Functional bowel disorders

  1. Rome criteria
    *Recurrent abdominal pain or discomfort** at least 3 days/month in the last 3 months (symptom onset more than 3 months before diagnosis) associated with two or more of the following:

    • Improvement with defecation.
    • Onset associated with a change in frequency of stool.
    • Onset associated with a change in form (appearance) of stool*
  2. Functional BloatingDiagnostic criteria
    • Must include both of the following:.
    • Recurrent feeling of bloating or visible distension at least 3 days/month inthe last 3 months.
    • Insufficient criteria for a diagnosis of functional dyspepsia, irritable bowelsyndrome, or other functional GI disorder
  3. Rome, IBS constipation
    presence of Bristol StoolForm Scale Types 1 and 2.
  4. Functional Constipation
    • Must include two or more of the following:
    • a. Straining during at least 25% of defecations
    • b. Lumpy or hard stools in at least 25% of defecations
    • c. Sensation of incomplete evacuation for at least 25% of defecations
    • d. Sensation of anorectal obstruction/blockage for at least 25% of defecations
    • e. Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor)
    • f. Fewer than three defecations per week.

    Loose stools are rarely present without the use of laxatives.

    Insufficient criteria for irritable bowel syndrome
  5. Functional Diarrhea
    Loose (mushy) or watery stools without pain occurring in at least 75% of stools
  6. rome criteria contd
    • Criterion fulfilled for the last 3 months with symptom onsetat least 6 months prior to diagnosis** “Discomfort” means an uncomfortable
    • sensation not described as pain.In pathophysiology research and clinical
    • trials, a pain/discomfort frequency of at least 3 days a week during
    • screening evaluation is recommended for subject eligibility.
  7. constipation physiology
    • Segmental contractions
    • high amplitude propagating contractions
    • Defecation
  8. physiology mass movements or giant migrating contractions (GMC)
    • high amplitude propagated contractions
    • right after awakening
    • after meals
    • followed by an urge to defecate
    • (benzofurans
  9. defecation physiology
    determined by the propulsive force of the stool and the resistance of the anus

    triggered by distention of the rectum
  10. defecation physiology
    propulsive force of the stool
    • (voluntary increases in intra-abdominal pressure,
    • involuntary high amplitude contractions of the
    • rectum
  11. defecation dec resistance of the anus
    • voluntary straightening of the anorectal angle
    • relaxation of the external sphincter
    • involuntary relaxation of the internal analsphincter
  12. ibs-physiology
    Abnormalities in intestinal motility,alterations in the migratory motor complex

    heightened visceral sensory input and processing,exaggerated response to intestinal distentio

    infectious gastroenteritis may increase the possibility of developing IBS later in life (5,6), presumably by damaging the enteric nerves responsible for peristalsis.
  13. (benzofurans
    • selective stimulation of serotonin 5HT4 receptors
    • cholinergic as well as non-cholinergic excitatory neurotransmission
  14. history
    • stool size, frequency, consistency, and ease and efficacy of evacuation
    • age at onset of symptoms, diet and exercise details, medical history, surgical history and medications
    • psychiatric illness and sexual and physical abuse

    • A patient diary of dietary intake, evacuation frequency, stool consistency and any
    • associated symptoms (pain, mucus,blood, sense of incomplete evacuation, whether manual means are used to effect evacuation)
    • Multicompartment pelvic floor symptoms such as
    • urinary dysfunction, pelvic organ and prolapse, and sexual dysfunction and appropriate referrals to other pelvic floor specialists in urology and urogynecology should be made for combined treatment.
  15. History: alarm sx
    hemochezia, weight loss of more than 10 pounds,family history of colon cancer or inflammatory boweldisease, anemia, change in bowel habits or blood inthe stool
  16. history: obstructed defecation
    straining with bowelmovements, incomplete evacuation, sensation ofobstructed defecation, and the use of manual maneuversto aid defecation.1
  17. digital rectalexamination, plus the selective use of anoscopyproctosigmoidoscopy
    fecal impaction, stricture, external or internal rectalprolapse, rectocele, paradoxical or nonrelaxing puborectalisactivity, or a rectal mass
  18. physical
    • abdominal distension
    • Bulging of the posterior vaginal wall (prolapse and may represent a rectocele, enterocele, or sigmoidocele.
    • aping patulous anus(neurological injury, intraanal intussusception or full thickness rectal prolapse)
    • Flattening of the perineum during valsalva beyond the ischial tuberosities
    • Sphincter coordination ( squeeze, relax, and push)
    • Digital examination (resting anal tone and squeeze strength,
  19. Tests for organic disease
    • cbc
    • cmp
    • esr
    • ANA
    • ionized calcium
    • TFT
    • glucose
    • stool occult
    • stool o and p
    • colonoscopy with biopsies in diarrhea
  20. anal manometry
    • internal sphincter hypertonia
    • poor incremental squeeze pressures
    • volume noted at first sensation can be blunted
    • maximum tolerated volume can also be blunted
    • RAIR
    • Electromyography diagnosis of puborectalis syndrome
  21. (Motility Disorders)-slow transit,
    • Irritable Bowel Syndrome (IBS),
    • pelvic floor dysfunction, also described as Obstructed Defecation Syndrome (ODS)
    • mixed disorders.
  22. Tests for constipation IBS
    colon transit study (r/o slow transit vs. outlet obstrxn)

