A common disorder with a heavy socioeconomic burden, constipation has numerous causes and is described differently by different patients. Gastroenterologist Myung S. Ko, MD, offers an efficient method of getting to the underlying problem, breaking the condition into useful categories and discussing tests that range from the basic – but essential – digital rectal exam to advanced methods, such as anorectal manometry to detect pelvic floor dysfunction. She shows that when you understand the cause, your treatment plan becomes clear.
Good afternoon, pleasure to meet all of you today and thank you very much for having me. I'm really very excited to be here speaking with you about a topic that is a clinical and academic interest of mine. Mhm. So for today I will start out by touching on the epidemiology of constipation and the medical and economic burden of this very common problem. Then I will share with you how I approach constipation in broad strokes with a specific focus on pelvic floor dysfunction or dis energy. Yet Here are some quick slides on the burden of constipation on our society. The prevalence of constipation is thought to range anywhere between two and 28%. It tends to be generally a recalcitrant condition. In one study, 89 of patients with constipation were symptomatic. At one year apart and 45 continued to have symptoms for at least five years As you probably have seen in your practice, females tend to be more predominantly affected with a female to male ratio of 2-1. While smaller studies have not shown this, a recent large and Haynes database study showed that women of higher educational backgrounds were more likely to be constipated and constipation tended to run in families with higher prevalence and sisters, mothers and daughters have constipated family members. One of the points I want to emphasize here is that patients use the term constipation to describe many different symptoms ranging from hard stools, excessive straining, infrequent bowel movements, use of digital maneuvers, abdominal bloating and even the feeling of incomplete evacuation. So it's quite varied in their description. So I would really encourage all of you to ask detailed and specific questions regarding their symptoms to get at the root cause of constipation. Constipation not only poses significant morbidity for our patients, but it also imposes a huge socio economic burden on our society. In the us, nearly 85 of physician visits for constipation resulted in a prescription of laxatives and more than $820 million dollars are spent per year on nonprescription agents. I'm not really sure whether this is a chicken or an egg problem, but constipation has also been associated with higher prevalence of anxiety, depression, obsessive compulsiveness, psychotics is um and stigmatization. This is one of the earlier works that was published in 2007 by my personal mentor, Dr Satish Rao, who is currently in Augusta Georgia that shows the prevalence of psychological symptoms and patients with constipation. The dark blue and white bars represent folks with either decision ergic or slow transit constipation and the light blue are at the healthy controls. And unsurprisingly in the study and also show that the quality of life measures were significantly lower in patients with constipation compared to healthy controls. So as you can see, our patients with constipation have a great deal of other medical and psychological comorbidities that we are often addressing at the same time. Hence the complex nature of these visits. So as you can see, constipation is a heterogeneous policy, symptomatic and multifactorial disease, and my hope is that you will leave this talk with a simple schematic you can use to approach and categorize constipation in your practice. This categorization is something that I use also on a daily basis and it's been quite helpful for me and caring for patients who often have many other co morbid gi conditions and other symptoms. So one of the first questions that I asked to a constipated patient is the acuity of their symptoms, acute onset constipation is constipation that is occasional or transient, and for the most part it is usually due to changes in diet, travel stress or even a departure from their daily activities. This type of constipation tends to resolve spontaneously or might require any short term fiber supplementation. Dietary changes or laxatives. However, we do want to make sure to always think about some rare causes of constipation which can be acute, including significant narcotic or opioid use constipation resulting from prolonged immobilization or hospitalization for major surgeries or colonic obstruction from strictures or cancers. So please do make sure to assess for alarm symptoms in patients with acute onset constipation and referred to us for further endoscopic evaluation. If you suspect that the constipation may be secondary to a colonic mass or other obstructive lesions. We do see this quite frequently in the inpatient setting. When we are on call a common consult, we received from the surgical services as post operative constipation and alias for which We often will encourage maximizing conservative measures which include being out of bed as much as possible to chair early ambulance station. Minimizing narcotics and correcting any electrolyte imbalances. But for the most part, you and I both deal with patients with more chronic constipation. Constipation that is more persistent and likely has been ongoing for months to years broadly speaking, chronic constipation can be divided into primary versus secondary causes of constipation. Secondary constipation is constipation that will improve after the underlying problem is identified and corrected. This is a very long list but it usually results from a plethora of potentially reversible factors which include effects of diet drugs. And you can open these metabolic neurological or other derangement. When I see patients in clinic with chronic constipation, I always try to take a detailed history regarding any recent surgeries, fiber intake, any new initiation of drugs with a particular focus on narcotic use, any metabolic arrangements and underlying neurologic conditions. Unfortunately, despite our best efforts, I think we are sometimes the culprit behind the