Treatment of chronic constipation Current management options for chronic constipation

Treatment of chronic constipation Current management options for chronic constipation
Constipation is a common problem and often difficult to treat, affecting approximately 2-27% of the population in Western countries. British study conducted on 731 women found that 8.2% of them suffering from constipation, according to the criteria of Rome III, and 8.5% knew of contracting constipated.
Constipation is common in women than in men, and in non-Caucasian race, and when children and the elderly.

 developed several definitions of constipation. But the agreed definition of functional constipation is according to the criteria of Rome III.
And patients often complain of displaying one or more of the following symptoms: lack of stand out (typically less than three times a week), hard stools, excessive stress, a sense of completion of defecation and spend excessive time in the toilet or the inability to defecate. Constipation can be chronic, and difficult treatment, and can be debilitating. The following is a focus on the causes of constipation, evaluation and treatment of patients with chronic constipation.

 Rome III criteria for constipation in adults: A person has to show two or more of the following symptoms, lasting more than 12 weeks (need not be continuous), and appeared before at least 6 months of diagnosis:

Rome III criteria for the diagnosis of constipation in adults:
• stress of more than 25% of the defecation process.
• Lumpy or hard stools in at least 25% of defecation.
• a sense of completion of defecation at least 25% of defecation.
• a sense of blockage or obstruction in the anorectal region in at least 25% of defecation.
• Manual maneuvers to facilitate defecation at least 25% of the defecation (ie, finger or defecate for ways to help the pelvic floor).
• the number of defecation times of less than 3 times a week.
• rarely appears loose stools without the use of laxatives.
• standards are insufficient for the diagnosis of irritable bowel syndrome IBS.


Classification of constipation Classification of constipation:

Classified into three categories. With it is the adoption of this classification are characterized by large and Bkablath to update that suits many patients more than others, but it is not free of defects by not always predict the response to treatment.

Normal transit constipation Normal-transit constipation (functional constipation): It is most common forms of constipation, stools passed through the colon at a normal rate, and the frequency of the stool is normal. This is likely to have constipation as a result of significant difficulty during defecation or the presence of hard stools. Patients can suffer from flatulence and abdominal pain or discomfort, and can show an increase in psychological fatigue and some have an increase in rectal compliance or lack of a sense of rectal, or both.

Defecation disorders Defecatory disorders:
Defecation disorders occur due to a defect in the function of the muscles of the pelvic floor or anal pounders. May result in global functional stools in children secondary to fecal incontinence, leakage of waste liquid stool around the jammed (diarrhea false) and then an error may occur in the diagnosis.
It can also occur when defecation disorders the patient tries to avoid imprisonment stool pain associated with the passage of a large mass of fecal and harsh, or to avoid the pain associated with anal fissure or hemorrhoids, anal.
There are other reasons for defecation disorders, but less common, including: rectal intussusception, rectal and hydrocele, varicocele and sigmoid colon gentlemen, severe perineal and landing. Some patients with a history of sexual or physical disorder, or disorder of nutrition. Failure to empty stool in the rectum completely may be due to the inability of coordination between the abdominal muscles, muscle and rectal anal, and pelvic floor muscles during defecation. To ignore or suppress the need for defecation may contribute to the development of mild constipation before the Emptying disorders (bowel movements) severe.

Slow Transit Constipation Slow-transit constipation:
When you see young women who have the number of bowel movements a few times (once per week), and often begins with puberty. Although the bran-rich diet may increase the fecal mass, and decrease transit time in the colon and address constipation mild, but severe cases of slow transit constipation have a weak response to diet and laxatives pityriasis. This might be the case as a result of the slow emptying the colon and the near lack of effective peristaltic movements after meals.

Herhpring disease Hirschsprung's disease in adults is a severe form of so slow transit constipation is associated with the expansion of the colon. Failure to cross the pretend Cologne slow with the lack of response to stimuli. Nothing to do with crossing Cologne age, though, the problems of defecation more common in adults. The older they are less active, and receiving treatments have a role costive, with an increased risk of age-related injuries such as exposure to the work of surgeons, and this in turn contributes to constipation.


