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Nature's Quick Constipation Cure

The First Step-by-step Plan To Cure Constipation Using A Combination Of Unique All-natural Remedies. This plan uses a strategically organized and ordered combination of the safest and most effective natural remedies for constipation. Everything used in this plan is from natures garden. No use of harmful laxatives. People who have used these swear they work Better than over-the-counter laxatives! Every strategy is carefully researched for safety and effectiveness. Each remedy builds on the last while helping out the next. The plan takes into account human physiology, anatomy, nutrition, metabolic needs and deficiencies while using specific dietary remedies and the almost always neglected but extremely powerful, mechanical remedies. All of these have been carefully planned and refined to provide you the most powerful, synergistic constipation relief plan that will relieve you of even the most stubborn of constipation episodes within as quick as 15 minutes and less than 24 Hours. Read more...

Natures Quick Constipation Cure Overview


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Definitions and Epidemiology of Constipation

Constipation is among the most common gastrointestinal disorders. It is so prevalent, in fact, that it has been considered endemic in the elderly population. In the United States alone, more than 3 million prescriptions are written for cathartics yearly and over 800 million is spent for over-the-counter (OTC) laxatives.1 It is clear that constipation represents a major public health problem. Despite its significant impact, the etiology of constipation remains largely unknown. The variety of symptoms and risk factors associated with constipation suggest that its etiology is likely to be multifactorial. Although epidemio-logic studies cannot establish etiologic relationships, consistent epidemiologic distributions may suggest potential causative risk factors. The more uniform the epidemiologic pattern, the more likely an environmental agent(s) may be contributing to its etiology. Elucidation of the epidemiology of constipation, therefore, is helpful both in suggesting potential...

Etiology of Acquired Colorectal Disease Constipation

Functional constipation is defined by the Rome II Coordinated Committees as a group of functional disorders that present with resistant, difficult, infrequent, or seemingly incomplete defecation.1 Previous definitions have included a regular occurrence (in more than 25 of defecations) of excessive straining, lumpy or hard stools, a sense of incomplete evacuation, a sensation of anorectal obstruction or blockage, or less than three bowel movements per week over at least 12 consecutive weeks in the preceding 2 years. Such disorders may be congenital, as in Hirschsprung's disease, or acquired later in life as a result of lifestyle or behavior, infection, or because of anatomic or physiologic abnormalities (Fig. 3.1). The causes of constipation, even after an exhaustive evaluation, often remain unclear and, in many cases, multifactorial. This chapter discusses the etiology of acquired constipation.

Indications for Testing Constipation

Defecography was initially developed to assess patients with complaints of constipation and a sensation of rectal outlet obstruction. The diagnostic armamentarium has expanded to include anal manometry, electromyography, and colonic transit time studies, all of which are crucial for distinguishing end-organ versus total organ etiologies. Therefore, although the major indication for performing defecography continues to be constipation, other complaints may occasionally warrant defecographic evaluation. Table 9.1 demonstrates the primary indications and their proportionate prevalence among our referred patients. There is considerable overlap in many of these symptoms and diagnoses.

Biofeedback for Constipation

Constipation, with its associated symptoms, is the most common chronic gastrointestinal complaint, accounting for 2.5 million physician visits per year1 with a prevalence of 2 in the United States population.2 Rome II diagnostic criteria for a diagnosis of constipation are specified in Table 13.1.3 After identification and exclusion of extracolonic or anatomic causes, many patients respond favorably to medical and dietary management. However, patients unresponsive to simple treatment may require further physiologic investigation to evaluate the patho-physiologic process underlying the symptoms. Physiologic investigation generally includes colonic transit time study, cinedefecography, anorectal manometry, and electromyography (EMG),4 which allows for definitive diagnosis of treatable conditions including anismus, colonic inertia, rectocele, and sigmoidocele.5 Anismus, also termed pelvic floor dyssyner-gia, spastic pelvic floor syndrome, paradoxical puborectalis contraction, and...

Practical Aspects of Biofeedback Therapy for Constipation

Practical aspects of using biofeedback therapy for pelvic floor muscle (PFM) dysfunction to treat symptoms of constipation and fecal incontinence include the technical, therapeutic, behavioral, and the pelvic muscle rehabilitation (PMR) components. The technical component involves the instrumentation used to provide meaningful information or feedback to the user. There are several technical systems available, and the advantages of any one device have not been scientifically tested. Devices include surface electromyography (sEMG), water-perfused manometry systems, and the solid-state manometry systems with a latex balloon. Although each system has inherent advantages and disadvantages, most systems provide reproducible and useful measurements. The choice of any one system depends on many factors, including cost constipation (Table 13.1) There must be manometric, EMG, or radiologic evidence for inappropriate contraction or failure to relax the pelvic floor muscles during repeated...

Treatment of Constipation

In nature.27 Furthermore, diagnostic data from physiologic testing beyond confirmation of spastic pelvic floor syndrome is often not reported. Patient's concomitant conditions disclose a significant variance in inclusion criteria (e.g., presence of rectoceles, rectal sensory thresholds, previous surgery), which presumably contribute to the success of treatment.27 Park et al28 described two varieties of anismus, anal canal hypertonia, and nonrelaxation of the pub-orectalis muscle that appear to correlate with the success of biofeedback specifically, anal canal hypertonia may be responsible for failure of biofeedback therapy. McKee et al29 concluded that biofeedback for outlet obstruction constipation is more likely to be successful in patients without evidence of severe pelvic floor damage. Biofeedback is a conservative treatment option for patients with idiopathic constipation, although some studies have had less favorable results. The most recent study, by Emmanuel and Kamm22 in...

Botulinum Toxin and Other New Pharmacologic Approaches to Constipation

Much of the medical treatment of constipation is based on pharmacologic intervention using simple bulking agents and laxatives. The growing acceptance of the use of botulinum toxin in the treatment of anal fissure1 has highlighted the diverse clinical use of this agent, and has generated further interest in its use in patients with constipation from functional outlet obstruction.2 This chapter describes the background relating to the therapeutic use of botulinum toxin, its pharmacologic properties, and its use in patients with disordered defecation. We also describe other new pharmacologic agents used in the treatment of patients with chronic constipation such as serotonin (5-hydroxytryptamine) receptor agonists, colchicines, and neurotrophin-3 agonists.

Medical Treatment of Constipation

Constipation is commonly defined as the paucity of bowel movements. However, patients may have constipation regardless of the number of bowel movements in a unit of time. The inability to satisfactorily evacuate one's colon and rectum can be manifested by different degrees of abdominal discomfort associated with normal bowel habits, infrequent stools, or even overflow diarrhea. In addition, many other abdominal complaints are related to constipation, including pain syndromes, bloating, fullness, and even heartburn and dyspepsia. It is not unusual for patients referred for constipation to present to the specialist having had at least one (and possibly multiple) full anatomic evaluation(s) of the bowel, including computed tomography (CT) scans, contrast studies, and colonoscopies. The reported results of these studies are usually normal, except for varying degrees of diverticulosis coli. Usually, a careful history suffices to reveal the underlying problem. Issues to be addressed in the...

Psyllium Bran and Other Herbs for Constipation

Psyllium is an herb used to relieve constipation. It is of potential importance to people with MS because constipation is a relatively frequent symptom of the disease. Clinical studies have shown that psyllium effectively treats constipation. Unlike most other herbs, psyllium is approved by the FDA. It is referred to as a bulk-producing laxative because it increases in size, or bulk, when it comes in contact with water. Psyllium, probably the most popular bulk-producing laxative, is used daily in some form by approximately four million Americans. Other herbal therapies are available for constipation. One source of fiber is bran, the outer coat of grains, including wheat, oats, and rice. Bran may be consumed as a breakfast cereal, in tablet form, or as crude fiber. Other fiber-rich foods include apples, citrus fruits, and beans. Other herbs that appear to be effective for relieving constipation and are generally safe for short-term use (1 to 2 weeks) include buckthorn, cascara, castor...

Recurrent Constipation

The incidence of recurrent constipation varies quite considerably in the literature. This measure is an important end point for success after colec-tomy. The definition of constipation used after colectomy is variable and may contribute to the wide range reported the definition of Drossman et al,27 most commonly used elsewhere in the literature (two or fewer stools per week and or straining at stool more than 25 of the time) is often not followed after colectomy. Knowles and colleagues24 reported a median constipation rate of 9 (range 0-46 ) from 15 series. It is difficult to identify the precise reasons for these wide variations but several factors may be relevant. Follow-up time is important since function after subtotal colectomy may deteriorate with time. Selection criteria for surgery may explain some differences. It is possible that in some series in which objective evidence of slow-transit constipation was not obtained in all cases, patients with irritable bowel syndrome and...

