Medical Management of Intractable Constipation (FINAL)2
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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 - 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
Leung, L, et al. Chronic Constipation: An Evidence-Based Review. J Am Board Fam Med. 2011;24:436451.
6
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
7
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
Leung, L, et al. Chronic Constipation: An Evidence-Based Review. J Am Board Fam Med. 2011;24:436451.
8
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
11
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 by
clinicians.
Reported symptoms:
the presence of hard stools
a perceived difficulty with evacuation
on testing, stool transit is not delayedthe stool frequency is often within the
normal range
may experience bloating and abdominalpain or discomfort, will frequently meet
criteria for irritable bowel syndrome withconstipation (IBS-C)
may exhibit increased psychosocialdistress.
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 bowelmovements (typically less thanonce per week)
most common in young women
often, patients do not feel the urge
to defecate may complain of associated
bloating and abdominal discomfort
colonic transit time is prolonged in
these patients believed to be a neuromuscular
disorder of the colon.
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.
Cn Andrews, M storr. The pathophysiology of chronic constipation. Can J gastroenterol
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
Cn Andrews, M storr. The pathophysiology of chronic constipation. Can J gastroenterol
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
Cn Andrews, M storr. The pathophysiology of chronic constipation. Can J gastroenterol
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 of Irritable Bowel Syndrome
24Gastroenterology 2006;130(5):1481
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Evaluation Stool consistency. (Bristol Stool Chart)
Patient
s description of constipationsymptoms; symptom diary:
Bloating, pain, malaise
Nature of stools
Bowel movementsProlonged/excessive straining
Unsatisfactory defecation Laxative use (past and present; frequency
and dosage) Current conditions, medical history, recent
surgery, 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 puborectalisactivity
Rectal 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
31
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
32
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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Balloon expulsion test
BE Lee et al, J Neurogastroenterol Motil, Vol. 20 No. 3 July,
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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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Specific consideration
Elderly
Pregnancy and lactation
Diabetes
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
+-
+
Algorithm for Management of Constipation
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Algorithm for Management of Constipation
in Normal Transit Constipation (NTC)
Continue the treatment
No improvement
Fiber+probiotic+bisacodyl+laktulosa/
MOM/PEGContinue the treatment
Fiber+probiotic+bisacodyl+lactulose+PEG
Improvement
Continue the treatment
Normal Ttransit Constipation (NTC)
Fiber + Probiotic
Milk of magnesia/bisacodyl/lactulose/PEG
No improvementImprovement
Therapy adjustment
No improvementImprovement
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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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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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Further diagnostic step
Intestinal transit time
Anorectal manometry (complemented
by the rectal balloon expulsion test and
defecography Upper gastrointestinal (which might limit or
preclude surgical procedures) and colonic
manometry (possibly with pharmacologicaltesting in patients regarded as eligible forsurgery.
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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 ; Lubiprostone at a dose of 24 g
twice a day linaclotide, a guanylate cyclase-C agonist (dose 145
ug/day)
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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
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Frequency and stool form in Indian
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Frequency and stool form in Indian
PopulationConclusions
Median stool frequency in the studied population was
14/week (range 2-42) and predominant form was Bristol type
IV. Older age was associated with lesser stool frequency,
particularly among female subjects
Multivariate Analysis
On multivariate analysis, female gender (< 0.001) and age > 35
years (< 0.001) were independent predictors of passing 3
stools per week but vegetarianism and physical activity were
not significant
J Neurogastroenterol Motil. Jul 2013; 19(3): 374380.
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Prevalence
median ; 16% (range, 0.7%79%) in adults overall
and 33.5% in adults aged 60 to 101 years.
nonwhite population more than in the white
population.
median female-to-male ratio of 1.5:1
in institutionalized more than community-living
elderly residents Women seek laxative >>
Forest plot of standardized mean difference in intestinal
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Forest plot of standardized mean difference in intestinal
transit time across studies with probiotic in constipated
patients
World J Gastroenterol 2013 August 7; 19(29): 4718-4725
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Flow diagram for management of chronic constipation
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Leung et al , J Am Board Fam Med 2011;24:436
451
Summary of Various Management Options for Chronic Constipation
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Summary of Various Management Options for Chronic Constipation
According to the Strength of Recommendations Taxonomy (SORT)