Manuel Francisco T. Roxas, MD, FPCS, FPSCRS, FACS
CONSTIPATION• 95% of US adults
– Bowel movement between 2x daily to once every 2 days
(Bartolo, 1992)
• Prevalence of constipation in the US– 2 to 34% of population– 40% among elderly (Talley, 1993,
1996)
The Colon• Function
• Colon– Absorption of water
and electrolytes– Repository of Bacteria
flora
• Rectum– Storage and
defecation
• Anus– Continence– Defecation
Normal Intestinal Transit
Intestinal Segment
Hours
Oral-Cecal 6
Right colon 12
Left colon 12
Sigmoid colon 12
Overall, normal mean colonic transit time is 36 hours, but the range is wide
Colonic Innervation• Intrinsic/Enteric
Nervous system– Myenteric neuronal
plexuses regulate smooth muscle function and motility
– Aganglionosis causes constipation
• Extrinsic Nervous System– Parasympathetic
autonomic innervation• Supplied by vagus and
sacral (S2-4) nerves• Excitatory to gut
– Sympathetic autonomic innervation• Along the mesenteric
vessels• Excitatory to sphincters• Inhibitory to non-
sphincteric smooth muscles
The Sphincter Muscles of the AnusLevator ani
Form pelvic floor
External SphinctersVoluntary Comprised of:
Puborectalis sling Deep Superficial
Internal SphinctersInvoluntaryContinuation of circular
muscles of rectum
Anorectal PhysiologyContinence involves
Detection of rectal contentsDiscriminationVoluntary and subconscious
retentionControlled expulsion
Anorectal Physiology
HEMORRHOIDAL CUSHIONS
Anorectal PhysiologyRecto-anal inhibitory reflexAnal sampling reflexGastro-colic reflex
Paradoxical puborectalis contraction
Developmental Milestones in Infancy
Walk – 12 monthsSpeak 2 words other
than mama and papa – 12 months
Run – 15 monthsToilet train – 36
months
CONSTIPATIONRome Definition:• 2 or more of the
following complaints for at least 12 months, without laxatives– Straining during >
25% of BM– Sensation of
incomplete evacuation on > 25% of BM
– Hard or pellety stools on > 25% of BM
– < 3 stools per week
Common Causes of Constipation• Primary
– Idiopathic slow transit/colonic inertia
– Irritable bowel syndrome
– Functional pelvic outlet obstruction
• Secondary– Endocrine/metabolic
• Hypothyroidism• Hypercalcemia
– Neurologic• Parkinson’s disease• Multiple sclerosis• Autonomic neropathy• Spinal cord injury• Sacral parasympathetic
nerve injury– Psychiatric
• Depression• Anorexia nervosa
Common Causes of ConstipationPhysical gastrointestinal causes
DiverticulosisStricturePolyps CancerIschemia
1st Line Treatment of Constipation
Increase dietary fiberBulk laxatives like psyllium
Normal Frequency of Bowel Movement in Children
Age BM per day
0 – 3 months
breast-fed 2.9
formula-fed 2.0
6 – 12 months 1.8
1 – 3 years 1.4
> than 3 years 1.0
Fontana MB, et al 1987
Constipation in ChildrenDefinition
Delay or difficulty in defecation present for 2 or more weeks
Functional constipationConstipation without objective evidence of a
pathologic conditionFecal impaction
Hard mass in the lower abdomen identifiedDilated rectum filled with large amounts of stoolExcessive stool in the colon on abdominal
radiography
Possible Causes of Constipation in ChildrenNonorganic
Developmental Cognitive handicaps Attention deficit disorders
Situational Coercive toilet training Toilet phobia School bathroom avoidance Excessive parental
intervention Sexual abuse
DepressionConstitutional
Colonic inertia Genetic predisposition
Possible Causes of Constipation in ChildrenReduced stool volume and
dryness Low fiber diet Dehydration Underfeeding or
malnutritionDrugs
Opiates Anticholinergics Antidepressants Anticonvulsants
Others Heavy metal (lead) ingestion Vitamin D intoxication Cow’s milk protein
intolerance
Possible Causes of Constipation in ChildrenOrganic
Anatomic malformation Imperforate anus Anal stenosis Anteriorly displaced anus Pelvic mass (sacral teratoma)
