During this 20-25 minute pre-recorded lecture, Dr. Brijen J. Shah discusses the topic of constipation. This in-depth review will provide an update on this topic for your clinical practice as well as supplement your learning for the ABIM Gastroenterology and Hepatology boards.
My name is brian Shaw. I'm an associate professor of medicine. Gi and geriatrics at the Icahn School of Medicine in this section will focus on constipation and colonic motility disorders. Yeah, I have no disclosures. I'm a member of the A. J. Quality Committee and receive modest funding from the Veterans Affairs Administration to help coach clinicians and quality improvement. The objective of this session are one to help you apply call in physiology to constipation disorders to to list treatments for constipation. and three discuss guidelines for constipation management for background as you all know as gastroenterologist. Constipation is a common problem. The results in over two million outpatient visits a year with over $230 million dollars in costs to the health care system and for in patients it can increase length of stay by almost today. The prevalence of constipation varies by setting With a community prevalence of about 38 And a prevalence of almost 80% in a purely geriatric setting. The highest risk hospitals groups for constipation are those that are critically ill or in the and those that are postoperative before delving into the disorders of constipation in the colon. First, let's review the basic physiology of the colon. The colon has three main purposes is to transport fecal contents from the small intestine to the rectum. It is used for water resort option and is the major organ for water resort option and plays a key role in defecation. The house tre of the rectum as well as the muscles of the pelvic floor surrounding the rectum are critical in order to allow for normal defecation and continents. On the left hand side of the slide, you can see a figure which reminds you of the nervous system innovation to the various gi organs focusing on the colon. There are both sympathetic inputs to the colon as well as parasympathetic inputs and a reminder that the lower part of the colon and the public floors innovated by the lumbar sacral area, while some of the other parts of the colon are innovated by the rocco lumbar spine. Mhm. The colon, like other segments of the Gi tract, is made up of smooth muscle, both longitudinal and circular and this configuration allows for high and low amplitude contractions. These contractions are critical to get the work done that the colon needs to perform high amplitude contraction Is about over 100 of mercury and occurs approximately six times a day. The function of this movement is for mass movement of air and fecal contents to the next segment of colon. It is these types of contractions that are strongly associated with defecation. Low amplitude contractions on the other hand, are less than 50 of mercury. These contractions occur over 100 times a day and their function is to help transport fluid contents increasing the contact with the colonic mucosa, allowing for absorption. These smaller, less intense contractions is what is associated with distention inflate us. Yeah, Before delving into most colonic motility disorders which are predominantly thought of as outpatient disorders. for the purposes of reviewing completeness. I want to spend a moment speaking about the presentation of two colonic dis motility disorders which present in the inpatient setting. The first is mega colon where there is an extraordinary dilation of the colon due to either a lack of nervous system input. Such as such as we can see in Her Springs disease which is a congenital condition, it can occur idiopathic lee or it can be acquired. Acquired mega colon disorders include infection with chagasdisease, other enteric infections which can lead to mega colon and basically Kalanick stasis and severe all sort of colitis. Mega colon is one of the severe complications which um changes urgent treatment for all sort of colitis. The other acute in patient condition for colonic motility is ogilvy syndrome, otherwise known as an intestinal L. E. S. This predominantly occurs in very sick, multi morbid patients commonly in the ICU symptoms are a lack of phlebitis, abdominal distention and pain signs include a lack of um bowel sounds and ostentation and tympani and complications can include um severe pseudo membranes and ischemia and treatment. Um can include number one finding and treating reversible causes including removing offending medications and correcting electrolyte abnormalities. Considering the stigma with proper monitoring and potentially using erectile to which has had controversy And the key number to remember when evaluating patients for this type of condition is a sequel diameter of greater than 9 mm for which surgical consultation and operative intervention or placement of a decompression tube may be needed. Uh wait a minute when I think about cause of constipation. There are a few different ways in which one can try to categorize the items. In the differential diagnosis. First would be conditions that lead to slow transit so you lose the amplitude, the large and small high amplitude contractions which can occur conditions which can do this include various medications, diabetes, spinal cord disease, scleroderma, metabolic conditions such as hyper calc mia, yuri mia, thyroid disease, particularly hypothyroidism, chronic colonic pseudo obstruction, inadequate dietary intake. Some of these more systemic conditions