patient's constipation with our prescription medications. And we should get in the habit of always just combing through the medication list very carefully to see if there are any other culprit medications we can identify in gastroenterology. A lot of my patients have kind of functional abdominal pain and many of the agents that I used to treat abdominal pain unfortunately also have constipation as a side effect. So I'm always trying to kind of undo the the harm that I have inadvertently imposed on my patients with regards to neuro muscular disorders. I do see a number of patients in clinic with constipation, secondary to scleroderma or Parkinson's disease. And in fact, one of the first signs of Parkinson's even before the onset of neurologic symptoms is constipation. Just for you all to be aware of. So for the remainder of the talk, I do want to focus more specifically on primary chronic constipation and in my clinic, majority of the constipation patients I see belong to this category of constipation. And here I just want to spend a few slides reviewing the functions of the colon. You probably as well as I have been taught in medical school that the colon sole job is to serve as a tube for stool to make mainly just travel and exit through the body. And in fact, people used to joke about the colon a lot to add during med school saying that it was one of the dumbest organs of our body, but it turns out that this is not entirely an accurate statement. The cool and is really much more intricate Oregon than we often give it credit for. The right colon actually has the job of mixing and fermenting stool and salvaging any remaining digestive residues left in the extreme it the left colon. The primarily serves as a conduit for defecation by allowing for rapid transit of stool, but the recto sigmoid is a really fascinating sensory motor organ that stores stool and allows for defecation to occur. Primary chronic constipation occurs when there is disordered regulation of these colonic and rectal neuro muscular functions and disorders in the brain, gut communication and as a neuro gastroenterologist, my interest lies in understanding the interactions between the brain and the gut, which carefully regulate both the transport of stool throughout the colon and also allow us to evacuate the stool that has reached our rectum. Primary constipation includes three broad categories which are slow transit constipation, evacuation disorders, which we broadly call pelvic floor dis energia, and constant constipation predominant irritable bowel syndrome, or I. B. S. C. Slow transit. Constipation is characterized by delayed transit of stool due to an underlying myopathy, or dysfunction of the colonic smooth muscle or neuropathy. This type of constipation, that is what I described to my patients as just your colon is a bit lazier and slower in its movement than those of others. It can all occur for various reasons, including on the smooth muscles, colon, colonic reflexes or Kalanick pacemaker. Cell activity. Studies have shown that when patients with slow transit constipation are given pharmacologic stimulation with basic auteuil or neo Stickney, there is a reduction in Kalanick responses, presumably due to abnormal regulation or autonomic control of colonic neuro muscular function. This hypothesis is supported by a study that showed a reduction in the number of intrinsic Kalanick nerves and interstitial cells of CA hall in patients with slow transit constipation. When a patient is suspected to have slow transit constipation, there are three diagnostic tests that can be performed to confirm the suspicion at UCSF. We offer two out of three of these tests um and which are the SITS marker study test and the motility capsule test. Kalanick geometry is currently not offered at UCSF and it is only offered a very select institutions but institutions like C. P. M. C, do routinely perform based tests for your information. So in the six marker study the patient in just one capsule, which is shown on the left here um containing 24 radio opaque markers on day zero and they go home on day five, they come back and then we take a radiograph of the abdomen. The test is considered abnormal. If more than five or greater than 20 of the sits markers are retained in the colon at day five. Please do note, however, that slow transit constipation can be present in two thirds of patients with also dis synergies, defecation. So you can imagine even if even if the six markers are able to travel through the colon in good time, if there is an evacuation issue, all the markers maybe just remaining in the rectum and that will be a falsely positive study for slow transit. So this study cannot really fully differentiate between slow transit and versus patients with just an isolated dishonor justification. So in those patients where you suspect this energy, please make sure to also refer them for an indirect all geometry test. The second modality of testing for slow transit constipation is the wireless motility capsule test, also known as the smart pill test. This involves the patient ingesting a wireless ph temperature and pressure recording capsule. The test assesses not only regional but also whole gut transit time. So it can test for gastric, small bowel and colonic transit time without any radiation exposure. So this is a very convenient test that will give us a lot of information on basically the whole gut motility. We do offer this test that UCSF but please do counsel the patients that it's unfortunately pretty rare that the insurance companies will cover this test. And I believe right now currently, United Health is the only insurance company that covers the test right now and out of pocket costs can be up to several thousands of dollars. So as a result, I usually reserve this test only for patients in whom I suspect whole gut this motility or in patients who are really hesitant to start a pharmacologic medication for constipation without evidence of gut motility. Kalanick manama tree is the third test to test for slow transit. And it's a test that provides information regarding resting colon colon motility profile as well as pressure changes after provocative stimulation such as meals or drugs. Um It should be considered in patients usually with slow transit constipation