STUDY - Technical - New Dacian's Medicine
Constipation
Translation Draft
Constipation is a common accusation in clinical practice. Due to the wide register of normal intestinal manifestations, constipation is difficult to define exactly. Most people have at least 3 chairs per week. Therefore, constipation was defined as a frequency of defecation less than 3 times/week. However, the frequency of the stools itself is not a sufficient criterion, as many constipated patients describe a normal frequency of defecation, but subjective sensations of excessive defecate or effort, hard stools, lower abdominal fullness and an incomplete discharge sensation. Thus, a combination of subjective and objective criteria must be used to define constipation.
From the point of view of the cause, physiopathologically, constipation comes from colonic transit or altered anorectal function as a result of a primary disorder of motility, certain drugs or in association with an increased number of systemic diseases affecting the gastrointestinal tract. Constipation of any cause can be exacerbated by chronic diseases that lead to physical or mental injury and cause inactivity or physical immobility. Favouring factors are lack of fiber in the diet, generalized muscle weakness and probably stress and anxiety.
An obstructive lesion of the colon should be sought in patients presenting with a recent onset of constipation. In addition to a colon neoplasm, other causes of colonic obstruction include strictures due to colon ischemia, diverticular disease or inflammatory bowel diseases, foreign bodies or strictures.
Anal sphincter spasm due to hemorrhoids or a painful fissure can also inhibit the desire to evacuate faeces. In the absence of obstructive damage to the colon, altered colic motility can mimic colon obstruction. Disruption of parasympathetic innervation of the colon as a result of disorders or lesions of the lombosacrate spine or sacral nerves may cause constipation with hypomobility, colonic dilation, low rectal tone and sensations and defective defecation.
In patients with multiple sclerosis, constipation may be associated with neurogenic dysfunction of other organs. Similarly, constipation may be associated with CNS lesions caused by parkinsonism or stroke. Parasitic infection in Chagas disease can cause constipation by damaging the ganglion cells of the myenteric plexus (in South America). Hirschsprung's disease or aganglionosis is characterized by the absence of myenteric neurons in a segment of the distal colon immediately proximal to the anal sphincter.
This causes a segment of the contracted intestine that causes obstruction and proximal dilation. In addition, an absent inhibitory rectosphincterian reflex causes the impossibility of relaxation of the internal anal sphincter after rectal distension. Most patients with Hirschsprung's disease are diagnosed from the age of 6 months, but in some cases the symptoms are mild enough for the diagnosis to be delayed to adulthood.
Medications that can cause constipation are those with anticholinergic properties, such as antidepressants and antipsychotics, codeine and other narcotic analgesics, antacids containing aluminum or calcium, sucralfate, iron compounds and calcium channel blockers. In patients with certain endocrinopathies such as hypothyroidism and diabetes mellitus, constipation is generally mild and responds to therapy. Rarely, a life-threatening megacolon occurs in patients with mixedema.
Constipation is common during pregnancy, probably as a result of altered levels of progesterone and estrogens that decrease intestinal transit. Vascular collagen diseases can be associated with constipation, which can be a particularly important feature of progressive systemic scleroderma, in which delayed intestinal transit is caused by atrophy of smooth colic muscles.
In the vast majority of patients with severe constipation, no clear cause can be identified. In the idiopathic constipation of childhood, both psychological and physiological factors are considered to play a role. Affected children often have slow colonic transit, localized to the distal colon and rectum, and it has been suggested that voluntary abstention behaviour or abnormal anorectal function would play a role in these disorders.
Young and middle-aged women may experience severe constipation characterized by low frequency defecation, excessive defecation effort and lack of response to fiber intake or mild laxatives. In 70% of such cases, slow colonic transit (colon inertia) can be demonstrated by the delayed passage of radioopaque markers through the proximal colon. In 30% of cases, colonic transit is normal and abnormalities of motor functions and anorectal sensitivity can be demonstrated.