Diseases that cause constipation:
Neurological disorders (multiple sclerosis, MS, Parkinson's disease, intestinal pseudo-obstruction chronic idiopathic, ischemic stroke, spinal cord injuries).
Cases of glandular and metabolic (diabetes, lack of activity or hyperthyroidism, Uraemia, high calcium).
Systemic disorders (amyloidosis, systemic lupus erythematosus, SLE, scleroderma).
These disorders can slow down the passage of stool through the colon, Ooualemstakim, or anus.

Clinical examination:
 can take advantage of the degree of cohesion of the stool (texture) to estimate the maximum time to cross the beach access because the stool is very hard or very soft cross linked Cologne rapid or slow. And hope the area around the anus is necessary for all patients because it can reveal to us many things. Look for scars and fistulas, cracks and external hemorrhoids and then ponder over the perineum downward (normal 1-3.5 cm).

 lack of decline may indicate an inability to relax the muscles of the pelvic floor, the landing excess (> 3.5 cm) may indicate looseness and suppleness to the perineum, leading to incomplete emptying.

 finger examination of the rectum is also essential for detecting the presence of fecal impaction, Otadhaq anal, rectal Oktl. The expansion of the anal sphincter may indicate the presence of trauma or neurological disorder, and should assess the winepress anal pressure at rest.

Constipation may occur because:
 defects in the anterior wall of the rectum (eg rectocele).
 down mucous.
 anal stenosis.

Physiological and laboratory tests: these tests:
 thyroid function tests.
 calcium.
 sugar.
 electrolytes.
 Full blood count FBC.
 Analysis of Paul.

Require the following symptoms would thoroughly to Cologne especially in adults over 50 years, these symptoms are: (the emergence of constipation talk or aggravate constipation is, blood in the stool, weight loss, fever, loss of appetite, nausea, vomiting, history of positive for the disease inflammatory bowel and colon cancer ).

Some specialized centers to conduct physiological tests to patients who show symptoms of Mandh and have no other reason for the unexpected failure of constipation when laxatives and high fiber diet to control constipation. These tests include:
 anal rectal pressure measurement.
 remove the balloon.
 portray the process of defecation.
 Cologne transit time tests (in the natural state less than 72 hours).


Treatment of constipation:
 must support the option in the initial treatment on the initial evaluation of the underlying cause of constipation and style. Currently, there are several options for treatment, Table 1 summarizes the number of instruments used.

 But we are forced to experience a large number of treatment options to control constipation, patients may have pre-fixed points of view about things that use to them or not.

 There are a large number of drugs used to treat common conditions (more than 900 medicine) said that they cause constipation and should pay attention to first as possible.


Bran and the factors inflated to block Bran and bulking agents:
These materials play an important role in water retention in the stool (see Figure 1), which includes several articles. Should alert the patient to increase dietary intake of fiber gradually until reaching a value of 20-25 g / day, and be eating foods rich in fiber (such as fruits and vegetables) or eating Maadhat (supplements) fiber canned, with attention to these foods may cause flatulence or bloating belly (and Maadhat fiber canned the same effect but the taste is unpalatable). For this reason, the dose increased gradually and has been calibrated to be replaced by fibrous materials other artefacts. In the end, is the secret of the success of this treatment by the commitment of the patient and to address water and fluid enough.

Lubricants Lubricating agents:
Mineral oils (eg liquid paraffin): substances that can not be fixed for the metabolism, function and a protective layer and coated sled to the rectum. But it has side effects including:
 Ceylon (oozing) Anal.
 pneumonia and adipose.
 and poor absorption of fat-soluble vitamins. Therefore not recommended as first-line treatment.

