Approach to constipation.pptx

Comprehensive approach to Constipation.

1. APPROACH TO CONSTIPATION

2. Physiology of Defecation Defecation is a spinal reflex. Distension of the rectum reflex contractions of its musculature desire to defecate  

3. Rectal pressure Response 18 mm Hg Urge to defecate 55 mm Hg defecation Rectal pressure Response Urge to defecate defecation 90-100 * Ganong , Guyton and Hall Physiology Straining abdominal muscles puborectalis muscle relaxes pelvic floor descent anorectal angle straight relaxation of the external anal sphincter Defecation

4. *Guyton and Hall Physiology 1 2 3 4 5 6 Rectal nerve endings Spinal cord colon sigmoid rectum Parasympathetic nerves Persistalsis relaxed internal sphincter   defecation

5. CONSTIPATION Very common clinical problem all over the world. Serious impact on quality of life of the patients, financial burden. It is said that  2.5 million individuals with constipation undergo evaluation annually. $500 million is spent on laxatives each year. The traditional definition of constipation has been 3 bowel movements per week. ACG Task force defines it as “Unsatisfactory defecation characterized by infrequent bowel movements/ difficult to pass stools/ both”. Objectively defined by recent ROME IV criteria.  

6. These disorders should be thought of as existing on a continuum, rather than as in isolation. *Bowel, Gastroenterology 2016;150:1393–1407

7. *Van Oudenhove et al Gastroenterology 2016;150:1355 – 1367 Biopsychosocial model for FGID

8. Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. Any 2 of the below Loose stools rarely present without use of laxatives Not meeting IBS criteria Straining Lumpy/hard stools Incomplete evacuation Sensation of obstruction Manual maneuvers 3 spontaneous movements/week   25% of the defecations ROME IV Patient might be passing stools daily and can still have constipation

9. Epidemiology The prevalence of constipation is estimated to be 14% based on a meta-analysis of 41 studies with over 261,000 subjects throughout the world. STUDY SAMPLE SIZE CRITERIA FOR Dx Prevalence Ghoshal et al. 2008 Complainants: 2785 Non-complainants: 4500 Self-perception 53% Makharia et al 2011 4767 Self perception 11.6% Rajput and Saini 2014 505 ROME II 16.8% Self Perception 24.8% Ghoshal , Singh 2017 2774 ROME III 2.4% Indian studies Advanced age Female gender Low level of education Low level of physical activity Low socioeconomic status Multiracial ethnicity Use of certain medications

10. Types Functional – Most common type – 80% Organic – 20 % Anal stenosis Intestinal stricture Rectocele Sigmoidocele Colorectal cancer Extrinsic compression Diabetes mellitus Heavy metals Hypercalcemia Hypokalemia Hypothyroidism Amyloidosis Multiple sclerosis Parkinsonism dermatomyositis Anti depressants, Anti Parkinson Vinca alkaloids opioids Diuretics Iron

11. Functional constipation

12. NORMAL TRANSIT CONSTIPATION Patients report that they have constipation, inspite of normal frequency. Presence of hard stools or a perceived difficulty with evacuation. Stool transit, stool frequency - within the normal range. Bloating and abdominal pain. May exhibit increased psychosocial distress. Respond to therapy with dietary fibre osmotic laxative or enterokinetic. Typically will not require a formal transit test.   NTC IBS C

13. Slow transit constipation Slow transport of stool across colon. Infrequent bowel movements (<1 /week) Young Women. Colonic inertia - most severe end of the spectrum. Colonic dysmotility Colonic neuropathy Neuro-hormonal cause Methanogenic bacteria Slow Transit Constipation

14. Colonic dysmotility Colonic motor activity has temporo-spatial variation influenced by sleep, waking, meals , physical and emotional stressors, gender, aging. STC- overall colonic motor activity. Blunted Gastrocolonic response, no increase in activity after waking up. frequency, amplitude and duration of HAPCs.  