The terms obstruction of discharge and anism were used to describe this form of constipation that appears to result from insufficient relaxation or inadequate contraction of the puborectal muscles and external anal sphincter. Since the relaxation of these muscles involves the cortical inhibition of the spinal reflex during defecation and can be modified by biofeedback, it is speculated that such rectosphincterian dysfunction is acquired or learned rather than an organic or neurogenic disease.
Chronic "snoring" at defecation can cause the perineal floor to be lowered and the nerve to stretch, thus leading to an incompetent anal sphincter and fecal incontinence. Rectal prolapse may affect defecation as a result of rectal invasion or chronic damage to the shameful nerve. Rectocele is an anterior rectal hernia that can interfere with defecation by filling with preferential faeces during defecation tests.
Chronic idiopathic intestinal pseudoocclusion is a rare disorder in which episodes of intestinal occlusion are not accompanied by signs of mechanical blocking. This disorder can be familial, as a result of neuropathy or myopathy affecting the intestine and in some cases the bladder. The idiopathic megacolon or megarect is characterized by a colon and dilated rectum, respectively, with constipation and difficulty with defecation attributed to neurogenic dysfunction.
In young and middle-aged adults, constipation is most commonly attributed to irritable bowel syndrome. Unlike other idiopathic constipation syndromes described above, irritable bowel syndrome is characteristically accompanied by abdominal pain, especially in the lower abdomen, as well as the evacuation of small and hard stools with incomplete discharge sensation and excessive exertion. Patients also experience flatulence, abdominal bloating, heartburn, nausea, dysphagia, back pain and genitourinary symptoms. Colonic transit is usually normal in these patients and the exact physiopathological basis for symptoms is uncertain.
Let's proceed to present a few elements about the approach of the patient with constipation! An accurate description of the symptoms and duration must first be obtained. A recent change in bowel habits always requires an assessment for an obstructive neoplasm. A description of the frequency and nature of the defecation must be obtained, including the presence of excessive exertion, hard scibale scibale or incomplete exhaust sensation.
The patient should be questioned about associated abdominal pain and bloating and upper gastrointestinal or genitourinary symptoms. It is very important to obtain a history of the use of laxatives and the duration of this use. A gentle but careful assessment should be undertaken for signs of anxiety, emotional distress or affective disorders and the use of medications that alter the emotional state.
The physical examination should be directed towards the detection of non-gastrointestinal diseases that may contribute to constipation. Particular attention should be paid to the neurological examination, including an assessment of vegetative functions. The abdomen should be examined for signs of surgical history, intestinal distension or stool retention. A careful perineal and anorectal examination should be performed to highlight deformities, ghesier muscle atrophy, rectal prolapse, stenosis, fissure, rectal tumor or fecal impact.
The patient should be asked to strain to highlight a rectal rectum or prolapse. The presence of an "anal blink" should be assessed by demonstrating reflex contraction of the anal canal after a needle sting on the perineum. The various complications of constipation or its treatment can also be detected and may be the reason why the patient seeks the attention of the doctor (at the treatment of hemorrhoids may occur as a complication ischemic colitis, for fissure may occur colonic volvus, for rectal prolapse may occur colonic perforation, for the stercoral ulcer may occur fecal incontinence, for colonic melanosis may occur urinary retention may occur , cardiac and cerebrovascular dysfunction manifested by syncope, arrhythmias, angina and others may occur for the purging colon.
Sigmoidoscopy or flexible colonoscopy may demonstrate colon melanosis as a brown-black disorder of the intestinal mucosa as a result of chronic use of anthrachinonic laxatives. The absence of haustrations at endoscopy or irrigation suggests a "purging colon" due to the abuse of laxatives. Irrigography can also highlight obstructive colic lesions, megacolon or megarect and, in Hirschsprung's disease, will show the characteristic denervated intestinal segment with proximal dilation of the colon.
In such cases, rectal biopsies can be obtained to demonstrate the absence of neurons. Investigations of colonic and anorectal functioning should be reserved for patients with severe idiopathic constipation refractory to simple therapeutic measures. In patients with rare defecation, colonic transit investigations may highlight colonic inertia. Radioopaque markers are ingested and their transit is monitored by serial abdominal X-rays until at least 80% have passed or a predetermined period of time has elapsed. The normal upper limit for most adults is about 70 hours.