    • rule out coexisting outlet obstruction with
    • anorectal manometry,(r/o hirschprung w/ RAIR), anismus

    • balloon expulsion test screening test for pelvic floor dyssynergia (PFD)
    • dynamic proctography: pelvic floor path (rectocele, enterocele, rectal prolapse)rectal intussuception, paradoxical puborectalis activity
    • Defecating MRI
  23. tests for diarrhea IBS
    • lactulose H2 breath test,
    • celiac sprue
    • stool osmolarity and electrolytes,
    • jejunal aspirate for ova and parasites
    • small bowel and colon transit.
  24. Pain-predominant IBS
    • abdominal films
    • small bowel series,
    • lactulose H2 breath test
    • gastrointestinal manometry
  25. Rx Diarrhea-predominant IBS
    • dietary restriction (lactulose, fructose, sorbitol)
    • loperamide (immodium)
    • diphenoxylate (lomotil)
    • Tricyclic antidepressants
    • Calcium channel blocker
    • 5HT3 (alosetron)
    • 5HT4 receptor antagonists
  26. Rx pain-predominant IBS
    • antispasmodics with or without anxiolytics
    • avoidance of gas forming foods

    • Smooth muscle relaxants (clinical trial)
    • mebeverine, octylonium and cimetropium

    kappa opioid agonist fedotozine(clinical trial)
  27. Constipation-predominant IBS
    • bulking agents, fiber 25-30 g
    • water intake to 64oz a day
    • Osmotic laxatives
    • stool softeners
    • tegasord (women)
  28. 20 causes of constipation-endocrine
    • insulin-dependent diabetes mellitus,
    • hypopituitarism, hypothyroidism, hypoparathyroidism
    • hypercalcemia, hypokalemia
    • crf
    • pseudo-hypoparathyroidism,
    • pheochromocytoma, glucagonoma,
    • pregnancy,
    • reduction of steroid hormones in luteal and follicular
    • phases of menstrual cycle
  29. 20 causes of constipation-metabolic, collagen vascualr d
    • porphyria,
    • uremia,
    • hypokalemia,
    • amyloid neuropathy
    • scleroderma, lupus
  30. 20causes of constipation-neurologic d/o
    • Cerebral
    • Parkinson's disease,
    • cerebral or spinal tumors,
    • cerebrovascular accidents,

    • aganglionosis,
    • ogilvie

  31. 20causes of constipation-neurologic d/o
    • spinal
    • cauda equinalesion
    • myelomeningocele
    • truma (spinal cord injury)
    • MS
    • tertiary syphillis
  32. 20causes of constipation-neurologic d/o
    • peripheral
    • DM
    • autonomic neuropathy
    • chagas, hisrschprungs
    • Von reckinghausen
    • stimulant laxative abuse
    • vincristine
  33. 20causes of constipationSurgery resulting in localized damage to autonomic nervous plexus
    pelvic surgery (cystectomy, rectopexy, hysterectomy)
  34. 20causes of constipationPharmacologic agent
    • Opioids, narcotics
    • anticholinergics, anitdepressants
    • anticonvulsants,
    • antacids (calcium and aluminum containing), bismuth
    • anti-Parkinsonian agents,
    • antihypertensive agents(diurectics, ganglionic blockers, calcium channel blockers
    • ion exchange resins
    • bulk laxatives without adequate hydration
    • chronic stimulant laxative abuse (senna, cascara, anthraquinones, bisacodyl),
    • monoamine oxidase inhibitors,
    • tricyclics,
    • phenothiazines, diuretics
    • alkaloids (vincristine), chemo
    • heavy metal poisoning (lead, mercury), arsenic,
    • phosphorus, iron,
    • oral contraceptives,
    • muscle relaxants
  35. 20causes of constipationObstructive bowel diseases
    • Endometriosis,
    • carcinoma,
    • diverticular d
    • ibd
    • ischemic colitis
    • volvulus,
    • hernia,
    • benign strictures, anastamotic
    • pseudo-obstruction,
    • polyps,
    • adhesions
  36. 20causes of constipationAnal Outlet
    • Thrombosed hemorrhoids,
    • anal fissure,
    • rectal prolapse,
    • proctitis,
    • rectocele,
    • nonrelaxing puborectalis,
    • hypertrophic internal anal sphincter.
  37. fecal impaction associated causes in elderly
    • fecal incontinence, spurious diarrhea
    • urinary retention
    • mental disturbance and anxiety
    • rectal hyposensitiviy
    • arrhythmia
    • syncope
    • autonomic dysreflexia
    • ptx
    • hypoxia
    • hypotension
    • dysfunctional labor
    • volvulus
    • stercoral ulceration
    • cecal perf
    • hemorrhoids, anal fissure
    • rectal prolapse
  38. 20causes of constipation Functional
    • Irritable bowel syndrome,
    • anismus,
    • sedentary-bedridden patients, inadequate toilet facilities, depression, psychosis, ignoring need for bowel movement, immobility.
    • encopresis
    • major depression, anxiety, obsessional personality
  39. 20causes of constipation-dietary
    • inadequate fiber or fluid intake
    • ingestion of stool hardening foods.
  40. 20causes of constipation-colonic inertia
    • slow transit
    • ogilvies
  41. causes of constipation-idiopathic
    number and duration of these GMC's is smaller
  42. rx-idiopathic constipation
    • Underlying pathology
    • Correct causative underlying conditions and eliminate offensive medications if possible

