Constipation resident survival guide: Difference between revisions
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❑ [[Lactulose]]: 15-30 ml OD or BID</div>}} | ❑ [[Lactulose]]: 15-30 ml OD or BID</div>}} | ||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | |!| | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | I01 | | | | | | | | |I01= Response to | {{familytree | | | | | | | | | | | | | | | I01 | | | | | | | | |I01= Response to treatment}} | ||
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{{familytree | | | | | | | | | | | | J01 | | | | J02 | | | | | | |J01=Yes| J02=No}} | {{familytree | | | | | | | | | | | | J01 | | | | J02 | | | | | | |J01=Yes| J02=No}} | ||
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{{familytree | | | | | | | | | | | | | | | H01 | | | | H02 | | | |H02=Continue the initial therapeutic regimen| H01=Repeat colonic transit test with medications}} | {{familytree | | | | | | | | | | | | | | | H01 | | | | H02 | | | |H02=Continue the initial therapeutic regimen| H01=Repeat colonic transit test with medications}} | ||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | |!| | | | | | | |}} | ||
{{familytree | | | | | | | | | | | | | | | I01 | | | | | | | | |I01= Response to | {{familytree | | | | | | | | | | | | | | | I01 | | | | | | | | |I01= Response to treatment}} | ||
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{{familytree | | | | | | | | | | | | J01 | | | | J02 | | | | | | |J01=Normal | J02=Delayed}} | {{familytree | | | | | | | | | | | | J01 | | | | J02 | | | | | | |J01=Normal | J02=Delayed}} | ||
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{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree/end}} | {{familytree/end}} | ||
===Management of Pelvic Floor Dysfunction=== | |||
{{Family tree/start}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | A01= '''Pelvic floor dysfunction'''}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | B01=<div style="float: left; text-align: left; height: 20em; width: 17em; padding:1em;">'''Fiber'''<br> | |||
---- | |||
❑ [[Psyllium]]: 1 tsp up to 3 times daily <br> '''OR''' <br> | |||
❑ [[Methylcellulose]]: 1 tsp up to 3 times daily<br> | |||
---- | |||
'''PLUS''' | |||
---- | |||
'''Stimulant laxative'''<br> | |||
---- | |||
❑ [[Bisacodyl]]: 10 mg suppositories or 5-10 mg orally up to 3 times/wk <br> '''OR''' <br> | |||
❑ [[Glycerin]]: Suppository OD</div>}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | C01= <div style="float: left; text-align: left; height: 23em; width: 17em; padding:1em;">'''Biofeedback'''<br> | |||
---- | |||
❑ Anorectal and pelvic floor muscle activity are recorded by surface electromyographic sensors <br> | |||
❑ Patients are taught to increase intraabdominal pressure and relax the pelvic floor muscles during defecation<br> | |||
❑ Patients practice by expelling an air filled balloon or through external traction to a catheter attached to the balloon <br> | |||
❑ Patients are taught to recognize weaker sensations of rectal filling<br> | |||
❑ Patients are taught Kegel exercises<br> | |||
</div>}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | C01= Response to treatment}} | |||
{{familytree | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | D01 | | | | D02 | | | | | | | | | | | D01=Yes | D02=No}} | |||
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | E01 | | | | E02 | | | | | | | | | | | E01= Follow clinically | E02=Repeat balloon expulsion test}} | |||
{{familytree | | | | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | G01 | | | | G02 | | | | G02=Normal| G01=Abnormal}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | |!| | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | H01 | | | | H02 | | | |H02=Manage as normal transit constipation| H01=Perform defecating proctogram}} | |||
{{familytree | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | J01 | | | | J02 | | | | | | |J01=Normal | J02=Abnormal}} | |||
{{familytree | | | | | | | | | | | | |!| | | | | |!| | | | |}} | |||
{{familytree | | | | | | | | | | | | H01 | | | | H02 | | | |H01=Reassess biofeedback + medications if needed |H02=Define anatomic rectal defect}} | |||
{{familytree | | | | | | | | | | | | |!| | | |,|-|^|-|-|.| | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | I03 | | I01 | | | I02 | | | | | | | | I01=Clinically significant | I02= Insignificant| I03=No response}} | |||
{{familytree | | | | | | | | | | | | |!| | | |!| | | | |!| | | | |}} | |||