Stimulant laxatives Stimulant laxatives:
Increase the mobility of the intestine and their secretions (see Figure 1), and shows its influence within hours and may cause abdominal cramps (spasms). Of these drugs currently used (see Table 1)

 drugs impact surface (allow water to penetrate and fat mass fecal): docusate Docusate.
 two-Phenyl methane derivatives (bisacodyl Bisacodyl).
 Kudantron Co-danthramer (palliative treatment).
 Senna Senna (senna leaf), and castor oil, and Bekosilvat Alsodoyum, and Alontrakinont (Alkescara Cascara bark a vegetarian).
• Do not documented Balumblynat stimulant because it causes severe diarrhea Mitrkie Cologne, in addition to harm the intestinal muscular plexus, but the data do not support this theory.
• may become infected patients who use stimulant laxatives containing Alontrakinont Palmlan Cologne melanosis coli (pigmentation of the colon). The cause of this pigmentation is the accumulation of remnants of epithelial cells and exposure to phagocytosis by macrophages. Does not lead to the development of melanosis colon cancer, a drug that causes back off.
• may cause excessive use of stimulant laxatives hypokalemia.
• Uses Bekosilvat sodium usually bowel preparation (for surgical work) but it may be beneficial in the treatment of severe chronic constipation, but with medical supervision.

Pantheism laxatives Osmotic laxatives:
Lead laxatives pantheism (see Table 2) to water secretion in the intestine (see Figure 1) to maintain equal tension with the plasma, and thus may need several days to begin their impact. This group includes pharmaceutical certain drugs cheap, but the most effective, in all parts of the country, including the salts Alapsom Epsom salts (magnesium sulfate), which are used widely, but it may cause overload volumetric and Chardy caused by absorption of sodium, or magnesium, or phosphorus in patients with renal insufficiency or cardiac failure.
Also, the drug to Aktuluz Lactulose, which is a saccharide pairs of non-absorption, which is metabolized by intestinal bacteria-mediated, but may lead to an uncomfortable swelling in the abdomen.
It is noteworthy that excessive intake of laxatives can cause dehydration pantheism or spasmodic abdominal pain.
Been the development of polyethylene glycol with a high molecular weight, and became a PEG-3350 does not contain any salts in the composition may be absorbed, as it is non-toxic. Although it was used mainly to prepare the bowel for surgery, endoscopy and radiology tests, but it may be useful in the treatment of constipation (Movicol).

Kinetic treatment Prokinetic drugs:
Lead cholinergic drugs, such as neostigmine and Albethanicol, to increase the alarm of the cholinergic smooth muscles in the intestine. And help address the Albethanicol 25-50 mg / 3-4 times a day to relieve constipation caused by the use of tricyclic antidepressants, TCA, while neostigmine is usually used in the treatment of obstructive Cologne is false, but we do not have enough data about use in the treatment of chronic constipation is rarely used .

In fact, there is no clear evidence proving the effectiveness of such drugs in the treatment of chronic constipation.
In some cases, lead erythromycin (antibiotic) to the significant improvement of the motor through incitement, although the effectiveness of the medium in most cases.

Synergistic treatment Combination therapy:
In case of intractable chronic constipation resort to doses higher than usual doses may also resort to address the synergistic participation of several different factors, most common of these posts: the use of bran, laxatives Atelin poly glycol, laxatives and pantheism and other factors.

Table 1 shows the drugs used in the treatment of constipation

1 - the bran and the factors inflated to block:
- Bran Bran.
- Peel Alasbagula Ispaghula husk.
Sterculia.
- Methyl cellulose Methylcellulose.

2 - Slipway factors:
- Liquid paraffin. Liquid paraffin

-3 Laxatives:
Osmotics Huloolis laxatives include:
 candy a few absorption: the Aktuluz lactulose, sorbitol Sorbitol, mannitol Mannitol.
 salt products: salts, magnesium salts of magnesia, sulphate sulphate, phosphate poly ethylene glycol, polyethylene glycol phosphate.

Stimulant laxative Stimulants include:
 impact surface: docusate Docusates, bile salts Bile salts.
 Alontrakinont: Alkescara. Cascara
 two-Phenyl methane derivatives: bisacodyl Bisacodyl.
 castor oil Castor oil.
 Senna Senna.


