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What is the 3/3 rule of constipation?
It is normal to go 3 times per week or 3 times per day or anything in between
What are the 3 Fs?
Fiber, fluid and fun
What are the drugs that can cause constipation
- analgesics and anticholinergics
- antihistamines, antispasmodics, antidepressants, antipsychotics
- Cation containting supplements: iron, calcium, aluminum
- neurally active agents: opioids antihypertensives
What is an Enterocele?
Weakness in the tissue that holds the bowel in place and the bowel falls down behind the uterus and into the vagina
What are some things that can weaken the wall and cause an enterocele?
Straining, manual labor, child birth
What is an anterior rectocele?
Rectum that pushes the wall of the vagina, pelvic floor dysfunction
What are the Alarm symptoms for constipation that might be colon cancer?
- Over 50
- unexplained weight loss
- evidence of GIB
- perisistent or progressive pain
- FH colon cancer
- fasting nocturnal or large volume diarrhea
what are B symptoms
- wt loss
- low grade fever
- night sweats
A Gaping or asymetric anal opening (i.e. a �gaping asshole�) is a sign of what type of disorder?
Neurologic disorder impairing sphincter function
Having the patient strain during the rectal exam is useful for diagnosing patients with what?
Dyssynergic defication, rectal prolapse
How do you do a physical examination for a rectocele?
Have female patient strain with the examining finger oriented anteriorly
In a patient with constipation you can do a barium X ray to identify what 4 disorders
obstruction, megarectum, megacolon, hirshsprungs disease
loss of normal colonic relfexes and sensation
colon that is dialated and the patient is unable to move through the colon, thus they are dependent on more and more laxitives for defecation
- in coordination of contraction of colonic and rectal muscles and internal and external sphincters
- leads to attempts to defecate against closed anal sphincters
- with or without difficulty deficating strain even with soft stools
- on examination they are inable to voluntarily relax the external sphincters on request
- Lifelong constipation
- occasional passage of an enormous formed stool
- causes are congenital (hirschsprung disease) or aquired defects in the intrinsic innervation of the colon
What are some bowel diseases that can cause constipation
IBS, slow colonic transit, pelvic floor dysfunction
what are some neurological conditions that can cause constipation?
Parkinson's, MS, colon surgery, spinal cord injury, diabetes mellitus, pseudo-obstruction
What are some complications of chronic constipation
- urinary obstruction/infection
- spontaneous perforation
- stercolar ulcer � ischemia on bowel wall
- fecaliths- appendix
What anticonstipation medications should be avoided unless nessisary?
Prokinetics, lubricating agents, routine enemas
What medications should be used for constipation
- stool softeners/ bulking agents
- osmotic agents
- stimulating agents
what are some lifestyle/diet modifications that can help constipation
- fiber fluids fun
- D/C or change offending meds if possible
- bowel retraining
- educations and reassurance
What must you give with fiber/bulk laxitives?
How do surfactants work?
Lower stool surface tension and soften so that more water enters more easily not as good as laxatives
What are osmotic agents?
- Non-absorbable agents to promote fluid shift
- intestinal water secretion increases
- increases stool frequency
Name some osmotic agents
PEG, Lactulose, Saline
How do stimulant laxatives work?
Alter electrolyte transit at mucosa and increase motor activity
What is a fecal impaction?
- Large mass of bulky dry hard stool in the rectum secondary to chronic constipation
- watery stool may form higher in the bowel and leak around the impaction causing soiling or diarrhea
What are some complications of fecal impaction
- dilitation- toxic megacolon
- rectal tears
- rectal tissue necrosis
What are some symptoms of fecal impaction?
- Urge to deficate without ability to have a BM
- abdominal pain
- bloated or hard abdomen
- nausea and vomiting
- rectal discomfort
- generally ill feeling
- leakage of wet stool or thin/pencil stool
What is a contraindication to manual disimpaction, suppositories and enemas for fecal impation?
Patients who are myelosuppressed or have altered bleeding times
What are some motility tests that can be done for a patient with chronic constipation
- anorectal manometry
- pelvic floor electromyography
- anal endosonography
Anal fissures found on the sides of the anus are indicative of what diseases?
- Chron's disease
- ulcerative colitis
Anal fissures that are in the verticle plain of the rectum (the top and bottom) are indicative of what?
Acute and chronic anal fissures
Your patient has a tearing pain with defecation and sometimes a throbbing pain following defecation. They also report blood on the toilet paper after they go. You diagnose
blood on toilet paper or stool
- can ulcerate with internal sphincter fibers seen at base
- may develop sentinel pile or sentinel tag
- may require surgery
Which hemorrhoids are painful internal or external
what are some risk factors for hemorrhoids
pregnancy, obesity, chronic diarrhea, loss of muscle tone, chronic constipation, portal hypertension, professions with lots of sitting
First degree hemorrhoids
second degree hemorrhoids
prolapse through anus on straining but spontaneous reduction
Third degree hemorrhoids
Prolapse and may require manual/digital reduction
Fourth degree hemorrhoids
Cannot be reduced just hang out all the time
What are some treatments for internal hemorrhoids
- rubber band ligation
- infrared coagulation
- bipolar diathermy
- laser photocoagulation
Treatment for a bleeding hemorrhoid
Treatment for a iritation and pruritus from a hemorrhoid
analgesic creams hydrocortisone suppositories sitz baths
Treatment for thrombosed hemorrhoids
acute may require surgical intervention if significant symptoms