Red flag features in chronic constipation

Transcription

1 Chronische obstipatie

2 Red flag features in chronic constipation Recent onset of constipation in older age (> 50 years) Obstructive symptoms Rectal bleeding Weight loss Family history of colon cancer Iron deficiency anaemia

3 Chronische obstipatie De aanwezigheid van 2 of meer van de volgende symptomen gedurende tenminste 12 weken in de afgelopen 12 maanden: (a) de noodzaak tot persen bij meer dan 25 van de defecaties; (b) harde feces bij meer dan 25% van de defecaties; (c) het gevoel van incomplete lediging bij meer dan 25% van de defecaties; (d) het gevoel van anorectale blokkade bij meer dan 25% van de defecaties; (e) de noodzaak van toepassing van manuele manoeuvres bij meer dan 25% van de defecaties; (f) minder dan 3 defecaties per week Smout en Brummer in Ned Tijdschr Geneeskd. 2000;144:878-84

4 ROME III criteria Functionalconstipation (modified from Longstreth in 2006 ) Symptom onset at least 6 months prior to diagnosis Presence of symptoms for the last 3 months (see below) Insufficient criteria for irritable bowel syndrome Loose stools are rarely present without the use of laxatives - Less than three bowel movements per week Symptoms include two or more of the following during at least 25% of defecations: Straining Lumpy or hard stools Sensation of incomplete evacuation Sensation of anorectal obstruction or blockade Manual maneuvers to facilitate evacuation

5 Constipation and history Description of subjects bowel habits Onset of symptom Duration of symptom Severity of symptoms History of precipitating events Laxative use type, number and frequency Dietary history-fiber and fluid intake Family history of bowel function

6 Best Pract Res Clin Gastroenterol February; 25(1):

7 Best Pract Res Clin Gastroenterol February; 25(1):

8 Grade A1: Excellent evidence in favor of the test based on high specificity, sensitivity, accuracy and positive predictive values Grade B2: Good evidence in favor of the test with some evidence on specificity, sensitivity, accuracy, and predictive values Grade B3: Fair evidence in favor of the test with some evidence on specificity, sensitivity, accuracy, and predictive values Grade C: Poor evidence in favor of the test with some evidence on specificity, sensitivity, accuracy, and predictive values

9 Constipation and X-BOZ No concordant relation between CAS and plain abdominal radiographic constipation score (n= 50 cancer patients) J Pain Symptom Manage Aug;42(2): Significant correlations were found between the radiograph scores and frequency of defaecation, faecal consistency and stool weight (n=30) Z Gastroenterol Jul;28(7):335-8

10 Constipation and X-BOZ Best Pract Res Clin Gastroenterol February; 25(1):

11 Diseases and abnormalities that can cause secondary constipation Endocrine and metabolic diseases Diabetes mellitus, hypercalcaemia, hyperparathyroidism, hypothyroidism, uraemia Myopathies Amyloidosis, myotonic dystrophy,scleroderma Neurological diseases Autonomic neuropathy, cerebrovasculardisease, Hirschsprung s disease, Multiple sclerosis, Parkinson s disease, medullarytrauma, tumours Psychological diseases Anxiety, depression, somatization Structural causes Anal fissures, haemorrhoids, colonicstenosis, chronic intestinal inflammatorydisease, obstructive colonic lesions, rectalprolapse, rectocele Other situations Irritable bowel, pregnancy

12 Drugs related to secondary constipation Antacids (containing aluminium hydroxide and calcium) Anticholinergics Antidepressants Antihistamines Calcium channel antagonists Clonidine Diuretics Iron Levodopa Opioids NSAIDs Psychotropic drugs Sympathicomimetics

13 Bulk laxatives Bulk laxatives, including soluble fibre (such as psyllium) and insoluble fibre (such as bran), work by increasing the volume of stools. Soluble fibre is preferable, but bulk laxatives generally are not very effective for treating constipation. Side effects may include abdominal pain and bloating

14 Osmotic laxatives Osmotic laxatives, including lactulose and polyethylene glycol, also increase stool volume by increasing water content in the large bowel. They are effective for treating constipation, and side effects are generally well tolerated, although people often find the taste of lactulose unacceptable. As they increase water content in the large bowel, symptoms of dehydration (such as lightheadedness, headache, or dark urine) may develop. Side effects :bloating, flatulence, noise

15 Stimulant laxatives Stimulant laxatives, including bisacodyl and sodium picosulfate, act on the large bowel to help the stool pass through it. They are effective for treating constipation but often cause diarrhoea Side effects (in elderly) : ischaemic colitis

16 Prucolapride

17 Prucolapride Dose Camilleri et al. [2008] Tack et al. [2012] Quigley et al [2012] Percentage of women 88% 90.8% 86.6% Mean age (years) Mean duration of symptoms (years) Total randomized Total completed 534 (85%) 597 (83%) 567 (89%) Total evaluated Placebo mg Mean CSBMs/week (at baseline) CSBMs/week Placebo 12% 9.6% 12.1% 2 mg 30.9%^ 19.5%# 23.9%# Increase in 1 Placebo 25.8% 20.9% 27.5% CSBMs/week 2 mg 47.3%^ 38.1%^ 42.6%^ Median time Placebo to 1st CSBM 2 mg 1.3^ 4.7^ 2.3 (in days) Note: *p < 0.05; #p < 0.01; ^p < CSBM, complete spontaneous bowel movement

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