H.A.M.

AKIL
FARDAH AKIL

“GI Disorders” Lecture in GERIATRI System, FKUH

INTRODUCTION
 Constipation is a symptom caused by anorectal
disorders.
 General population occuring 20%
 Geriatric patients 25 % (normal colorectal function)
 ♀ more often than ♂
Defining chronic constipation
ROME III Criteria
• Symptom onset at least 6 months prior to last diagnosis
- ≥ 2 of the following, for the last 3 months:
• Straining
• Lumpy or hard stools
• Sensation of incomplete evacuation ≥ 25% of
• Sensation of anorectal obstruction/blockage defecations
• Manual maneuvers needed
• < 3 bowel movements per week
• Loose stools rarely present without use of laxatives
• Insufficient criteria for irritable bowel syndrome (IBS)

ROME Foundation website : www.romecriteria.org

Bristol Stool Chart
• The Bristol Stool Chart is a
medical aid designed to
classify the form of human
feces (patient’s description of
symptoms) into seven
categories
• Types 1 and 2 indicate
constipation

Lewis SJ, Heaton KW. Scan J Gastroenterol 1997;32(9):920–924

ETIOLOGY
Primary Psycho-social
• Functional motility disorders (colonic or
anorectal )
Problems
Constipation • lifestyle/ dietary habits : lack of dietary fiber
(common cause) and physical activity
(idiopatic / intrinsic)
Depression
• Mechanical disorders: extrinsic or lumen obstruction
(cancer, prolaps, intususepsion)
• EndocrineAnorexia
/metabolic disorders : DM, hypercalsemia,
hypotiroid, etc.
Secondary nervosa
• Neurogenic disorders: Hirschsprung’s disease,
Constipation multiple sclerosis, Parkinson,cerebrovascular accident,
(known cause) etc.
Sexual
• Drugs: opiates, antidepressants, anticholinergic,
abuse,
antihistamin, etc antihypertensives,
antidepresan,
antidiarrhoeals
 SUBTYPE OF
FUNCTIONAL CONSTIPATION
DIAGNOSIS

Physical • Laboratory
examination • Endoscopy

• Role out
secondary cause
• Rectal
examination
Supporting
History test
 Diagnostic tools for chronic
constipation
Medical history Rectal examination Diagnostic testing

• Nature of symptoms • Perianal excoriation • Colonic transit

- Duration of constipation • Skin tags, hemorrhoids • Balloon expulsion
- Description of stool • Anocutaneous reflex • Anorectal manometry
movements • Anal fissure • Dynamic pelvic magnetic
• Frequency • Prolapse resonance imaging
• Formation • Rectocele • Defecography
• Current medications, • Sphincter resting tone
including:
- OTC laxatives
- Prescription
agents
• Health conditions

OTC: Over-the-counter
Eoff JC, Lembo AJ. J Manag Care Pharm 2008;14:1–15
MANAGEMENT
Distinguished
CONSTIPATION
between
PRIMARY
and
SECONDARY
GENERAL CONSIDERATION
Treat the
Patient Education
underlying diseases
(secondary
• constipation
Maintain adequate hydration )
& regular non-strenuous
exercise
• Reassure & explain normal bowel habit: defecate when
colonic activity highest (upon waking, after meals)
Pharmacotherapy Surgical
treatment
• Dietary fiber : gradually increase dietary fiber 20-
25g/day (fruits, vegetables & whole grains)
• Laxatives
Potential adverse effects with
laxative use
Therapy Potential adverse effects/precautions
 Bloating, flatulence and abdominal pain
Bulking agents  Mechanical obstruction if fluid intake is insufficient
 Calcium and iron malabsorption

 Abdominal cramping, electrolyte depletion

Emollients
 Contraindicated in patients with acute or suspected bowel obstruction

 Poorly absorbed sugars can cause electrolyte abnormalities, bloating,

flatulence, diarrhea, abdominal cramping
Osmotic
 Saline: Electrolyte abnormalities can occur
 Polyethylene glycol (PEG): Abdominal bloating and diarrhea

 Electrolyte imbalances
 Link with damage to colonic mucosa or the enteric nervous system poorly
Stimulant established
 Potential for overuse/abuse; fluid depletion, hypokalemia, and
 Metabolic alkalosis can manifest as a result of abuse

Drost J, Harris LA. JAAPA 2006;19(11):24

 Patient present w/ complaints of constipation

History & Physical Ex

Alarm sign / YES – Specialist

patient > 40y.o Referral

NO YES –
Symptoms IBS treatment IBS

NO Not improved
A. Patient education
B. Dietary fiber & or bulk producing laxantive
A. Osmotic laxantive
B. Tegaserod
(< 65 y.o)

Not improved
Specialist Referral
Camilleri and Bharucha Gut 2010;59:1288-1296