15. Colonic Neuropathy Interstitial cells of cajal –evoke basic electrical rythms for intestinal movements, Pacemaker cells for intestinal motility. Pancolonic in the icc volume across the circular and longitudinal muscle layers and submucosa, myenteric ganglion cells   *GUT- BMJ

16. Neuro-hormonal Women>Men. Possible Hormonal cause?? Low levels of ovarian and adrenal steroid hormones has been suggested (not confirmed) Colectomy specimens from women with STC -- progesterone-dependent contractile G proteins, inhibitory G proteins in constipated women.   Stimulation of mucosa Acetyl choline Substance P NO,VIP Descending inhibitory Ascending excitatory Myenteric plexus Mechanical, 5HT,CGRP Relaxation of circular muscle Peristaltic contractions Role of paracrine neurotransmitters serotonin   receptor density   function of the serotonin reuptake transporter   Impaired ascending contractions

17. Dyssynergic defecation Inability to coordinate the abdominal, rectoanal , and pelvic floor muscles during defecation Symptoms often begin in childhood. Functional constipation Abnormal balloon expulsion test Impaired Rectal evacuation Abnormal ARM/Anal surface EMG 2 of following   Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. ROME IV STC DD Am J Gastroenterol. 2008;103(3):692-698.

18. spasm or inability to relax the external anal sphincter is NOT the sole mechanism. Incoordination or dyssynergia of the muscles, impaired rectal sensation are the primary causes. Three phenotypes have been described Sphincter pressure   Inadequate propulsive force Mixed phenotype J Neurogastroenterol Motil , Vol. 22 No. 3 July, 2016

19. Approach to a patient of constipation History Onset – whether it began in childhood Urge , frequency, need for straining, stool consistency, stool size, history of ignoring a call to stool precipitating events, use of any maneuver to assist the defecation. Dietery history- Fiber and fluid intake, number of meals, Breakfast habits Significant past history: Obstetric and Surgical procedures. Weight loss Rectal bleeding Recent change in the caliber of stool Abdominal pain Family history of colon cancer Be alert to manifestations of depression, such as insomnia, lack of energy, loss of interest in life, loss of confidence, and a sense of hopelessness. In one study of dyssynergic defecation,22% had a history of sexual abuse, 32% had physical abuse

20. Functional Organic Dyssynergic defecation Long standing symptoms Recent onset Heaviness in perineum No constitutional symptoms Loss of appetite Excess straining No bleeding/mass Loss of weight Feeling of obstruction No symptoms of obstruction Bleeding/mass Digital evacuation/support of perineum Family h/o colonic malignancy Can History differentiate between types of constipation?

21. Examination Complete General Physical examination along with neurologic assessment to screen for organic cause Abdominal examination, for distention, hard feces, presence of mass per abdomen. One thing that is very important and is very commonly not performed!??

22. sensitivity and specificity of DRE were75% sensitive and 87% specific for identifying dyssynergia. PPV was 97%. paradoxical contraction of the external anal sphincter and puborectalis muscles with fingertip being displaced anteriorly during attempted defecation, suggesting dyssynergic defecation * The American Journal of Gastroenterology

23. Investigations Young patients without alarm features can be treated empirically after thorough history taking and DRE. Patients with alarm features- mandate work up. Tests for systemic diseases - ESR, CBC, Biochemistry profile, FBS/PPBS/HBA1C Thyroid function tests To exclude systemic/structural disease To detect underlying cause if patient is unresponsive to simple treatment

24. Tests for structural diseases Plain X ray Abdomen to complement clinical history and physical examination Identifies excessive amount of stool in the colon Not recommended if no alarm features Barium enema To identify redundant sigmoid colon, megacolon, megarectum, stenosis, extrinsic compression intraluminal masses. Not recommended if no alarm features C C

25. Endoscopic procedures In younger patients, a flexible sigmoidoscopy may be sufficient. *ACG Taskforce recommendation

26. Tests for functional constipation Colonic Transit studies-- The American and European Neurogastroenterology and Motility Societies recommend 3 methods for assessing colonic transit time. radiopaque markers wireless motility capsule scintigraphy 20% or more retention of markers X rays taken after 120 hours Single capsule swallowed on day 1 STC

27. If the markers are retained exclusively in the sigmoid colon and rectum, the patient may have a defecatory disorder. Ghoshal's protocol 20 radio-opaque markers filled in capsules administered at 0, 12, and 24 h, and then abdominal radiographs obtained at 36 and 60 h is found useful. Retention of ≥ 30 radio-opaque markers at 36 h (sensitivity 90%, specificity 82%) and ≥ 14 markers at 60 h (sensitivity 95%, specificity 100%) is quite accurate to detect slow colon transit.

