Chronic constipation.

M.K.KGOMO.

INTRODUCTION.
Definition. Epidemiology. Diagnostic approach. Non pharmacological Pharmacological management.

Definition.
Symptom based disorder. Characterized by: unsatisfactory defecation due to infrequent stools, difficult stool passage or both

Difficult stool passage.

Symptoms of straining. Difficulty expelling stool. Sense of incomplete evacuation. Prolonged time to stool. Hard or lumpy stool. Need for manual maneuvers to pass stool. Three months of the prior 12 months.

Rome 3 diagnostic criteria for functional constipation.

Must include two of the following: straining during 25% of defecations. lumpy or hard stools in 25%. sensation of incomplete evacuation 25% sensation of anorectal obstruction 25% manual maneuvers in 25% fewer than three defecations per week.

Rome criteria continue.

Loose stools are rarely present without laxatives. There are insufficient criteria for IBS. Criteria fulfilled for the last three months of six months before diagnosis.

Ref AJG 2012;107

Epidemiology.
20% of the population. Prevalence increases with age. More frequent in females. Impairment of QOL. High costs.

Classification.
Primary and Secondary.

Primary constipation.
Slow-transit constipation. Defecation disorders eg.dys-synergic defecation. IBS constipation.

Secondary constipation.
Drugs. Neuropathic and myopathic disorders. Idiopathic. Other: anorexia. hyperglycemia. thyroid disease.

Mechanism of constipation in elderly.

Reduced number of neurons in M plexus. Increased collagen deposition in left colon. Increased binding of endophins to intestinal receptors. Reduction of inhibition to circular muscles.

Evaluation.
History. Physical examination. Alarm symptoms. involuntary weight loss. hematochezia. FH of CRC or IBD. positive occult blood. iron deff anemia. acute onset. Colonoscopy or CT colonography.

Testing for constipation.

Colonic transit time or nuclear medicine. Anorectal manometry with balloon expulsion. MRI defecogram. Proctography.

Non pharmacologic.
Education first line. Diet. Exercise. Toilet training Note slow transit and pelvic floor dyssernegy. Anorectal Biofeedback. Probiotics.

Pharmacologic treatment.
Fiber or bulking agent. Stool softeners. Stimulant laxatives. Osmotic laxatives. Surgery only STC & defecatory constipaion.

Irritable bowel syndrome with constipation.

Recurrent abdominal pain or discomfort at least 3 days a month in the past 3 months associated with 2 or more of the following: Improvement with defecation. Associated change in frequency of stool. Associated change in form of stool. < 25% of bowel movements were loose stools. ROME CRITERIA 3

Epidemiology.
10-20% in western countries. No biomarkers. Primary care. Young patients. Females. IBD (Calprotectin) Post infectious G/E. Smoking. Lower socioeconomic groups.

Diagnosis.
Rome 3 criteria diagnoses 75%. It is not a diagnosis of exclusion. Exclude alarm symptoms and signs. Celiac disease.

Management.
Constipation. Antispasmodics. Non-absorbable antibiotics eg rifaximin. Probiotics. 5HT4 receptor agonist. C2 chloride channel activator. Eg lubiprostone. TCA.

MANAGEMENT.
Psychological therapies. cognitive therapy. dynamic psychotherapy. hypnotherapy.

Conclusion.
Constipation is mainly a functional disorder. IBS is not a diagnosis of exclusion. IBS is a disease of young females Chronic constipation is a disease of old females. Both should receive a trial of treatment. Surgery rarely indicated.

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