Extracolonic Causes of Constipation

In clinical practice, it is commonly accepted that fiber therapy and stool-bulking agents are the main therapeutic agents of choice in the initial management of primary constipation.1 Several clinical trials have been performed on the effects of fiber therapy and constipation. Meta-analyses of these trials have had discordant conclusions. In one study, a total of seven double-blind, placebo-controlled trials were analyzed five of the studies resulted in improvement in overall symptoms, an increase in fecal weight and frequency, and decreased transit time.2 However, another meta-analysis reviewed 13 clinical trials, and only four found beneficial results. Moreover, the improvements noted were in several nonspecific outcomes, such as ease of stool passage and frequency of satisfaction with bowel movements, and no significant improvement was noted in the more specific symptoms such as stool frequency, abdominal pain, and bloating.3 Reviews of fiber therapy have pointed out that the most...

Associated Constipation

A careful history in patients with rectal prolapse indicates that between 30 and 45 of women suffering from full-thickness rectal prolapse have constipation.2-8 Often there is a history of incomplete rectal evacuation. It is more common, however, to elicit a history of fecal incontinence in patients with rectal prolapse, as approximately 70 of women with a full-thickness rectal prolapse suffer bowel

Constipation Caused by Dysfunction of the Pelvic Floor Muscles

It is acknowledged that in a proportion of patients with chronic constipation, the symptoms are due to obstructed defecation caused by dysfunction of the pelvic floor musculature.2 Initially labeled as puborectalis syndrome11 but also In patients with chronic constipation and pelvic floor dysfunction, injecting botulinum toxin into the puborectalis muscle weakens or paralyzes the overactive muscle and causes straightening of the anorectal angle to allow easier defecation. It was first used in patients with obstructed defecation in 1988 by Hallan and colleagues.13 In their study, seven patients with obstructed defecation diagnosed using electromyographic (EMG) studies and dynamic proctography, received botulinum toxin injection to the puborectalis muscle. Taking an empirical dose of 3 ng botulinum toxin (approximately equivalent to 60 U of Botox), four patients derived benefit from the treatment. This finding was based on symptom questionnaires as well as a reduction in the maximum...

Constipation After Rectopexy in Patients Who Have Had No Apparent Constipation Beforehand

Factors that seem to increase the risk of constipation for the first time after rectopexy are age under 40, the use of mesh, anterior rectopexy, avoidance of resection, and the use of an open operation as opposed to laparoscopic rectopexy and division of the lateral stalks.22 The problem with postoperative constipation after rectopexy is that it is very difficult to predict who will become constipated and thus in whom concomitant resection would be justified. To help avoid disappointed patients, it is crucially important to warn patients that rectopexy might conceivably precipitate or exacerbate constipation. Similarly, they should have these same expectations about new or preexisting fecal incontinence.

Initial Evaluation of Constipation

Constipation is a common and subjective symptom that can be related to a multitude of factors, including, dietary, psychological, cultural, anatomic, and functional aspects. In addition, constipation is still surrounded by misconceptions and taboos that hamper an objective evaluation and encourage self-medication that is not always innocuous to the patient. The definition of constipation varies tremendously among both patients and physicians. When adults not seeking health care were asked to define constipation, their most frequent definitions included straining (52 ), hard stools (44 ), infrequent stools (32 ), as well as terms such as abdominal discomfort and sense of incomplete evacuation.1 According to Ruben,2 62 of the general population believes that a daily bowel movement is a sign of good health they may report constipation if they fail to achieve a daily bowel movement or even if they fail to achieve a bowel movement at their usual time each day. Definitions used by...


Defining Characteristics (Specify inability to feel urge to defecate, fecal impaction, hard, dry formed stool, locomotion impairment, inability to exert force necessary to defecate, painful defecation, mental retardation, poor and sphincter tone, paralysis, autonomic dysreflexia.) Goal Client will obtain relief from constipation by (date and time to evaluate). Outcome Criteria V Resolution of constipation with establishment of pattern of soft formed stool elimination depending on age (specify). V Bowel elimination alteration (constipation) relieved and return of preoperative or prehospitalization pattern (describe). NOC Bowel Elimination Provides information that indicates baseline parameters for comparison frequency varies among children depending on age and foods ingested, but may be as few as 3 to 5 day in infant, as few as 6 week in child less than 3 years of age, and few as 4 week in older child presence of constipation may be associated with disorders in children that lead to...

Epidemiology Incidence

It is difficult to estimate the incidence of this common disorder because of the widespread availability of OTC therapies. The overwhelming majority of patients self-medicate when they initially develop symptoms of constipation, making it difficult to capture these individuals at the time they initially develop constipation. Since incidence defines the number of new cases per specified time period, it is essential to determine the frequency and time frame of new cases. Two studies have provided estimates of the incidence of constipation. Talley and colleagues6 observed onset rates of 40 1000 person-years when resurveying white residents of Olmsted County a median of 15 months after an initial survey of the same population. The corresponding constipation symptom disappearance rate was 309 1000 person-years. A study by Everhart et al10 showed that over a 10-year period between the first National Health and Nutrition Examination Surrey (NHANES I) and National Health and Nutrition...

Decontamination Cathartics

Use Most organic and inorganic materials, ASA, acetaminophen, barbiturates, glu-tethamide, phenytoin, theophylline, TCAs. Dose Early (within 1-4 hours) administration of a flavored 8 1 water slurry, 10 1 AC drug, 1-2 g kg body weight (bw). Side effects Vomiting, aspiration, diarrhea, later constipation, possibly small bowel obstruction (SBO) AC is usually combined with a cathartic, particularly 70 sorbitol preferred over Mg citrate.

Patients Seeking Health Care

A number of studies have utilized health care databases to examine various aspects of the epidemiology of constipation. Although these databases have been used at times to provide estimates of the prevalence of constipation, they are not true population-based data sources. These data sources may be biased and underestimate the true prevalence of constipation because entrance is dependent on health care seeking. Since a large proportion of patients with self-reported constipation self-medicate rather than seek health care for their constipation, they would never be included in a health care data-base.12'17'23 Nevertheless, studies from individuals seeking health care are still helpful in examining the demographic distributions of constipation because there are not likely to be any systematic differences among individuals who self-medicate and those who seek medical attention for their symptoms of constipation. Referral population studies are beneficial in corroborating the demographic...

Gender Ethnicracial And Life Span Considerations

Approximately one to two out of four patients with allergic purpura have GU symptoms such as dysuria and hematuria. Other symptoms include headaches fever peripheral edema and skin lesions accompanied by pruritus, paresthesia, and angioedema (swelling of the skin, mucous membranes, or organs). Other patients describe severe GI symptoms (spasm, colic, constipation, bloody vomitus, bloody stools) and joint pain.

Diseases Associated with Hirschsprungs Disease

Congenital anomalies associated with HD have been reported from various series and have an overall incidence of about 14.7 in 2856 patients.31 Down syndrome is the most common chromosomal abnormality associated with HD, and the genetic modifiers have been located on chromosome 21q 22.32 The diagnosis of HD in Down syndrome is often delayed because other associated anomalies take precedence and because constipation is often present in these patients due to hypotonia and hypothyroidism.

Anatomic Abnormalities

Anatomic alterations of the colon, rectum, and anus may also cause constipation. These problems can be divided into disorders associated with obstruction, either mechanical or functional, above the level of the pelvis or at the level of the pelvis, and disorders of transit with increased length of the colon. While functional colonic motility may be normal in the individual with constipation, the mechanical obstruction of the passage of stool by extrinsic or intrinsic causes may have an important role.

Primary Nursing Diagnosis

Encourage the patient to urinate, but avoid catheterization and the use of suppositories. Postoperatively, a bulk laxative or stool softener is often prescribed on the day of the surgery. Intramuscular injections of analgesics are given to control pain. Assess the perirectal area hourly for bleeding for the first 12 to 24 hours postoperatively. When open fistula wounds are left, as in a fistulotomy, the anal canal may be packed lightly with oxidized cellulose. PATIENT TEACHING. Teach the patient how to keep the perianal area clean teach the female patient to wipe the perineal area from front-to-back after a bowel movement in order to prevent genitourinary infection. Teach the patient about the need for a high-fiber diet that helps prevent hard stools and constipation. Explain how constipation can lead to straining that increases pressure at the incision site. Unless the patient is on fluid restriction, encourage him or her to drink at least 3 L of fluid a day.

