seminar topic- chronic constipation.pptx

Diagnosis and treatment of chronic constipation

1. Chronic constipation and its Management MODERATOR – Dr Vinod Kumar Presenter - Dr Ashutosh vardhan

2. Schematic Representation of cells in Colon

3. Spontaneous Activity SLOW WAVES Large amplitude slow myogenic oscillations Freq of 2-4/min Arises from the Pacemaker region located at S ubmucosal plexus of circular muscle Causes mixing of contents with slow propulsion MYENTERIC POTENTIAL OSCILLATIONS Small amplitude rapid oscillations Freq of 12-20/min Arises from the Myenteric plexus . Summate with slow waves and reach a Threshold potential to generate Action Potentials PROPAGATING SEQUENCES OR MASS MOVEMENTS Powerful patterned contractions Longer duration propagating for long distances Due to activation of Polarised Enteral Neural pathways . Also known as ‘Neurogenic Peristalsis’ COLONIC MIGRATIONG MOTOR COMPLEXES (CMMC) Cyclical spontaneous contractions Arising from Enteric Nervous system Occuring in the non distended colon Slowly migrate aborally to assist in content propulsion

4. Interstitial Cells of Cajal (ICC) ICC are non-neuronal cells derived from the common progenitor of smooth muscle cells They are the Pacemaker Cells that generate the Spontaneous Electrical Activity ICC’s are electrically coupled to smooth muscle cells via Gap junctions Jing Wui Yeoh. Cellular and Moleculer Bioengineering. 2017

5. Enteric Nervous System

6. PARASYMPATHETIC INNERVATION SYMPATHETIC INNERVATION

7. Motor Neurons Excitatory Motor Neurons Release Ach Subs. P Neurokinin A Typically project either directly to smooth muscle or orad Branch extensively, form transmitter release sites Closely a/w ICC-IM and Fibroblast like cells. Inhibitory Motor Neurons Release NO, ATP, VIP, PACAP etc. Slightly larger than excitatory neurons but are fewer in number. They have shorter dendrites and single axon. They project aborally . Tonically active and modulate the ongoing contractile activity. Particularly important in relaxing sphincteric muscles in IC junctn and Internal anal sphincter. Interneurons Involved in propagation of migratory contractions Some are involved in spreading descending inhibition. Some are stretch sensitive functioning as Primary Affarent Neurons

8. Law of the Intestine When a region of colon is stimulated, both types of motor neurons are activated which causes contraction of the muscle orad to the bolus and relaxation aborally resulting in a Peristaltic Propulsion which tend to propel the contents aborally . This Ascending excitatory reflex and Descending inhibitory reflex is known ‘ The Law Of Intestine ’ or ‘ Myenteric Reflex ’. Walter C. Alvarez. American Journal of Physiology. July 1924

9. Colonic Motor Patterns A) Non-Propagating Motor Patterns Makes up majority of colonic motor activity Predominant frequency of 2-4/min Relatively low amplitude contractions Serves ‘ Segmenting or Mixing functions ’ Patton V. Br J Surg 2013

10. B) Propagating Motor Patterns Powerful Lumen occlusive contractions when excitatory enteric neurons are strongly activated Commonly known as High Amplitude Propagating Contractions [HAPCs] Low amplitude propagating contractions Dinning PG. Neurogastroenterol Motil 2013;25:e640-e649 Antegrade (Aboral) Retrograde (oral) [Predominant colonic activity in descending and sigmoid colon]

11. Regional Variation of Propagating Sequences Proximal Colon – HAPC’s originate predominantly in proximal colon and propagate upto or beyond the splenic flexure. It moves contents towards the distal colon Distal Colon – Short extent Retrograde Propagating Patterns are the predominant colonic activity in the descending colon. Causes mixing of contents and helps in absorption of water and electrolytes

12. Physiologic Modulators of Colonic Motility Post Meal : Increased after 1-2 hour (Gastro-colic Response) Stable Sleep : Virtually ceases except antipropulsive RMC’s which increase Light Sleep : Increase in both Propagating and Non-propagating pressure waves Forced and Spont . early morning Awakening : Immediate increase in both waves Brierly SM. Gastroenterology 2009 .

13. Approach to an adult patient with Constipation

14. Most common digestive complaint in the general population… 16% Worldwide prevalence 24.8% Self-reported constipation in India Females More common * Best Pract Res Clin Gastroenterol. 2011 Feb;25(1):3-18. #Gastroenterol Nurs . 2014 Nov-Dec;37(6):425-9.