{{familytree | | | | | | | | | | | | I04 | | J01 | | | J02 | | | | | | | |J01=Surgical repair and follow up| J02= No surgery needed| I04= Consider surgery}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree/end}} | {{familytree/end}} | ||
===Management of Combined Pelvic Floor Dysfunction and Slow Transit Constipation=== | |||
{{Family tree/start}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | A01= '''Combined pelvic floor dysfunction and slow transit constipation'''}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | B01=<div style="float: left; text-align: left; height: 15em; width: 17em; padding:1em;">'''Biofeedback'''<br> | |||
---- | |||
'''PLUS''' | |||
---- | |||
'''Dietary fiber''': [[Psyllium]]/[[methylcellulose]]<br> | |||
---- | |||
'''PLUS''' | |||
---- | |||
'''Stimulant laxative''': [[Bisacodyl]]<br> | |||
---- | |||
'''PLUS''' | |||
---- | |||
'''Saline laxative''': [[Milk of magnesia]]</div>}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | C01= Response to treatment}} | |||
{{familytree | | | | | | | | | |-|-|-|-|-|-|^|-|-|.| | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | D01 | | | | | | | D02 | | | | | | | | | | | D01=Yes | D02=No}} | |||
{{familytree | | | | | | | | | |!| | | | | | | | |!| | | | | | | | | | | |}} | |||
{{familytree | | | | | | | | | E01 | | | | | | | E02 | | | | | | | | | | | E01= Perform colonic transit test without medications | E02=Repeat balloon expulsion test}} | |||
{{familytree | | | | | | |,|-|-|^|-|.| | | |,|-|-|^|-|-|.| | | | |}} | |||
{{familytree | | | | | | G04 | | | G03 | | G01 | | | | G02 | | | | G04=If delayed manage as slow transit constipation| G03= If normal follow clinically| G02=Normal| G01=Abnormal}} | |||
{{familytree | | | | | | | | | | | | | | | |!| | | | | |!| | | | |}} | |||
{{familytree | | | | | | | | | | | | | | | H01 | | | | H02 | | | |H02=Manage as slow transit constipation| H01=Perform defecating proctogram}} | |||
{{familytree | | | | | | | | | | |,|-|-|-|-|^|-|-|.| | | | | | | |}} | |||
{{familytree | | | | | | | | | | J01 | | | | | | J02 | | | | | | |J01=Normal | J02=Abnormal}} | |||
{{familytree | | | | | | | | | | |!| | | | | | | |!| | | | |}} | |||
{{familytree | | | | | | | | | | H01 | | | | | | H02 | | | |H01=Reassess biofeedback + add hyperosmolar agents ([[lactulose]]/[[PEG]]) |H02=Define anatomic rectal defect}} | |||
{{familytree | | | | | | |,|-|-|-|^|-|.| | | |,|-|^|-|-|.| | | | | | | |}} | |||
{{familytree | | | | | | I04 | | | | I03 | | I01 | | | I02 | | | | | | | | I04=No improvement| I03= Improvement| I01=Clinically significant | I02= Insignificant| I03=No response}} | |||
{{familytree | | | | | | |!| | | | | |!| | | |!| | | | |!| | | | |}} | |||
{{familytree | | | | | | I05 | | | | I04 | | J01 | | | J02 | | | | | | | |J01=Surgical repair and follow up| J02= No surgery needed| I04= Continue therapeutic regimen| I05=Repeat colonic transit test on medications}} | |||
{{familytree | | | |,|-|-|^|-|-|.| | | | | | | |}} | |||
{{familytree | | | J01 | | | | J02 | | | | | | |J01=Normal | J02=Delayed}} | |||
{{familytree | | | |!| | | | | |!| | | | |}} | |||
{{familytree | | | H01 | | | | H02 | | | |H01=Adjust medications as needed |H02=Consider surgery}} | |||
{{familytree | | | |!| | | | | | | | | |}} | |||
{{familytree | | | H01 | | | | | | |H01=Consider surgery if no improvement}} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}} | |||
{{familytree/end}} | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} |
Revision as of 20:15, 11 February 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]
Definition
Constipation is a syndrome that is defined by unsatisfactory defecation characterized either by difficult stool passage that includes straining, sense of difficulty passing stool, incomplete evacuation, hard/lumpy stool, prolonged time to passage of stool, need for manual maneuvers to pass stool or by infrequent bowel movement or both.[1][2]
Rome III Criteria for Functional Constipation
Any 2 of the following |
---|
Less than three evacuations per week |
Lumpy or hard stools in ≥ 25% of defecations |
Straining during ≥ 25% of defecations |
Anorectal obstruction sensation for ≥ 25% of defecations |
Manual maneuvers to facilitate ≥ 25% of defecations |
Incomplete evacuation sensation for ≥ 25% of defecations |
Loose stools are not present |
Insufficient criteria for irritable bowel syndrome |
† Criteria fulfilled for the past 3 months and symptom onset atleast 6 months before diagnosis.[3]
