CONSTIPATION

Question 1

what are the types of constipation and duration?

Answer 1

1. acute (< or equal to 12 weeks)
2. chronic (> 12 weeks)

Question 1

What is constipation?

Answer 1

infrequent, irregular, or difficult evacuation of the bowels

Question 2

do women or men get constipation more?

Answer 2

women

Question 3

epidemiology of constipation?

Answer 3

15% adults
1/3 of elderly patients

Question 4

etiology of primary constipation :

Answer 4

idiopathic or functional
not attributed to any structural abnormalities or systemic disease; 3 subtypes

Question 5

etiology of secondary constipation :

Answer 5

caused by systemic disease, medications, or obstructing colonic lesions

Question 6

what are the 4 most common causes of constipation? KNOWW THISS

Answer 6

1. inadequate fiber or fluid intake
2. poor bowel habits
3. physical inactivity
4. slow colonic transit

Question 7

how long is normal colonic transit?

Answer 7

about 35 hours

Question 8

what are the other common sx of constipation that aren’t the big 4?

Answer 8

• systemic dz-> hypothyroidism, hypercalcemia, paraplegia
• meds-> opioids, diuretics, iron
• structural abnormalities

Question 9

what is the PRIMARY MECHANISM that causes constipation?

Answer 9

1. altered stool consistency
2. altered bowel motility

Question 10

what is the first step of defecation?

Answer 10

1. colonic mass movements/peristalsis moves intestinal contents distally into rectum

Question 11

what is the second step of defecation?

Answer 11

2. rectal filling activates mechanoreceptors in the rectal wall causing awareness of the need to defacate

Question 12

what is the third step of defecation?

Answer 12

3. a small amount of is allowed to pass through to the anal canal by an involuntary relaxation of the internal anal sphincter (rectoanal inhibitory reflex) -> determine if the rectal contents is gaseous, solid, or liquid form

Question 13

what is the fourth step of defecation?

Answer 13

4. abdominal muscles contract and a Valsalva maneuver is performed while simultaneously relaxing the external anal sphincter and puborectalis muscle (pressure gradient generated between the rectum and anal canal expels the feces)

Question 14

what are the s/sx of constipation?

Answer 14

• infrequent bowel movements (<3/week)
• hard stools
• excessive straining
• sense of incomplete evacuation
• BLOATING
• abdominal cramping or pain
• tenesmus
• overflow diarrhea

Question 15

what can a dx of constipation be based upon?

Answer 15

based on complete hx and PE to include a digital rectal exam

Question 16

what people need additional dx testing for constipation?

Answer 16

• age >50
• severe constipation
• alarm sx
• inadequate response to empiric therapy

Question 17

what are the 3 ALARM SX of constipation?

Answer 17

1. hematochezia
2. weight loss
3. +FOBT

Question 18

what management do you do for patients with red flag features?

Answer 18

order a Colonoscopy or flexible sigmoidoscopy and biopsy to r/o colorectal cancer

Question 19

what management do you do for patients with NO red flag features?

Answer 19

1. assess for secondary causes of constipation
   - CBC w/diff with differential, serum electrolytes, calcium, glucose and TSH
   - Review medications

Question 20

what 2 tests are done for a patient who has inadequate response to empiric therapy?

Answer 20

1. anorectal manometry and a balloon expulsion test
2. colonic transit studies

Question 21

what are the 3 main tx modalities for constipation?

Answer 21

1. dietary and lifestyle measurements
2. d/c meds linked to constipation
3. pharmacotherapy

Question 22

what is overflow diarrhea?

Answer 22

pts w/ firm stool in sigmoid/rectum that they can not pass and softer stool above the firm stool

Question 23

what are the 4 main hx questions to ask for dx?

Answer 23

1. stool frequency, consistency, and color
2. length of time for a bowel movement
3. use of laxatives or enemas
4. review prescription medications

Question 24

what is an anorectal manometry and a balloon expulsion test?

Answer 24

measure pressures inside the rectum and anus and the ability of the pelvic muscles to expel stool from the rectum

Question 25

what do abnormal results of anorectal manometry and a balloon expulsion test indicate?

Answer 25

defecatory disorder

Question 26

what is a colonic transit study?

Answer 26

patient swallows radioopaque markers, which are then tracked through the GI tract using x-rays differentiate between slow and normal transit constipation

Question 27

what does a normal colonic transit study indicate?

Answer 27

disorder of gut-brain axis

Question 28

what are the recommended dietary and lifestyle measurements?

Answer 28

1. increase dietary fiber (20-35 g/day) 2. regular exercise 3. increase intake of water (2L/day if not on water restriction) 4. decrease constipating agents, such as dairy products, coffee, tea and alcohol

Question 29

what are the pharmacotherapy options?

Answer 29

1. laxatives: fiber, osmotic, or stimulant laxative 2. suppositories-> glycerin 3. stool surfactants: colace, mineral oil 4. enemas: warm water, Na phosphate, milk of molasses 5. acute purgative/clean bowel prep: polyethelene glycol (PEG), magnesium citrate 6. opioid-receptor antagonists

Question 30

what are the 5 complications of constipation?

Answer 30

1. anal fissures 2. hemorrhoids 3. fecal incontinence 4. urinary retention 5. syncope w/ straining 6. fecal impaction 7. bowel obstruction

Question 31

what is anal fissures?

Answer 31

passage of hard, lumpy stools causes a tear in anoderm leads to painful defecation and rectal bleeding

Question 32

what are hemorrhoids?

Answer 32

d/t excessive straining w/ hard, lumpy stools leads to rectal pain, itching, and/or bleeding

Question 33

what is fecal incontinence?

Answer 33

- chronic constipation-> formation of a hard stool mass-> progressive distention of the anal sphincter complex-> patient no longer feels urge to defecate - soft or liquid stool begins to seep around the obstructing stool mass, causing overflow incontinence

Question 34

what age population is fecal impaction seen in?

Answer 34

elderly

Question 35

what happens (pathophys) in fecal impaction?

Answer 35

increased rectal capacity, decreased colonic motility

Question 36

what is fecal impaction?

Answer 36

firm often puttylike mass in rectal vault on DRE; sometimes rock-like

Question 37

what are the sx of fecal impaction

Answer 37

rectal pain tenesmus overflow (paradoxic) diarrhea: watery fecal material leaking around impacted stool

Question 38

what is the tx of fecal impaction?

Answer 38

enema and manual disimpaction

Question 39

what are the categories of bowel obstruction?

Answer 39

partial or complete

Question 40

what are the sx of bowel obstruction?

Answer 40

decreased appetite N/V abdominal pain and/or distention

Question 41

what is the dx test of bowel obstruction?

Answer 41

flat and upright abdomen x-ray or CT scan