Manuel Francisco T. Roxas, MD, FPCS, FPSCRS, FACS

CONSTIPATION• 95% of US adults

– Bowel movement between 2x daily to once every 2 days

(Bartolo, 1992)

• Prevalence of constipation in the US– 2 to 34% of population– 40% among elderly (Talley, 1993,

1996)

The Colon• Function

• Colon– Absorption of water

and electrolytes– Repository of Bacteria

flora

• Rectum– Storage and

defecation

• Anus– Continence– Defecation

Normal Intestinal Transit

Intestinal Segment

Hours

Oral-Cecal 6

Right colon 12

Left colon 12

Sigmoid colon 12

Overall, normal mean colonic transit time is 36 hours, but the range is wide

Colonic Innervation• Intrinsic/Enteric

Nervous system– Myenteric neuronal

plexuses regulate smooth muscle function and motility

– Aganglionosis causes constipation

• Extrinsic Nervous System– Parasympathetic

autonomic innervation• Supplied by vagus and

sacral (S2-4) nerves• Excitatory to gut

– Sympathetic autonomic innervation• Along the mesenteric

vessels• Excitatory to sphincters• Inhibitory to non-

sphincteric smooth muscles

The Sphincter Muscles of the AnusLevator ani

Form pelvic floor

External SphinctersVoluntary Comprised of:

Puborectalis sling Deep Superficial

Internal SphinctersInvoluntaryContinuation of circular

muscles of rectum

Anorectal PhysiologyContinence involves

Detection of rectal contentsDiscriminationVoluntary and subconscious

retentionControlled expulsion

Anorectal Physiology

HEMORRHOIDAL CUSHIONS

Anorectal PhysiologyRecto-anal inhibitory reflexAnal sampling reflexGastro-colic reflex

Paradoxical puborectalis contraction

Developmental Milestones in Infancy

Walk – 12 monthsSpeak 2 words other

than mama and papa – 12 months

Run – 15 monthsToilet train – 36

months

CONSTIPATIONRome Definition:• 2 or more of the

following complaints for at least 12 months, without laxatives– Straining during >

25% of BM– Sensation of

incomplete evacuation on > 25% of BM

– Hard or pellety stools on > 25% of BM

– < 3 stools per week

Common Causes of Constipation• Primary

– Idiopathic slow transit/colonic inertia

– Irritable bowel syndrome

– Functional pelvic outlet obstruction

• Secondary– Endocrine/metabolic

• Hypothyroidism• Hypercalcemia

– Neurologic• Parkinson’s disease• Multiple sclerosis• Autonomic neropathy• Spinal cord injury• Sacral parasympathetic

nerve injury– Psychiatric

• Depression• Anorexia nervosa

Common Causes of ConstipationPhysical gastrointestinal causes

DiverticulosisStricturePolyps CancerIschemia

1st Line Treatment of Constipation

Increase dietary fiberBulk laxatives like psyllium

Normal Frequency of Bowel Movement in Children

Age BM per day

0 – 3 months

breast-fed 2.9

formula-fed 2.0

6 – 12 months 1.8

1 – 3 years 1.4

> than 3 years 1.0

Fontana MB, et al 1987

Constipation in ChildrenDefinition

Delay or difficulty in defecation present for 2 or more weeks

Functional constipationConstipation without objective evidence of a

pathologic conditionFecal impaction

Hard mass in the lower abdomen identifiedDilated rectum filled with large amounts of stoolExcessive stool in the colon on abdominal

radiography

Possible Causes of Constipation in ChildrenNonorganic

Developmental Cognitive handicaps Attention deficit disorders

Situational Coercive toilet training Toilet phobia School bathroom avoidance Excessive parental

intervention Sexual abuse

DepressionConstitutional

Colonic inertia Genetic predisposition

Possible Causes of Constipation in ChildrenReduced stool volume and

dryness Low fiber diet Dehydration Underfeeding or

malnutritionDrugs

Opiates Anticholinergics Antidepressants Anticonvulsants

Others Heavy metal (lead) ingestion Vitamin D intoxication Cow’s milk protein

intolerance

Possible Causes of Constipation in ChildrenOrganic

Anatomic malformation Imperforate anus Anal stenosis Anteriorly displaced anus Pelvic mass (sacral teratoma)