are important to remember and recall, especially from the purposes of taking a board exam. Normal transit constipation includes those individuals who are taking low fiber and then lastly outlet obstruction. Where there's an issue with getting contents into the rectum and expelling them normally. These conditions include a rectal mass, a rectal stricture and public florida's function which will be covered elsewhere within our board review course. But I will make mention of a few comments of this throughout the presentation. Mhm. There are three major constipation finna types. Those include functional constipation, irritable bowel syndrome and difficult or disorder. And our jobs as clinicians or to help figure out whether people have predominantly functional constipation or I. B. S. And if there is a concomitant, difficult or disorder. It's important to remember that about a third of patients that present with constipation in the outpatient setting will have a concomitant defamatory disorder, functional constipation. Their own criteria are summarized here. Please remember that in order to meet this definition, you must have two following those includes straining during 25% or more of dedications, harder, lumpy stools more than a quarter of the time, a sensation of incomplete evacuation, sensation of intellectual obstruction or blockage. The use of manual maneuvers to facilitate defecation and fewer than three defecation per week. This last point is really important to know because you can have a daily bowel movement yet still meet the criteria for this first bullet point within the functional constipation, loose stools are insufficient. Um The President, without the use of laxatives and lastly, you do not meet the criteria for ibs. What's important is that your history taking while sometimes difficult to do around some of the issues is they're very sensitive, are really critical in order to be able to help make the diagnosis both a functional constipation and tip you off to a common in pelvic floor disorder. This is the room for criteria from an excellent review in New England Journal from 2017. The main feature which is different is that the patient is recurrent abdominal pain with an onset of greater than Um six months before diagnosis. In addition, the pain is related to either defecation, change in frequency of stool or change in stool form or appearance. And to help with that. The bristol stool scale can be used with patients below are some of the red flag signs which are very common to all of us, which should warn the consideration for a different diagnosis other than I. B. S. So let's proceed to our first board review question to delve deeper into the topic. The 66 year old woman presents for an evaluation For three years of constipation. She reports ahmad abdominal pain which is related to constipation. She denies gi bleeding and any relevant family history of colon cancer or IBD. A previous trial of fiber and polyethylene glycol was unsuccessful. Physical examination is normal, including erectile exam, evaluation including routine blood work and thyroid evaluation was also normal. Her last colonoscopy was one year ago, which was also normal. She undergoes an orca manama tree, balloon expulsion testing and de photography, which do not reveal any significant abnormalities. A six marker test reveals 14 markers remaining in the colon. On day five she started on intestinal secretive dog therapy with no significant improvement in symptoms and he is colonic transit transit testing on medications and the learning objective for this item was to be able to select the appropriate evaluation in laxative refractory constipation. So based on the stem, it's pretty clear that multiple types of medication were tried to treat her constipation. In addition, the presence of a public floor disorder was also ruled out. Therefore, she would be considered to have laxative fact or factory constipation. Let's take a look at the first part of the recent guidelines for constipation. Yeah. After performing interview, physical exam and considering whether a metabolic or structural evaluation is needed. Such as the colonoscopy. The first move is to do a trial therapeutic um laxatives and fiber. And those laxatives can include cena peg cottle or saline laxative if there is an inadequate response, the guidelines recommend going ahead and starting evaluation for public floor dysfunction. This is a change for those of you that have been practiced for many years from moving public floor dysfunction evaluation too much later in the process to now much earlier in the process based on incorrect Ominami tree or the balloon expulsion test whatever is found will lead you down a different path. Mhm. Mhm. In this case we have a patient which allow or normal transit constipation. First line laxatives were tried and failed. After that the patient was put on secrete a dog or a newer pharmacologic agent with no improvement. It's at this time that repeat colonic transit testing on medications is recommended. And this is where we are with this patient and you can see if it shows it shows the delay on medication to consider an evaluation for an upper motility disorder as well. If it is normal. The consideration would be to try to adjust the medications and titrate to the maximum effective dose. Question two. A 42 year old woman presents with several months of constipation. She is 2-3 bowel movements per week which are pebble like requiring straining. She has some lower abdominal cramping which improves with some bowel movements. She has