Any underlying cause should be treated. In patients with normal and slow- transit constip ation the main focus should be directed to increasing the fibre content of the diet in conjunction with increasing fluid intake. Fibre intake should be increased by dietary means rather than by prescribing commercially available fibre sources in order to avoid substrate inducibility of colonic bacterial polysaccharidase enzyme systems. These patients should therefore be referred to a dietician.
The use of laxatives should be restricted to severe cases. Osmotic laxatives act by increasing colonic inflow of fluid and electrolytes; this acts not only to soften the stool but to stimulate colonic contractility. Magnesium sulphate 5-10 g dissolved in a glass of hot water should be taken before breakfast; it works in 2-4 hours. The polyethylene glycols (Macrogols) have the advantage over the synthetic disaccharide lactulose in that they are not fermented anaerobically in the colon to gas which can distend the colon to cause pain. The osmotic laxatives are preferred to the stimulatory laxatives, which act by stimulating colonic contractility and by causing intestinal secretion. The use of irritant suppositories can be helpful in some patients with defecatory disorders. The use of enemas should be restricted to the management of elderly, infirm and immobile patients and those with neurological disorders.
What are the available laxatives?
Bulk-forming laxatives
Dietary fibre
Wheat bran
Methylcellulose
Mucilaginous gums - sterculia
Mucilaginous seeds and seed coats, e.g. ispaghula husk
Stimulant laxatives (stimulate motility and intestinal secretion)
Phenolphthalein Bisacodyl
Anthraquinones - senna and dantron (only for the terminally ill)
Docusate sodium
Osmotic laxatives
Magnesium sulphate
Lactulose
Macrogols
Suppositories
Bisacodyl
Glycerol
Enemas
Arachis oil Docusate
Sodium Hypertonic
Phosphate Sodium citrate
Patients with defecatory disorders should be referred to a specialist centre as surgery may be indicated for, for example, anterior rectocele or internal anal mucosal intussusception. Anterior mucosal prolapse can be treated by injection, and those with pelvic floor dyssynergia (anismus) can benefit from biofeedback therapy.
Other Related Articles:
Constipation Causes and Diagnosis
Different Types of Constipation
Treatment Options Of Constipation
Showing posts with label Constipation. Show all posts
Showing posts with label Constipation. Show all posts
Thursday, April 2, 2009
Different types of constipation
Classification of constipation:
Constipation can be classified into three broad categories but there is much overlap:
normal transit through the colon (59%)
defecatory disorders (25%)
slowtransit (13%).
Defecatory disorders with slow transit can occur together (3%).
Normal-transit constipation:
In normal-transit constipation, stool traverses the colon at a normal rate, the stool frequency is normal and yet patients believe they are constipated. This is likely to be due to perceived difficulties of evacuation or the passage of hard stools. Patients may complain of abdominal pain or bloating. Normal-transit constipation can be distinguished from slow-transit constipation by undertaking marker studies of colonic transit. Capsules containing 21 radio-opaque shapes are swallowed on days 1, 2 and 3 and an abdominal X-ray obtained 120 hours after ingestion of the first capsule. Each capsule contains shapes of different configuration and the presence of more than 4 shapes from the first capsule, 6 from the second and 12 from the
third denotes moderate to severe slow transit.
Slow-transit constipation:
Slow-transit constipation occurs predominantly in young women who have infrequent bowel movements (usually less than once a week). The condition often starts at puberty and the symptoms are usually an infrequent urge to defecate, bloating, abdominal pain and discomfort, which can make the condition difficult to distinguish from constipation-predominant irritable bowel syndrome. Some patients with severe slow-transit constipation have delayed emptying of the proximal colon and others a failure of 'meal-stimulated' colonic motility. Histopathological abnormalities have been demonstrated in the colons of some patients with severe slow-transit constipation, and some patients have coexisting disorders of small intestinal motility, consistent with a diagnosis of chronic idiopathic intestinal pseudo-obstruction.
