criteria for constipation
ROME criteria– 2+ is positive
* straining a lot
* lumpy or hard stools
* incomplete evacuation
* anorectal blockage
* manual maneuvers
* under 3 defecations/wk
normal vs slow vs outlet delay severe idiopathic chronic constipation
- normal transit: under 68 hrs is normal or 2.8 day
- slow: no increase in motor function after meals or to stimulation or over 5 hinton markers
- outlet delay: normal transit through colon but slows at rectum
which type of constipation suggests anorectal dysfunction and 3 conditions where its seen
outlet delay
- mega-rectum/impaction
- hirschsprung dz– no smooth muscle relaxation
- dyssynergic defecation
failure of relaxation or inappropriate contraction causing narrowed anorectal angle & an increase in anal canal pressure; can be conscious or unconscious
dyssynergic defecation
abnormal dilation of colon that is not caused by mechanical obstruction
Megacolon
6 classes of meds that can cause constipation
- narcotics
- CCB
- antidepressants
- antipsychotics
- diuretics
- anticonvulsants
4 neuro disorders & 4 systemic/metabolic disorders associated with constipation
- neuro– MS, parkinsons, stroke, SCI
- systemic/metabolic– hypothyroid, DM, scleroderma, amyloidosis
5 red flag sx of constipation
- fever, wt loss
- blood in stool to the point that water is red
- anemia
- fam h.o
- waking up d/t pain or needing poop
diagnostic tool to evaluate for outlet delay? if thats normal whats next?
anal rectal manometry. if normal then colonic transit study w/ radiopaque markers
good for kids w/ severe constipation or adults w/ anorectal dysfunction
watch EMG activity and modify responses
biofeedback
- Used for solid immobile stool in rectum
- manual, mineral oil enema, gastrografin enema
disimpaction
when is surgical subtotal colectomy used (2)? when is it not used (1)?
severe sx
colonic inertia
NOT for pelvic floor dysfunction
- absorbs water and increases fecal mass which can lead to increased frequency and softer stools
- SE: gas, bloating
- C/I: bowel obstruction
bulk forming laxative
(methylcellulose, psyllium, polycarbophil)
- Lowers surface tension of stool so water can easily enter→ softens stools
- Often used in combo w/ bulk forming laxatives
- SE: contact dermatitis, diarrhea, cramping
what is this & what are the 3 CI?
docusate sodium
* if concerned for bowel obstruction
* acute abdomen
* appendicitis
Increase intestinal water secretions→ increased stool frequency
* caution– electrolyte distrubaces in renal & cardiac dysfunction
* caution in elderly
osmotic agents (polyethylene glycol, Mg citrate, glycerin)
Alters electrolyte transport through intestinal mucosa→ increases intestinal motility
ok for long term
C/I: acute abdomen, GI obstruction/perforation, toxic megacolon
SE: melanosis coli, cramping, low K+ (salt overload)
stimulants (senna, bisacodyl)
- Increases intestinal fluid secretion & motility
- Best for severe constipation when other things failed
- C/I: severe diarrhea, liver impairment, obstruction
lubiprostone
Stimulates intestinal fluid secretion & transit; Minimally absorbed peptide agonist of guanylate cyclase-C receptor
* CI: Under 18 y.o; Concern for obstruction
* SE: Diarrhea, Abdominal pain, bloating
linaclotide
symptoms of abdominal pain or discomfort and associated with disturbed defecation
NO structural abnormalities
IBS
ROME Criteria for IBS
Recurrent abdominal pain or discomfort 1day/wk in last 3 months w/ 2+ of:
1. related to defecation
2. associated w/ change in frequency
3. or form of stool
- Abdominal tenderness
- Abnormal stool passage – incomplete evacuation or rectal dissatisfaction
- Passage of mucous
- Abdominal bloating with distention
- Sensation of distention
- Sexual dysfunction
- Dysmenorrhea
- Increased urination
- Body aches and pains
extraintestinal sx of IBS
4 types of IBS
- IBS-D
- IBS-C
- IBS-M
- IBS-unclassified
3 tests for IBS
CBC
stool hemoccult
colonscopy if patient is over 50