a poor appetite in stable weight. On review of systems. The patient endorses a few months of difficulty getting up from a chair and reaching up to get items from a shelf. Physical exam reveals a rash over the eyelids and raise popular over the proximal inter Fanjul joints Neurologic exam shows a four out of five bilateral strength and hip flexors. And with shoulder abduction finger to nose test is normal. Labs review on elevated es are normal. TSH normal cbc. The CPK is elevated and the patient has a positive anti M. I. Two and anna antibodies anti SCL antibody is negative. What is the likely diagnosis? A irritable bowel syndrome? Be systemic sclerosis? See hypothyroidism, D. Parkinson's disease or E. Door metal myocarditis. Yeah. The correct answer is e. The learning objective for this question was being able to distinguish systemic conditions that have constipation as a symptom and distinguishing it this from I. B. S. Yeah. The rationale for this question. First I. B. S. Would not be possible as the patient has not only pain but systemic features and a poor appetite in systemic sclerosis, patients have obstructive symptoms and would be anti SCL negative. She had a normal TSH rolling out hypothyroidism and in Parkinson's disease. You would have a tremor, you would have an abnormal finger to nose task and the constipation in this disease is B is thought to be due to a neurologic mechanism. Dramatic myocarditis is a reminder will have the classic malar rash seen below as well as um populace which can be found on the fingers. In addition, the lab tests will reveal an elevated yes are the cause of the problem. In toronto Sias d'amato. Myocarditis is thought to be due to inflammation of the muscles so the smooth muscle in the colon gets affected, leading to the constipation. Here's a review of a list of secondary cause of constipation that you should become familiar with. Um Of note to highlight would be eating disorders, particularly anorexia, nervosa and then other myopathy such as amyloid and infiltrated processes which have already been discussed, such as scleroderma and amyloid, Opioid induced constipation is another really prevalent entity which has been on the rise in the last 10 years. Um in these patients, about 50% of patients on opiates will fail. Traditional constipation remedies helpful to note that looby process. Stone is one of the secret of dogs which has been approved for opioid induced constipation. Two studies have shown that this medication will reach school significance but it is less effective in methadone users. Methanol Truxton is an older agent which has definitely been used in patient hospice setting. Um In advanced illness as well as a non malignant pain syndromes. However, it is a subcutaneous injection and I'll move up pam. There is an oral agent which is related to methanol trade zone and there are four studies in non cancer pain syndrome showing its effectiveness, and again these medications, the last two medications work by blocking the gut specific mu opioid receptor without crossing the blood brain barrier. Another entity which is worth considering when evaluating patients for constipation is the presence of overflow diarrhea. Overflow diarrhea presents with patients reporting several loose bowel movements throughout the day, as well as potentially feeling a sense of incomplete evacuation. The way to evaluate for this is one that they have um that they say that they have diarrhea. Um and then performing examinations to confirm the presence of the stool burden that can include a rectal exam, as well as considering an abdominal X ray to assess for stool burden. In my own practice, about three quarters of the time when I'm presented with a chief complaint of diarrhea and somebody over 75 most often I find this to be overflow diarrhea and I confirmed that through the presence of a high school burden on X ray and obviously this has a lot of implications for treatment. Treatment in this condition should include maintaining a regular bowel regiment setting goals in order to have regular bowel movements. You may set a goal with the patient depending on the severity of 3 to 4 bowel movements per week, you can also add an NMR suppository if you think that rectal distension and retention is a big part of the patient's physiology and lastly for patients with diminished cognition such as those with dementia, you might want to consider time, toilet ng having them automatically go to the bathroom with their caregiver an hour after mealtime and before bed question three. You are seeing a 55 year old woman with diabetes with a history of i. v. drug abuse and alcoholism. She has recurrent admissions for epic gastric abdominal pain radiating to her back due to chronic pancreatitis. She endorses some bloating and lower abdominal pain. She sees a pain management specialist who has her own a fentaNYL patch and oral oxyCODONE for breakthrough pain. She's referred to you by her primary care doctor for two months of constipation. She's wanted to bowel movements a week with straining and lumpy stool with some relief in her lower abdominal pain. She's failed santa visit kyoto and miraculous. A physical exam reveals tender, epic gastro um and some lower abdominal distention. A rectal exam reveals hard stool and normal tone and function of the anal sphincter. Her labs are unremarkable. What is the next step in management? A loopy pro stone be polyethylene glycol. See alecks and darlene D tap water enema or e fiber, the correct answer is a the learning objectives for this question were to be able