Defecatory disorders:
A 'paradoxical' contraction rather than the normal relaxation of the puborectalis and external anal sphincter and associated muscles during straining may prevent evacuation (pelvic floor dyssynergia, anismus). These are mainly due to dysfunction of the anal sphincter and pelvic floor. An anterior rectocele is a common problem where there is a weakness of the rectovaginal septum, resulting in protuberance of the anterior wall of the rectum with trapping of stool if the diameter is more than 3 cm. In some patients the mucosa of the anterior rectal wall
prolapses downwards during straining impeding the passage of stool, whilst in others there may be a higher mucosal intussusception. In some patients the rectum can become unduly sensitive to the presence of small volumes of stool, resulting in the urge to pass frequent amounts of small-volume stool and the sensation of incomplete evacuation.. The defecatory disorders can often be characterized by performing evacuation proctography and tests of anorectal physiology.
Other Related Articles:
Constipation Causes and Diagnosis
Different Types of Constipation
Treatment Options Of Constipation
Constipation can be classified into three broad categories but there is much overlap:
normal transit through the colon (59%)
defecatory disorders (25%)
slowtransit (13%).
Defecatory disorders with slow transit can occur together (3%).
Normal-transit constipation:
In normal-transit constipation, stool traverses the colon at a normal rate, the stool frequency is normal and yet patients believe they are constipated. This is likely to be due to perceived difficulties of evacuation or the passage of hard stools. Patients may complain of abdominal pain or bloating. Normal-transit constipation can be distinguished from slow-transit constipation by undertaking marker studies of colonic transit. Capsules containing 21 radio-opaque shapes are swallowed on days 1, 2 and 3 and an abdominal X-ray obtained 120 hours after ingestion of the first capsule. Each capsule contains shapes of different configuration and the presence of more than 4 shapes from the first capsule, 6 from the second and 12 from the
third denotes moderate to severe slow transit.
Slow-transit constipation:
Slow-transit constipation occurs predominantly in young women who have infrequent bowel movements (usually less than once a week). The condition often starts at puberty and the symptoms are usually an infrequent urge to defecate, bloating, abdominal pain and discomfort, which can make the condition difficult to distinguish from constipation-predominant irritable bowel syndrome. Some patients with severe slow-transit constipation have delayed emptying of the proximal colon and others a failure of 'meal-stimulated' colonic motility. Histopathological abnormalities have been demonstrated in the colons of some patients with severe slow-transit constipation, and some patients have coexisting disorders of small intestinal motility, consistent with a diagnosis of chronic idiopathic intestinal pseudo-obstruction.
Defecatory disorders:
A 'paradoxical' contraction rather than the normal relaxation of the puborectalis and external anal sphincter and associated muscles during straining may prevent evacuation (pelvic floor dyssynergia, anismus). These are mainly due to dysfunction of the anal sphincter and pelvic floor. An anterior rectocele is a common problem where there is a weakness of the rectovaginal septum, resulting in protuberance of the anterior wall of the rectum with trapping of stool if the diameter is more than 3 cm. In some patients the mucosa of the anterior rectal wall
prolapses downwards during straining impeding the passage of stool, whilst in others there may be a higher mucosal intussusception. In some patients the rectum can become unduly sensitive to the presence of small volumes of stool, resulting in the urge to pass frequent amounts of small-volume stool and the sensation of incomplete evacuation.. The defecatory disorders can often be characterized by performing evacuation proctography and tests of anorectal physiology.
Other Related Articles:
Constipation Causes and Diagnosis
Different Types of Constipation
Treatment Options Of Constipation
CONSTIPATION – Causes and Diagnosis
'Constipation' is a very common symptom, particularly in women and the elderly. It is often more of a perception than a real entity. A consensus definition used in research (The Rome II criteria) defines constipation as having two or more of the following for at least 12 weeks: infrequent passage of stools (less than 3 per week), straining more than 25% of time, passage of hard stools, incomplete evacuation and sensation of anorectal blockage. According to these definitions 'constipation' affects more than 1 in 5 of the population.