Discharge And Home Healthcare Guidelines

Explain the need to remain on a diet that will not cause physical trauma or irritation to the perirectal area. A diet high in fiber and fluids will help soften the stools, and bulk laxatives can help prevent straining. Emphasize to the patient the need to avoid spicy foods and hot peppers to decrease irritation to the perirectal area upon defecation.

Physiologic Abnormalities

Other than the anatomic and functional causes of constipation described above, a host of other, less common medical problems may present with constipation. Systemic illness such as diabetes mellitus, multiple sclerosis, hypothy-roidism, hypopituitarism, and porphyria may cause or exacerbate constipation. Neurologic disorders, including brain and spinal cord neoplasms, central nervous system trauma, and Parkinson's disease, are known to be associated with constipation, significantly altering the quality of life.

Diseases That Lead to an Increased Risk of Kidney Failure

Potassium deficiency is another cause of kidney failure, though it is uncommon. Kidney function decreases in severe potassium deficiency and may never recover. Chronic diarrhea or overuse of laxatives can induce chronic potassium deficiency and renal failure. The ability of the kidneys to produce highly concentrated urine, and to decrease the output of urine in response to dehydration is characteristically impaired in patients with potassium deficiency, so these patients tend to excrete large volumes of urine (despite their reduced kidney function). Replenishing potassium stores usually restores kidney function, but not always. Laura Melton came to Johns Hopkins at the age of 56. She told us that in order to lose weight, she had been taking laxatives every day for 30 years and still takes 2 to 3 pills daily. She had first exhibited urinary protein in an exam 11 years earlier. Three years before, she had 500 mg per day of urinary protein (normal urinary protein amounts to less than 150...

Health Benefits of Complex Carbohydrates

In the treatment of diabetes and hyperlipidemia and the latter in the treatment of gastrointestinal problems such as constipation, diverticulitis and may even be protective against bowel cancer. The fiber era in the United States began with a paper by Burkitt, Walker and Painter (9) which summarized the view that a high fiber diet prevented or protected against the disease conditions most prevalent in this country. Heaton (33) has pointed out that dietary fiber exerts its effects throughout the length of the gastrointestinal tract. In the mouth it stimulates salivary flow and in the stomach it dilutes the contents and prolongs storage. In the small intestine fiber is a diluent of the contents and delays absorption and in the large intestine it acts as a diluent, bacterial substrate and traps water. Finally, dietary fiber softens and enlarges the stool. To expand on some of the above, constipation is relieved by the addition of fiber to the diet, the most effective fiber being wheat...

Physiological Factors Metabolic

Measurement of serum electrolytes is an important diagnostic modality in evaluating patients who present with constipation. It is known that electrolyte abnormalities such as hypokalemia, hypo- and hypercalcemia, and metabolic derangements seen in uremia are associated with symptoms of constipation.20 Endocrine disorders are associated with gastrointestinal complications, for example, constipation. Among the endocrinopathies discussed here are diabetes mellitus, hypothyroidism and hyperparathyroidism, multiple endocrine neo-plasia type lib (MEN lib), and pregnancy. The prevalence of gastrointestinal symptoms in individuals with diabetes mellitus is higher as compared to the general population.21 The impact of diabetes mellitus on gastrointestinal function and quality of life was assessed by Talley et al22 in a total of 1101 Australian diabetics. Among the gastrointestinal symptoms that were assessed, 24.5 of patients reported having constipation, which was the most prevalent symptom...

Differential Diagnosis

Constipation is a disorder and not a disease. It may be secondary to several diseases, including colonic disease (stricture, cancer, anal fissure, proctitis), metabolic and endocrine disturbances (hypercalcemia, hypothyroidism, diabetes mellitus), neurologic disorders (Parkinson's disease, spinal cord lesions), or pharmaco-logic (antidepressive) (Table 5.2). Therefore, exclusion of both intestinal and systemic organic etiologies is an imperative step prior to referring the patient with functional symptoms to the physiology laboratory. Barium enema or colonoscopy is usually indicated and the primary pathology treated. Additional tests, dictated by the history and physical examination, may be necessary to exclude the above-named diseases. Table 5.2. Etiology of constipation

Additional Evaluations

Patients with chronic refractory idiopathic constipation must be referred for investigation. The mechanisms responsible for both anal continence and defecation are complex and maintained by the interaction of multiple factors. These factors include stool consistency and delivery of colonic contents to the rectum, rectal capacity and compliance, anorectal sensation, anal sphincter mechanism function, and the pelvic floor muscles and nerves. To adequately evaluate these various aspects, a combination of physiologic studies is usually required, including colonic transit time study, anorectal manometry, defecography, electromyography (EMG), puden-dal nerve latency, and small bowel transit study.59,60 There is no single test that is pathog-nomonic thus, final a diagnosis of functional disorders must be based on a collective interpretation of these studies. According to Rantis et al,61 the mean cost to investigate chronic constipation in the United States is 2752 (range, 1150 to 4792),...

Nonrelaxing Puborectalis Syndrome Anismus

Whether paradoxical contraction of the pub-orectalis muscle during defecation is a cause of constipation or a coincidental finding is unclear. A study by Jorge et al15 evaluated 112 constipated patients with EMG and defecography. One third of these patients displayed findings consistent with paradoxical puborectalis contraction as measured by these techniques. However, the correlation between EMG and defecography was poor 33 of patients displaying findings of anismus on defecography had a normal EMG, and 30 of patients with an EMG suggesting anismus had normal defecography. Treatments directed at inhibiting contraction of the pub-orectalis muscle, such as injection of botulinum toxin or division of the puborectalis muscle, have yielded mixed results.

Epidemiology and Health Care Costs

Rome II criteria for functional constipation* At least 12 weeks (consecutive or nonconsecutive) in the preceding 12 months of two or more of the following Straining for more than 25 of defecations Lumpy or hard stools for more than 25 of defecations Sensation of incomplete evacuations in more than 25 of defecations * In the absolute definition of functional constipation, no loose stools are present and the patient has insufficient criteria for IBS.

Indications for Measuring Transit

In patients with prolonged orocecal transit, differentiation between delayed gastric emptying and slow small-bowel transit is important since it identifies those in whom enteral nutrition via a jejunal tube may bypass a dysfunctional stomach and thereby avoid total parenteral nutrition. Colonic transit data can be used to assess the severity of constipation or colonic inertia in the past, prolonged whole-gut (oroanal) transit time had been assumed to Assessment of severity of constipation or colonic inertia Assessment of therapeutic response reflect predominantly colonic transit. However, many patients with colonic inertia have a generalized disturbance of gut motility with considerable retardation in small-bowel transit. Thus, oroanal transit times do not merely reflect colonic transit selective assessment of colonic transit is important, as it may lead to appropriate treatments to correct this disturbance. The results of the transit study may be pivotal in the decision to perform a...

Monoamine Transport Inhibitors

The tricyclic antidepressants (TCAs) were originally designed to improve upon the efficacy and side effect profile of the phenothiazine class of antipsychotics. Their pharmacological spectrum was quite well understood in that these compounds interact with multiple brain neurotransmitter systems. The TCAs inhibit reuptake of monoamine neurotransmitters (dopamine (DA), 5HT, and NE) increasing their levels and function in the brain. TCAs include imipramine, desipramine, nortriptyline, amitriptyline, clomipramine, and doxepin (Figure 5). These compounds also interact with a variety of biological targets like muscarinic receptors, complicating their pharmacology and contributing to side effects such as orthostasis, dry mouth, and constipation. Clomipramine is the most effective TCA for panic disorder, OCD, and SAD87 but more selective reuptake inhibitors have displaced the use of the tricyclics due to their improved side effect profile.

Head Computerized Tomographic CT Scan

Head Septic Emboli

FIGURE 3.10 Opioid bowel colonic ileus in a methadone abuser. Abdominal radiograph (KUB) that demonstrates air distension of the small bowel and transverse colon consistent with chronic constipation and colonic ileus in a methadone abuser. (Courtesy of Carlos R. Gimenez, M.D., Professor of Radiology, LSU School of Medicine, New Orleans, LA.)