American Gastroenterological Association, however have stopped using the term functional constipation because a subset these patients have slow colonic transit that has been associated with a marked reduction in colonic intrinsic nerves and interstitial cells of Cajal which is against the true definition of functional disorder.[4]
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Atropine poisoning
- Hypokalemia
- Lead poisoning
- Opium poisoning
- Severe dehydration
- Spinal cord injury
- Superior mesenteric artery occlusion
Common Causes
- Hardening of the feces: Improper mastication, low dietary fiber, dehydration and medications (aluminium, calcium, diuretic, iron).
- Paralysis or slowed transit: Hypothyroidism, hypokalemia, injured anal sphincter, medications (loperamide, codeine, morphine, tricyclic antidepressants) and severe systemic illness due to other causes.
- Constriction, where part of the intestine or rectum is narrowed or blocked: Diverticulosis, pelvic masses and stenosis.
- Psychosomatic constipation: Functional constipation and irritable bowel syndrome.[5]
- Smoking cessation[6]
- Abdominal surgery and childbirth
Management
The algorithm is based on the American Gastroenterological Association guidelines for management of constipation in adults.[7][2]
Initial Evaluation
Characterize the symptom: ❑ Any desire to defecate but an inability to pass a stool Associated symptoms: ❑ Abdominal pain or abdominal discomfort:
❑ Abdominal distention Obtain a detailed history: ❑ Dietary history: Dietary pattern change, low fiber diet, food intolerance, dehydration etc | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ General status: Pulse, blood pressure, respiratory rate, weight, thyroid
❑ Abdominal examination: Mass, distension, tenderness and bowel sounds | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Order tests: ❑ Complete blood count (CBC) When secondary causes are suspected: ❑ Colonoscopy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Possible etiologies after initial evaluation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Irritable bowel syndrome(IBS) | Unknown etiology | Organic constipation (mechanical obstruction or drug side effect) | Constipation secondary to systemic disease | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Rx for IBS | Dietary fiber supplementation and simple laxatives | Treat the underlying etiology | Treat the underlying systemic disease | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Refractory constipation if there is no response to initial management | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Management of Refractory Constipation
Chronic constipation who have not responded to a high-fiber diet and/or over-the-counter laxatives after organic disorders have been excluded | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Normal BET, ARM, BD, CTT | Abnormal CTT Normal BET, ARM, BD | Abnormal BET, ARM, BD Normal CTT | Abnormal BET, ARM, BD, CTT | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Normal transit constipation | Slow transit constipation | Pelvic floor dysfunction | Combined slow transit constipation and pelvic floor dysfunction | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Management of Normal Transit Constipation
Normal transit constipation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Fiber ❑ Psyllium: 1 tsp up to 3 times daily PLUS Saline laxative ❑ Milk of magnesia: 15-30 ml OD or BID | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Continue the same regimen | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Continue the same regimen | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Continue the same regimen | Adjust and change medications periodically | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Management of Slow Transit Constipation
Slow transit constipation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Fiber ❑ Psyllium: 1 tsp up to 3 times daily PLUS Saline laxative ❑ Milk of magnesia: 15-30 ml OD or BID PLUS Stimulant laxative ❑ Bisacodyl: 10 mg suppositories or 5-10 mg orally up to 3 times/wk | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Continue the initial therapeutic regimen ❑ Fiber ❑ milk of magnesia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Repeat colonic transit test with medications | Continue the initial therapeutic regimen | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Normal | Delayed | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adjust medications as needed | Repeat BET and BD | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Normal | Abnormal | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider illeo rectal anastamosis or subtotal colectomy | Manage for pelvic floor dysfunction | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Management of Pelvic Floor Dysfunction