In patients suspected of obstruction of evacuation, investigations of anorectal motility provide information about rectal sensations, viscoelasticity, relaxation of the internal anal sphincter and defecation of air-filled balloons of various sizes inserted into the rectum. While patients with constipation due to irritable bowel syndrome often have low rectal compliance and hardly tolerate rectal distension, those with megarect have a very high rectal compliance.
The absence of relaxation of the internal anal sphincter suggests Hirschsprung's disease. In some centers, anorectal manometry is supplemented with electromyographic investigations to record the function of the external anal sphincter, and defecography in which it is inserted into the thickened barium rectum approximateing the consistency of the stool and its discharge is monitored by fluoroscopy, while the patient sits on a toilet.
Treatment of constipation should be individualized, taking into account the duration and severity of constipation, potential contributing factors, the age of the patient and his expectations. Symptomatic therapy is quite empirical, to the extent that there are often few objective signs to support a particular strategy. Initial therapy is usually diet, with an emphasis on increasing the intake of fiber from the diet. Although there is little evidence that constipated people consume less fiber in their diet than unconstipated people, many constipated people respond to increases in fiber in the diet of 20-30g/ day, fiber supplementation can increase stool weight and the frequency of defecation and decrease gastrointestinal transit time.
Fibre supplementation is not appropriate in patients with obstructive gastrointestinal tract lesions or in those with megacolon or megarect. With the exception of volume purgatives, routine use of long-term laxatives should be discouraged due to the risk of side effects such as lipid pneumonia due to mineral oil or myenteric plex lesions causing "purging colon" due to antrachinonic stimulant laxatives such as senna.
Volume purgatives are made up of natural (psyllium) or synthetic polysaccharides, or cellulose derivatives that act in a fibre-like way. Ingestion of liquids should be increased when using these preparations. Emollient laxatives include mineral oil, which, administered orally or by enema, penetrates and softens the stool, and docused salts, which are anionic surfactants that lower the surface tension of the stool to allow the mixture of aqueous and thick substances and thus soften the stool.
Hyperosmolar agents include mixed electrolyte solutions containing polyethylene glycol and non-absorbable sugars such as lactulose and sorbitol that act as osmotic agents and are used in bowel cleansing before colonoscopy. Lactulose can sometimes be prescribed for long-term use. Saline laxatives contain cations and anions that exert an osmotic effect to increase intraluminal water content (in elderly patients, they may cause fluid retention).
Stimulant laxatives include beaver oil, antraquinones like senna and diphenylmethane, as phenolphtalein and bisacodil. Beaver oil is converted into ricinoleic acid, which stimulates intestinal secretion and increases intestinal motility. Antrachinones increase the accumulation of fluids and electrolytes in the distal ileum and colon. phenolphthalein and bisacodil stimulate colonic motor activity and inhibit the absorption of sodium and glucose.
Recently, it has been shown that cisaprid, a prokinetic agent, increases intestinal transit through the proximal colon, but its role in the treatment of constipation is uncertain. A role of excessive endogenous opioids in constipation related to motility disorders was assumed and the benefit of opioid receptor antagonists in the treatment of constipation was noted, but requires further studies. Biofeedback techniques have shown promising in the treatment of constipation resulting from inadequate contraction of the pelvic floor muscles and external anal sphincter.
Surgical treatment for severe chronic constipation is generally controversial, with the exception of Hirschsprung's disease in which surgical resection of the aganglionic segment is the elective treatment. In colonic inertia, subtotal cholectomy with ileorectal anastomosis may be indicated in carefully select edive patients where upper gastrointestinal motility is normal and anorectal motility disorders have been excluded. Surgery to reduce or resection a rectocele, invasion or prolapse should be carefully performed, as symptoms often do not improve.
Ready for today... On June 26th we will talk about weight gain and decrease which, from a medical point of view, has some "causes" that may include it in gastrointestinal disorders.