    • Activity level
    • Increase mobility
  43. IBS-C
    constipation since childhood, fewer than 3 BMs per week, and laxative dependence
  44. rx-idiopathic constipationDietary manipulations
    High fiber intake (20-30 g / day) , increases stool freq

    Konsyl(r) / Metamucil(r) / Citrucel(r),1 tbs.PO BID

    Increase non-caffeinated fluid intake (8-10 8 oz glasses /day), inc stool freq

    increased physical activity
  45. rx-idiopathic constipationStool softeners
    • Sodium docusate 100 mg PO BID
    • Mineral oil 1 oz PO BID
  46. rx-idiopathic constipationStimulant laxatives
    Pericolace(r) 1 PO QD

    Dulcolax(r) 5-15 mg PO if no BM for 3 or more consecutive days
  47. rx-idiopathic constipationEnemas
    Fleets(r) enema if no BM for 3 days
  48. rx-idiopathic constipationOsmotic agents
    • Milk of Magnesia 30-60 PO QD
    • Lactulose 30 ml PO QD-BID
    • Polyethyleneglycol (PEG) 10-20 oz PO QD
    • Miralax(r) 17 gm PO QD
  49. rx-idiopathic constipationPsychological support and evaluation as indicated
    Counseling, MMPI
  50. rx-idiopathic constipationSurgical intervention
    • Subtotal colectomy with ileorectal anastomosis
    • Subtotal colectomy with ileostomy
    • Diverting ileostomy
  51. slow transit constipation
    constipation since childhood, fewer than 3 BMs per week, and laxative dependence
  52. slow transit constipation
    • abnormality of the myenteric plexus
    • medical management

    • total abdominal colectomy with ileorectal anastomosis 80-90% success
    • ileus in approximately one-third of patients, small bowel obstruction, diarrhea, and possible incontinence (17).

  53. Colonic inertia
    • totalabdominal colectomy with ileorectal anastomosis, subtotal colectomy with ileosigmoid anastomosis,
    • subtotal colectomy with cecorectal anastomosis.
    • failure>completion proctectomy, IPAA
    • concomitant small bowel transit problems and obstructed defecation lowers success
  54. ODS, sx
    • prolonged repeated straining at bowel movements,
    • sensation of incomplete evacuation,
    • need for digital manipulation
  55. rx obstructive defecation
    • biofeedback success 70%
    • rare patient may benefit from internal sphincterotomy
  56. pelvic floor dyssynergia (PFD
    biofeedback 35-90 % success
  57. anismus or paradoxical puborectalis
    • Electromyography
    • paradoxical contraction of voluntary sphincter m during attempts at evacuation
  58. rx-combined slow transit constipation and pelvic outlet obstruction
    TAC-IRA and repair or treatment of the outlet obstruction
  59. rx-combined slow transit Constipation and associated pelvic floor dyssynergia
    • biofeedback and TAC-IRA,
    • higher rate of recurrentdefecatory problems and lower satisfaction
  60. rx-combined slow transit Constipation with rectal intussuception and/or nonemptyingrectocele/enterocele can be treated with
    TACIRAafter repair of the anatomic cause of the outletobstruction
  61. rectocele
    • repair of non-emptying rectoceles, usually greater than 4 cm in size and those benefiting from posterior vaginal pressure
    • Transvaginal and transanal techniques appear to have similar functional results,
    • further data with transperineal route and the use of mesh
  62. sns
    • improved fecal continence, an increase in bowel frequency, and improved defecation.
    • sacral neuromodulation may involve afferent cortical stimulation leading to increased motility and rectal sensitivity.
  63. ace
    intermittent catheterization, irrigation of the colon and rapid, controlled bowel purging.
Card Set
Functional bowel disorders
diarrhea, constipation, IBS