15. Definition Physician’s definition Western population : Stool frequency lesser than 3/week Heaton KW et al. Gut. 1992 Indian Population : Stool frequency of less than 5/week. Gautam Ray et al. JCDR 2016 Patient’s definition: Straining and unsuccessful defecation Hard stools with excessive straining Inability to have bowel movements CIC is defined as the presence of these symptoms for at least 3 months Am J Gastroenterol 2014; 109:S2 – S26

16. Chronic Constipation… Patient Perception Symptoms-based (e.g. Straining, Hard stools, Incomplete evacuation ) Physician Perception Frequency-based (Bowel movement no more than every 3-4 days )

17. Classification Primary/ Functional/CIC 1)Normal transit constipation (Most common) 2) Defecatory dysfunction 3) Slow transit constipation Secondary Neurological Metabolic Mechanical Drugs

18. RISK FACTORS Female sex (but India due to less reporting male patient more prevalent) Advanced age(>33% after age 70) Low physical activity Low fiber intake Low socio-economic status Smoking and Alcohol Dehydration

19. BRISTOL STOOL CHART NOTE-In an Asian context, type III stool is also considered constipation Gwee KA J Neurogastroenterol Motil . 2013

20. History Constipation symptoms ( Duration, frequency, consistency) Bristol stool type Symptoms suggestive of fecal evacuation disorder Prolonged (>30 min) and excessive straining Incomplete evacuation, Sensation of anorectal obstruction, Manual evacuation, need of perineal and vaginal pressure Obstetric history Toilet type (Indian vs. Western) Dietary history (veg. vs. non-veg.), dietary fibers , water intake Physical exercise Neuro-psychiatric diseases and drugs Degen LP et al. Gut 1996

21. Symptoms A bdominal Bloating H eadache H ard stool L ow back pain ± rectal fullness S training V omiting may occur

22. Medications Associated With Constipation

23. Alarming sign and symptoms Sudden change in bowel habits after age 50 years Blood in stool Weight loss Fever Abdominal mass Family history of colon cancer Anemia Should alert the clinician to undertake investigations including colonoscopy Gwee KA et al. J Neurogastroenterol Motil . 2013

24. Medical Conditions Associated With Constipation

25. Physical examination

26. Ghosal UC et al. Indian consensus on CC. Indian J Gastroenterology 2019 Digital Rectal Examination (DRE)

27. PR examination Normal perineal descent 2 to 4 cm Patients with defecatory disorders may have High anal resting tone (inc. resistance to insertion of examining finger) Impaired relaxation or paradoxical contraction of the sphincter complex Reduced perineal descent Tantiphlachiva K et al. Clin Gastroenterol Hepatol 2010

28. A PR examination by an experienced physician has reasonable sensitivity to detect puborectal dyssynergia Digital Rectal Examination Sensitivity 69.7% Specificity 81.5% PPV 82.1% NPV 68.75% Jain M. Indian J Gastroenterol. 2018

29. Assessment of severity Ghosal UC et al. Indian J Gastroenterol . 2018

30. If the history and physical examination show features of organic disease e.g. Diabetes, Hypothyroidism, Hypercalcemia etc Further diagnostic tests are required

31. Evaluation algorithm for chronic constipation  J. Coloproctol . (Rio J.) 38 (2) •  AprJun  2018 •  https://doi.org/10.1016/j.jcol.2018.02.003

32. Diagnosis of pelvic floor dysfunctions Anorectal Manometry Balloon Expulsion Test Defecography Wireless motility capsule COLONIC TRANSIT STUDY Scintigraphy Radio-Opaque Marker study

33. At 0,12 &24hrs, 4 capsules at a time with 5 markers each are given X-ray abdomen taken at 36hrs and 60 hrs <10hrs= fast transit >72hrs= slow transit and >20%or>5 markers r emaining after 3-5 days fast transit Slow transit RADIO-OPQAUE MARKER STUDY (MODIFIED GHOSHAL PROTOCOL) Normal Transit 18-36 hrs STC- Stagnation at proximal colon Outlet delay- Stagnation at rectum