Many symptoms are attributed by patients to constipation and include headaches, malaise, nausea and a bad taste in the mouth. Other symptoms include abdominal bloating and/ or discomfort (undistinguishable from the irritable bowel syndrome) as well as local and perianal pain.
The causes of constipation are:
General
#Pregnancy
#Inadequate fibre intake
#Immobility
Metabolic/endocrine
#Diabetes mellitus
#Hypercalcaemia
#Hypothyroidism
#Porphyria
Functional
#Irritable bowel syndrome
#Idiopathic slow transit
Drugs
#Opiates
#Antimuscarinics
#Calcium-channel blockers, e.g. verapamil
#Antidepressants, e.g. tricyclics
#Iron
Neurological
#Spinal cord lesions
#Parkinson's disease
Psychological
#Depression Anorexia nervosa
#Repressed urge to defecate
#Gastrointestinal disease
#Intestinal obstruction and pseudo-obstruction Colonic
disease, e.g. carcinoma, diverticular disease Aganglionosis,
e.g. Hirschprung's disease, Chagas' disease Painful anal
conditions, e.g. anal fissure
Defecatory disorders
#Rectal prolapse, mucosal prolapse intussusception and
solitary rectal ulcer syndrome
#Large rectocele
#Pelvic floor dyssynergia/anismus
#Megarectum
Diagnosis of the cause of constipation
This relies on the history. When there has been a recent change in bowel habit in association with other symptoms (e.g. rectal bleeding) a barium enema or colonoscopy is indicated. A barium enema should always be preceded by a rectal examination and rigid sigmoidoscopy to exclude anorectal lesions that can otherwise be missed. By these means, gastrointestinal causes such as colorectal cancer and narrowed segments due to diverticular disease can be excluded.
Other Related Articles:
Constipation Causes and Diagnosis
Different Types of Constipation
Treatment Options Of Constipation
Many symptoms are attributed by patients to constipation and include headaches, malaise, nausea and a bad taste in the mouth. Other symptoms include abdominal bloating and/ or discomfort (undistinguishable from the irritable bowel syndrome) as well as local and perianal pain.
The causes of constipation are:
General
#Pregnancy
#Inadequate fibre intake
#Immobility
Metabolic/endocrine
#Diabetes mellitus
#Hypercalcaemia
#Hypothyroidism
#Porphyria
Functional
#Irritable bowel syndrome
#Idiopathic slow transit
Drugs
#Opiates
#Antimuscarinics
#Calcium-channel blockers, e.g. verapamil
#Antidepressants, e.g. tricyclics
#Iron
Neurological
#Spinal cord lesions
#Parkinson's disease
Psychological
#Depression Anorexia nervosa
#Repressed urge to defecate
#Gastrointestinal disease
#Intestinal obstruction and pseudo-obstruction Colonic
disease, e.g. carcinoma, diverticular disease Aganglionosis,
e.g. Hirschprung's disease, Chagas' disease Painful anal
conditions, e.g. anal fissure
Defecatory disorders
#Rectal prolapse, mucosal prolapse intussusception and
solitary rectal ulcer syndrome
#Large rectocele
#Pelvic floor dyssynergia/anismus
#Megarectum
Diagnosis of the cause of constipation
This relies on the history. When there has been a recent change in bowel habit in association with other symptoms (e.g. rectal bleeding) a barium enema or colonoscopy is indicated. A barium enema should always be preceded by a rectal examination and rigid sigmoidoscopy to exclude anorectal lesions that can otherwise be missed. By these means, gastrointestinal causes such as colorectal cancer and narrowed segments due to diverticular disease can be excluded.