Constipation is a common accusation in clinical practice. Due to the wide register of normal intestinal manifestations, constipation is difficult to define exactly. Most people have at least 3 chairs per week. Therefore, constipation was defined as a frequency of defecation less than 3 times/week. However, the frequency of the stools itself is not a sufficient criterion, as many constipated patients describe a normal frequency of defecation, but subjective sensations of excessive defecate or effort, hard stools, lower abdominal fullness and an incomplete discharge sensation. Thus, a combination of subjective and objective criteria must be used to define constipation.
From the point of view of the cause, physiopathologically, constipation comes from colonic transit or altered anorectal function as a result of a primary disorder of motility, certain drugs or in association with an increased number of systemic diseases affecting the gastrointestinal tract. Constipation of any cause can be exacerbated by chronic diseases that lead to physical or mental injury and cause inactivity or physical immobility. Favouring factors are lack of fiber in the diet, generalized muscle weakness and probably stress and anxiety.
An obstructive lesion of the colon should be sought in patients presenting with a recent onset of constipation. In addition to a colon neoplasm, other causes of colonic obstruction include strictures due to colon ischemia, diverticular disease or inflammatory bowel diseases, foreign bodies or strictures.
Anal sphincter spasm due to hemorrhoids or a painful fissure can also inhibit the desire to evacuate faeces. In the absence of obstructive damage to the colon, altered colic motility can mimic colon obstruction. Disruption of parasympathetic innervation of the colon as a result of disorders or lesions of the lombosacrate spine or sacral nerves may cause constipation with hypomobility, colonic dilation, low rectal tone and sensations and defective defecation.
In patients with multiple sclerosis, constipation may be associated with neurogenic dysfunction of other organs. Similarly, constipation may be associated with CNS lesions caused by parkinsonism or stroke. Parasitic infection in Chagas disease can cause constipation by damaging the ganglion cells of the myenteric plexus (in South America). Hirschsprung's disease or aganglionosis is characterized by the absence of myenteric neurons in a segment of the distal colon immediately proximal to the anal sphincter.
This causes a segment of the contracted intestine that causes obstruction and proximal dilation. In addition, an absent inhibitory rectosphincterian reflex causes the impossibility of relaxation of the internal anal sphincter after rectal distension. Most patients with Hirschsprung's disease are diagnosed from the age of 6 months, but in some cases the symptoms are mild enough for the diagnosis to be delayed to adulthood.
Medications that can cause constipation are those with anticholinergic properties, such as antidepressants and antipsychotics, codeine and other narcotic analgesics, antacids containing aluminum or calcium, sucralfate, iron compounds and calcium channel blockers. In patients with certain endocrinopathies such as hypothyroidism and diabetes mellitus, constipation is generally mild and responds to therapy. Rarely, a life-threatening megacolon occurs in patients with mixedema.
Constipation is common during pregnancy, probably as a result of altered levels of progesterone and estrogens that decrease intestinal transit. Vascular collagen diseases can be associated with constipation, which can be a particularly important feature of progressive systemic scleroderma, in which delayed intestinal transit is caused by atrophy of smooth colic muscles.
In the vast majority of patients with severe constipation, no clear cause can be identified. In the idiopathic constipation of childhood, both psychological and physiological factors are considered to play a role. Affected children often have slow colonic transit, localized to the distal colon and rectum, and it has been suggested that voluntary abstention behaviour or abnormal anorectal function would play a role in these disorders.
Young and middle-aged women may experience severe constipation characterized by low frequency defecation, excessive defecation effort and lack of response to fiber intake or mild laxatives. In 70% of such cases, slow colonic transit (colon inertia) can be demonstrated by the delayed passage of radioopaque markers through the proximal colon. In 30% of cases, colonic transit is normal and abnormalities of motor functions and anorectal sensitivity can be demonstrated.
The terms obstruction of discharge and anism were used to describe this form of constipation that appears to result from insufficient relaxation or inadequate contraction of the puborectal muscles and external anal sphincter. Since the relaxation of these muscles involves the cortical inhibition of the spinal reflex during defecation and can be modified by biofeedback, it is speculated that such rectosphincterian dysfunction is acquired or learned rather than an organic or neurogenic disease.
