Constipation defined as either:- Decrease in frequency of stools (fewer than 3 bowel movement per week) - Increase in difficulty in passing stools.

Patients may also complain of hard bowel movement, small actions, inability to evacuate, or sensation of incomplete evacuate.

Chronic severe constipation: - Bowel movements < once in 5 days - Symptom persisting > 18 monthsCorman M et al. Hand book of colon & rectal Surgery 2002

DIETARYLow fiber intakePoor intake of fluid

FUNCTIONALDepressionConfusionInadequate toilet facilitiesImmobilityPsychosisEncopresisMEDICATIONAnticholinergicAntidepressantsNarcotics & opiatsIronBismuthAntiparkinsonAntacid (aluminium)AntihypertensiveAnticonvulsantsIron-exchange resinBulk laxative without adequate hydration

ENDOCRINE, METABOLIC & COLLAGEN VASC. DISEASEHypothyroidismHypoparathyroidismD.M.HypokalemiaCRFPregnancyHypopituitarismPorphyriaSclerodermaAmyloidosisHypercalcemiaNEUROMUSCULAR DISORDERCEREBRALCerebrovasc. Acc.Parkinson diseaseIntracranial tumorSPINALCauda equina lessionMyelomeningoceleCord injuryMultiple sclerosisTertiary sypilisPERIPHERALD.M.Autonomic neuropathyChagas diseaseHirshprungs diseaseVon RecklinghousenStimulant laxative abuseVincristine

ANO-RECTAL FUNCTION

Outlet obstruction (Anismus, obstructed defecation, spastic pelvic floor syndrome)

COLONIC INERTIA

Slow transit constipationIntestinal pseudo-obstruction (Ogilvies Syndrome)

Older than 55 YRecent abdominal or perineal surgeryLimited physical activity such as bed restDiet less than 15 gr fiber per dayInadequate fluid intake (

HISTORYDIARY OF BOWEL MOVEMENTCLINICAL EXAMINATION, ENDOSCOPYORGANICDISEASENO ORGANICDISEASETRANSIT TIME MEASUREMENTSLOW TRANSITCONSTIPATIONOUTLETOBSTRUCTIONDEFECOGRAPHYABNORMALITYOF THE RECTALWALLANISMUSEMGANORECTAL MANOMETRYCONFIRMATION:ANISMUSIMPAIRMENT OFINTERNAL ANAL SPHINCTER:HIRSPRUNGAPPLICATION OF DIAGNOSTIC METHOD IN CONSTIPATIONBuchmann P. Investigation of Anorectal Functional Disorders 1992

Constipation is not a disease, but symptom of many diseases of mixed origins and mechanisms

Hard stool 98%Diff. in evacuation 92%Abdominal pain 82%Large size stool 80%Obstruction of toilet 66%Rectal bleeding 64%Abdominal distention 60%Faecal impaction 50%Faecal digitation 48%Episodic diarrhea 44%Incontinence 40%Poor appetite 38%Nausea 35%Abdominal mass 27%Passage of pellete stool 25% Vomiting 22%Abdominal tenderness 17%Audible borborygmi 10%History maybe unreliable, duration of constipation may be variable

Diary of bowel movement

Keighley MRB, Williams NS. Surgery of the anus, rectum and colon Sounders 1993.

Inspection on resting, squeezing and straining: (swelling, fissure, tumor, cicatrix, descending perineum, prolapse, rectocele)

Rectal digital exploration: (pain, stricture, tumor, sphincter tone, intussusceptions, rectocele, length of anal canal)

Fist diagnostic procedure for patient with symptom of defecation disorderPrevious digital examination is mandatoryThe normal length of anal canal is 3-5 cmCommon finding related to chronic constipation is Solitary rectal ulcer (SRU)Anterior mucosal prolapse anterior intussusceptions circular intussusceptions complete rectal prolapse (all as the cause of SRU) are difficult to be detected endoscopically defaecography is the best mean.

SCINTIGRAPHY Using radioisotop technetium 99m (half life 6 hours) or indium 111 (half life 3 days)

RADIOLOGIC MARKER

WMC (wireless Motility Capsule)

Normal: within 48 hours of ingestion much of the radioisotope has been passed from bowelSevere constipation due to prolonged transit time, over the 4 days radioisotope does not progress beyond the thansverse colonSCINTIGRAPHY

Radio-opaque marker tablet20 tablet, followed by serial daily abdominal X-rayNormal:80% had passed by the end of 5th daysTT through right colon 6.9-13.0 hoursTT through left colon 9.1-15 hoursTT through rectosigmoid 11-18.4 hours

More than 40% marker left in the colon after 5 days considered pathology.Colonic inertiaHindgutinertiaOutlet obstruc tion

A condition in which large bowel becomes markedly distended with all the symptom and sign of large bowel obstruction but where there is no evidence of mechanical obstruction. Primary pseudo-obstruction: familial visceral myopathy (normal ganglionic cells but thinning and collagen replacement of the longitudinal muscle were found on biopsy)Secondary pseudo-obstruction: metabolic origin, electrolyte disturbances, uremia, diabetes, myxoedema, hyperparatyroidism, disturbance of the adrenopituitary axis.