Other Related Articles:
Constipation Causes and Diagnosis
Different Types of Constipation
Treatment Options Of Constipation
Monday, March 30, 2009
Irritable bowel syndrome (IBS) – Symptoms, Diagnosis and Treatment
IBS is the commonest Functional Gastro Intestinal Disorder. Female sufferers outnumber male counterpart. Reasons for this include the fact that anxiety and depression scores are higher in women than in men and the gut may be more sensitive to various stimuli in women. It is likely that men and women perceive internal events in the abdomen differently and that women may be more focused on these events. Food and eating are of more special psychological significance for women, as evidenced by a much higher incidence of eating disorders in women. The whole pelvic region carries a more specific significance for women, being associated not only with defecation, urination and sexuality but additionally with menstruation, pregnancy and childbirth.
IBS - a multisystem disorder
IBS patients suffer from a number of non-intestinal symptoms as stated below. The non-intestinal symptoms of IBS can be more intrusive than the classical features of IBS. IBS coexists with chronic fatigue syndrome, fibromyalgia and temporomandibular (Jaw joint) joint dysfunction
Gynaecological symptoms
Painful periods (dysmenorrhoea)
Pain following sexual intercourse (dyspareunia)
Premenstrual tension
Urinary symptoms
Frequency
Urgency
Passing urine at night (nocturia)
Incomplete emptying of bladder
Other symptoms
Back pain
Headaches
Bad breath, unpleasant taste in the mouth
Poor sleeping
Fatigue
Infectious diarrhoea precedes the onset of IBS symptoms in 7-30% of patients. Whether this is a factor for all patients or just a small subgroup remains controversial. Risk factors in these patients have been shown to include female gender, severity and duration of diarrhoea, pre-existing life events and high hypochondriacal anxiety and neurotic scores at the time of the initial illness.
Symptoms of anxiety and depression are more common in IBS patients and stress or life events often precedes the onset of chronic bowel symptoms.
Factors which are known to trigger IBS
Gastrointestinal infection
Antibiotic therapy
Pelvic surgery
Psychological stress
Psychological trauma
Sexual, physical, verbal abuse
Mood disturbances
Anxiety, depression
Eating disorders
Food intolerance
Diagnostic criteria (Rome II 1999)
These criteria state that, in the preceding 12 months there should be at least 12 weeks (consecutive) of abdominal discomfort or pain that has two of three of the following features:
Relieved with defecation; and/or onset associated with a change in frequency of stool; and/ or onset associated with a change in form(appearance) of stool.
The following symptoms cumulatively support the diagnosis of IBS:
#abnormal stool frequency ('abnormal' may be defined as > 3/day and <>
#abnormal stool form (lumpy/hard or loose/watery stool)
#abnormal stool passage (straining, urgency, or feeling of incomplete evacuation)
#passage of mucus
#bloating or feeling of abdominal distension.
These symptoms can be used to sub classify patients into diarrhoea- and constipation-predominant forms of IBS. In practice a third subgroup of alternating IBS exists, in which constipation and diarrhoea alternate. The three forms have equal frequency. Many patients with constipation have abdominal discomfort or pain with bloating or distension so there is considerable overlap with constipation-predominant IBS. The decision as to whether to investigate and if so what choice of investigations is required should be based on clinical judgement. Pointers to the need for thorough investigation are the presence of the above symptoms in association with rectal bleeding, nocturnal pain, fever and weight loss. Treatment Current strategies for treatment of IBS are based on the biopsychosocial conceptualization of IBS with targeting of central and end-organ therapies. End organ and central approaches to treatment should not be mutually exclusive and can be used in sequence and in combinations. Hydroxytryptamine (HT3)-receptor antagonists for diarrhea predominant IBS, HT4-receptor agonists for constipation predominant IBS as well as kappa opioid agonists for use in patients in whom visceral hyperalgesia plays a predominant role in the pathogenesis of their symptoms may become available.
