management of constipation Dr Mekky.pptx

management of constipation

1. Dr. Mohamed A. Mekky

2. Welcome message

3. Objectives Definition Terms Clinical Manifestations IBS-C Vs Ch.C . ..ROME IV Diagnostic Evaluation Alarms Treatment

4. What is constipation

5. Terms Dysentery: painful with blood and mucous Tenesmus : urge constantly needing to pass stools Are they inter- changable ?

6. Etiology & Types

7. 8 Pathophysiology Adapted from Camilleri and Choi. Aliment Pharmacol Ther. 1997;11:3. Enhanced Perception Sympathetic Vagal Nuclei 5-HT Altered Motility Visceral Hypersensitivity

8. Types of ChC

9. NTC: - stool passes through the colon at a normal rate , patients find it difficult to evacuate their bowels. IBS-C-like but without abd . pain or discomfort in IBS. Patients with NTC usually have a normal workup. STC : infrequent BMs…No straining to defecate. commonly in female patients. impaired phasic colonic motor activity. PFD : - E xcessive straining Use perineal pressure during defecation to allow the passage of stool, or they may report digital evacuation of stool.

10. Secondary constipation Structural local causes. Systemic diseases ( Endocrinologic Hypercalcemia , hyperparathyroidism, hypokalemia , hypothyroidism , pregnancy, and diabetes mellitus ) CT- disorders - Scleroderma , amyloidosis , and mixed connective-tissue disease Neurologic - Stroke, Hirschsprung disease , Parkinson disease , multiple sclerosis , diabetic neuropathy, spinal cord lesion, head injury, cerebrovascular accident, Chagas disease , Psychological ( eg , depression, anxiety, somatization . - Medications

11. Clinical Issues

12. Rome IV

13. Diagnostic workup

14. Good history/Ex. (Duration, frequency, Consistency, blood in the stool, weight loss, Diet , Exercise, Toilet habits, Laxative use (what), other drugs EX. PR Basic laboratory tests: CBC, Electrolytes, BS, BUN, Cr, TSH Structural imaging: US Sigmoidoscopy , Colonoscopy Barium enema, CT /MRI…. Others Defecography … Colonic Transit Study… Anorectal Manometry EMG

15. IBS EXAMINATIONS (Roma criteria) RECOMMENDED NOT RECOMMENDED 1. Full blood count (FBC) 1. Ultrasound 2. Erythrocyte sedimentation rate (ESR) or plasma viscosity 2. Rigid/flexible sigmoidoscopy 3. C-reactive protein (CRP) 3. Colonoscopy; Barium enema 4. Antibody testing for coeliac disease ( endomysial antibodies [EMA] or tissue transglutaminase [TTG]) 4. Hydrogen breath test (for lactose intolerance and bacterial overgrowth) 5. T hyroid function test (TSH) 6. Faecal ova and parasite test 7. Faecal occult blood test

16. Pitfalls Chronic dysentery Pediatric megacolon ( Hirschsprung ) Reflex painful perianal cause Intestinal Obstruction

17. Early satiety GI bleeding Painful defecation Weight loss Iron deficiency anemia Alarm Signs/Symptoms

18. Management

19. Treatment Treatment of underlying disease (Malignancies, Hypothyroidism,…) Alteration of lifestyle ( Diet, Exercise, Liquids) Laxatives

20. Pharmacologic Perspectives

21. Laxatives Drugs Cathartics / Stimulant/purgative OTC ..Laxative or remedies Prokinetics Prosecretory Bicasodyl Senna caster Oil Bulk-forming fibers Emollient / softeners lubricants Osmotic agents

22. OTC laxatives

23. Pro- secretory / prokinetics

24. Prucalopride Selective 5-HT4 receptor antagonist that stimulates colonic motility and decreases transit time [ stimulation of propulsive motility ] 1 mg & 2 mg oral tabs Precautions : Elder people (>65 years), younger than 18, renal impairment (eGFR <30), hepatic impairment ( Child-C). CI: Intestinal structural Diseases (e.g. obstruction, ileus , IBD, megacolon) .

25. Lubiprostone Stimulate ClC-2 chloride channels producing a chloride-rich fluid secretion. Soften the stool, increase motility, and promote spontaneous bowel movements .

26. Renzapride Renzapride , a mixed 5-HT4 receptor agonist and 5-HT3 receptor antagonist, treatment of chronic constipation. Linaclotide linaclotide stimulate intestinal chloride secretion through activation of guanylcyclase C Resulting in increased intestinal fluid and accelerated colonic transit. It should be reserved for patients who have suboptimal response or side effects with less expensive agents.

27. Biofeedback training Therapist who uses devices to help you learn to relax and tighten the muscles in your pelvis. During a biofeedback session, a special tube (catheter) to measure muscle tension is inserted into your rectum. The therapist guides you through exercises to alternately relax and tighten your pelvic muscles. A machine will gauge your muscle tension and use sounds or lights to help you understand when you've relaxed your muscles.

28. Special populations

29. Pregnant women Dietary, anatomic, fluid shifts, decreased exercise levels, and reduced mobility. First-line treatment is fiber supplementation, increased water intake, gentle exercise , and occasional laxative use as required. Attentive management is particularly important to minimize acute and subacute hemorrhoidal complications induced by the straining associated with vaginal delivery. Avoid Cathartics

30. Surgical Treatment Surgical care is generally restricted to the evaluation of underlying causes, such as large bowel obstruction, volvulus , or intra-abdominal infection or ischemia. Surgical care may also be indicated for the management of acute complications of constipation, such as hemorrhoidal thrombosis.

31. Summary points

32. ?QUESTIONS?

33. Further readings