Chapter 040. Diarrhea and Constipation (Part 17) ppsx

Chapter 040. Diarrhea and Constipation (Part 17) Constipation: Treatment After the cause of constipation is characterized, a treatment decision can be made. Slow-transit constipation requires aggressive medical or surgical treatment; anismus or pelvic floor dysfunction usually responds to biofeedback management (Fig. 40-4). However, only ~60% of patients with severe constipation are found to have such a physiologic disorder (half with colonic transit delay and half with evacuation disorder). Patients with spinal cord injuries or other neurologic disorders require a dedicated bowel regime that often includes rectal stimulation, enema therapy, and carefully timed laxative therapy. Patients with slow-transit constipation are treated with bulk, osmotic, prokinetic, secretory, and stimulant laxatives including fiber, psyllium, milk of magnesia, lactulose, polyethylene glycol (colonic lavage solution), lubiprostone, and bisacodyl. Newer treatment aimed at enhancing motility and secretion may have application in circumstances such as constipation-predominant IBS in females or severe constipation. If a 3- to 6-month trial of medical therapy fails and patients continue to have documented slow-transit constipation unassociated with obstructed defecation, the patients should be considered for laparoscopic colectomy with ileorectostomy; however, this should not be undertaken if there is continued evidence of an evacuation disorder or a generalized GI dysmotility. Referral to a specialized center for further tests of colonic motor function is warranted. The decision to resort to surgery is facilitated in the presence of megacolon and megarectum. The complications after surgery include small-bowel obstruction (11%) and fecal soiling, particularly at night during the first postoperative year. Frequency of defecation is 3–8 per day during the first year, dropping to 1–3 per day from the second year after surgery. Patients who have a combined (evacuation and transit/motility) disorder should pursue pelvic floor retraining (biofeedback and muscle relaxation), psychological counseling, and dietetic advice first, followed by colectomy and ileorectosomy if colonic transit studies do not normalize and symptoms are intractable despite biofeedback and optimized medical therapy. In patients with pelvic floor dysfunction alone, biofeedback training has a 70–80% success rate, measured by the acquisition of comfortable stool habits. Attempts to manage pelvic floor dysfunction with operations (internal anal sphincter or puborectalis muscle division) have achieved only mediocre success and have been largely abandoned. FURTHER READINGS Bartlett JG: Narrative review: The new epidemic of Clostridium difficile- associated enteric disease. Ann Intern Med 145:758, 2006 [PMID: 17116920] Camilleri M: Chronic diarrhea: A review on pathophysiology and management for the clinical gastroenterologist. Clin Gastroenterol Hepatol 2:198, 2004 [PMID: 15017602] Farrell RJ, Kelly CP: Celiac sprue. N Engl J Med 346:180, 2002 [PMID: 11796853] Gadewar S, Fasano A: Current concepts in the evaluation, diagnosis and management of acute infectious diarrhea. Curr Opin Pharmacol 5:559, 2005 [PMID: 16207535] Lembo A, Camilleri M: Chronic constipation. N Engl J Med 349:1360, 2003 [PMID: 14523145] Musher DM, Musher BL: Contagious acute gastrointestinal infections. N Engl J Med 351:2417, 2004 [PMID: 15575058] Wald A: Constipation in the primary care setting: Current concepts and misconceptions. Am J Med 119:736, 2006 [PMID: 16945605] Wald A: Clinical practice. Fecal incontinence in adults. N Engl J Med 356:1648, 2007 [PMID: 17442907] BIBLIOGRAPHY American Gastroenterological Association: Medical Position Statement: Guidelines for the evaluation and management of chronic diarrhea. Gastroenterology 116:1461, 1991 Brandt LJ et al: Systematic review on the management of irritable bowel syndrome in North America. Am J Gastroenterol 97(Suppl):S1, 2002 DuPont HL and Practice Parameters Committee of the American College of Gastroenterology: Guidelines on acute infectious diarrhea in adults. Am J Gastroenterol 92:1962, 1997 [PMID: 9362174] Enck P: Biofeedback training in disordered defecation. A critical review. Dig Dis Sci 38:1953, 1993 [PMID: 8223066] Fine KD, Schiller LR: AGA technical review on the evaluation and management of chronic diarrhea. Gastroenterology 116:1461, 1999 Higgins PD, Johanson JF: Epidemiology of constipation in North America: A systematic review. Am J Gastroenterol 99:750, 2004 [PMID: 15089911] Lembo A, Camilleri M: Chronic constipation. Current Concepts. N Engl J Med 349:1360, 2003 [PMID: 14523145] Proano M et al: Transit of solids through the human colon: Regional quantification in the unprepared bowel. Am J Physiol 258:G856, 1990 Locke GR et al: AGA Medical Position Statement: Guidelines on constipation. Gastroenterology 119:1761, 2000 [PMID: 11113098] Rohner P et al: Etiological agents of infectious diarrhea: Implications for requests for microbial culture. J Clin Microbiol 35:1427, 1997 [PMID: 9163457] Surrenti E et al: Audit of constipation in a tertiary-referral gastroenterology practice. Am J Gastroenterol 90:1471, 1995 [PMID: 7661172] . Chapter 040. Diarrhea and Constipation (Part 17) Constipation: Treatment After the cause of constipation is characterized, a treatment decision can be made. Slow-transit constipation. lubiprostone, and bisacodyl. Newer treatment aimed at enhancing motility and secretion may have application in circumstances such as constipation- predominant IBS in females or severe constipation. . (evacuation and transit/motility) disorder should pursue pelvic floor retraining (biofeedback and muscle relaxation), psychological counseling, and dietetic advice first, followed by colectomy and