Chronic "snoring" at defecation can cause the perineal floor to be lowered and the nerve to stretch, thus leading to an incompetent anal sphincter and fecal incontinence. Rectal prolapse may affect defecation as a result of rectal invasion or chronic damage to the shameful nerve. Rectocele is an anterior rectal hernia that can interfere with defecation by filling with preferential faeces during defecation tests.
Chronic idiopathic intestinal pseudoocclusion is a rare disorder in which episodes of intestinal occlusion are not accompanied by signs of mechanical blocking. This disorder can be familial, as a result of neuropathy or myopathy affecting the intestine and in some cases the bladder. The idiopathic megacolon or megarect is characterized by a colon and dilated rectum, respectively, with constipation and difficulty with defecation attributed to neurogenic dysfunction.
In young and middle-aged adults, constipation is most commonly attributed to irritable bowel syndrome. Unlike other idiopathic constipation syndromes described above, irritable bowel syndrome is characteristically accompanied by abdominal pain, especially in the lower abdomen, as well as the evacuation of small and hard stools with incomplete discharge sensation and excessive exertion. Patients also experience flatulence, abdominal bloating, heartburn, nausea, dysphagia, back pain and genitourinary symptoms. Colonic transit is usually normal in these patients and the exact physiopathological basis for symptoms is uncertain.
Let's proceed to present a few elements about the approach of the patient with constipation! An accurate description of the symptoms and duration must first be obtained. A recent change in bowel habits always requires an assessment for an obstructive neoplasm. A description of the frequency and nature of the defecation must be obtained, including the presence of excessive exertion, hard scibale scibale or incomplete exhaust sensation.
The patient should be questioned about associated abdominal pain and bloating and upper gastrointestinal or genitourinary symptoms. It is very important to obtain a history of the use of laxatives and the duration of this use. A gentle but careful assessment should be undertaken for signs of anxiety, emotional distress or affective disorders and the use of medications that alter the emotional state.
The physical examination should be directed towards the detection of non-gastrointestinal diseases that may contribute to constipation. Particular attention should be paid to the neurological examination, including an assessment of vegetative functions. The abdomen should be examined for signs of surgical history, intestinal distension or stool retention. A careful perineal and anorectal examination should be performed to highlight deformities, ghesier muscle atrophy, rectal prolapse, stenosis, fissure, rectal tumor or fecal impact.
The patient should be asked to strain to highlight a rectal rectum or prolapse. The presence of an "anal blink" should be assessed by demonstrating reflex contraction of the anal canal after a needle sting on the perineum. The various complications of constipation or its treatment can also be detected and may be the reason why the patient seeks the attention of the doctor (at the treatment of hemorrhoids may occur as a complication ischemic colitis, for fissure may occur colonic volvus, for rectal prolapse may occur colonic perforation, for the stercoral ulcer may occur fecal incontinence, for colonic melanosis may occur urinary retention may occur , cardiac and cerebrovascular dysfunction manifested by syncope, arrhythmias, angina and others may occur for the purging colon.
Sigmoidoscopy or flexible colonoscopy may demonstrate colon melanosis as a brown-black disorder of the intestinal mucosa as a result of chronic use of anthrachinonic laxatives. The absence of haustrations at endoscopy or irrigation suggests a "purging colon" due to the abuse of laxatives. Irrigography can also highlight obstructive colic lesions, megacolon or megarect and, in Hirschsprung's disease, will show the characteristic denervated intestinal segment with proximal dilation of the colon.
In such cases, rectal biopsies can be obtained to demonstrate the absence of neurons. Investigations of colonic and anorectal functioning should be reserved for patients with severe idiopathic constipation refractory to simple therapeutic measures. In patients with rare defecation, colonic transit investigations may highlight colonic inertia. Radioopaque markers are ingested and their transit is monitored by serial abdominal X-rays until at least 80% have passed or a predetermined period of time has elapsed. The normal upper limit for most adults is about 70 hours.