who have failed to respond to medical therapy. And we usually reserve this testing for people in whom we're actually considering total collect amis due to refractory constipation. The second category of primary chronic constipation which I won't spend too much time on today is constipation predominant, irritable bowel syndrome, which is usually defined by the Rome criteria. But the main thing to remember here is that I. B. S. Constipation is characterised by abdominal pain or presence of discomfort that's associated with infrequent or difficult defecation. The development of I. B. S. Um You know, there's still a lot of studies and theories as to why I. B. S. Develops but it's usually influenced by multiple factors which include a component of genetic predisposition, psychological factors, biological social and environmental factors. Several environmental factors which you are all aware of include things like acute gastroenteritis. Up to 10% of patients who suffer from either a campylobacter, e. Coli, norovirus or giardia infection actually can develop irritable bowel syndrome, which is now classified as post infectious I. B. S. This also has been associated with development of small intestinal bacterial overgrowth for whom, you know, you can always consider doing a CBO breath test. We don't offer the CBO breath testing at UCSF due to poor test characteristics and in fact, when we suspect that patients actually have, see bill will just empirically treat them with a course of reef Axman or a combination therapy with reef axeman and Neo Myson and people in whom we suspect with androgenic cibo, which tends to present more with constipation as opposed to diarrhea. Lastly, um I. B. S. Constipation has also shown to be associated with intolerance to fructose or for preventable. Allah go diamond of Sacha right intolerance or the roadmap group intolerances. But this last category of primary constipation is pelvic floor dis energia, which is a special interest of mine. So dis synergies, defecation broadly refers to the inability to evacuate stool from your rectum. Classically, patients with this energy certification will say doc, I have the urge to go to the restroom, but I'm spending 10 2030, 40 minutes just pushing and pushing on the toilet and I just cannot get my stool out. So really this is a problem with evacuation of solar outlet obstruction of stool in order to understand how or why pelvic floor dis energy occurs. I want to spend a moment reviewing the structures of the indirect um and the normal sequence of events that need to occur for effective evacuation to occur. So most of us take pooping and defecation for granted. But really defecation is something that we have been doing, although we've been doing it ever since we were newborns without effort. It really turns out that the act of defecation is quite complicated and requires very careful and intricate coordination of various muscles in your pelvic floor. In patients with this inner justification, for whatever reasons it may be, their bodies just have forgotten how to coordinate these abdominal and recto anal and pelvic floor muscles to allow for this process to occur. So looking at this diagram here on the left, it shows you what your pelvic floor looks like at rest at rest. The rectum sits at an angle called the anal rectal angle. The acuity of this angle, which is in part maintained by the contraction of the Cuban wrecked Alice muscle, which is the red sling like muscle that you see in this diagram, the Cuban rock palace actually contracts and it makes the angle to be quite acute, which makes it difficult for stool to exit out of the rectum. And this is how we can usually prevent episodes of incontinence at rest when a ball of stool travels down to the rectum. Uh The sensory nerves in the rectum detect the pressure from the stool and sends a signal to the brain to coordinate a series of events. So if you look at the right diagram first the pupil right talus muscle needs to straighten out so relaxes and and hence as a result, the indirect angle becomes more obtuse. Now the rectum is more straight and will last for the easy passage of stool to occur at the same time. Direct um also has to contract to propel the stool and the external anal sphincter relaxes to allow for passage of stool out. And it's this intricate coordination of various muscular function that ultimately leads to the descent of the pelvic floor and allows for effective verification. People can have dishonored rectification when one or more of these processes go awry. They either may have inadequate rectal or abdominal propulsive force. They may have impaired anal relaxation or an increased outlet resistance from paradoxical external anal sphincter or cuba rectal is contraction. So part of my clinical practice is to test the coordination of these pelvic floor muscles and patients in whom we suspect this energia. So this is um in a directory geometry test which is a fancy test that we do in our center for pelvic physiology which basically tests for the function or dysfunction of the pelvic floor muscles. On the right here is the catheter that we use. It's basically a straw like catheter with a balloon that is attached to the end. We inserted this catheter up to seven cm into the patient's rectum. Well the patient is lying laying flat or not flat but laying on on his or her left side And for the entire procedure because they need to participate. So for the next 30 or 40 minutes of the testing, the patient is usually asked to do a variety of universe, including squeezing. Their aim is tight as if they're trying to prevent themselves from having to go to the bathroom and also to bear down and push to simulate having a bowel movement. And while the patient is doing these maneuvers, the sensors at various levels on this catheter will measure the external sphincter muscle will be able to test for the pupil wrecked Alice muscle and its coordination with defecation as well as the rectal, a propulsive force at the end of the test. We also will inflate the balloon to varying degrees of volume, to stimulate our to simulate a bowel movement. And the patient will actually tell us when they feel the urge to go when they feel maximum urgency, as if they cannot hold any stool further. And the measurements that