Functional constipation

HEGAZY SURGERY

1. Functional Constipation By M. Osama Shetta. Professor of Surgery Ain Shams University

2. 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

3. Definition(cont.) - These symptoms need to be chronic. - All other aetiological causes of constipation must be excluded specially the organic causes.

4. Aetiology of constipation I Dietary Endocrine / Metabolic Neurological Psychogenic Drugs & poisons General causes

5. Drugs: opiates anticholinergics. Iron therapy. antiacids

6. Aetiology of constipation II - Organic obstruction - Functional constipation

7. Organic Obstruction

8. Functional Constipation In terms of pathophysiology: - Slow gut transit(colonic inertia). - Rectal evacuatory dysfunction. - Combination of both.

9. Functional Constipation Slow transit Outlet obstruction Rectocele Rectal prolapse, intussusception Anismus Solitary rectal ulcer syndrome Descending perineum syndrome Slow transit + Outlet obstruction Constipating form of IBS

10. 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

11. Evaluation & Management Initial evaluation Initial management Secondary management Secondary evaluation Tertiary management

12. Aim of Initial Evaluation Exclude organic obstruction

13. 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

14. Initial Management with Apparent cause Treatment of the cause.

15. Initial Management No 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

16. Secondary Management By Stimulant laxatives:

17. Aim of Secondary Evaluation Document the presence and the type of functional constipation

18. Secondary Evaluation Extensive lab. Studies Colonic transit Pelvic floor tests (PFT) Manometry (press., sens., RAIR) EMG Defecography Balloon expulsion test Biopsy for ultrashort segment Hirschsprung Psychological consultation

19. 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

20. 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

21. Treatment Rectocele Surgical repair Biofeedback

22. Treatment Slow transit constipation Total colectomy Segmental colectomy Biofeedback

23. Treatment Complete rectal prolapse Rectopexy Resection Delorme

24. Treatment Internal intussusception Biofeedback Rectopexy Delorme Rectopexy + Resection Other extensive operations

25. Treatment Solitary rectal ulcer Biofeedback Excision Injection Rectopexy

26. Treatment Anismus Biofeedback Botulinum toxin

27. Treatment Descending perineum Biofeedback

28. Proper Management Starts With Proper Diagnosis

29. Surgical Aspects Of Constipation by Ahmed A. Abou-Zeid Professor of Surgery Ain Shams University