CONSTIPATIONAHMAD AMINUDDIN

CONSTIPATIONCONSTIPATION IS A COMMON COMPLAI IN CLINICAL PRACTICE AND USUALLY REFERS TO PERSISTENT, DIFFICULT, INFREQUEN OR SEEMINGLY INCOMPLETE DEFE- CATION

CONSIDERATIONMOST PATIENT HAVE AT LEAST THREE BOWEL MOVEMENT PER WEEK, EXCESSIVE STRAINING, HARD STOOLS, LOWER ABDOMINAL FULLNESS AND A SENSE OF INCOMPLETE EVACUATION. PSYCHOSOCIAL FACTORSCONSTIPATION OR DIFFICULTY WITH DEFECATION

CAUSESPATHOPHYSIOLOGICALLY, CHRONIC CONSTIPATION GENERALLY RESULT FROM INADEQUATE FIBER INTAKE OR FROM DISORDERED COLONIC TRANSIT OR ANORECTAL FUNCTION AS A RESULT OF A NEUROGASTROENTERO- LOGIC DISTURBANCE, CERTAIN DRUGS OR IN ASSOCIATION WITH A LARGE NUMBER OF SYSTEMIC DISEASES THAT AFFECT THE GASTROINTESTINAL TRACT

CAUSES OF CONSTIPATIONRECENT ONSET - Colonic obstruction - Neoplasm - Stricture ; ischemic, diverticular, inflamatory. - Anal sphincter spasm - Anal fissure. - Painful hemorrhoids. - Medication

CAUSES OF CONSTIPATIONCHRONIC - Irritable bowel syndrome - Constipation predominat, alternating. - Medication - Ca blockers, antidepressants. - Colonic pseudo-obstruction - Slow colonic constipation, megacolon. - Disorders of rectal evacuation - Pelvic floor dysfuction, anismus, descending perineum syndrome, rectal mucosal prolapse

CAUSES OF CONSTIPATIONCHRONIC - Endocrinopathies - hypothyroidism, hypercalcemia, and pregnancy. - Psychiatric disorders - depression, eating disorders and drugs. - Neurologic diseases - Parkinsonism, multiple sclerosis, spinal cord injury. - Generalized muscle disese - progresive systemic sclerosis.

APPROACH TO THE PAIENTA CAREFUL HISTORY EXPLORE THE PATIENT S SYMPTOM AND CONFIRM WETHER HE OR SHE IS INDEED CONSTIPATED; - FREQUENCY. - CONSISTENCY. - EXCESSIVE STRAINING. - PROLONGED DEFECATION TIME. - NEED TO SUPPORT THE PERINEUM OR DIGITATE THE ANORECTUM.

PHYSICAL EXAMINATIONDIGITAL RECTAL EXAMINATION -anal sphincter, rectocele,rectal prolapse or perineal descent during straining.SIGMOIDOSCOPY PLUS BARIUM ENEMA OR COLONOSCOPY ALONE. - rectal bleeding or anemia with constipation.COLONIC RADIOGRAPHLABORATORY STUDY - complete blood count - serum electrolytes - calcium - glucosa - TSH.

INVESTIGATION OF SEVERE CONSTIPATIONNORMAL COLONIC TRANSIT TIME IS APPROXIMATELY 35 HOURS, MORE THAN 72 HOURS IS SIGNIFICANTLY ABNORMAL.MEASUREMENT OF COLONIC TRANSIT - RADIOPAQUE MARKER TRANSIT TEST - RADIOSCINTIGRAPHY WITH A DELA- YED- RELEASE CAPSULE CONTAINING RADIO-LABELLED PARTICLES.

INVESTIGATION OF SEVERE CONSTIPATIONANORECTAL AND PELVIC FLOOR TEST - PELVIC FLOOR DYSFUNCTION - inability to evacuate the rectum. - rectal pain. - the need to extract stool from the rectum digitally. - application of pressure on the posterior wall of the vagina. - support the perineum during straining. - excessive straining. - DIGITAL RECTAL EXAMINATION

INVESTIGATION OF SEVERE CONSTIPATIONANORECTAL AND PELVIC FLOOR TEST - DIGITAL RECTAL EXAMINATION motion of the puborectalis muscle posterior- ly during straining indicate proper coordi- nation of the pelvic floor and puborectalis. - MEASUREMENT OF PERINEAL DESCENT

INVESTIGATION ..ANORECTAL AND PELVIC FLOOR TEST - MEASUREMENT OF PERINEAL DESCENT - patient in the left decubitus position. - watching the perineum to assess; - pacuity or lack of descent < 1,5 cm is pelvic floor dysfunction. - perineal balloning during strain relative to bony landmark, > 4 cm suggesting excessive perineal descent.

ANORECTAL ND PELVIC FLOOR TESTTHE BALLON EXPULSION TEST - URINARY CATHETER IS PLACED IN THE RECTUM. - THE BALLON IS INFLATED TO 50 ml WITH WATER. - WHETHER THE PATIENT CAN EXPEL IT ; - seated on toilet. - lateral left decubitus.

ANORECTAL AND PELVIC FLOOR TEST.DEFECOGRAPHY - A DYNAMIC BARIUM ENEMA INCLU- DING LATERAL VIEWS OBTAINED DURING BARIUM EXPULSION REVEAL - RECTOANAL ANGLE. - ANATOMIC DEFECTS OF THE RECTUM. - ENTEROCELES OR RECTOCELES.

TREATMENT OF CHRONIC CONSTIPATIONDIETARY AND LIFE STYLE MEASURES - Adverse psychosocial issies should be identi- fied should be instructed in ; - normal defecatory function. - optimal toileting habits. - Proper dietary fiber intake should be empha- sized. Fiber is most likely to benefit patient with normal colonic transit. - Regular exercise.

TREATMENT OF CHRONIC CONSTIPATIONLAXATIVE 1. OSMOTIC LACXATIVES Magnesium hydroxide - 15 30 ml orally, once or twice daily - onset of action 6 24 hours. Lactulose or 70% sorbitol - 15 60 ml orally once to three time daily - onset of action 6 48 hours. Polyethylene glycol - 17 g in 8 oz liquid, once or twice daily - onset of action 6 24 hours 2. STIMULANT LAXATIVES

TREATMENT OF CHRONIC CONSTIPATION2. STIMULANT LAXATIVES - Stimulate fluid secretion and colonic contraction, resulting in a bowel move- ment within 6 12 hours after oral inges- tion or 15 60 minutes after rectal admi- nistration. - Oral agents are usually administered once daily of bedtime.

STIMULANT LAXATIVEBISACODYL 5 20 mg orally, onset of action 6 -8 hours.BISACODYL 10 mg per rectum, onset of action 1 hour.CASCARA 4 8 ml or 2 tablets, onset of action 8 12 hrsSENNA 8,6 17,2 mg orally, onset of action 8 -12 hrs