Studies in MS and Other Conditions

People with MS also may experience bowel incontinence. Biofeedback may be beneficial for this problem. In people with bowel incontinence related to conditions other than MS, biofeedback produces improvement in approximately 70 percent. In a small study of the effects of biofeedback on 15 people with MS-related constipation or stool incontinence, five showed improvement. Those who benefited from biofeedback had mild to moderate disability and had relatively stable disease during the time of treatment.

Combined Measurement of Gastrointestinal and Colonic Transit

The noninvasive techniques that evaluate transit of solid particles of the same size through the stomach, small bowel, and colon provide reliable assessments in the majority of patients with common GI symptoms such as nausea,vomiting, abdominal pain, diarrhea, and constipation. There is likely to be a significant growth in the application of these methodologies in the near future. The combination of transit measurements within one study limits radiation exposure, and by optimal use of personnel and equipment, leads to improved efficacy and reduction in costs. window. Gastric emptying is summarized by calculating the duration of the lag phase and the slope of postlag emptying.21 Small-bowel transit time is estimated by subtracting the time for a proportion (10 or 50 ) of isotope to empty from the stomach from the time taken for the same proportion to enter the colon.20 Overall colonic transit is evaluated by the geometric center, that is, the weighted average of the proportions of...

Hormonal versus nonhormonal

Pelvic pain associated with severe dysmenorrhea and or pain at the time of ovulation is likely due to endometriosis or adenomyosis. Women with endometriosis report premenstrual spotting, dyspareunia, dyschezia, poor relief of symptoms with nonsteroidal anti-inflammatory drugs, progressively worsening symptoms, inability to attend work or school during menses, and the presence of pelvic pain unrelated to menses more often than women with primary dysmenorrhea.

Clinical evaluation

Endometriosis should be considered in any woman of reproductive age who has pelvic pain. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsens during menses. Rectal pain and painful defecation may also occur. Other causes of secondary dysmenorrhea and chronic pelvic pain (eg, upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms.

Clinical Application of Anal Manometry

Abnormalities in the sphincteric mechanisms can occur in a variety of conditions, including constipation. In this particular situation, anal manometry can evaluate a hypertonic sphincter, an uncoordinated pelvic floor, a nonrelaxing puborectalis, or an absent or altered rectoanal inhibitory reflex. Therefore, anal manometry can be utilized in a constipated patient to assess sphincter tonus, both at rest and during squeeze, the presence or absence of the RAIR, a non-relaxing pelvic floor, and abnormalities in rectal sensation and the capacity to function as a reservoir.

Neuronal Intestinal Dysplasia

Neuronal intestinal dysplasia (NID) is characterized by a reduced motility of the large intestine due to abnormalities of the enteric nerves. The unusually slow passage of waste through the large intestine leads to chronic problems, such as constipation and uncontrollable soiling. Neuronal intestinal dysplasia can be diagnosed soon after birth and may mimic or coincide with Hirschsprung's disease. Therefore, in well-selected patients, anal manometry, specifically through anal reflex evaluation, could be of value in the differentiation of these cases.

System Reconstructive Procedures

The primary cause of cystoceles and rectoceles is a weakened vaginal wall. Factors that contribute to this loss of pelvic muscle tone are repeated pregnancies, especially those spaced close together, congenital weaknesses, and unrepaired childbirth lacerations. Obesity, advanced age, chronic cough, constipation, forceps deliveries, and occupations that involve much standing and lifting are also contributing factors. Lack of estrogen after menopause frequently aggravates the condition. Patients with a rectocele have a history of constipation, hemorrhoids, pressure sensations, low back pain, difficulty with intravaginal intercourse, and difficulty controlling and evacuating the bowel. Symptoms may be worse when standing and lifting and are relieved somewhat when lying down. Obstetric history often reveals a forceps delivery. Some report that they are able to

Other Dietary Considerations in MS

Constipation is a frequent complaint in people with MS. One way to improve constipation is to increase the amount of fiber in the diet. Good sources of fiber include whole grain breads and cereals, as well as fruits and vegetables. An increased intake of water and other fluids also may be beneficial for constipation six to eight 8-oz. glasses of fluid daily generally are recommended. Some people with MS may have frequent urinary tract infections, and increased fluid intake also may be helpful for this problem. Finally, for some people with MS-associated fatigue, it may be beneficial to avoid large increases or decreases in the blood sugar level. This may be accomplished by eating small meals and snacks throughout the day.

Clinical Implications

Preoperative physiologic investigation is mandatory to select the very small subset of patients with chronic idiopathic constipation who will benefit from colectomy and ileorectal anastomosis.22 With respect to rectal reservoir and sensory function in this category of patients, Akervall et al,23 using the manovolumetric method, considered that rectal sensitivity is an important predictive variable for a favorable outcome after colectomy and ileorectal anastomosis. They also concluded that sensory abnormalities, which can be demonstrated by manovolumetry, might be overlooked if only the distending volume is recorded.

Endogenous Depression

In this condition, the patient experiences profound misery (beyond the observer's empathy) and feelings of severe guilt because of imaginary misconduct. The drive to act or move is inhibited. In addition, there are disturbances mostly of a somatic nature (insomnia, loss of appetite, constipation, palpitations, loss of libido, impotence, etc.). Although the patient may have suicidal thoughts, psychomotor retardation prevents suicidal impulses from being carried out. In A, endogenous depression is illustrated by the layers of somber colors psychomotor drive, symbolized by a sine oscillation, is strongly reduced. The side effects of tricyclic antide-pressants are largely attributable to the ability of these compounds to bind to and block receptors for endogenous transmitter substances. These effects develop acutely. Antagonism at muscarinic cholinoceptors leads to atropine-like effects such as tachycardia, inhibition of exocrine glands, constipation, impaired micturition, and blurred...

B Large Bowel Irritant Purgatives p 177 ff

Frangulae Cortex The Microscope

Purgatives must not be given in abdominal complaints of unclear origin. 3. Lubricant laxatives. Liquid paraffin (paraffinum subliquidum) is almost non-absorbable and makes feces softer and more easily passed. It interferes with the absorption of fat-soluble vitamins by trapping them. The few absorbed paraffin particles may induce formation of foreign-body granulomas in enteric lymph nodes (paraffinomas). Aspiration into the bronchial tract can result in li-poid pneumonia. Because of these adverse effects, its use is not advisable. B. Large-bowel irritant laxatives diphenylmethane derivatives B. Large-bowel irritant laxatives diphenylmethane derivatives

General autopsy considerations

In situ changes typical of intravenous narcotic abuse include hepatosplenomegaly, enlargement of lymph nodes about the celiac axis and or porta hepatis, and fecal impaction (from the pharma-cologic property of opiates that inhibits intestinal motility).

Salt and Water Deficit

Other individuals drink fluids compulsively. This is not connected with chronic kidney disease, except that the occurrence of both compulsive water drinking and chronic kidney disease in the same person makes hyponatremia very likely. This occurrence is greater than one would predict from chance alone, because neuropsychiatric disorders, including bipolar disorders and compulsive taking of laxatives, can both lead to the development of kidney disease (see Chapter 2), and compulsive water drinking can be associated with either of these disorders.

Clinical Manifestations

Typhoidal 5-day prodrome, fever, chills, sore throat, joint pain, rose spots (30 ) cramps, hepatosplenomegaly (H S) (50 ), neuropsychi-atric symptoms, lymphadenopathy, constipation, no diarrhea, bradycardia, CFR < 30 . Complications Bowel perforations from perforated Peyer's patch, osteomyelitis. Warning Infants and elderly in homes with pet amphibians and reptiles turtles > lizards (iguanas) > snakes.

History and Physical Examination

The medical history should assess diabetes, stroke, lumbar disc disease, chronic lung disease, fecal impaction and cognitive impairment. The obstetric and gynecologic history should include gravity parity the number of vaginal, instrument-assisted and cesarean deliveries the time interval between deliveries previous hysterectomy and or vaginal or bladder surgery pelvic radiotherapy trauma and estrogen status. C. Because fecal impaction has been linked to urinary incontinence, a history that includes frequency of bowel movements, length of time to evacuate and whether the patient must splint her vagina or perineum during defecation should be obtained. Patients should be questioned about fecal incontinence.

Physical Examination

While performing the bimanual examination, levator ani muscle function can be evaluated by asking the patient to tighten her vaginal muscles and hold the contraction as long as possible. It is normal for a woman to be able to hold such a contraction for five to 10 seconds. The bimanual examination should also include a rectal examination to assess anal sphincter tone, fecal impaction, occult blood, or rectal lesions.