Provide a picture of the successive phases of defecation and may reveal disorder of defecation (outlet obstruction constipation)

Documentation of functional and morphological changes of anorectum and pelvic floor during defecation

SymptomsFeeling of incomplete evacuationBlocked evacuationHeaviness perineal massHeavy straining during defaecationNeed for digital assistance Chronic constipationFaecal incontinenceObjective findingsMucosal lesion of anterior rectal wallRectocele of more than 2 cm on palpationSlow transit through distal part of colonIntussusception as seen by rectoscopy

Suspicion ofOccult intussusceptionOccult prolapseEnterocele

SQUEEZINGRESTINGSTRAININGThe position of the anorectal junction (ARJ) with respect to the tip of the coccyx (in cm) and values of anorectal angle (ARA) andanal canal width (ACW) during succesive stage of defaecationNORMAL APPEARANCE OF ANORECTAL DURING RESTING, SQUEEZING AND STRAINING DEFAECOGRAPHY

Rectal intussusception and rectal prolapseRectoceleEnteroceleAnismus/spastic pelvic floor syndromeDescending perineum syndrome

Anterior mucosal prolapse

Annular intussusception

Complete rectal prolapseSolitary ulcer syndrome

Rectocele: Anterior outpocketing of the rectal wall with incomplete evacuation (usually more than 2 cm).High incidence of ventral outpocketing some author consider normal appearance507 defaecografi: 66.7% outpocketing, where 89% ventral , 8% lateral and ventral, 3% dorsal.Symmetry anal heightAsymmetryanal height

Small intestine located between vagina and rectum. Rectum compressedSigmoid (contrast +) and small intestine located between vagina and rectum. Rectum compressedENTEROCELE

Dyskinaesia of the puborectal (anismus/ spastic pelvic floor syndrome): the muscle contracted during defaecation instead of being relaxed incomplete evacuationANISMUS

Descending perineal syndrome (DPS)During straining perineum descent less than 2-3 cm, more 3 cm decided as DPS (fig. b) Measure:DefaecographyPerineometerClinic: Constipation or incontinenceEtiology:Chronic straining chronic pudendal neuropathy

Scematic videoproctography to measure perineal descent

Changes in anal canal pressure and smooth and striated muscle activity during straining.After an initial rise, the anal canal pressure fall, and this is associated with loss of of the internal anal sphincter electrical slow wave activity. The integrated electromyographic signal from the striated external anal muscle also fallNormal subject

Rectoanal inhibitory reflex:Distention of the rectum followed by relaxation of the internal anal canal muscle. This reflex absent in Hirshprung disease

ABA: The striated muscle normally relax during defecation straining, so the anal canal pressure decrease.B. Paradoxical contraction means striated muscle contract during defecation straining, the anal canal pressure increase. It is shown in anismus

Dynamic videoproctography with simultaneous rectal and anal manometry and puborectal measurement

Especially in severely constipated woman with slow transit problemTest: Beck Depression Inventory, Minnesota Multiphasic Personality InventoryAssess psychological factors that may contribute the patient complaintAdministered to every patient for whom surgical alternative is considered

HISTORYDIARY OF BOWEL MOVEMENTCLINICAL EXAMINATION, ENDOSCOPYORGANICDISEASENO ORGANICDISEASETRANSIT TIME MEASUREMENTSLOW TRANSITCONSTIPATIONOUTLETOBSTRUCTIONDEFECOGRAPHYABNORMALITYOF THE RECTALWALLANISMUSEMGANORECTAL MANOMETRYCONFIRMATION:ANISMUSIMPAIRMENT OFINTERNAL ANAL SPHINCTER:HIRSPRUNGAPPLICATION OF DIAGNOSTIC METHOD IN CONSTIPATIONBuchmann P. Investigation of Anorectal Functional Disorders 1992

Constipation consisted of 2 types: prolong transit time and outlet obstruction.Use algorithm for diagnosis of chronic constipationDiary of bowel movement more reliable than recallColonic transit study may differentiate 2 type of constipationFor outlet obstruction type, defecography may identify anatomical abnormality as the cause of constipationAnal manometry and electromyography may identify Hirsprung disease and anismusPsychological test should be considered in patient with constipation, especially whom surgical alternative is considered