#GIT
#Constipation approach :
āĻĒā§āϰāĻĨāĻŽā§ āĻĻā§āĻā§ āύā§ā§āĻž āĻāĻāĻž constipation āĻāϰ criteria fulfill āĻāϰ⧠āĻāĻŋāύāĻžāĨ¤
āĻāĻāĻž āĻšāϤ⧠āĻĒāĻžāϰ⧠functional (80%)
âāĻ āύā§āĻ āĻĻāĻŋāύ āϧāϰ⧠āϏāĻŽāϏā§āϝāĻžāĨ¤ fever,wt loss,anaemia,per rectal bleeding āύāĻžāĻ
āĻšāϤ⧠āĻĒāĻžāϰ⧠organic cause(20%)
--features of obstruction,wt loss,anaemia,fever,per rectal bleeding āĻĨāĻžāĻāϤ⧠āĻĒāĻžāϰā§āĨ¤
āϝāĻĻāĻŋ functional āĻšā§ āĻšāϤ⧠āĻĒāĻžāϰ⧠āĻ
Normal Transit constipation (IBS Type)
āĻāĻĻā§āϰ defecation frequency normal. Dx criteria â
(āύāĻŋāĻā§ āĻāĻŦāĻŋ āĻĻā§ā§āĻž āĻāĻā§)
Slow Transit constipation
(Young aged female, 5- 6 āĻĻāĻŋāύ āĻĒāϰ āĻĒāϰ āĻā§āϞā§āĻ āĻšā§,
āĻā§āϞā§āĻā§āϰ āĻā§āύ urge āĻĨāĻžāĻā§ āύāĻž, hard, dry stool)
Pelvic floor dyssynergia
(Straining āĻĨāĻžāĻā§,persistent urge āĻĨāĻžāĻā§, hard pillet shape stool,āĻŽāĻžāĻā§ āĻŽāĻžāĻā§ manual evacuation āĻāϰāϤ⧠āĻšā§)
Functional āĻā§āϞāĻžāĻā§ āĻāĻŋāĻāĻžāĻŦā§ differentiate āĻāϰāĻŦ?
1 āĻāĻž sign āĻāϰ 1āĻāĻž symptom
Urge āĻā§āĻŽāύ āĻ
Normal transit â normal urge
Slow transit â no urge(almost)
Pelvic floor dyssynergia- persistant urge
DRE:
āĻĒā§āĻļā§āύā§āĻ bear Down āĻāϰāϞ⧠anal sphincter paradoxically contract āĻāϰāϞā§ā§ˇā§ˇā§ˇ āĻāĻāĻž pelvic floor dyssynergia
Secondaary āĻāĻŋāĻā§ causes :Hypothyroid, hypercalcemia, DM. Slow transit constipation āĻāϰ āύāϤ feature āύāĻŋā§ā§ āĻāϏāϤ⧠āĻĒāĻžāϰā§āĨ¤
#Management
IBS type constipation /Slow transit constipation
Non pharmacological: (Common for all)
Lifestyl change
Regular food habit
āĻĒāϰā§āϝāĻžāĻĒā§āϤ āĻĒāĻžāύāĻŋ,āĻļāĻžāĻ āϏāĻŦāĻāĻŋ(20-40g/day) āĻāĻžāĻŦā§
āϞāĻžāĻāĻĢ style modifications, Wt loss āĻāϰāϤ⧠āĻšāĻŦā§āĨ¤
Gastro-colic reflex āĻā§ āĻāĻžāĻā§ āϞāĻžāĻāĻžāĻŦā§āĨ¤