Genetic Considerations

Determine a history of risk factors, with a particular focus on medications. Establish a history of anorexia, nausea, vomiting, constipation, polyuria, or polydipsia. Ask about muscular weakness or digital and perioral paresthesia (tingling) and muscle cramps. Ask family members if the patient has manifested personality changes.

Patient Education and Behavior Modification

Some patients feel they need to have daily bowel movements and resort to laxative and enema misuse. Some patients may make several daily attempts straining to evacuate, while others may postpone the urge or make hurried attempts for convenience. Another frequently observed behavioral pattern, common among elderly women with symptoms of urinary incontinence, is the restriction of fluid intake to avoid leakage in fact, this may worsen symptoms of constipation as well as symptoms of urinary incontinence. Reviewing a daily record of bowel habits guides the clinician to tailor education specifically to the underlying functional disorder.

Intussusception Introduction

Intussusception is a telescoping of one section of the bowel into another section which results in obstruction to passage of the intestinal contents and inflammation and decreased blood flow to the parts of the intestinal walls that are pressing against one another. If left untreated, eventual necrosis, perforation, and peritonitis occurs. It occurs in infants most commonly between 3 to 12 months of age or in children 12 to 24 months of age. The actual cause is unknown but risk for the condition increased in children with Meckel's diverticulum, celiac disease, cystic fibrosis, diarrhea, or constipation. Surgical correction is indicated if the obstruction of the involved segment cannot be reduced manually or by hydrostatic pressure or if bowel becomes necrotic.

Anorectal Coordination Maneuver

Patients with symptoms of difficult, infrequent, or incomplete evacuation or those individuals with increased muscle activity while performing the Valsalva maneuver during the initial evaluation are taught the anorectal coordination maneuver. The goal is to produce a coordinated movement that consists of increasing intraabdominal (intrarectal) pressure while simultaneously relaxing the pelvic muscles. During the initial sEMG evaluation of the Valsalva maneuver, patients are asked to bear down or strain as if attempting to evacuate, which may elicit an immediate pelvic muscle contraction and closure of the anorectal outlet (Fig. 13.11). This correlates with symptoms of constipation including excessive straining and incomplete evacuation. The results of the sEMG activity observed on the screen display must first be explained and understood by the patient before awareness and change can occur. Change begins with educating the patient on diaphragmatic breathing, proper positioning, and...

Cohoba Yopo Yupa Vilca Anadenanthera spp Fabaceae

A number of species of trees in the Anadenanthera genus (A. peregrina, A. colubrina among them) have hallucinogenic properties and have been widely used to make powerful psychoactive snuff in a number of indigenous South-American Indian cultures. The snuff is prepared by making a paste from the beans, then mixing in an alkaline additive made from either snail shells or a plant source. It plays a central role in shamanistic practices such as divination, trance, communication with spirits, and the diagnosis of illness. Its use is usually limited to adult males. Although it is a powerful hallucinogen in larger doses, smaller amounts are sometimes taken as a stimulant. The seeds are also used to treat urinary disorders and infertility, and as emetics, purgatives, and laxatives.

Behavioral Considerations

Common causes of constipation include long-term voluntary restraint of evacuation, eventually leading to involuntary problems, highly efficient colonic dehydration of stools, and the inability to initiate defecation. There is strong evidence from the literature as well as everyday experience in the practice of medicine that many patients' problems with constipation and related symptoms originate from chronic voluntary restraint of evacuation. The exact profiles and underlying psychological stimuli for this behavior is beyond the scope of this chapter. However, treatment of constipation should include reteaching the patient proper bowel habits. The concept of reteaching the colon should not be ignored. Patients who can achieve at least one evacuatory bowel movement every day or so will have significantly fewer symptoms, despite often years or even decades of problems with constipation-related complaints. Reeducation of the colon often begins at the time of the first office visit, when...

Therapy Past Present and Future

When bulking agents with or without a mild laxative do not provide relief for the constipated patient, the treating physician has a myriad of treatments, prescription and over-the-counter, to turn to. If the patient's complaints do not suggest anatomic problems or such problems are excluded by other investigations, then continued medical therapy is warranted. Even for patients with pelvic floor disorders or structural bowel problems likely related to chronic constipation and straining, often conservative measures with medications is warranted, since surgical repair is typically seen as a last resort and is frequently not 100 successful at relieving symptoms. Below are a few examples of second-line medications for the treatment of constipation. Practitioners should always be ready to use treatments empirically for lactose intolerance when patients continue to complain of cramps or pain even when first-line therapies help the patient to have more frequent bowel movements. In a referral...

Serotonin and the Gastrointestinal Tract

In an industry-sponsored, multinational randomized trial, researchers assessed the efficacy of Tegaserod in 1348 adults of whom 90 were females.42 These subjects had complaints of chronic constipation, which was defined as a weekly average of fewer than three spontaneous bowel movements. These patients received 2 mg, 6mg, or placebo twice a day for 12 weeks. The study showed that Zelnorm (Tegaserod) caused a statistically significant improvement and increased the frequency of spontaneous bowel movements and relieved symptoms including straining, hard stool, incomplete evacuation, and abdominal discomfort. Recently Tegaserod has been approved for chronic constipation in men.

Antidiuretic Hormone ADH and Derivatives B

Cimetidine Induced Gynecomastia

Since food has a buffering effect, antacids are taken between meals (e.g., 1 and 3 h after meals and at bedtime). Nonabsorbable antacids are preferred. Because Mg(OH)2 produces a laxative effect (cause osmotic action, p. 170, release of cholecystokinin by Mg2+, or both) and Al(OH)3 produces constipation (cause astringent action of Al3+, p. 178), these two antacids are frequently used in combination.

Disorders of the Large Intestine and Rectum

Irritable bowel syndrome is a group of symptoms that includes cramping pain, gas, bloating, and alternating bouts of constipation and diarrhea. Sometimes people with irritable bowel syndrome pass mucus with their bowel movements. Irritable bowel syndrome is also called irritable colon, spastic colon, spastic bowel, mucous colitis, and functional bowel disease. Diagnosis of irritable bowel syndrome is usually made by ruling out other possible causes of the symptoms. Irritable bowel syndrome does not cause permanent damage to the intestines and does not increase the risk of colon cancer. Diverticula are small bulges or pouches that develop in the colon. These pouches form when the colon strains to move hard stool, and the increased pressure pushes through weak spots in the lining of the colon. This condition may result from eating a diet that is low in fiber. If there are no symptoms or mild symptoms, the condition is called diverticulosis. If the pouches become infected or inflamed...

Definition of Colonic Inertia

Colonic inertia is the failure of the colon to propel stool toward the rectum, including the failure to produce mass movement of stool around the time of defecation. The condition manifests as a syndrome of infrequent bowel actions, bloating, abdominal pain, and systemic symptoms including lethargy and nausea. Colonic motor activity is abnormal, with reduced high-amplitude propagating contractions, and transit time through the colon is pro-longed.3-5 There is failure to enhance colonic phasic pressure activity by a meal or stimulant, and impaired propagated colonic contractile response to bisacodyl and cholinergic agents.6-8 Preston and Lennard-Jones7 postulated that the relative inactivity of the colon may be due to a congenital or acquired disorder of the myenteric plexus. Bassotti and colleagues8 found that patients with slow-transit constipation displayed an impaired colonic motor response to strong cholinergic stimulation (edrophonium chloride) in the descending colon when...

Licorice Glycyrrhiza glabra Fabaceae

This shrub originated in the semi-arid areas of the Eastern Mediterranean, Near East and Central Asia. The oldest report on the use of the roots of this species comes from a Sumer tablet of Mesopotamia (2000 bc), and shortly thereafter the use of Glycyrrhiza uralensis in China is documented. By then the sweet taste of the licorice root was already known (its botanical name, Glycyrrhiza, sweet root, comes from Greek). Alexander the Great, the Scythian armies, Julius Caesar, and even India's great prophet, Brahma, were known to have endorsed the benefits of licorice. Arab physicians used licorice to treat coughs and relieve side effects of laxatives.