34. Hinton technique Capsule containing 24 radiopaque markers is swallowed AXR 6 days Normal: < 5 markers in the colon Alternative Capsule containing 24 radiopaque markers ingested on days 1, 2 and 3 AXR on day 4 and 7 Normal : ≤ 68 markers in colon Slow transit: ≥ 68 markers Hinton JM et al. Gut 1969 Metcalf AM et al. Gastroenterology 1987 DISADVANTAGE- Can not measure regional transit time Colonic transit study

35. WIRELESS MOTILITY CAPSULE

36. COLON TRANSIT SCINTIGRAPHY Serial abdominal images using gamma camera at specified times after ingestion of labelled meal (In111-DTPA-labelled water with standard 99mTc Egg sandwich or 111In-labelled activated charcoal particles contained in capsule) Images of colon are obtained at specified times over 2-3 days after meal ingestion Using scintigraphy: Mean colonic transit time expressed as Geometric centre (weighted average of radioactivity distribution within colon and stool)= 2.7 at 24 hrs 24 hrs colonic transit time < 1.7 = Slow Transit

37. Scintigraphy

38. Balloon Expulsion Test Lee BE et al. J Neurogastroenterol Motil 2014 Balloon expulsion test is a simple, office-based screening test for defecatory disorders. For defecatory disorders Sensitivity: 87 Specificity 89%

39. Anorectal manometry

40. RAO Classification of dyssynergia

41. Defecation index Maximum rectal pressure divided by the minimum anal sphincter pressure Defecation index(DI) of at least 1.5 is needed to expel the feces DI ≤1.4 indicates FED Ghoshal UC et al. Indian J Gastroenterol . 2016

42. Defecography Types Barium defecography Magnetic resonance defecography Particularly useful when Results of anorectal testing are inconsistent with the clinical impression and To identify anatomic abnormalities Bharucha AE. J Clin Gastroenterol 2006

43. Detects both Most relevant finding in Defecatory Disorders Structural Abnormalities like Rectocele, Rectal Intussusception Functional Abnormalities like Puborectal Dyssynergia Abnormalities of Anorectal angle and/or Perineal Descent Excessive Widening Flaccid Perineum Or Descending Perineum Syndrome Inadeqaute Widening Spastic Disorder

44. MR defecography Avoids radiation exposure Better for visualizing the bony landmarks (necessary for measuring pelvic floor motion) Measurements are reproducible among observers Reiner CS Br J Radiol 2011

45. Normal MR defecography Normal position of the anorectal junction at rest (arrow) Descent of the anorectal junction (rectum and anal canal in a straight line)

46. Spastic pelvic floor syndrome Descent of anorectal junction and bladder with anterior rectocele Persistent indentation of the puborectalis sling on the posterior rectal wall with an acute anorectal angle

47. Algorithm for diagnosis and treatment of chronic constipation Ghosal UC et al. Indian consensus on CC. Indian J Gastroenterology 2019

48. Algorithm for diagnosis and treatment of Refractory chronic constipation Ghosal UC et al. Indian consensus on CC. Indian J Gastroenterology 2019

49. Complications of constipation

50. TREATMENT NON-SURGICAL SURGICAL COLECTOMY

51. Patient Education Life-Style causes of constipation: Diet: Should drink at least 1.5- 2 litre water daily B) Patients should be advised to try to defecate after meals, thereby taking advantage of normal postprandial increases in colonic motility. This is particularly important in the morning when colonic motor activity is highest Ghoshal UC, Verma A, Misra A. Frequency, spectrum, and factors associated with fecal evacuation disorders among patients with chronic constipation referred to a tertiary care center in northern India. Indian J Gastroenterol. 2016;35:83–90.

52. Patient Education Inadequate dietary fibers Diets include a good quantity of soluble fibers are less likely to suffer from constipation E.g. oat bran,barley , nuts, seeds, lentils, peas, some fruits and vegetables Fiber retains water, softening stool & ease evacuation N ormal daily fiber intake 25-30 g NOTE- Insoluble fibre are less tolerable and may aggravate the symptoms

53. Patient Counseling Inadequate exercise Physical exercise should be encouraged for the patient with inactive life style Loss of defecatory reflex If you ignore the urge to have a bowel movement The urge can gradually go away The longer can you delay it, the drier and harder stool will become

54. Patient Counseling Explain what is normal- Bristol stool form scale Don’t deny the urge to pass a bowel movement Avoid excessive straining Don’t worry if you don’t go every day Explain the correct toileting position