These are the plan of management of IBS
Explore dietary triggers - Refer to dietician
High-fibre diet ± fibre supplements for constipation - Refer to dietician ± prescribe ispaghula husk
Anti-diarrhoeal drugs for bowel frequency – Loperamide, Codeine phosphate, Co-phenotrope
Smooth muscle relaxants for pain - Mebeverine hydrochloride, Dicycloverine hydrochloride, Peppermint oil
Central treatment consists of - Physiological explanation of symptoms, Psychotherapy, Hypnotherapy, Cognitive behavioural therapy and Antidepressant drug therapy
IBS - a multisystem disorder
IBS patients suffer from a number of non-intestinal symptoms as stated below. The non-intestinal symptoms of IBS can be more intrusive than the classical features of IBS. IBS coexists with chronic fatigue syndrome, fibromyalgia and temporomandibular (Jaw joint) joint dysfunction
Gynaecological symptoms
Painful periods (dysmenorrhoea)
Pain following sexual intercourse (dyspareunia)
Premenstrual tension
Urinary symptoms
Frequency
Urgency
Passing urine at night (nocturia)
Incomplete emptying of bladder
Other symptoms
Back pain
Headaches
Bad breath, unpleasant taste in the mouth
Poor sleeping
Fatigue
Infectious diarrhoea precedes the onset of IBS symptoms in 7-30% of patients. Whether this is a factor for all patients or just a small subgroup remains controversial. Risk factors in these patients have been shown to include female gender, severity and duration of diarrhoea, pre-existing life events and high hypochondriacal anxiety and neurotic scores at the time of the initial illness.
Symptoms of anxiety and depression are more common in IBS patients and stress or life events often precedes the onset of chronic bowel symptoms.
Factors which are known to trigger IBS
Gastrointestinal infection
Antibiotic therapy
Pelvic surgery
Psychological stress
Psychological trauma
Sexual, physical, verbal abuse
Mood disturbances
Anxiety, depression
Eating disorders
Food intolerance
Diagnostic criteria (Rome II 1999)
These criteria state that, in the preceding 12 months there should be at least 12 weeks (consecutive) of abdominal discomfort or pain that has two of three of the following features:
Relieved with defecation; and/or onset associated with a change in frequency of stool; and/ or onset associated with a change in form(appearance) of stool.
The following symptoms cumulatively support the diagnosis of IBS:
#abnormal stool frequency ('abnormal' may be defined as > 3/day and <>
#abnormal stool form (lumpy/hard or loose/watery stool)
#abnormal stool passage (straining, urgency, or feeling of incomplete evacuation)
#passage of mucus
#bloating or feeling of abdominal distension.
These symptoms can be used to sub classify patients into diarrhoea- and constipation-predominant forms of IBS. In practice a third subgroup of alternating IBS exists, in which constipation and diarrhoea alternate. The three forms have equal frequency. Many patients with constipation have abdominal discomfort or pain with bloating or distension so there is considerable overlap with constipation-predominant IBS. The decision as to whether to investigate and if so what choice of investigations is required should be based on clinical judgement. Pointers to the need for thorough investigation are the presence of the above symptoms in association with rectal bleeding, nocturnal pain, fever and weight loss. Treatment Current strategies for treatment of IBS are based on the biopsychosocial conceptualization of IBS with targeting of central and end-organ therapies. End organ and central approaches to treatment should not be mutually exclusive and can be used in sequence and in combinations. Hydroxytryptamine (HT3)-receptor antagonists for diarrhea predominant IBS, HT4-receptor agonists for constipation predominant IBS as well as kappa opioid agonists for use in patients in whom visceral hyperalgesia plays a predominant role in the pathogenesis of their symptoms may become available.
These are the plan of management of IBS
Explore dietary triggers - Refer to dietician
High-fibre diet ± fibre supplements for constipation - Refer to dietician ± prescribe ispaghula husk
Anti-diarrhoeal drugs for bowel frequency – Loperamide, Codeine phosphate, Co-phenotrope
Smooth muscle relaxants for pain - Mebeverine hydrochloride, Dicycloverine hydrochloride, Peppermint oil
Central treatment consists of - Physiological explanation of symptoms, Psychotherapy, Hypnotherapy, Cognitive behavioural therapy and Antidepressant drug therapy
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