Mission im ..poo ..sible

Dr. Naresh Bhat

Bangalore

Clinical approach

Is it constipation ? Are drugs or systemic disease responsible ? Are there alarm symptoms ? What is the cause of constipation ?

Clinical exam

Perineal and rectal exam essential

Labs

TSH Calcium

Management of evacuation disorders

STC Defecatory disorderNormal transit

Medications commonly used for constipation•Hyperosmolar agents

•Lactulose

•Sorbitol

•PEG

•Suppository

•Glycerin

•Bisacodyl

•Stimulant

•Senna

•Bisacodyl

•Fiber

•Saline laxative

•Milk of magnesia

•Lubricant

•Mineral oil

•Enemas

•Tap water

•Phosphate

•Soap water enema

Which one to use?

Constipation -classification

Normal transit Slow colonic transit Defecatory disorder

Modalities to evaluate

Transit study Anorectal manometry and balloon expulsion Defecography

Defecatory disorder …clues

Adequate urge Daily visits Prolonged ET Digital evac / Perineal pressure

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Basal (15.08:27)

Basal pressure

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64Basal (13.53:32)

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Balloon Expulsion (15.16:10)

Balloon Expulsion

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Balloon Expulsion# 1 (14.47:56)

Pelvic floor disorder

Abnormal ARM Abnormal BET/BDAbnormal ARM Abnormal BET/BD

Absent RAIR High RP, SP

Hirschsprung’s disease

AnismusAnal fissure

Abnormal anorectal anglePerineal descent

Constipation Due to Pelvic Floor Disorder

Anterior rectocele Non relaxing puborectalis

Biofeedback Therapy

Dyssynergic defecation: 40% of chronic constipation

Paradoxical anal contraction,

inadequate push effort,

incomplete anal relaxation,

altered rectal sensation

Overlap with delay in colonic transit in 2/3rds

Biofeedback Therapy

Neuromuscular training “operant conditioning” technique

Visual cues Toilet training – capitalise on intrinsic

physiological mechanisms, avoid certain maneuvers

Duration of sessions: 30-60 mins, 4-6 sessions reinforcement session Time consuming, labour intensive.

Efficacy of biofeedback in evacuation disorder

Author Year Mode % well

Bleijenberg 1988 Inpatient-home 70Weber 1988 Outpatient 18Lestar 1991 Outpatient 69Kawimbe 1991 Home 87Dahl 1991 Inpatient 78Wexner 1992 Outpatient 89Fleshman 1992 Outpatient 100

Dig Dis Sc 1993; 38: 1953-60

Our experience in biofeedback

110 patients in last 3 years- Defecatory disorder, fecal incontinence

80-85% patients had significant positive response

Role of surgery

• Hirschsprungs disease• Rectocele• Colonic inertia

Summary

All constipation are not IBS

Clinical history – exclude secondary causes

Defecatory disorders to be kept in mind

Anorectal manometry, transit study very useful

Significant overlap – use more than one test

Biofeedback therapy – treatment of choice in defecatory disorders

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206Balloon Expulsion (15.19:05)

Balloon expulsion

Check list

Hypothyroidism Parkinsons Diabetes

Parkinson drugs Antihistaminics Anti histaminics