Treatment of Excessive Potassium

In less urgent cases, sodium polystyrene sulfonate, an exchange resin taken in the sodium form that is not absorbed in the intestine, but takes up potassium in exchange for sodium and is excreted in the stool, can be taken by mouth. This drug is expensive and difficult to take. (It tastes like sand.) It is usually dispensed in sorbitol suspension so as to reduce its constipating effects. However, in some patients the sorbitol leads to diarrhea or to more serious intestinal problems. Other laxatives may be safer and may in fact lower potassium somewhat when given alone (that is, without the SPS). SPS without sorbitol is also available (Kionex). In mild cases, reduction of dietary potassium also may help, though in my opinion that idea is a nonstarter. I never use this last option because small doses of SPS are so effective and these patients already struggle with a multitude of dietary restrictions. If there is associated acidosis and the hyperkaliemia is...

Multiplesystem Atrophy

The parkinsonian features are usually unresponsive to levodopa therapy. There may be gait and limb ataxia, orthostatic hypotension, erectile dysfunction, constipation, and decreased sweating. Whereas multiple-system atrophy is a distinct neuropathological entity, the consensus diagnostic criteria depend on specific clinical features. Pathologically, glial cytoplasmic inclusions and degeneration are found throughout the basal ganglia, substantia nigra, brainstem autonomic nuclei, and Purkinje cells of the cerebellum.

Patient Satisfaction and Success Rates

We would question some of the figures quoted for example, Hasegawa et al32 reported 29 of 61 patients (48 ) to be asymptomatic and an additional 16 of 61 patients (26 ) to be improved, yet Knowles et al24 quoted a 39 success rate for Hasegawa's paper. There are a number of large studies from separate centers that show patient satisfaction rates of 80 to 90 (Table 15.3). We found that 47 of 52 patients (90 ) were satisfied with the operation in response to direct questioning, and would elect to have the operation done again.19 The five patients dissatisfied with the operation were the one patient in the study who had an anastomotic leak, the one patient who developed recurrent constipation, which required an ileostomy, and three patients with incontinence. Table 15.3. Percentage of patients satisfied with the outcome of colectomy for constipation Redmond et al28 noted that 90 of patients with motility abnormalities restricted to the colon had a successful outcome, but only 13...

Psyllium Plantago spp Plataginaceae

The seeds, which have a seed coat particularly rich in mucilage, are used medicinally for treating constipation, dysentery, irritable-bowel syndrome, and a variety of skin conditions. Certain types of mucilage are well known to have beneficial effects, on the gastrointestinal tract including antidiar-rheal and anti-inflammatory effects. A number of species are used, including blond psyllium (Plantago ovata, Asia), black psyllium (P. afra, Asia), P. asiatica in Indochina, and great plantain (P. major, widespread throughout Asia).

Small Bowel Obstruction

The incidence of small-bowel obstruction after colectomy and ileorectal anastomosis seems to be higher when the procedure has been carried out for constipation rather than for other conditions after resection for large-bowel tumors it was 2 and for inflammatory bowel disease 9 .42 The reason for these differences is unclear but small bowel inertia as a part of generalized intestinal involvement in patients with colonic inertia may explain the higher incidence in this group. Another possible reason may be that resection for carcinoma involves ligating the vessels closer to their origins,with fewer ligatures and less denuded peritoneal surface to form adhesions. One study had contrary conclusions, with no difference noted in the incidence of small-bowel obstruction among the three groups of patients who underwent subtotal colectomy

Enterocele Peritoneocele

Enterocele Defecography

Halligan and colleagues30 prospectively studied 50 consecutive patients with constipation, and compared their results with 31 controls undergoing peritoneography for groin pain. Although a majority of constipated patients (77 versus 10 in the control group) had deep rectogenital pouches, only 58 filled with small-bowel contents during the study. Moreover, those patients with an enterocele evacuated more rapidly and completely than did the constipated patients with or without a deep pouch.

Conclusions for Colonic Resection

Subtotal colectomy and ileorectal anastomosis are effective in relieving constipation in patients with colonic inertia. Careful selection of patients with physiologic investigations to exclude those with irritable bowel syndrome or significant small-bowel dysmotility is important. Patients should be fully informed about the risk of sepsis, albeit small, and about a possible poor functional outcome. Severe pain may be significantly reduced in properly selected patients. Segmental colectomy offers the possibility of avoiding the risk of severe diarrhea but is still associated with recurrent constipation in up to 18 of cases, requiring a further major procedure. More precise isolation of the abnormally functioning part may improve the prospect for segmental resection.

Ileostomy and Colostomy

End ileostomy may be required in patients with recurrent constipation after subtotal colectomy for colonic inertia. In some instances, it may be the primary treatment for these patients either as a definitive procedure, or as mentioned previously as a prelude to another operation. Failure after colectomy may result in the need for a stoma Hasegawa et al32 found that 14 of 61 patients (23 ) eventually had a permanent stoma. They noted that the permanent stoma rate was significantly higher in patients with psychological disease. One study found that six of 44 patients who underwent subtotal colectomy had a subsequent ileostomy, three for persistent constipation, two for diarrhea, and one for diarrhea with incontinence.31 Yoshioka and Keighley30 noted that six of 40 patients eventually required an ileostomy, and Ghosh et al39 reported three of 21 patients had an ileostomy but continued to be symptomatic after the ileostomy possibly as a result of global intestinal dysfunction. Initial...

Small Bowel Dysmotility

Traditional thinking has been that patients with significant small-bowel dysmotility should be excluded from colectomy because recurrent constipation and abdominal pain are likely to occur. Much of this has been speculative, because accurate means of measuring small-bowel transit have been lacking. Radiopaque marker studies measure whole-gut transit (of which colonic transit time forms a large part) and are not useful to assess the small bowel. Barium studies are helpful only when motility is severely affected, causing megaduodenum and grossly delayed small-bowel transit. Gastric emptying studies are probably similarly helpful only to exclude patients from surgery if emptying is markedly abnormal. Small-bowel transit, assessed in the initial phase of an isotope colon transit study,provides a rough measure of small-bowel motility. All of the ingested isotope should reach the cecum after 6 hours, and failure to do so is an indication of delayed small-bowel transit.11 Small-bowel transit...

Psychiatric Influences on Functional Results

Anxiety and depression scores compared with those who were not improved.63 The authors concluded that good functional outcome after surgery for constipation can be predicted by preoperative psychiatric screening. Kamm et al31 reported 10 of 44 patients who underwent colec-tomy had a history of psychiatric illness. Four patients developed serious psychiatric disturbances postoperatively. The authors suggested that patients with psychological disturbances might have the lowest threshold for seeking surgery and also the least ability to tolerate the side effects of surgery. Several other studies have drawn similar con-clusions.40 Patients with constipation have significantly elevated scores in hypochondriasis, depression, and hysteria scales, manifesting the psychological defense mechanism of somato-sization.64 A significantly higher anxiety and depression score was found in a group of patients undergoing colectomy for constipation compared with a group of other colon resection...

Laparoscopic Colectomy

There has been one retrospective study comparing laparoscopic and open colectomy for slow-transit constipation. Ho et al57 studied 17 patients having the open procedure and seven patients having the laparoscopic procedure. They found the laparoscopic colectomy group was more satisfied with the cosmetic outcome, but had a longer operation (by a mean of 74 minutes), and had more complications. Blood loss, recovery of ileus, and hospitalization time were the same in the two groups. Two patients in each group developed adhesive small-bowel obstruction, but only the two in the open colec-tomy group failed conservative treatment and

Treatment of Combined Colonic Inertia and Obstructed Defecation

Transit studies and anorectal physiology tests can subdivide severely constipated patients into three groups colonic inertia causing slow transit, obstructed defecation, and a combination of both. Patients with obstructed defecation may have mechanical outlet obstruction related to the presence of anatomic abnormalities such as a rectocele, or functional outlet obstruction. The principles of treating slow-transit constipation or obstructed defecation alone are generally agreed upon. The optimal treatment of patients with combined colonic inertia and obstructed defecation is controversial. Some advocate pre-operative treatment of obstructed defecation, some favor postoperative treatment, some feel that no treatment is required, and others exclude patients with obstructed defecation from colectomy. Other studies have shown a poor functional result after subtotal colectomy in patients with untreated obstructed defecation. Kuijpers59 reported persistent constipation in two of four...