28. The wireless motility capsule is ingested following a standardized meal and 50 mL of water Patients wear a data receiver on their waists for 5 days, or until the capsule is passed. After the passage of capsule,the data is analysed to assess the transit time.   pH     Temp   Gastric Transit Small bowel Transit Colonic Transit J Neurogastroenterol Motil , 2014 Apr; 20(2): 265–270 Wireless motility capsule 2-5 hr 2-6 hr 10-59 hr

29. Scintigraphy Scintigraphy transit tests involve the ingestion of radioactive isotopes. There are 2 methods for the delivery of markers in clinical uses:  111 In-DTPA labeled water consumed in a standard solid-liquid meal, 111 In  activated charcoal slurry contained in a capsule. Anterior and posterior images of the colon are obtained using a gamma camera at specified times over 2 to 3 days following ingestion of the meal. Results are expressed as geometric center(GC). It is a Single figure that indicates the region where the median of the radioactivity lies. A GC of 1 would indicate that activity is mostly in region 1 (cecum and ascending colon), and a GC of 5 would indicate that most of the activity is in region 5 ( feces ). Normal values GC : 1.6–3.8 at 24 h and 3.0– 4.8 at 48 h. Slow colon transit is defined as a GC less than these reference values at 24 and 48 h. A low GC is considered slow transit, high GC center is considered accelerated transit. * THE JOURNAL OF NUCLEAR MEDICINE • vol. 54 • no. 11 • november 2013

30. *Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies, Rao et al 2010

31. Anorectal manometry

32. TYPE 3 TYPE 2 TYPE 1 TYPE 4 The patient can generate an adequate pushing force, (rise in intra abdominal pressure) along with a paradoxical increase in anal sphincter pressure .

33. TYPE 3 TYPE 2 TYPE 1 TYPE 4 Patient is unable to generate an adequate pushing force (no increase in intrarectal pressure) but can exhibit a paradoxical anal contraction.

34. TYPE 3 TYPE 2 TYPE 1 TYPE 4 The patient can generate an adequate pushing force but, either has absent or incomplete (<20%) sphincter relaxation ( i.E. No decrease in anal sphincter pressure) .

35. TYPE 3 TYPE 2 TYPE 1 TYPE 4 The patient is unable to generate an adequate pushing force and demonstrates an absent or incomplete anal sphincter relaxation

36. Balloon expulsion test a 4 cm long balloon filled with 50 mL of warm water is placed in the rectum. After placement, the patient is given privacy and asked to expel the balloon. A stop watch is provided to assess the time required for expulsion Useful as Screening test for Dyssynergic defecation. Sensitivity- 50% Specificity- 80-90%

37. Defecography Barium defecography- 150 mL barium paste into the patient’s rectum--having the subject squeeze, cough, and expel the barium. radiation exposure embarrassment limited availability interobserver bias inconsistent methodology

38. Indian J Radiol Imaging.  2013 Jan-Mar; 23(1): 92–96.

39. MR defecography No preparation needed. Rectal instillation of Ultrasound jelly. Wears adult diaper Patient in supine position Dynamic T2 Images are taken. 4 Phases. Clear instructions before sending patient on to MRI machine

40. Multiple test positivity including balloon expulsion test, anorectal manometry, and defecography has better accuracy than a single test for diagnosis of FED.

41. History, Physical exam Baseline evaluation Inadequate response To Therapeutic trial Anorectal Manometry Balloon Expulsion Test Normal Abnormal Inconclusive Colonic Transit Defecography Defecatory Disorder Algorithm for chronic constipation AGA.,GASTROENTEROLOGY Vol. 144, No. 1,PAGE 214

42. Colonic Transit Defecatory Disorder Defecography Normal Slow Abnormal Normal Slow Transit Constipation Normal Transit constipation Algorithm for chronic constipation AGA.,GASTROENTEROLOGY Vol. 144, No. 1,PAGE 214

43. Use of technology Mobile app – constipation diary

44. Education Address patient concerns Modifiable factors Diet, exercise Fibre supplemation Osmotic laxatives Prokinetics Surgery lwc liu . chronic constipation: current treatment options. can J gastroenterol 2011;25( suppl B):22B-28B .

