hd-medical management of intractable constipation (final)

8/10/2019 HD-Medical Management of Intractable Constipation (FINAL)

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Medical Management ofIntractable Constipation

Hery Djagat Purnomo

Division Of Gastroentero-Hepatology Departement of Internal MedicineDr Kariadi Hospital - Diponegoro University Semarang

SEMARANG DISGESTIVE WEEK (SDW), Hotel Grand Candi ,28 November 2014


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Epidemiology - General

The prevalence of constipation among the general populationin North America has been quoted as 1.9% to 27.2%

50% to 74% of the institutionalized elderly reportingdaily use of laxatives.

11 January 2015

Leung, L, et al. Chronic Constipation: An Evidence-Based Review. J Am Board Fam Med. 2011;24:436451.

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1/11/2015 3

Sumber: Riskesdas 07

Indonesian Modern Way of Life:

Lack of Fibers & Physical Activity,

More Food Additive


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47.6%of FEMALE WORKERS AGED 18-55 YEARS

in Jakarta, INDONESIA had constipation symptoms or

functional bowel disorders

Women aged less than 30 y had a significantly higher prevalence ofconstipation as compared to those aged 30 y and over

The frequency of stool was found to be highly varied from 1 to 21stools per week.

Bardosono, Sunardi: Study on 210 female workers. MKI vol 6,no 3 Maret 2011


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Epidemiology - Children

Worldwide prevalence of childhood constipation of 0.7-29.6%(median 12%).

Prevalence was 10-20%in the United States and UK and 20-30%inAustralia, South Africa, and China.

11 January 2015

Auth, M. K. H, et al. Childhood constipation. BMJ 2012;345:e7309. 38-43.

5

Up to one third of children ages six to 12 years

report constipation during any given year.

Constipation generally first appears between

the ages of two and four years.

Biggs, W. S, et al. Evaluation and Treatment of Constipation in Infants and Children.

Am Fam Physician 2006;73:469-77,479-80,481-2


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Epidemiology - Adults

Women are 2 to 3 times more likely to have constipation than menin terms of prevalence and physical symptoms.

Possible reasons include higher risk of injury to the pelvicfloor from childbirth and the general willingness of womento report their symptoms and respond to surveys.

11 January 2015


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It is estimated that constipation affects

between 2% and 27% of the population

(European perspective).12% of people worldwide reporting self-defined

constipation

Tack, J. Diagnosis and treatment of chronic constipationa European perspective.

Neurogastroenterol Motil. 2011; 23:697710


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Epidemiology - Pregnancy

11 January 2015

Tytgat, G. N, et al. Contemporary understanding and management of reflux and

constipation in the general population and pregnancy: a consensus meeting.Aliment

Pharmacol Ther .2003; 18: 291301

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The prevalence of

constipation in pregnant

women is as high as 11

38%.


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Epidemiology- Geriatric

Advanced age is also a risk factor for chronic constipation,with the largest increase in prevalence after the age of 70years.

This can be due to effects of medication, immobility,and blunted urge to defecate.

11 January 2015


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In studies of self-reported constipation:Age 65 years or older:

26 % women and 16 % men considered themselves

to be constipated

Subgroup 84 years or older:

34% women and 26 % men

Gallegoz-Orozco, J. F., et al. Chronic Constipation in the Elderly.Am J Gastroenterol

2012; 107:1825


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Chronic Constipation and Quality of Life

11 January 2015 Tuteja, A.K, et al. Chronic Constipation: Overview and Treatment Options. P&T. 2007; 32(2): 91-92,

99-102, 104-105

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PHYSIOLOGY OF DEFECATION

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Pathophysiology

11 January 2015World Gastroenterology Organization Global Guidelines. Constipation: a global perspective. 2010

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PATHOPHYSIOLOGY OF FUNCTIONAL CONSTIPATION


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Definition of functional constipation

Can J Gastroenterol Vol 25 Suppl B October 2011


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3 Types of Constipation

11 January 2015 13

Tack, J. Diagnosis and treatment of chronic constipationa European perspective. Neurogastroenterol Motil. 2011; 23:697710


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Normal-transit constipation Normal-transit constipation (=functional constipation)

The most common form of constipation seen byclinicians.