to manage opioid induced constipation and to recognize contra indications for certain constipation medications. In this patient there is multifactorial causes of her constipation. As the stem revealed. Peg is less likely to be effective as Latinos failed. So she already tried my osmotic and adding another. Asthmatic will not help the situation and in this case using a tap water enema would not be helpful. There's no suggestion of a difficult story disorder and the patient does have opiate induced slow transit constipation. Therefore the use of the socratic oxygen will be processed. Own is appropriate. The last portion of this talk will focus on Eib's medications. You can see both my BSC and I BSD medications listed here. I list the BSD medications. As a reminder to you. However, I will not be discussing these as this will be covered in another speakers talk for my BSC medications. The major costs of medications are laxatives as we have had for many, many years, including osmotic laxatives and mild stimulant laxatives such as sun asides and bicycle. The newest class of medications are secreted dogs and it's in this area. We've seen the greatest growth of options for treatment of both I. D. S. And functional constipation. The subcategories of the security guard class include chloride channel activators such as movie props, stone cyclic GMP activators such as inadequate tied and pluck and I'D and lastly a sodium Hydrogen Exchange three inhibitor Which is known as 10 a banner pro kinetics can also be useful and those include the new drug scalp for Kala pride and the re emergence and FDA approval for Targa Surat which was taken off the market to an increased risk of of AM I. And has now been approved for use in patients under 65 will be prosecuted, is approved for all three major indications for constipation and you can see here in the slide. Um some of the clinical trial data, the study duration goes from 0 to 24 weeks and the mean rating on the patient assessment scale is from 0 to 4. There are two scales which were used in these studies and you can see them here and you can see that in an open label study of ruby process Stone louis process Stone helped particularly with abdominal bloating, the sense of abdominal discomfort And improve the self rating of constipation severity by 18- 24 weeks. And all of these endpoints reached statistical significance to happen or as I mentioned is a newer medication. This is a medication that is looking to block the sodium NHE three transporter by blocking this, you no longer have movement of sodium and um water across the membrane. This has been approved. Yeah, for my BSC However, the study did use room three criteria and the combined endpoint did show a decrease in pain, an increase in spontaneous bowel movements by one Um by one bowel movement per week. This was a placebo controlled trial and you can see the data here, patients with 10 upon or reached the trial in point at 12 weeks. 27%, of patients at 26 weeks. And the safety study which went out one year showed 98 98% compliance with medication and no on toward adverse effects. This table, which is a summary from a 2018 read journal paper shows the relative risk and number needed to treat. Um and the type of strength of evidence for common constipation remedies of no fiber actually has a very nice relative risk of .7 Good quality data and a number needed to treat of 11. Also impressive was the use of anti spasmodic antidepressants and TCS for the treatment of patients with my B. Sc. Um And interestingly enough of the newer agents, Lennox, The Tide has the smallest number needed to treat with strong evidence um and high strength compared to pluck a night and Loopy process Stone and we have very little data around the use of Peg. This is a summary specifically the eBS treatments using anti depressant medications. Um Three classes SnR S. S. S. R. I. S. And TCS. The potential benefits for our patients could include improvement of pain as well as improvement of their mood disorder. It's important here to consider the adverse effects and in selecting medications to exploit the adverse effect to help with patients with their gi symptoms. So for example, a patient with I. B. S. D. May benefit from a. T. C. A. As the side effect of constipation will maybe help to decrease their bowel movements. However, in a patient would potentially upper got symptoms. We must be concerned about worsening nausea, particularly if they have heartburn or chronic nausea as part of their symptoms. Pathology you can see the cost for a month below T. C. A. Still remain one of the cheapest and most high value choices and it does dose adjustment is needed to make sure that patients get to the proper dose for them. Um So in summary chronic motility in public floor function evaluation are part of the work up for constipation. This was a change in the recent guidelines and should become part of your office based evaluation of these patients. You should consider systemic causes for constipation. Constipation is often multifactorial and on boards questions when you are presented with the patient with multiple symptoms and lab findings across their entire body. Consider a systemic disease which might be part of the clue to the answer. Use medications, treat constipation based on mechanism of action and setting goals for treatment. And lastly, the new classes of I. B. S. C. Medications show some significant benefit over over the counter alternatives. So do not hesitate to bring those on earlier into your treatment algorithm. I thank you for your time