Metabolic and gastrointestinal Hypothyroidism Hypercalcemia Hypokalemia Cystic fibrosis Diabetis mellitus Multiple endocrine neoplasia Gluten enteropathy

Possible Causes of Constipation in ChildrenOrganic

Neuropathic conditions Spinal cord abonormalities Spinal cord trauma Neurofibromatosis Static encephalopathy Tethered cord

Abnormal abdominal musculature Prune belly Gastroschisis Down syndrome

Connective tissue disorders Scleroderma Lupus Ehlers-Danlos Syndrome

Possible Causes of Constipation in ChildrenOrganic

Intestinal nerve or muscle disorders Hirschprung disease Intestinal neuronal

dysplasia Visceral neuropathies Visceral myopathies

Management of Constipation in Children

Thorough history and PEFecal occult blood in all infants and in children

with abdominal pain, failure to thrive, diarrhea, or a family history of colorectal polyps or cancer

Abdominal x-rays in selected patients to diagnose fecal impaction

Rectal biopsies and manometry are the only tests that can reliably exclude Hirschprung disease

Transit time studies in selected patients to determine if truly consipated

PE findings distinguishing organic from functional constipation in children

Failure to thriveAbdominal distentionLack of lumbosacral curvePilonidal dimple covered by

a tuft of hairMidline pigmentary

abnormalities of the lower spine

Sacral agenesisFlat buttocksAnteriorly displaced anusPatulous anusAbsent anal wink

Tight, empty rectum in the presence of a palpable abdominal fecal mass

Gush of liquid stool and air on withdrawal of examining finger

Occult blood in stoolsAbsent cremasteric reflexDecreased lower extremity

tone and/or strengthAbsence of delay in

relaxation phase of lower extremity deep tendon reflexes

Management of Constipation in Children

In InfantsRectal disimpaction with glycerine

suppositoriesAvoid enemasMineral oil and stimulant laxatives not

recommendedJuices containing sorbitol (prune, pear, and

apple, corn syrup, lactulose and sorbitol (osmotic laxatives) may be used

Management of Constipation in Children

In ChildrenDisimpaction with oral and rectal medications ,

including enemasBalanced diet with whole grain, wheat, fruits

and veggiesMineral oil, magnesium hydroxide, lactulose

and sorbitol are safe to useMedication and behavioral management may

decrease time to remissionBio-feedback may be effective short-term

treatment

Fecal Incontinence“frequent and

inadvertent voiding per anum of formed stool”

“loss of anal sphincter control resulting in unwanted release of gas, liquid or solid stool”

Fecal Incontinence

GradeI – incontinent to gasII – incontinent to gas and liquid, but not to

solid BMIII – incontinent to all types of BM, including

solid BM

Fecal IncontinenceCommon Causes

Sphincter injury related to birth traumaNeuropathic causes

Pudendal neuropathy or injury Auntonomic neuropathy or injury

Anatomy of the Anorectum

Upper

Mid

Lower

Upper Anal Canal

Mid Anal Canal

Low Anal Canal

There is a defect in the external sphincter between 1 O'clock and 3 O'clock (arrow). The normal external anal sphincter is shown (arrowhead).

There is a defect in the anterior portion of the external anal sphincter with an anterior anal fistula (arrow). The tiny focus of increased reflectivity is from gas within pus in the fistula track.

Management of Fecal IncontinenceDetermine and treat primary cause

Medical TreatmentDietary modification (high fiber, less fat)Fiber supplements (psyllium)Anti-diarrheals (loperamide)Pelvic floor exercises / biofeedback

Management of Fecal Incontinence

Surgical TreatmentDirect sphincter repairMuscular flapsArtificial sphincters

Among the various disciplines of Surgery,

the most philosophical is that of Colorectal Surgery

For no one else is as deeply contemplative

Of the End of Man

Fr. Miguel Bernad, SJ