Functional bowel disorders

*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*

• 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

presence of Bristol StoolForm Scale Types 1 and 2.

• 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

Loose (mushy) or watery stools without pain occurring in at least 75% of stools

• 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.

• Segmental contractions
• high amplitude propagating contractions
• Defecation

• high amplitude propagated contractions
• right after awakening
• after meals
• followed by an urge to defecate
• (benzofurans

determined by the propulsive force of the stool and the resistance of the anus

triggered by distention of the rectum

• (voluntary increases in intra-abdominal pressure,
• involuntary high amplitude contractions of the
• rectum

• voluntary straightening of the anorectal angle
• relaxation of the external sphincter
• involuntary relaxation of the internal analsphincter

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.

• selective stimulation of serotonin 5HT4 receptors
• cholinergic as well as non-cholinergic excitatory neurotransmission

• 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.

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

straining with bowelmovements, incomplete evacuation, sensation ofobstructed defecation, and the use of manual maneuversto aid defecation.1

fecal impaction, stricture, external or internal rectalprolapse, rectocele, paradoxical or nonrelaxing puborectalisactivity, or a rectal mass

• 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,

• cbc
• cmp
• esr
• ANA
• ionized calcium
• TFT
• glucose
• stool occult
• stool o and p
• colonoscopy with biopsies in diarrhea

• 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

• Irritable Bowel Syndrome (IBS),
• pelvic floor dysfunction, also described as Obstructed Defecation Syndrome (ODS)
• mixed disorders.

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

• lactulose H2 breath test,
• celiac sprue
• stool osmolarity and electrolytes,
• jejunal aspirate for ova and parasites
• small bowel and colon transit.

• abdominal films
• small bowel series,
• lactulose H2 breath test
• gastrointestinal manometry

• dietary restriction (lactulose, fructose, sorbitol)
• loperamide (immodium)
• diphenoxylate (lomotil)
• Tricyclic antidepressants
• Calcium channel blocker
• 5HT3 (alosetron)
• 5HT4 receptor antagonists

• 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)

• bulking agents, fiber 25-30 g
• water intake to 64oz a day
• Osmotic laxatives
• stool softeners
• tegasord (women)

• 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

• porphyria,
• uremia,
• hypokalemia,
• amyloid neuropathy
• scleroderma, lupus

• Cerebral
• Parkinson's disease,
• cerebral or spinal tumors,
• cerebrovascular accidents,

• aganglionosis,
• ogilvie

hyperganglionosis,

• spinal
• cauda equinalesion
• myelomeningocele
• truma (spinal cord injury)
• MS
• tertiary syphillis

• peripheral
• DM
• autonomic neuropathy
• chagas, hisrschprungs
• Von reckinghausen
• stimulant laxative abuse
• vincristine

pelvic surgery (cystectomy, rectopexy, hysterectomy)

• 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

• Endometriosis,
• carcinoma,
• diverticular d
• ibd
• ischemic colitis
• volvulus,
• hernia,
• benign strictures, anastamotic
• pseudo-obstruction,
• polyps,
• adhesions

• Thrombosed hemorrhoids,
• anal fissure,
• rectal prolapse,
• proctitis,
• rectocele,
• nonrelaxing puborectalis,
• hypertrophic internal anal sphincter.

• 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

• Irritable bowel syndrome,
• anismus,
• sedentary-bedridden patients, inadequate toilet facilities, depression, psychosis, ignoring need for bowel movement, immobility.
• encopresis
• major depression, anxiety, obsessional personality

• inadequate fiber or fluid intake
• ingestion of stool hardening foods.

• slow transit
• ogilvies

number and duration of these GMC's is smaller

• Underlying pathology
• Correct causative underlying conditions and eliminate offensive medications if possible

• Activity level
• Increase mobility

constipation since childhood, fewer than 3 BMs per week, and laxative dependence

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

• Sodium docusate 100 mg PO BID
• Mineral oil 1 oz PO BID

Pericolace(r) 1 PO QD

Dulcolax(r) 5-15 mg PO if no BM for 3 or more consecutive days

Fleets(r) enema if no BM for 3 days

• 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

Counseling, MMPI

• Subtotal colectomy with ileorectal anastomosis
• Subtotal colectomy with ileostomy
• Diverting ileostomy

constipation since childhood, fewer than 3 BMs per week, and laxative dependence

• 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).

ileostomy

• 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

• prolonged repeated straining at bowel movements,
• sensation of incomplete evacuation,
• need for digital manipulation

• biofeedback success 70%
• rare patient may benefit from internal sphincterotomy

biofeedback 35-90 % success

• Electromyography
• paradoxical contraction of voluntary sphincter m during attempts at evacuation

TAC-IRA and repair or treatment of the outlet obstruction

• biofeedback and TAC-IRA,
• higher rate of recurrentdefecatory problems and lower satisfaction

TACIRAafter repair of the anatomic cause of the outletobstruction

• 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

• 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.

intermittent catheterization, irrigation of the colon and rapid, controlled bowel purging.