Serotonin Modulating Drugs

In relation to the use of 5-HT in patients with slow-transit or functional constipation, therapy Cisapride, a 5-HT4 agonist, was shown to benefit patients with functional constipation.36 However, the demise of Cisapride use due to its potentially lethal cardiac side effects led to interest in newer 5-HT4 agonists, such as Tegaserod and prucalopride. Tegaserod has been shown to have effects on visceral sensation and to accelerate colonic transit time. It has therefore been primarily used in irritable bowel syndrome (IBS) patients with constipation.37 Prucalopride is probably a more potent laxative than Tegaserod. Since its increased potency may cause symptoms of abdominal cramps, its use has been directed toward patients with severe constipation rather than constipated IBS patients.26

Segmental Colonic Resection

If a particular segment of the colon could be reliably identified as the cause of constipation, then segmental colectomy could offer some advantage by preventing severe diarrhea or incontinence that occurs in a small number of cases after subtotal colectomy and ileorectal anastomosis. Another potential advantage of a limited colonic resection is a reduction in the de-peritonealized area that may reduce the risk of postoperative adhesions. In general, the published functional results of segmental colectomy have been unsatisfactory. There are other proponents of segmental colon resections for colonic inertia. DeGraaf et al38 had a prospective series of patients who underwent partial left hemicolectomy and compared them with those individuals who underwent a subtotal colectomy. They selected patients for left hemicolectomy if total transit time was prolonged but transit in the right colon was normal. Recurrent constipation was seen in three of 18 patients who underwent left...

Colchicine and Neurotrophin3

Preliminary studies using other new approaches to treat patients with constipation include the old and the new, such as the use of colchicine44 and neurotrophin-3 (NT-3)45 agonists, respectively. The latter agent belongs to the family of protein growth factors, neurotrophins, involved in the growth, development, and function of neurons. A double-blind, randomized study comparing five treatment schedules using NT-3 with placebo showed statistically significant improvements in stool frequency, consistency, and passage in one arm of the treatment group when compared with placebo.45 This study highlighted the fact that the optimum therapeutic dose of NT-3 is yet to be established, and its route of administration by subcutaneous injection may make its use less desirable. Colchicine, an alkaloid prepared from the dried seeds and corns of Colchicum autumnale, the autumn crocus or meadow saffron, has well-established clinical use in the treatment of patients with acute gout and in patients...

Opioid Analgesics Morphine Type

Opioid Receptors Cochlea

Peripheral effects concern the motility and tonus of gastrointestinal smooth muscle segmentation is enhanced, but propulsive peristalsis is inhibited. The tonus of sphincter muscles is raised markedly. In this fashion, morphine elicits the picture of spastic constipation. The antidiarrheic effect is used therapeutically (loperamide, p. 178). Gastric emptying is delayed (py-loric spasm) and drainage of bile and pancreatic juice is impeded, because the Tolerance. With repeated administration of opioids, their CNS effects can lose intensity (increased tolerance). In the course of therapy, progressively larger doses are needed to achieve the same degree of pain relief. Development of tolerance does not involve the peripheral effects, so that persistent constipation during prolonged use may force a discontinuation of analgesic therapy however urgently needed. Therefore, dietetic and pharmacological measures should be taken prophylacti-cally to prevent constipation, whenever prolonged...

Overview and Comparison of Drug Classes

The first nonstimulant therapy designed for ADHD, Strattera (atomoxetine, Lilly), was introduced in January 2003 and has rapidly gained acceptance. Atomoxetine is not a scheduled drug, has a low risk for abuse and dependency, has a nonstimulant side-effect profile (although sleep and growth disturbances are shared with stimulants), and is the first indicated product for adults with ADHD. Unlike stimulants, for example, atomoxetine lacks methylphenidate-like drug reinforcement properties in monkeys,77 leading to the conclusion of reduced likelihood for abuse potential in human patients. On the other hand, there is no consensus that patients with ADHD abuse prescribed stimulants.46 The efficacy of atomoxetine is not better, and perhaps less, than methylphenidate. In one clinical report,78 atomoxetine was reported to have better effects on inattentive symptoms compared to the hyperactive impulsive symptoms consistent with the proposed role for norepinephrine in measures of...

Unmet Medical Needs

In the case of inflammatory or nociceptive pain, opioids provide significant analgesic efficacy however, long-term use of these analgesics is limited by both opioid-mediated side effects including constipation, and regulatory concern of opioid dependence and abuse liability. NSAIDs also provide moderate pain relief in these pain states, but are associated with GI disturbances. The COX-2 inhibitors represent an analgesic advance due to their enhanced GI safety profile however, the long-term cardiovascular safety of these agents is controversial.

Clinical Trial Results

The short-term clinical and physiologic effect of continuous sacral nerve stimulation in 12 patients (mean age 50.2 years) with rectal constipation was first described in 2001. In the 10 patients who completed the minimum stimulation period, the mean number of voluntary bowel movements per week weekly bowel Table 17.3. Results of 10 patients who completed the minimum stimulation period after SNS for rectal constipation We have also presented the results of nine patients implanted out of 25 short-term tests (mean age 49.8 years), or patients complaining of outlet constipation with normal5 or prolonged colon transit time.4 The stimulatory electrodes were positioned in the S3 foramen in all patients there were no early or late electrode displacements. An infection at the IPG implant site necessitated the temporary removal of the pulse generator in one patient. One patient complained of pain at implant site when the IPG case was used as an anode (unipolar impulse), and no adverse changes...

Labor and Delivery Admitting Orders

Nalbuphine (Nubain) 5-10 mg IV SC q2-3h prn OR Butorphanol (Stadol) 0.5-1 mg IV q1.5-2h prn OR Meperidine (Demerol) 25-75 mg slow IV q1.5-3h prn pain AND Promethazine (Phenergan) 25-50 mg, IV q3-4h prn nausea OR Hydroxyzine (Vistaril) 25-50 mg IV q3-4h prn Fleet enema PR prn constipation.

Delivery of the placenta

Acetaminophen codeine (Tylenol 3) 1-2 tab PO q3-4h prn OR Oxycodone acetaminophen (Percocet) 1 tab q6h prn pain. Milk of magnesia 30 mL PO q6h prn constipation. Docusate Sodium (Colace) 100 mg PO bid. Dulcolax suppository PR prn constipation. A and D cream or Lanolin prn if breast feeding. Breast binder or tight brazier and ice packs prn if not to breast feed. Labs Hemoglobin hematocrit in AM. Give rubella vaccine if titer < 1 10.

A Small Bowel Irritant Purgative Ricinoleic Acid

Castor oil comes from Ricinus communis (castor plants Fig sprig, panicle, seed) it is obtained from the first cold-pressing of the seed (shown in natural size). Oral administration of 10-30 mL of castor oil is followed within 0.5 to 3 h by discharge of a watery stool. Ricinoleic acid, but not the oil itself, is active. It arises as a result of the regular processes involved in fat digestion the duodenal mucosa releases the enterohormone cholecystokinin pancreozymin into the blood. The hormone elicits contraction of the gallbladder and discharge of bile acids via the bile duct, as well as release of lipase from the pancreas (intestinal peristalsis is also stimulated). Because of its massive effect, castor oil is hardly suitable for the treatment of ordinary constipation. It can be employed after oral ingestion of a toxin in order to hasten elimination and to reduce absorption of toxin from the gut. Castor oil is not indicated after the ingestion of lipo-philic toxins likely to depend...

Surgical Treatment of Rectocele Gynecologic Approaches

Herniation of the rectum or posterior vaginal wall into the vaginal canal, resulting in a vaginal bulge, is commonly termed a rectocele. Women may complain of perineal and vaginal pressure, obstructive defecation, constipation, and the need to splint or digitally reduce the vagina in order to effectuate a bowel movement. These anatomic defects arise from a superior, inferior, or lateral tear or central stretching of the rectovaginal fascia. If the weakness is present below the levator musculature, it is termed a rectocoele. If the weakness occurs above the levator muscles, it is more likely an enterocele. Very commonly, both anatomic defects coexist. Although anatomic cure rates with surgery are high, there are conflicting reports with regard to functional outcome, postoperative defecatory symptoms, and sexual dysfunction including dyspareunia.

Central Nervous System

After the event of a stroke, fecal incontinence is more frequent (31-40 ) and is associated with the severity of the stroke after 6 months, the frequency of fecal incontinence is reduced to 3 to 9 .34 The frequent association of constipation with disorders involving neuronal malfunction suggests that disruption of the neural modulation of colonic motility may play an important role in the development of constipation. In a study of 8.8 million Medicare patients in the United States, the closest associations were observed between constipation and neurologic diseases.35 A prospective study to determine the incidence of constipation was conducted on a population of 152 inpatients at a stroke rehabilitation center. The authors found that constipation occurred in 60 of the patients, and that the incidence of constipation was not related to age or gender but was strongly related to functional status of patients as assessed by the Barthel Index.36 Among the plethora of complications...