Faecal impaction Faecal impaction:
Treated in children and adults with: enemas, suppositories, manual displacement of the feces, intestinal irrigation complete solutions for intestinal irrigation, poly glycol Aataln 3350-PEG or surgery.
The episodes dealt with through adequate dietary intake of bran in addition to the use of laxatives to induce regular bowel movement.

Children Children:
There is insufficient information for the management of constipation in children, so I usually have treatment options are similar to those used in adults. Few have the intake of fiber in addition to the role of modern foods play a role in aggravating the problem in children. And can use the newly Aataln poly glycol 3350 in children Studies have shown its safety and effectiveness, and other factors Vdilth Khdroxad Allaktuluz and magnesium.

In pregnancy are advised to:
• fecal softeners may be used due to safety, with a preference to avoid laxatives as possible.
• bran and inflated to block laxatives Laxatives are physiological and safe during pregnancy.
• Avoid salt osmotic laxatives (magnesium salts) of the impact of retention is desirable for water and sodium.
• You can use the stimulant laxatives, osmotic laxatives, and other (poly Aataln glycol, to Aktuluz, sorbitol, bisacodyl, and senna leaf) and the best Atelin poly glycol.
• castor oil should be avoided because it induces the contraction of the uterus and therefore had a child is born premature.

Baltgaym reflux treatment is vital:
• can be applied to bio-feed only Abralousel recurrent anorectal and that did not support yet in the United Kingdom, a process that seeks to correct inappropriate contraction of the muscles of the pelvic floor muscle and external winepress during defecation.
• The application in constipation resulting from disorders of defecation allows patients to observation and receive visual or auditory cues, or both, affect the performance of the winepress anal muscle and the muscles of the pelvic floor.
• This type of therapy to train patients to relax the pelvic floor muscles during stress and coordinated with abdominal exercises to help pass the stool toward the rectum.
• You can make this feed with the planning of electrical muscle anal or rectal catheter to measure pressure. Studies have shown that the success rate of feed of 67% bio-reflux despite the lack of available data, and appears to be useful in the long term.


Surgery Surgery:
Only surgical treatment in constipation Almand on the following cases:
 blocked the exit.
 the laziness of the intestine.
 Hrhpring disease Hirschsprung's disease.
 in patients with defecation disorders.

And is resorting to surgical treatment after the failure of drug therapy.
Measures will vary depending on the case of surgical procedures, such measures are: the eradication of colon, rectal and ileal anastomosis, and ileostomy, and eradication hyperbolic.

Be used for rectal surgery in the following cases:
 When a rectocele.
 When women suffer from difficulties in defecation and benefited from the application of finger pressure vaginal.


Conclusion Conclusion:
Figure 1 shows a summary of the management of constipation.
 to increase fluid intake with increased physical activity: the role of the two little in the treatment of chronic constipation, except cases that have been caused by dehydration of the patient.
 to increase fiber intake in patients with constipation or normal transit is slow and this increase through redundant fiber diet or fiber Maadhat business.
 If no response give laxatives osmolarity (osmotic) Hdroxad suspensions such as magnesium, sorbitol, to Aktuluz, PGE 350, and other doses vary from patient to patient.
 If the patient has severe constipation does not respond to fiber or laxatives, then give the osmolarity colonic stimulant laxatives such as bisacodyl bisacodyl, senna or derivatives senna.
 use of specialized centers for treatment and when the motor failed drug use to participate.
 when pregnant women start treatment with laxatives, bran and mass, if the resort fails to PEG, or Aktuluz or bisacodyl, or share them.
 can be re-training of patients with defecation disorders on the process of emptying using dynamic recurrent Baltgaym.
 If the patient has severe disruptions in the bowel, it usually does not respond to oral laxatives without taking relatively high doses, causing diarrhea harmful aquatic.
 Rarely the patient needs surgical treatment, however, surgery is a good option in patients with selective assessed anatomically and physiologically, and radiologically in detail in specialized centers.