In patients suspected of obstruction of evacuation, investigations of anorectal motility provide information about rectal sensations, viscoelasticity, relaxation of the internal anal sphincter and defecation of air-filled balloons of various sizes inserted into the rectum. While patients with constipation due to irritable bowel syndrome often have low rectal compliance and hardly tolerate rectal distension, those with megarect have a very high rectal compliance.
The absence of relaxation of the internal anal sphincter suggests Hirschsprung's disease. In some centers, anorectal manometry is supplemented with electromyographic investigations to record the function of the external anal sphincter, and defecography in which it is inserted into the thickened barium rectum approximateing the consistency of the stool and its discharge is monitored by fluoroscopy, while the patient sits on a toilet.
Treatment of constipation should be individualized, taking into account the duration and severity of constipation, potential contributing factors, the age of the patient and his expectations. Symptomatic therapy is quite empirical, to the extent that there are often few objective signs to support a particular strategy. Initial therapy is usually diet, with an emphasis on increasing the intake of fiber from the diet. Although there is little evidence that constipated people consume less fiber in their diet than unconstipated people, many constipated people respond to increases in fiber in the diet of 20-30g/ day, fiber supplementation can increase stool weight and the frequency of defecation and decrease gastrointestinal transit time.
Fibre supplementation is not appropriate in patients with obstructive gastrointestinal tract lesions or in those with megacolon or megarect. With the exception of volume purgatives, routine use of long-term laxatives should be discouraged due to the risk of side effects such as lipid pneumonia due to mineral oil or myenteric plex lesions causing "purging colon" due to antrachinonic stimulant laxatives such as senna.
Volume purgatives are made up of natural (psyllium) or synthetic polysaccharides, or cellulose derivatives that act in a fibre-like way. Ingestion of liquids should be increased when using these preparations. Emollient laxatives include mineral oil, which, administered orally or by enema, penetrates and softens the stool, and docused salts, which are anionic surfactants that lower the surface tension of the stool to allow the mixture of aqueous and thick substances and thus soften the stool.
Hyperosmolar agents include mixed electrolyte solutions containing polyethylene glycol and non-absorbable sugars such as lactulose and sorbitol that act as osmotic agents and are used in bowel cleansing before colonoscopy. Lactulose can sometimes be prescribed for long-term use. Saline laxatives contain cations and anions that exert an osmotic effect to increase intraluminal water content (in elderly patients, they may cause fluid retention).
Stimulant laxatives include beaver oil, antraquinones like senna and diphenylmethane, as phenolphtalein and bisacodil. Beaver oil is converted into ricinoleic acid, which stimulates intestinal secretion and increases intestinal motility. Antrachinones increase the accumulation of fluids and electrolytes in the distal ileum and colon. phenolphthalein and bisacodil stimulate colonic motor activity and inhibit the absorption of sodium and glucose.
Recently, it has been shown that cisaprid, a prokinetic agent, increases intestinal transit through the proximal colon, but its role in the treatment of constipation is uncertain. A role of excessive endogenous opioids in constipation related to motility disorders was assumed and the benefit of opioid receptor antagonists in the treatment of constipation was noted, but requires further studies. Biofeedback techniques have shown promising in the treatment of constipation resulting from inadequate contraction of the pelvic floor muscles and external anal sphincter.
Surgical treatment for severe chronic constipation is generally controversial, with the exception of Hirschsprung's disease in which surgical resection of the aganglionic segment is the elective treatment. In colonic inertia, subtotal cholectomy with ileorectal anastomosis may be indicated in carefully select edive patients where upper gastrointestinal motility is normal and anorectal motility disorders have been excluded. Surgery to reduce or resection a rectocele, invasion or prolapse should be carefully performed, as symptoms often do not improve.
Ready for today... On June 26th we will talk about weight gain and decrease which, from a medical point of view, has some "causes" that may include it in gastrointestinal disorders.
Let's read each other well
next time!
Dorin, Merticaru