| ID | 24 |
|---|---|
| Name | CONSTIPATION |
| Cause | Causes:2 Gastrointestinal disorders: 1. Dietary factors- lack of fibres (highly refined food with low roughage); lack of or low fluid intake. 2. Motility disorders, due to- i. Irritable bowel syndrome, ii. Slow-transit constipation, iii. Chronic intestinal pseudo-obstruction, iv. Drugs- e.g aluminium antacids, anticholinergics, calcium and iron preparations, calcium channel blockers, ganglion blocking agents, diuretics, opioid narcotics, antidepressants, NSAIDs etc. 3. Structural abnormality of the colon, rectum and anus, such as- i. Anorectal- rectal prolapse, rectocoele, rectal intussusception, anorectal stricture, anal fissure, hemorrhoids. ii. Colonic- adenocarcinoma, colonic stricture, diverticular disease, Crohn’s disease. iii. Hirschsprung’s disease, iv. Idiopathic megarectum. 4. Defecation problems, such as- i. Obstructed defecation, Non-gastrointestinal disorders: 5. Drugs- as above. 6. Metabolic abnormalities- e.g hypokalemia, hypercalcemia, hyperglycemia, uremia etc. 7. Endocrine abnormalities- e.g, diabetes mellitus, hypothyroidism, hypopituitarism, pheochro-mocytoma etc. 8. Pregnancy. 9. Neurogenic abnormality- e.g innervation disorders of the bowel wall; spinal cord disorders (trauma, multiple sclerosis, tabes dorsalis); cerebral disorders (e.g strokes, parkinsonism, neoplasm). 10. Others- i. prolonged bed rest, ii. depression, iii. chronic use of enemas. |
| Signs Symptoms | Fewer than three bowel movements a week. Stools that are hard, dry, or lumpy. Stools that are difficult or painful to pass. A feeling that not all stool has passed. |
| Diagnosis | Diagnosis: 1. Careful examination & investigations should be done to findout the cause and to treat it. 2. Questions to be asked to a constipated patient: - is the constipation of recent origin ? if so, full g.i investigation is needed in those over 30 years. - is the diet well balanced & containing fibre ? - what drugs the patient receiving- particularly opioid, antacid, psychotropic agents ? - are the laxatives being used ? - are there any psychiatric, neurological or systemic disease ? 3. The onset, duration and characteristics play an important role in dignosis, e.g a neonatal onset suggests Hirschsprung’s disease; a recent onset in a middle aged patient develops the suspicion of colonic carcinoma; symptoms such as rectal bleeding, pain and weight loss may indicate excessive straining, irritable bowel syndrome, emotional distress etc.2 |
| Investigations | Blood tests. ... An X-ray. ... Examination of the rectum and lower, or sigmoid, colon (sigmoidoscopy). ... Examination of the rectum and entire colon (colonoscopy). ... Evaluation of anal sphincter muscle function (anorectal manometry). ... Evaluation of anal sphincter muscle speed (balloon expulsion test). |
| Management | Management: A. General advice: Dietary & lifestyle measures: 1. Regular evacuation habit should be established by attending to lavatories at fixed hours even when the urge is not present. Temporary use of mild laxatives may be helpful. 2. High-fivre diet of adequate volume, as plenty of fresh vegetables, fruits etc. 3. Adequate fluid intake- such as water, milk and other drinks should be taken adequately (6 to 8 glasses regularly); drink a glass of hot water 1/2 an hour before breakfast, which may act as mild laxative. 4. Mild exercise may be needed, which is essential in bed ridden, & old age patients to improve tone of abdominal muscles. 5. Avoidence of anxiety & worries. B. Specific treatment of chronic constipation: A good number of patients may improve with the above measures. It would be wise to avoid laxative if at all possible. Where above measures are ineffective laxative can be advised as below- 1. Bulk forming laxatives- bulk forming laxatives should be tried first in the treatment of chronic constipation e.g- Methyl cellulose (a natural fibvre derived from vegetable matter) 2-4 tablets (l-2gm) twice daily with a glass (atleast 300ml) of water or liquid. Or, Isphaghula husk (nonproprietory bran of tropical seeds)- 2 tsf (10ml) in water once or twice daily with meals. 2. Osmotic laxatives: Osmotic laxatives cause softening of stool, may be used alone or in combination with fiber suppliments in the treatment of chronic costipation. (They are commonly used in elderly nonambulatory or institutionalized patients to prevent constipation.) The osmotic laxatives are- - Lactulose 15-60ml (3-12 tsf) daily. Or, - Mag. hydroxide 15-30ml (3-6 tsf) daily. Or - Polyethylene glycol 17gm of powder in a glass of water or juice (approx. 240ml) daily, should be used for 2 weeks or less and may be discontinued after several satisfactory bowel movements. 3. Stimulant laxatives- these should be avoided, as they often cause abdominal cramp and their long-term use may cause an atonic non-functioning colon. So, they are preparable in short-term treatment of acute constipation. C. Specific treatment of acute constipation: 1. Stimulant laxative- Bisacodyl 5-15mg orally or 10mg as suppository. Or, Sennoside 2-4 tablets; older children (above 2 yrs) 1-2 tablets in the morning. 2. Fecal softeners- Castor oil 15-45ml orally. Or, Liquid paraffin 10 ml twice daly may be given. 3. Enemas- Saline enema, 120-140ml (nonirritating). Or, Tap water enema, 500-1000ml (irritating). Or, Soap water as enema simplex. Or, Oil retention enema, 120ml may be used. N.B. These agents should not be used in patients with possible large gut obstruction or faecal obstruction. |
| Introduction | Constipation may be defined as infrequent passage of hard stools, less than 3 motions per week or as difficult or painful defecation (due to unusually hard & dry stool). Patient may also complain of straining, incomplete evacuation and constipation. Sometimes it may be the end result of many gastrointestinal and other medical disorders. However, about 10-15% of adults are complaining constipation as a medical problem and women are more commonly sufferer. Etiologically constipation may be classified as- i. Primary constipation, that cannot be attributed to any structural abnormalities or systemic disease; ii. Secondary constipation, that may be caused by systemic disorders, medications, or obstructing colonic lesions |
| History | |
| Etiology | Not eating enough fibre, such as fruit, vegetables and cereals. a change in your routine or lifestyle, such as a change in your eating habits. having limited privacy when using the toilet. ignoring the urge to pass stools. immobility or lack of exercise |
| Clinical Features | |
| Preventions | Include plenty of high-fiber foods in your diet, including beans, vegetables, fruits, whole grain cereals and bran. Eat fewer foods with low amounts of fiber such as processed foods, and dairy and meat products. Drink plenty of fluids. Stay as active as possible and try to get regular exercise. |
| Treatment | Change what you eat and drink. Changing what you eat and drink may make your stools softer and easier to pass. ... Get regular physical activity. ... Try bowel training. ... Stop taking certain medicines or dietary supplements. ... Take over-the-counter medicines. ... Prescription medicines. ... Biofeedback therapy. ... Surgery. MEDICINES Laxative for a short time. \ Fiber supplements Osmotic agents (Milk of Magnesia) Stool softeners NIH external link (Docusate) Lubricants, such as mineral oil Stimulants ( Dulcolax) |
| Complications | The most common complications associated with constipation are discomfort and irritation that can lead to: Hemorrhoids Rectal bleeding Anal fissures (tears in skin around the anus) Sometimes, the difficulty passing a bowel movement can cause more serious complications, such as: Rectal prolapse (the large intestine detaches inside the body and pushes out of the rectum) Fecal impaction (hard, dry stool is stuck in the body and unable to be expelled naturally) |
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