Reported symptoms:

the presence of hard stools

a perceived difficulty with evacuation

on testing, stool transit is not delayed

the stool frequency is often within thenormal range

may experience bloating and abdominalpain or discomfort, will frequently meetcriteria for irritable bowel syndrome

with constipation (IBS-C)may exhibit increased psychosocial

distress.

Cn Andrews, M storr. The pathophysiology of chronic constipation. Can J gastroenterol 2011;25(suppl B):16B-

21B

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Slow-transit constipation

causes infrequent bowel movements

(typically less than once per week) most common in young women

often, patients do not feel the urge todefecate

may complain of associated bloating and

abdominal discomfort colonic transit time is prolonged in these

patients

believed to be a neuromuscular disorder ofthe colon: decreased numbers of interstitial cells of Cajal (ICC)

alterations in the number of myenteric plexus neurons expressingthe excitatory neurotransmitter substance P in the gut wall

Cn Andrews, M storr. The pathophysiology of chronic constipation. Can J gastroenterol

2011;25 su l B :16B-21B

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Dyssynergia the most common functional Defecation

Disorder (DD), is an acquired behavioural DD result of poor toileting habits, painful

defecation, obstetric or back injury, or brain-gut dysfunction

In children, fecal retention may result inencopresis due to leakage of liquid stool

around impacted stool Patients with dyssynergia are unable to

coordinate the abdominal, rectoanal and pelvicfloor muscles during defecation, and may alsodemonstrate rectal hyposensitivity

Other terms: anismus, pelvic floor dysfunction,puborectalis spasm and outlet constipation.


2011;25 su l B :16B-21B

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Possible causes and constipation-associated

conditions/ Secondary constipation

11 January 2015World Gastroenterology Organization Global Guidelines. Constipation: a global perspective. 2010

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Medication associated with constipation

Antihypertensive drugs (clonidine, calcium

antagonists, and ganglionic blockers) reducesmooth muscle contractilitycan causeconstipation

In patients with constipation, these should be preferably replaced by beta-

blockers, angiotensin-converting enzyme inhibitors, or angiotensin II receptorantagonists

Antidepressants, especially tricyclicantidepressants.

Oral iron supplementation frequently causesconstipation

patients in whom iron supplementation is necessary, intravenoussupplementation of iron or the addition of a laxative may be options.

Aluminum-containing drugs such as sucralfateand antacids can cause constipationmay bereplaced by proton pump inhibitors


2011;25 su l B :16B-21B

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Medication associated with constipation

Analgesics, such as opiates and

cannabinoids, are especially notorious forcausing constipation.Switching to a different class of analgesic drugs or using an opiate incombination with a peripherally active opiate receptor antagonist, such asnaloxone or methylnaltrexone, may be considered

Anti-Parkinson, antiepileptic andantipsychotic drugsare associated withconstipation due to their anticholinergic anddopaminergic actions, and should beavoided or combined with the regular use oflaxatives.

Antihistamines, antispasmodics and vinca

alkaloidsare associated with constipation asa side effect and should be replaced


2011;25(suppl B):16B-21B 20


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DIAGNOSTIC APPROACH

11 January 2015 PLEASE INSERT Presentation title 21


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Symptoms of Chronic Constipation

Tuteja, A.K, et al. Chronic Constipation: Overview and Treatment Options. P&T. 2007; 32(2): 91-92,

99-102, 104-105

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Rome III Criteria

Tuteja, A.K, et al. Chronic Constipation: Overview and Treatment Options. P&T. 2007; 32(2): 91-92,

99-102, 104-105

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Rome III Diagnostic Criteria or Irritable Bowel Syndrome

24Gastroenterology 2006;130(5):1481


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Evaluation Stool consistency. (Bristol Stool Chart)

Patients description of constipationsymptoms; symptom diary:

Bloating, pain, malaise

Nature of stools

Bowel movementsProlonged/excessivestraining

Unsatisfactory defecation Laxative use (past and present; frequency

and dosage)

Current conditions, medical history, recentsurgery, psychiatric illness

Constipation: a global perspective. World Gastroenterology Organisation Global

Guidelines. 201025

Focus on identifying possible causative

conditions and alarm symptoms.


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Bristol Stool Chart

26Auth, M. K. H, et al. Childhood constipation. BMJ 2012;345:e7309. 38-43.


