Diagnosis of constipation

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ConstipationPresented by :Ghaida Al-Rashed

Diagnosis of constipation

Learning objectives

Investigations

Treatment

Diagnosis

Constipation is a very common condition.

Your GP will not usually need to carry out any tests or procedures, but will confirm a diagnosis of constipation based on:

Symptoms Medical history

If the patient experiencing severe symptoms, your doctor may request further tests and investigations .

Indications for investigation include:Age >40 years.A recent change in bowel habit.Associated symptoms (weight loss, rectal bleeding, mucous discharge).

Further tests

Do You Order Additional Laboratory Studies or Other Investigations?

Laboratory StudiesBlood tests, Serum chemistry and thyroid tests, to diagnose or rule out other conditions.

Fecal occult blood test.

. Laboratory TestsBlood testsmay reveal:Abnormal levels of potassium, calcium, sodium or magnesium (metabolic cause )Elevated white blood cells (in Crohns disease)Elevated blood glucose(in diabetes)Low thyroxine (in hypothyroidism)Fecal occult blood testmay be done in chronically constipated patients after age of 50; positive test raise suspicion for colonic cancer.

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Flexible Sigmoidoscopy or ColonoscopyBoth tests have similar procedure.Flexible Sigmoidoscopy: to view just the rectum and sigmoid until the splenic flexure is identified.

Colonoscopy : to view the rectum and entire colon.

Initially Sigmoidoscopy if reveals no abnormal findings we will use Colonoscopy.

During these tests, the doctor may perform a biopsy (several small pieces of tissue from different areas) .

Initially sigmoidoscopy if reveals no abnormal findings or absence of a rectosigmoid obstruction. we will use Colonoscopy

Procedure : the patient will lie on a table while your doctor inserts a flexible tube into your anus. A small camera on the tube sends a video image of your bowel lining to a monitor. Advance the flexible endoscope into the rectosigmoid until the site of the obstruction is reached or until the splenic flexure is identified, which suggests the absence of a rectosigmoid obstruction. If the initial sigmoidoscopy reveals no abnormal findings or if the constipation is more chronic, the patient should subsequently undergo a standard oral bowel preparation and either colonoscopy (the authors preference) or air-contrast barium enema for a fuller evaluation of the remainder of the colon.Colonoscopyshould not be performed if perforation or acute diverticulitis or other infectious processes are suspected because of the risk of worsening intra-abdominal contamination caused by colonic distension during the procedur8

Colorectal transit studiesTests show how the stool moves through your colon.

Determined in patients suspected of having a colonic motility disorder.

Achieve by observing the passage of orally administered radioactive markers and more X-rays are taken

to see how long it takes for the radioactive markers to pass through your digestive system.

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Con..

A patient with outlet obstruction tends to retain the markers in the left colon and sigmoid, whereas a patient with colonic dysmotility may move the markers throughout the colon.

:Type of radioactive markerRadiopaquemarkersScintigraphythe patient will swallow capsules with small radioactive markers.the patient will eat a meal that contains radioactive substances.

and one or more X-rays are taken later on to see how long it takes for the capsules to pass through your digestive system

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Anorectal Function TestsAnorectal ManometryInsert a thin tube that has pressure sensors + balloon that attached to one end is inserted into your rectum and is attached to a machine to check:

Sensitivity of your rectum is and how well it works.The tightness of the muscles around your anus.How well they respond to nerve signals.

Insert thin tube into the rectum and this tube contain pressure sensors + balloon , also this tube attach to machine to chick For this test, a health care professional puts a thin tube that has pressure sensors and a balloon on its tip into your anus. Once the balloon reaches your rectum and the pressure sensors are in your anus, the health care professional slowly pulls the tube out to measure muscle tone and contractions. The test takes about 30 minutes.If you cant push out a balloon filled with less than 150 milliliters of water, or it takes longer than 1 minute to push the balloon out, you may have a problem pushing out stool.Balloon expulsiona balloon filled with varying amounts of water is rectally inserted.The patient is asked to expel the balloon out.Decreased ability to expel a balloon filled with 150 mL of water suggests decreased defecatory ability12

Lower GI seriesX-rayexam of colon to help diagnose problem.

Determined in patients suspected of having obstructing colon cancer in the setting of chronic constipation

Before procedure Follow a clear liquid diet for 1 to 3 days before the procedure.During the procedure the doctor will fills the patients colon withbarium, to make the colon problem more visible on x-rays

For the procedure, youll lie on a table while your doctor inserts a flexible tube into your anus. Your doctor then fills your large intestine withbarium, which makes signs of problems that may be causing constipation show up more clearly on x-rays.Determined in patients suspected of having obstructing colon cancer, intermittent volvulus, or colonic stricture in the setting of chronic constipation

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DefecographyX-ray of the rectum during defecation.

Should be performed if an obstruction is suspected at the level of the anal canal.

During this procedure, the doctor inserts a soft paste made of barium into the patients rectum, then pass the barium paste as you would stool.

X-ray of the rectum during defecation (defecography).During this procedure, your doctor inserts a soft paste made of barium into your rectum. You then pass the barium paste as you would stool. The barium shows up on X-rays and may reveal a prolapse or problems with muscle function and muscle coordination.

During the test, a health care professional fills your rectum with a soft paste that shows up on x-rays and feels like stool. You sit on a toilet like seat, wich attach to x-ray table . The patient will ask to first pull in and squeeze muscles to keep stool in. Then, to puch and to empty the rectum have a bowel movement. The health care professional looks for problems as you push the paste ou14

Computed TomographyAbdominal CTcan reveal abdominal tumor.

Treatment

Suppose your additional studies do not provide a clue to underlying disorders, which treatment options do you discuss with this patient ?

Treatment For Constipation may Include The Following:General management:Treat the cause.Diet and lifestyle changes.

Drug therapy (Consider drugs only if the above measures fail)

If failed

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Diet and Lifestyle ChangesIncreased fluid intake.Eating more fruits and vegetables.Eating more fiber.Exercise most days of the week.Don't ignore the urge to have a bowel movement.

Fluid intake is the key to treatment. Patients should be advised to drink at least 8 glasses of water daily.Don't ignore the urge to have a bowel movement.Take your time in the bathroom, allowing yourself enough time to have a bowel movement without distractions and without feeling rushed.Exercise most days of the week.Physical activity increases muscle activity in your intestines. Try to fit in exercise most days of the week.

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Drug therapy Laxatives:

Use laxatives only if a doctor says you should.

There is Several types of laxatives each one have different mechanism.

Laxatives Therapy

Fiber supplements are best choice

Absorb water and make stool softer.Safe to use everyday.Be sure to drink at least 8 to 10 glasses of water everyday.

Con..Other types of laxatives should only be used for a short timeLubricants (mineral oil)Soften and lubricate stool.Stool SoftenersProvide moisture to stool.StimulantsCause muscle contractions in intestinesSaline laxativesDraw water into colon.

21These laxatives can interfere with the colons natural ability to contract. Only use them for very short periods of time if you must. Mineral oil can reduce the bodys ability to absorb vitamins A,D,E,and K.

Points to RememberEat a variety of foods. whole grains, and fresh fruits and vegetables.Drink plenty of liquids.Exercise regularly.Dont ignore the urge to have a bowel movement.Most people do not need laxatives. Your doctor may recommend them for a limited time only.Some Medicines may cause constipation

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Summary

References http://www.mayoclinic.org/diseases-conditions/constipation/basics/treatment/con-20032773http://emedicine.medscape.com/article/184704-treatment#aw2aab6b6b2http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/constipation/Pages/treatment.aspx

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