Functional constipation
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Transcript of Functional constipation
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Functional Constipation
ByM. Osama Shetta.
Professor of SurgeryAin Shams University
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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
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Definition(cont.)
- These symptoms need to be chronic.- All other aetiological causes of
constipation must be excluded specially the organic causes.
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Aetiology of constipation I
DietaryEndocrine / MetabolicNeurological PsychogenicDrugs & poisonsGeneral causes
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Drugs:opiatesanticholinergics.Iron therapy.antiacids
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Aetiology of constipation II
- Organic obstruction- Functional constipation
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Organic Obstruction
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Functional Constipation
In terms of pathophysiology:- Slow gut transit(colonic inertia).- Rectal evacuatory dysfunction.- Combination of both.
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Functional Constipation
Slow transitOutlet obstruction
–Rectocele–Rectal prolapse, intussusception–Anismus–Solitary rectal ulcer syndrome–Descending perineum syndrome
Slow transit + Outlet obstructionConstipating form of IBS
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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
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Evaluation & Management
Initial evaluation
Initial management
Secondary management
Secondary evaluation
Tertiary management
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Aim of Initial Evaluation
Exclude organic obstruction
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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
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Initial Management with Apparent cause
Treatment of the cause.
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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
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Secondary Management
By Stimulant laxatives:
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Aim of Secondary Evaluation
Document the presence and the type of functional constipation
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Secondary Evaluation
Extensive lab. StudiesColonic transitPelvic floor tests (PFT)
–Manometry (press., sens., RAIR)–EMG–Defecography–Balloon expulsion test
Biopsy for ultrashort segment HirschsprungPsychological consultation
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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
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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
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Treatment
Rectocele– Surgical repair
– Biofeedback
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Treatment
Slow transit constipation–Total colectomy–Segmental colectomy–Biofeedback
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Treatment
Complete rectal prolapse–Rectopexy–Resection–Delorme
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Treatment
Internal intussusception–Biofeedback–Rectopexy–Delorme–Rectopexy + Resection–Other extensive operations
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Treatment
Solitary rectal ulcer–Biofeedback–Excision–Injection–Rectopexy
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Treatment
Anismus–Biofeedback–Botulinum toxin
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Treatment
Descending perineum–Biofeedback
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Proper Management
Starts With Proper
Diagnosis
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Surgical Aspects Of Constipation
by
Ahmed A. Abou-Zeid
Professor of SurgeryAin Shams University
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