Pelvic floor dysfunction | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Fiber ❑ Psyllium: 1 tsp up to 3 times daily PLUS Stimulant laxative ❑ Bisacodyl: 10 mg suppositories or 5-10 mg orally up to 3 times/wk | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Biofeedback ❑ Anorectal and pelvic floor muscle activity are recorded by surface electromyographic sensors | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Follow clinically | Repeat balloon expulsion test | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Abnormal | Normal | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Perform defecating proctogram | Manage as normal transit constipation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Normal | Abnormal | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Reassess biofeedback + medications if needed | Define anatomic rectal defect | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No response | Clinically significant | Insignificant | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider surgery | Surgical repair and follow up | No surgery needed | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Management of Combined Pelvic Floor Dysfunction and Slow Transit Constipation
Combined pelvic floor dysfunction and slow transit constipation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Biofeedback PLUS Dietary fiber: Psyllium/methylcellulose PLUS Stimulant laxative: Bisacodyl PLUS Saline laxative: Milk of magnesia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Response to treatment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Perform colonic transit test without medications | Repeat balloon expulsion test | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
If delayed manage as slow transit constipation | If normal follow clinically | Abnormal | Normal | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Perform defecating proctogram | Manage as slow transit constipation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Normal | Abnormal | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Reassess biofeedback + add hyperosmolar agents (lactulose/PEG) | Define anatomic rectal defect | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No improvement | No response | Clinically significant | Insignificant | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Repeat colonic transit test on medications | Continue therapeutic regimen | Surgical repair and follow up | No surgery needed | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Normal | Delayed | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adjust medications as needed | Consider surgery | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider surgery if no improvement | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
References
- ↑ American College of Gastroenterology Chronic Constipation Task Force (2005). "An evidence-based approach to the management of chronic constipation in North America". Am J Gastroenterol. 100 Suppl 1: S1–4. doi:10.1111/j.1572-0241.2005.50613_1.x. PMID 16008640.
- ↑ 2.0 2.1 Locke GR, Pemberton JH, Phillips SF (2000). "American Gastroenterological Association Medical Position Statement: guidelines on constipation". Gastroenterology. 119 (6): 1761–6. PMID 11113098.
- ↑ Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC (2006). "Functional bowel disorders". Gastroenterology. 130 (5): 1480–91. doi:10.1053/j.gastro.2005.11.061. PMID 16678561.
- ↑ Farrugia G (2008). "Interstitial cells of Cajal in health and disease". Neurogastroenterol Motil. 20 Suppl 1: 54–63. doi:10.1111/j.1365-2982.2008.01109.x. PMID 18402642.
- ↑ Caldarella MP, Milano A, Laterza F; et al. (2005). "Visceral sensitivity and symptoms in patients with constipation- or diarrhea-predominant irritable bowel syndrome (IBS): effect of a low-fat intraduodenal infusion". Am. J. Gastroenterol. 100 (2): 383–9. doi:10.1111/j.1572-0241.2005.40100.x. PMID 15667496.
- ↑ "Nicotine withdrawal symptoms:Constipation". helpwithsmoking.com. 2005. Retrieved 2007-06-29.
- ↑ Bharucha AE, Pemberton JH, Locke GR (2013). "American Gastroenterological Association technical review on constipation". Gastroenterology. 144 (1): 218–38. doi:10.1053/j.gastro.2012.10.028. PMC 3531555. PMID 23261065.