
Document the presence and the type of functional constipation
Secondary Evaluation
Extensive lab. StudiesColonic transitPelvic floor tests (PFT)
–Manometry (press., sens., RAIR)–EMG–Defecography–Balloon expulsion test
Biopsy for ultrashort segment HirschsprungPsychological consultation
Categorization of Functional Constipation
Anorectal physiology testing
normal transit, abnormal PFT = PF dysfunction
abnormal transit, normal PFT = slow transit constip.
abnormal transit,abnormal PFT = slow transit &PF dysf.
normal transit,normal PFT = IBS
Intervention in functional constipation should be
considered only when medical treatment consistently failed to help the patient, constipation is
most intractable and the patient is thoroughly
investigated
Treatment
Rectocele– Surgical repair
– Biofeedback
Treatment
Slow transit constipation–Total colectomy–Segmental colectomy–Biofeedback
Treatment
Complete rectal prolapse–Rectopexy–Resection–Delorme
Treatment
Internal intussusception–Biofeedback–Rectopexy–Delorme–Rectopexy + Resection–Other extensive operations
Treatment
Solitary rectal ulcer–Biofeedback–Excision–Injection–Rectopexy
Treatment
Anismus–Biofeedback–Botulinum toxin
Treatment
Descending perineum–Biofeedback
Proper Management
Starts With Proper
Diagnosis
Surgical Aspects Of Constipation
by
Ahmed A. Abou-Zeid
Professor of SurgeryAin Shams University