IBS:Constipation - louisville.edu

Secondary Cause

Metabolic and Endocrinologic Dis
Diabetes mellitus*
Heavy metal poisoning (e.g., arsen
Hypercalcemia*
Hyperthyroidism
Hypokalemia
Hypothyroidism*
Panhypopituitarism
Pheochromocytoma
Porphyria
Pregnancy*

es

sorders
nic, lead, mercury)

Secondary Cause

Neurologic and Myopathic Diso
Amyloidosis
Autonomic neuropathy
Chagas’ disease
Dermatomyositis
Hirschsprung's Disease – comple
Intestinal pseudo-obstruction
Internal neural dysplasia
Multiple sclerosis
Myopathy of colon or rectum – an
Parkinsonism
Progressive systemic sclerosis
Shy-Drager syndrome
Spinal cord injury
Stroke

es

orders

ete or partial
nal sphincter genetics

Risk Factors

z Risk factors for Consti

z Advanced age
z Female gender
z Low level of education
z Low level of physical ac
z Low socioeconomic sta
z Nonwhite ethnicity
z Use of certain medicati

ipation

ctivity
atus
ions

Epidemiology

z Incidence – 15% Olmstea
z Prevalence – 2% - 28% v

demographics
z Cost - $6.9 billion/yr, med

(colonoscopy)

z Only 4% get to gastroentero

ad Study, non-elderly
variable methods,

dical eval $2,252

ologists

Colonic Function

z Luminal content Bacte
Fiber
Food

z Absorption H2O
Bowe

z Motor function 1. De
2. Mi
LAPCs 3. Sto
HAPCs 4. Pr
Low amplitude
High amplitude

z Innervation involuntary, EN

Voluntary defec

Myenteric plexus – excitatory Trans

inhibitory VIP (Vasoactive

Interstitial cells of Cajal (ICCS)

Intestinal pacemaker cell

Neural signaling between

n - Physiology

eria 55%
17%
residue, H2O, gas

Na, 1.5L-200/100 ml
el diameter 6-5 cm

elays passage
ixes contents
orage (distal bowel)
ropulsion:transit 35-72 hrs
propagated contractions
e propagated contractions

NS, Proximal colon
cation
smitter substance P
e Intestinal Polypeptide)

ls – provide slow wave propagation
n ENS and muscle

Colonic Function

z Defecatory function

n - Physiology

Secondary Causes



Pathophysiolog

Functional Causes
Disordered function of colon

59%
13%

25%

gy

n or rectum

If severe, is called colonic inertia

Pathophysiolog

Functional Causes

Disordered function of colon or rectum

z Also called dyssynergia, obstruc

z These commonly have inappro
sphincter, abnormal pelvic floo
pressure and sensation

Rome III Criteria for Functional Defec

z The patient must satisfy diagnostic criter
z During repeated attempts to defecate, th

following:

z Evidence of impaired evacuation, based o
z Inappropriate contraction of pelvic floor m

less than 20% relaxation of basal resting s
or EMG
z Inadequate propulsive forces assessed by

gy

m

ctive defecation, outlet obstruction

opriate contraction of anal
or descent and deficient rectal

cation Disorders

ria for functional constipation
he patient must have at least two of the

on balloon expulsion test or imaging
muscles (i.e., anal sphincter or puborectalis) or

sphincter pressure by manometry, imaging,
y manometry or imaging

Pathophysiolog

Functional Causes

gy

Bristol Stool Scal

le

Psychosocial Dis

z Depression
z Eating disorders
z Denied bowel movements
z Symptoms of somatizatio

compulsiveness and affec

sorders

s
on, obsessive
ctive disorders

Clinical Assessme

ent

Diagnostic Tests

1. To exclude systemic illn
2. To elucidate the underly

process

ness or structural disorders.
ying pathophysiology

Diagnostic Tests

z Tests to exclude systemic
biochemical screening tes
and to r/o inflammation, n
other systemic disorders.

z To exclude structure dise

z Do Ba enema, SBFT
z Endoscopy for ∆ BM, blood
z Age > 50y
z C-Scope or flexsign

c disease are Hb, ESR,
sts for thyroid, Ca, glucose
neoplasia, metabolic or
ease

d in stool, weight loss, fever

Diagnostic Tests

z Physiologic measures
diaries

z Do transit studies – rad
z Anorectal manometry

z Pressure measures rela
z Sensation

z EMG
z Defecating proctogram
z Balloon Expansion Tes

s aided by symptom

diopaque markers

axation of sphincter

m
st

Diagnostic Tests



Treatment



Treatment



Treatment

General measures – Reassurance,
support, fluids, dietary and fiber c

lifestyle changes, psychological
changes.

Treatment



Treatment



Treatment



Prokinetic Agents

z Tegaserid – 5HT4 ago
market

z Prucalopride – 5HT4 a
z Peripheral Mu – opioid

methylnaltrexone to re
syndrome
z Alvimopan – for surgic

s

onist – Withdrawn from

agonist – in clinical trials
d antagonists –
everse narcotic bowel

cal ileus recovery

Other Agents

z Cholinergic agents

z Bethanechol, neostigm

z Newer neurotrophins

z NGF, BDNF, neurotrop
z Linogliride – guanylate

mine, botulinum toxin

phin 3
cyclase C agonist