Loperamide hydrochloride

OTC Control symptoms of diarrhea, including traveler's diarrhea. Non-FDA Approved Uses With trimethoprim-sulfamethoxazole to treat traveler's diarrhea. Contraindications Discontinue drug promptly if abdominal distention develops in clients with acute ulcer-ative colitis. In clients in whom constipation should be avoided. OTC if body temperature is over 101 F (38 C) and in presence of bloody diarrhea. Use in acute diarrhea associated with organisms that penetrate the intestinal mucosa, such as E. coli, Salmonella, and Shigella. Special Concerns Safe use in children under 2 years of age and during lactation has not been established. Fluid and electrolyte depletion may occur in clients with diarrhea. Children less than 3 years of age are more sensitive to the narcotic effects of loperamide. Side Effects Oral Dry mouth. GI Abdominal pain, distention, or discomfort. Constipation, N& V, epigastric distress. Toxic megacolon in clients with acute colitis. CNS Drowsiness, dizziness,...

Surgical Treatment of Rectocele Colorectal Approaches

Rectocele Measurement Defecography

The true cause of anterior rectocele is unclear. Childbirth is a known risk factor due to the stretching and distention of the pelvic floor and tearing of the rectovaginal fascia. Prolonged straining during defecation in chronic constipation or in nonrelaxing puborectalis syndrome may also lead to the formation of a rectocele. Both of these events promote widening of the genital hiatus, perineal muscle laxity, and pelvic organ descent, which may subsequently lead to pudendal neuropathy. Postmenopausal status and hysterectomy are also proven to be predisposing factors of rectocele.

Star anise Illicium verum Illiciaceae

Star anise is the only non-poisonous species of Illicium. The tree is native to southwest China. The fruits and seeds are used in Chinese cooking and also medicinally for colic, constipation, insomnia, and other purposes. They contain a volatile oil, similar in composition to those of dill and aniseed. The first known record of trade in the fruits is from the Philippines in 1588. Clusius bought star anise fruits in London in 1601 and later they were traded to Europe along the tea route from China via Russia as Siberian cardamoms. Production today remains concentrated in China.

Results of Surgical Repair

As noted, there are conflicting reports with regard to functional outcome after posterior col-porrhaphy. Importantly, many authors suggest that the significant rate of postoperative dys-pareunia may be due to the plication of the levator ani muscles, and has led to the popularization of the discrete fascial defect repair. Several authors have reported a similar anatomic cure rate with this surgery, along with significant improvement in quality of life measures. Unlike the traditional posterior colporrhaphy, all these series report less postoperative dyspareunia. The authors noted significant improvement in splinting, vaginal pressure, and stooling difficulties. However, rates of fecal incontinence and constipation were unchanged postoperatively.

Other Techniques and Results

The use of synthetic mesh placed abdominally from the perineal body to the vaginal vault to correct a rectocele at the time of abdominal sacrocolpopexy for vaginal vault prolapse has been reported.13 The mesh is attached to the anterior longitudinal ligament overlying the sacral promontory in a tension-free fashion. The authors treated 29 patients and noted continued bowel symptoms including constipation and incomplete defecation. Others have noted a similar persistence or increase in bowel symptoms in 39 of patients who underwent this type of surgery.14 Rectocele operations performed transanally versus transvaginally have been compared.18 Complications occurred equally in the two groups of patients. In all, 54 had postoperative constipation, and 34 had gas and liquid or solid stool incontinence. Sexual dysfunction was reported in 22 . The only significant difference was that the patients receiving transvaginal repair had more persistent pain.

Perineal Procedures for Rectal Prolapse

Constipation and rectal prolapse frequently coexist. Estimates of preoperative constipation range from 30 to 67 in prospective studies.1 It is not clear whether constipation results in rectal prolapse, or prolapse results in constipation due to a functional outlet obstruction. Many patients report improvement in bowel function after surgery for rectal prolapse. Conversely, some patients with normal bowel function prior to surgery for rectal prolapse complain of constipation after surgery. Nevertheless, perineal procedures are often performed for patients with constipation and rectal prolapse.

Sacral Nerve Stimulation

Although most physicians consider two or fewer evacuations per week as constipation, many patients consider the subjective feeling of incomplete or difficult defecation and include symptoms such as hard feces or the need for dig-itation, enema suppositories, or the symptoms of tenesmus as part of constipation. Pelvic causes of abnormal evacuation include rectal aganglionosis, rectal intussusception or complete rectal prolapse, and anterior rectal wall hernia (rectocele), and they may sometimes be cured with surgery. Many patients with rectal constipation lack coordination of the rectum and the anal sphincters (outlet constipation),which is not amenable to simple surgical treatments. While biofeedback, stool softeners, and laxatives help some patients, these agents are often not a satisfactory long-term solution. Moreover some patients with colonic inertia are unresponsive to medical therapy, and the results of a subtotal colectomy are not always predictable. The application of sacral...

Anal Encirclement Procedure

In 1891, Thiersch initially described encirclement of the anus with silver wire for treatment of incontinence and rectal prolapse.5'6 It was hoped that the wire would produce an area of fibrosis around the anus that would act as a passive support for the pelvic floor (Fig. 20.1). Unfortunately, not only did the wire fail to provoke the desired fibrosis, but it also produced unwanted complications, including ulceration, erosion, breakage, and fecal impaction.

Injury to the spinal cord

The loss of voluntary movement and the resultant effects upon motor tasks are only one effect of spinal cord injury there is also a subsequent loss in the autonomic functions of the nervous system. In the cases of high cervical level injuries, sustained at the second cervical level and higher, loss of the ability of the brain stem to control the diaphragm results in the inability to breathe voluntarily. In the case of both cervical and lumbar level lesions, bladder, bowel, and sexual functions are lost. The loss of these functions can lead to secondary complications, including urinary tract infections, impacted bowel and constipation, and difficulties with procreation.3

Treatment Implications Warning About Risk

The key messages are that patients having a rec-topexy, even if they do not suffer from any pre-operative constipation, should be warned about the risks of postoperative constipation. Furthermore, the majority of these patients should be offered a resection rectopexy on the grounds that this does not in any way increase the risk of incontinence while reducing the incidence Constipation of postoperative constipation. Division of the lateral stalks will reduce the incidence of postoperative recurrence at the expense of increasing the incidence of postoperative constipation. A prospective randomized study was undertaken including 26 patients with full-thickness rectal prolapse.26 Fourteen patients had rectopexy with and 12 without division of the lateral ligaments. Incontinence improved in both groups of patients however, the authors note that division of the lateral ligaments statistically significantly increased the number of patient with postoperative constipation. While three...

Laparoscopic Procedures

To date,the results of laparoscopic rectopexy and resection rectopexy seem to be associated with less constipation than open rectopexy alone. Thus, laparoscopic treatment should be encouraged, provided the recurrence rates remain low. All patients who develop postoperative constipation should be investigated by colonic transit studies and probably also by small-bowel transit studies, videoproctography, and anal manometry and contrast enema. These studies should help identify both physiologic and anatomic causes of constipation. versely, sigmoid colectomy alone is unlikely to resolve the problems of persistent constipation, and a high proportion of these individuals require a subtotal colectomy and ileorectal anastomosis. Thus, the majority of patients with constipation after a previous rectopexy, after appropriate counseling and investigation, are likely to be offered some form of subtotal colec-tomy, provided that their sphincter anatomy and function are satisfactory and provided...

Preoperative Investigations and Management

Prolonged constipation prior to rectal prolapse is suggestive of colonic inertia, thus mandating a combined approach of resection with rectopexy.3-5 In patients with suspected incontinence, anal ultrasonography, manometry, and pudendal nerve latency tests should be performed prior to the procedure. It is suggested that these patients would benefit mostly from a suture rectopexy without the addition of bowel resection.6 These tests may be of some predictive value and serve as a point of reference in monitoring postoperative improvement. Also, they may dictate the preference of one method over the other.

Laparoscopic Anterior Resection

The idea behind this approach is that resection of redundant bowel reduces postoperative constipation while fibrosis associated with the healing process of the anastomosis will fix the bowel to the sacrum. However, this approach is subjected to higher morbidity due to an increased risk for anastomotic leakage (2-12 ). Technically, this procedure is more demanding when attempted laparoscopically.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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