Metabolic and gastrointestinal Hypothyroidism Hypercalcemia Hypokalemia Cystic fibrosis Diabetis mellitus Multiple endocrine neoplasia Gluten enteropathy
Possible Causes of Constipation in ChildrenOrganic
Neuropathic conditions Spinal cord abonormalities Spinal cord trauma Neurofibromatosis Static encephalopathy Tethered cord
Abnormal abdominal musculature Prune belly Gastroschisis Down syndrome
Connective tissue disorders Scleroderma Lupus Ehlers-Danlos Syndrome
Possible Causes of Constipation in ChildrenOrganic
Intestinal nerve or muscle disorders Hirschprung disease Intestinal neuronal
dysplasia Visceral neuropathies Visceral myopathies
Management of Constipation in Children
Thorough history and PEFecal occult blood in all infants and in children
with abdominal pain, failure to thrive, diarrhea, or a family history of colorectal polyps or cancer
Abdominal x-rays in selected patients to diagnose fecal impaction
Rectal biopsies and manometry are the only tests that can reliably exclude Hirschprung disease
Transit time studies in selected patients to determine if truly consipated
PE findings distinguishing organic from functional constipation in children
Failure to thriveAbdominal distentionLack of lumbosacral curvePilonidal dimple covered by
a tuft of hairMidline pigmentary
abnormalities of the lower spine
Sacral agenesisFlat buttocksAnteriorly displaced anusPatulous anusAbsent anal wink
Tight, empty rectum in the presence of a palpable abdominal fecal mass
Gush of liquid stool and air on withdrawal of examining finger
Occult blood in stoolsAbsent cremasteric reflexDecreased lower extremity
tone and/or strengthAbsence of delay in
relaxation phase of lower extremity deep tendon reflexes
Management of Constipation in Children
In InfantsRectal disimpaction with glycerine
suppositoriesAvoid enemasMineral oil and stimulant laxatives not
recommendedJuices containing sorbitol (prune, pear, and
apple, corn syrup, lactulose and sorbitol (osmotic laxatives) may be used
Management of Constipation in Children
In ChildrenDisimpaction with oral and rectal medications ,
including enemasBalanced diet with whole grain, wheat, fruits
and veggiesMineral oil, magnesium hydroxide, lactulose
and sorbitol are safe to useMedication and behavioral management may
decrease time to remissionBio-feedback may be effective short-term
treatment
Fecal Incontinence“frequent and
inadvertent voiding per anum of formed stool”
“loss of anal sphincter control resulting in unwanted release of gas, liquid or solid stool”
Fecal Incontinence
GradeI – incontinent to gasII – incontinent to gas and liquid, but not to
solid BMIII – incontinent to all types of BM, including
solid BM
Fecal IncontinenceCommon Causes
Sphincter injury related to birth traumaNeuropathic causes
Pudendal neuropathy or injury Auntonomic neuropathy or injury
Anatomy of the Anorectum
Upper
Mid
Lower
Upper Anal Canal
Mid Anal Canal
Low Anal Canal
There is a defect in the external sphincter between 1 O'clock and 3 O'clock (arrow). The normal external anal sphincter is shown (arrowhead).
There is a defect in the anterior portion of the external anal sphincter with an anterior anal fistula (arrow). The tiny focus of increased reflectivity is from gas within pus in the fistula track.
Management of Fecal IncontinenceDetermine and treat primary cause
Medical TreatmentDietary modification (high fiber, less fat)Fiber supplements (psyllium)Anti-diarrheals (loperamide)Pelvic floor exercises / biofeedback
Management of Fecal Incontinence
Surgical TreatmentDirect sphincter repairMuscular flapsArtificial sphincters
Among the various disciplines of Surgery,
the most philosophical is that of Colorectal Surgery
For no one else is as deeply contemplative
Of the End of Man
Fr. Miguel Bernad, SJ
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