we have of different volumes will actually let us know whether there is rectal hypo or hyper sensitivity based on the data from the anal rectal manama tree. Um This is uh we can actually categorize patients into four different types of the victoria dysfunction types one through four. I won't belabor the different types here, but basically it's looking at what the rectum and the anal muscles are doing in coordination with each other and trying to see whether they actually have patterns of appropriate contraction or appropriate relaxation at different points. One of the key points I want to emphasize though during this talk is the fact that we oftentimes don't need this fancy testing to suspect or even diagnose someone with pelvic floor dysfunction. And this is a point that actually took me a while to understand throughout G. I. Fellowship. Um You know, I oftentimes have underestimated the value of doing a very careful rectal exam. And actually with the with a thorough rectal exam, you can identify patients with suspected pelvic dysfunction with great accuracy. So this is a paper that was published in the Red Journal several years ago, which summarizes the process of performing a rectal examination. In the first panel a um you see the examiners finger is in the patient's rectum at rest, feeling for the patients resting an old tone and then panel be the patient is asked to bear down as is to stimulate stimulate having a bowel movement in decision ergic defecation. You may have paradoxical contraction of the pupil wrecked Alice muscle, which is usually felt during the examination as an anterior displacement of the examiners finger. And you may also be able to feel paradoxical contractions of the external sphincter muscles, which is the muscular ring that's felt at the base of your index finger. This is a paper that dr rao published in 2010 that illustrates the clinical utility of performing digital rectal examinations. In this paper, trainee physicians were taught the proper way of performing a rectal examination and their examination findings were compared with the gold standard, which was the diagnosis of pelvic distant energia using an erectile manama tree. And as you can see here, digital rectal exam performed quite well in detecting dis energia compared to the gold standard of an erectile manama tree, including ability to detect paradoxical contractions of the external sphincter muscles and the pure Baroque Palace muscles. So once we diagnose a patient with pelvic floor dis energia, we arrange monthly biofeedback sessions at our Center for pelvic physiology. This is an intensive, multidisciplinary treatment session that includes education of patients on proper defecation habits, retraining the pelvic floor muscles by allowing for visual and audio feedback to the patients during their attempted defecation electric stimulation of public floor muscles to allow for kind of retraining and rehabilitation of the muscles. And we also do an intensive dietary and lifestyle modification. So it's a very multifaceted multi modal therapy. We usually recommend about 6-8 sessions for patients to benefit from the therapies and depending on the patient's specific condition. Oftentimes they are able to also go home with a small handheld biofeedback device that they can use at home on a daily basis to do electrical stimulation and rehabilitation on their own. So this is the last lie that I want to leave you with, which is a schema of work up an approach to a patient with constipation. So, um you know, as I mentioned, thorough history taking and physical exam, including a digital rectal exam is very important. And if a patient has any alarm symptoms such as unexplained weight loss blood in their stools or they're above the age of 50, um you know, I would just recommend testing specifically for the specific diagnoses that you're concerned about and consider a timely referral for a colonoscopy in the absence of these alarms, symptoms. For both for both, irritable bowel syndrome and other causes of primary chronic constipation. Really, the treatment modalities include lifestyle modification as a first step. And then you can consider, you know, medications such as Lindsay's or am Atienza, which oftentimes the patients already have tried at your recommendation by the time they come to our G. I. Clinic and then if no improvement, consider additional testing which can include anal rectal manama tree, additional manama, Kalanick manama tree, smart pill test or a colonoscopy. But to be very honest, you know, in this schema, I would say that if you really suspect someone that has public floor this energy based on the history that you take or or the digital rectal exam findings, it's totally fine to skip many of these steps and go directly to incorrectly manama tree because that would be really, the biofeedback is really essentially what they need. Um So lastly, I wanted to kind of let you know, that's what my some of my research interests are in treatment of pelvic floor dis energia. Um I do have a specific interest in caring for patients with illegal pouch anal anastomosis. So folks who have either had total collect amIS for severe refractory, slow transit constipation or patients with all sort of colitis. We've had total collect amIS. Um this is an area that is still under investigation and not much data is out there with regards to the concomitant pelvic floor dysfunction in these patients. However, kind of anecdotally, we are seeing more and more patients with older pouches who've had pouches for the last 10 or 20 years who are now really exhibiting symptoms of dysfunction. Um so, if you have come across any of these patients in your practice, please send them over to UCSF and we would love to kind of figure out what's going on with their pelvic floor. Additionally, I'm sure that you have many patients with concomitant urinary symptoms of frequency or urinary incontinence or obstruction, as well as constipation. And this is also an area that we are in collaboration with at the urology department in terms of looking at the concomitant symptoms of both bowel and urination and figuring out treatment modalities such as Botox injections or electrical biofeedback therapy for these patients. So
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