55. Correct position for opening bowels Squatting is best position When sitting on a toilet: Feet supported, so knees higher than hips Lean forward Legs apart Elbows on knees Bulge out abdomen and widen waist Do not hold breath Sakakibara R, Tsunoyama K, Hosoi H, et al. Influence of body position on defecation in humans. Low Urin Tract Symptoms. 2010;2:16–21

56. Types of Laxatives Bulk-forming laxatives Psyllium , Polycarbophil, Wheat dextrin Surfactants (Stool softeners) Docusate sodium, Docusate calcium Osmotic agents Polyethylene glycol , Lactulose, Sorbitol, magnesium salts Stimulant laxatives Bisacodyl , Senna , sodium picosulphate Secretagogue Lubiprostone , Linaclotide, plecanatide 5-HT4 agonist prucalopride

57. Bulk-forming laxatives They are natural or synthetic polysaccharides or cellulose derivatives that primarily exert their laxative effect by absorbing water and increasing fecal mass These laxatives are effective in increasing the frequency and softening the consistency of stool with a minimum of adverse effects They may be used alone or in combination with an increase in dietary fiber Avoid bulk forming laxative if there is documented slow transit constipation Side effect -abdominal distension, flatulence and bloating Ineffective in severe constipation, STC and defecatory disorder

58. Surfactants (Stool softeners) Stool softeners such as  docusate  sodium are intended to lower the surface tension of stool, thereby allowing water to more easily enter the stool. Although these agents have few side effects, they are less effective than other laxatives A systematic review concluded that stool softeners may be inferior to  psyllium  for improvement in stool frequency 

59. Osmotic agents  Poorly absorbed or nonabsorbable sugars, and saline laxatives cause intestinal water secretion and thereby increase stool frequency

60. Stimulant laxatives Stimulant laxatives such as  bisacodyl ,  senna  and sodium picosulfate primarily exert their effects via alteration of electrolyte transport by the intestinal mucosa They also increase intestinal motor activity Continuous daily ingestion of these agents may be associated with hypokalemia, protein-losing enteropathy, and salt overload. Thus, these drugs should be used with caution if taken chronically

61. Sectretagogues

62. ENTEROKINETICS

63. Indian J Gastroenterol (May–June 2017) 36(3):163–173

64. Treatment algorithm for defecating disorders Gastroenterological Association Medical Position Statement on Constipation. Gastroenterology 2013; 144:211

65. Treatment algorithm for normal or slow transit constipation Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association Medical Position Statement on Constipation. Gastroenterology 2013; 144:211

66. SAFETY OF LONG TERM STIMULANT LAXATIVE

67. Is chronic use of stimulant laxatives harmful to the colon? Wald A. J Clin Gastroenterol . 2003 May-Jun;36(5):386-9.

68. The Bottom Line Stimulant laxatives appear to be a safe short-term treatment for constipation The ACG recommends sodium picosulfate and bisacodyl only. Other types lack of sufficient research If you are uncomfortable with the idea of using a stimulant laxative due to the safety considerations, consider using a stool softener as an alternative

69. Surgical treatment Severe refractory slow-transit constipation Colectomy  — Subtotal colectomy with ileorectal anastomosis can dramatically ameliorate incapacitating constipation in carefully selected patients C riteria The patient has chronic, severe, and disabling symptoms from constipation that are unresponsive to medical therapy The patient has slow colonic transit of the inertia pattern The patient does  not  have intestinal pseudobstruction , as demonstrated by radiologic or manometric studies The patient does  not  have pelvic floor dysfunction based on anorectal manometry, balloon expulsion testing, or defecography The patient does  not  have abdominal pain as a prominent symptom

70. When to refer for specialist care Alarm symptoms Psychological treatment for irritable bowel syndrome Painful anorectal conditions anal fissure, haemorrhoids , abscess, or fistula Obstructed defecation Paradoxical puborectalis contraction Solitary rectal ulcer syndrome Rectocoele Rectal intussusception and rectal prolapse

71. Take Home Message… Constipation is common and for some it can be chronic, where symptoms can be severe and can significantly affect a patient’s quality of life Although many laxative treatments are available as OTC, patients may often need additional prescription treatment to achieve optimal symptom relief There are many options for prevention and treatment. The choice should be tailored to each individual person Management of chronic constipation includes patient education, behavior modification, dietary change, bulk­forming laxatives, and the use of non­bulk­forming laxatives or enemas Evidence for the effectiveness for many of the older laxatives is limited and there are relatively few guidelines on the management of this condition, treatment is often empirically-based

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