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Evaluation (cont.) Patients lifestyle, dietary fiber, and fluid intake

Use of suppositories or enemas, other medications Physical examination:

Gastrointestinal mass

Anorectal inspection:

Fecal impaction

Stricture, rectal prolapse,rectocele

Paradoxical or nonrelaxing

puborectalis activityRectal mass If indicated: blood testsbiochemical profile,

complete blood count, calcium, glucose, andthyroid function

Constipation: a global perspective. World Gastroenterology Organisation GlobalGuidelines. 2010

27

Focus on identifying possible causative

conditions and alarm symptoms.

Di ti l ti


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Diagnostic evaluation

Jamshed, N, et al. Diagnostic Approach to Chronic Constipation in Adults.Am Fam Physician.

2011;84(3):299-306.

28

Clinical Findings and Possible Associated Causes

in Patients with Constipation


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Alarm Symptoms and Indication for Endoscopy

Constipation: a global perspective. World Gastroenterology Organisation

Global Guidelines. 2010

Jamshed, N, et al. Diagnostic Approach to Chronic Constipation in Adults.Am

Fam Physician. 2011;84(3):299-306. 29

Indications for endoscopy in

patients with constipation

ALARM SYMPTOMS in CONSTIPATION

ASGE GUIDELINE 2005


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Primary Care Management of Chronic Constipation in Asia:

The ANMA Chronic Constipation Tool

J Neurogastroenterol Motil, Vol. 19 No. 2 April, 2013


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Clinical Evaluation

11 January 2015Constipation: a global perspective. World Gastroenterology Organization Global

Guidelines. 2010

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Categories constipation based on clinical evaluation


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Screening tests (DIAGNOSTIC TESTING)

11 January 2015Constipation: a global perspective. World Gastroenterology Organization Global

Guidelines. 2010

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Laboratory studies, imaging or endoscopy, and function tests

indicated in patients with severe chronic constipation or alarm symptoms.

PHYSIOLOGY TESTS FOR CHRONIC CONSTIPATION

M t C l T it


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Measurement Colon Transit

( Sitzmarks Methode)

11 January 2015


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MANOMETRY ANORECTAL

11 January 2015 34


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Ballon expulsion test

11 January 2015 35

The balloon expulsion test is used to identify

problems with defecation. In this procedure,

the patient lies on a table so that a small

balloon can be inserted into the rectum. The

balloon is then filled with water. At thispoint, the patient is asked to go to the toilet

to expel the balloon. The length of time that

it takes to expel the balloon is recorded. A

normal expulsion time is considered to bewithin one minute. Longer expulsion times

would be indicative of problematic

defecation.
http://ibs.about.com/od/ibsglossaryae/g/Defecation.htmhttp://ibs.about.com/od/ibsglossaryae/g/Defecation.htm


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Management

1. Comprehensive therapy :

Physiological defecation function andetiology of constipation

2. Start empirical therapy:

Alarm sign (-)

Age < 40 yo

Abnormality in rectal toucher (-)

Secondary causes of defecation(-)


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3. Empirical therapy Non-pharmacological and pharmacological

therapy

Non pharmacological therapy:- Education

- Fiber and enough water consumption

- Probiotic consumption (Bifidobacterium sp) e.g

bifidobacterium animalis lactis DN -173010: Activia- Physical activity

- Defecation habits, avoid straining during defecation, trainpostprandial bowel movement reflex, avoid drugs that cancause constipation

Management


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Pharmacological therapy

A. Laxative

Bulk laxative

Osmotic laxative: saline, disaccharide, sugar alcohol, PEGStimulant laxative

Rectal enema/suppositoria

Lubiproston

B. Non-laxative ProkineticEmpirical therapy in 2-4 weeks

Further evaluation if there is no improvement

Management


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4. STC (slow transit constipation) : stimulantlaxative therapy + prokinetic besides nonpharmacological therapy

5. Anorectal dysfunction: biofeedbacktherapy/botulinum type A toxin injection intopuborectalis muscle

6. Secondary constipation: therapy for underlyingdisease

7. Operative therapy: no response from medicaltherapy, anorectal problems (-)

Management


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C ti ti M t Al ith


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Constipation Management Algorithm

in Primary Health Care Center

Constipation

Continue the treatment

Alarm sign

Age 40 y.o

Suspicion of secondary constipation

Abnormality in rectal toucher

Empirical therap

2-4 weeks

Further

investigation/reffered

+

-+

-

Algorithm for Management of Constipation


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Algorithm for Management of Constipation

in Advanced Health Care Center

Alarm signAge 40 y.o

Suspicion of secondary constipation

Abnormality in rectal toucher (+)