45. Treatment “Initial treatment of CC should include lifestyle modification and osmotic laxatives” Timed toilet training Dietery fibers Position of defecation Physical activity Water intake Squatting 1.5-2L Attempt for 5 min,30-60 min after meal, twice a day

46. fibres Dietery fibres Agent Dose remarks Psyllium 4-6g/day Natural,Can cause IgE mediated reaction Methyl cellulose 4-6g/day synthetic Polycarbophil 4-6g/day synthetic Fiber supplement should be avoided if the patient is already on high fiber diet and/or abdominal bloating is a prominent symptom Slow Transit Constipation, Dyssynergic defecation- Recommended dosage – 25-30g/day of soluble fibres – start at 12g/day, slowly increase. ( Oats,nuts,barley,beans,lentils,fruits ). The benefits of added fiber are not evident for days to weeks. Generous fluid intake along with fiber supplementation. If patients fail to respond to a dietary fiber trial, slow transit constipation and/or a defecatory disorder could be suspected. If results of therapy are inadequate, commercially packaged fiber supplements should be tried.

47. Osmotic laxatives Lactulose 15-30ml OD/BD Cramps,flatulance PEG 17-34g OD/BD Incontinence Milk of Magnesia 15-30ml OD/BD hypermagnesemia Stimulant laxatives Bisacodyl 5-10 mg H.S. Incontinence,cramps Sod Picosulfate 5-15 mg H.S Senna(anthraquinone) 1-2 7.5-mg Psudomelanosis coli Stool Softners Docusate sodium 100mg bd Enemas Phosphate enema Mineral oil enema Soapsuds enema Rectal mucosa damage , hyperphosphatemia ,electrolyte abnormalities Chloride channel activator Lubipristone 8-24 g/day Nausea,headache,diarrhea Guanyl cyclase C agonist Linaclotide 72-145 g/day diarrhea Plecanatide 3mg OD 5HT4 agonist Tegaserod Prucalopride 2-6mg BD 2mg OD Cardiovascular Headaches,nausea Chloride channel activator Lubipristone Nausea,headache,diarrhea Guanyl cyclase C agonist Linaclotide diarrhea Plecanatide 3mg OD 5HT4 agonist Tegaserod Prucalopride 2-6mg BD 2mg OD Cardiovascular Headaches,nausea

48. Prucalopride, a full 5-HT 4 agonist -- benzofuran derivative -- accelerates colonic transit. no cardiovascular side effects have been observed to date with prucalopride. Possible future agents- Chenodeoxycholate Elobixibat Velusetrag Rifaximin* * Intestinal research Journal,2015 Oct Lubiprostone Linaclotide Not recommended in <18years age.

49. Yvonne Tse et al. Canadian Journal of Gastroenterology and Hepatology  /  2017  /  Article   

50. Biofeedback therapy Principle - any behavior - such as eating or a simple task such as muscle contraction,when reinforced, its likelihood of being repeated and perfected increases several fold. Correct dyssynergia/incoordination of muscles Enhance rectal sensory perception

51. Rectoanal coordination Subject is supine/seated on commode with manometry probe in situ. Asked to take a good diaphragmatic breath and to push as if to defecate. Encouraged to watch the monitor. Visual display of the pressure changes in the rectum and anal canal on the monitor. 10-15 maneuvers  are performed. Balloon distended in rectum with 60cc air Subject is asked to attempt defecation while watching the monitor.5-10 attempts Simulated defecation training – To teach the subject to expel an artificial stool in the laboratory using the correct technique. 50ml of water filled balloon in rectum/artificial stool--- ask the patient to expel -– he is taught how to relax the pelvic floor, co-ordinate breathing cycles with the attempt.

52. Enhance rectal perception  progressively inflate the rectal balloon until the subject experiences an urge to defecate. Deflate and repeat the same step 2-3 times. Then with each inflation, balloon volume is decreased by 10% subject is encouraged to observe the monitor and to note the pressure changes and pay close attention to the sensation in their rectum. If patient fails to percieve a particular volume, deflate and again inflate with same volume or to previously perceived volume. By the end of each session, newer thresholds for rectal perception are established. Number of sessions- customised. Every session-1hr, one session every 2 weeks.Avg 4-6 sessions. Reinforcement after 1.5 months,3,6,12 months

53. Surgical therapy subtotal colectomy with an ileorectal anastomosis. Defecatory Disorders The stapled transanal rectal resection (STARR) procedure has been used with some success, especially for rectocele and intussusception.

54. Take Home message Thorough history taking is a keystone in constipation. Bristol stool chart is a very useful tool. Red flag signs should mandate relevant work up. Rectal Examination is a must in patients of constipation. Initial treatment of choice is lifestyle and dietary modifications . High Fiber diet will not be helpful in PFD. Biofeedback therapy is the treatment of choice for pelvic floor dyssynergia.

55. Thank you