āĻāĻžāĻŦāĻžāϰā§āϰ 20- 30āĻŽāĻŋāύāĻŋāĻ āĻĒāϰ āĻā§āϞā§āĻā§ āĻŦāϏ⧠āĻĨāĻžāĻāĻŦā§ 5- 10 āĻŽāĻŋāύāĻŋāĻ āϏāĻāĻžāϞ⧠āĻāĻŦāĻ āϰāĻžāϤā§( mainly slow transit constipation āĻ āĻāĻžāϞ benifit āĻĒāĻžāĻā§āĻž āϝāĻžā§)
1 āĻŽāĻžāϏ āĻĒāϰ if Not improved
âpharmacoloical treatment
synthetic bulk forming agent[Ispaghula husk(āĻā§āϏāĻŋ)⧎ ]
āĻāĻŋāĻāĻžāĻŦā§ āĻāĻžāĻŦā§āύ: āĻāĻ āĻā§āϞāĻžāϏ āĻĒāĻžāύāĻŋāϰ āϏāĻžāĻĨā§ 1 sachet āĻā§āϏāĻŋ āĻŽāĻŋāĻļāĻŋā§ā§ āϏāĻžāĻĨā§ āϏāĻžāĻĨā§ āĻā§ā§ā§ āĻĢā§āϞāϤ⧠āĻšāĻŦā§āĨ¤ āĻŦā§āĻļāĻŋāĻā§āώāύ āĻā§āϏāĻŋ āĻĒāĻžāύāĻŋāϰ āϏāĻžāĻĨā§ āĻāĻŋāĻāĻŋā§ā§ āϰā§āĻā§ āĻā§āϞ⧠āĻāĻžāĻ āĻšāĻŦā§ āύāĻž āϤā§āĻŽāύāĨ¤ āĻāĻžāϰāύ āϏ⧠already āĻĒāĻžāύāĻŋ absorb āĻāϰ⧠āĻŦāϏ⧠āĻĨāĻžāĻāĻŦā§ gut āĻ āĻāĻŋā§ā§ āĻāϰ āĻĒāĻžāύāĻŋ absorb āĻāϰāϤ⧠āĻĒāĻžāϰāĻŦā§ āύāĻžāĨ¤
âif not improved
Osmotic laxative (lactulose)
Syp.avolac 6tsf @night or 3/4 tsf tds
âIf not improved
Cl channel activator (lubiprostone)- Gut āĻ āĻĒāĻžāύāĻŋ āϧāϰ⧠āϰāĻžāĻāĻŦā§-stool āĻā§ soft āĻāϰāĻŦā§
Tab.lubigut 24mcg 1+0+1
âif not improved
5HT4 agonist(Prucalopride) -Colon āĻāϰ motility āĻŦāĻžā§āĻžāĻŦā§
tab.caloprid 1 or 2mg 0+0+1
āĻāĻ āĻĒāϰā§āϝāύā§āϤ āĻāĻ āĻāĨ¤ IBS type /slow transit type āĻāϰ āĻā§āώā§āϤā§āϰā§āĨ¤
âif not improved
In IBS variety constipation :
Tab.Duloxatine 30-60mg 0+0+1
Abdominal boating āĻĨāĻžāĻāϞā§:
Gluten free food(āĻŦā§āĻāĻžāϰāĻŋ āĻāĻžāĻŦā§ āύāĻž)
Tab.Rifagut 600mg daily -14 days
In slow transit constipation :
Stimulant drug(Bisacodyl)
Tab.Duralax 5mg 0+0+1 āĻāϰ āĻĒāϰ āĻ āĻāĻžāϞ āύāĻž āĻšāϞā§
tab.Neostigmine āĻāϰāĻĒāϰāĻ āĻāĻžāϞ āύāĻž āĻšāϞ⧠surgery
In pelvic floor dyssynergia :
Biofeedback mechanism apply āĻāϰāĻŦā§ (āĻāĻžāϞ outcome)
Constipation āϝāĻĻāĻŋ secondary āĻā§āύ cause āĻŦāĻž obstructive pathology(stricture/mass lesion/fissure/harmirrhoid) āĻāϰ āĻāύā§āϝ āĻšā§ āĻ
Management :Treatment of the cause
Digest medicine đ