Empirical therapy (2-4 wk) Faeces examination/lab/colonoscopy

Continue the treatment No organic lesion Organic lesion +

Constipation

NTC STC ARD

NTC Algorithm

STC Algorithm

ARD Algorithm

Treatment based on etiology

Colon transit

test/anorectal

manometry

+-

+


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Algorithm for Management of Constipation in

Slow Transit Constipation(STC)

Slow transit constipation

Fiber +probiotic+ MOM+bisacodyl/prokinetic

Improvement

Add lactulose/PEG

No improvement

Considered to operationContinue the treatment

Continue the treatment

No improvement

Improvement


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Algorithm of Anorectal Dysfunction Management

Anorectal Dysfunction

Fiber + Probiotic, Suppositoria, Enema

Follow up Re-investigation

Biofeedback + Fiber + Probiotic

Improvement No improvement


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Intractable Constipation

The definition of, and clinical approach to patients withdiffi-cult, refractory or intractable constipation is stillunclear.

Intractable chronic constipation in children as chronicconstipation with duration of symptoms > 2 years, notresponding to maximal laxative therapy, behaviouraltherapy or a toilet training program.

Another definition ; a subset of constipatedpatients fails to benefit from conventional and

sometimes even intensive treatments.


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General consideration

Refractory constipation is suspected when a

patient, fulfilling the standard diagnostic

criteria for functional constipation and lacking

any alarm featurefor organic conditions, failstoimprove upon intake of a high-fiber diet and

laxatives, usually polyethylene glycol (PEG) or

other osmotic agents, the former being superior

to lactulose in improving stool frequency, stool

consistency and abdominal pain.


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Several issue before judgment RC Reliability of information and patient compliance

Misunderstandings with the prescribing physician

Misconceptions

Patient expectations

Discontinued drug intake after a very few days of therapyowing to the lack of effect onset

Poor basal evaluation

should be accurately re-evaluated for secondary forms ofconstipation


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Two group of RC

STC (Slow transit constipation)

delayed colonic transit, a condition which canbe documented by a delayed distribution of

radiopaque markers (or radionuclides)throughout the visceral lumen and ischaracterized by a severe impairment ofcolonic motor activity that, in some instances,

can be almost absent or progress up to a truepicture of colonic inertia


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OD (Obstructed Defecation)

Main pathophysiological features

are basically related to rectoanal dysfunction,

including the inability to relax or the paradoxicalcontraction of the pelvic floor while attemptingto defecate, the lack of rectal motor activity, andan abnormal rectal sensitivity although

anatomical abnormalities (particularly rectoceleand rectal intussusceptions) can also play a role inthis setting.


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Pharmacologic Management

Combination agent :Osmotic laxative + Stimulant laxative (bisacodyl andsodium picosulfate)

Tegaserod

Prucalopride 1-2 mg/day (5HT4 full agonist,enterokinetic properties+) or combination with PEG.

Enteric secretagogues ; Lubiprostoneat a dose of 24 gtwice a day

linaclotide, a guanylate cyclase-C agonist (dose 145ug/day)


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Other pharmacological options

Colchicine 0.6 mg three times per day

(selected case)

The inhibitor of ileal bile acid transporter

A3309 (10 mg/day Fase 2 study)

Cholinesterase inhibitor pyridostigmine (60-

120 mg three times per day)DM patients

with constipation (available market)

OTHER


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OTHER

THERAPEUTIC APPROACHES

Behavioral and retraining techniques

(biofeedback)particularly in OD patients

Electrogalvanic stimulation

Local injections of botulinum toxin

Surgery approach/procedures


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Take Home messeges

Reassesment of define/precense ofrefractory/intractable constipation beforetherapy

Define type of constipation STC or OD

Start with combination therapy withdifference mechanism of drugs (old drugs ornew drug its available)

Used other therapeutic approach its possible

Think for surgery if not improve

hd-medical management of intractable constipation (final)

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