Constipation defined as either:

- Decrease in frequency of stools (fewer

than 3 bowel movement per week)
- Increase in difficulty in passing stools.

Patients may also complain of hard bowel

movement, small actions, inability to evacuate,
or sensation of incomplete evacuate.

Chronic severe constipation:

- Bowel movements < once in 5 days
- Symptom persisting > 18 months
Corman M et al. Hand book of colon & rectal Surgery 2002

DIETARY
Low fiber intake
Poor intake of fluid

FUNCTIONAL
Depression
Confusion
Inadequate toilet
facilities
Immobility
Psychosis
Encopresis

MEDICATION
Anticholinergic
Antidepressants
Narcotics & opiats
Iron
Bismuth
Antiparkinson
Antacid (aluminium)
Antihypertensive
Anticonvulsants
Iron-exchange resin
Bulk laxative without
adequate hydration

ENDOCRINE, METABOLIC &

COLLAGEN VASC. DISEASE
Hypothyroidism
Hypoparathyroidism
D.M.
Hypokalemia
CRF
Pregnancy
Hypopituitarism
Porphyria
Scleroderma
Amyloidosis
Hypercalcemia

NEUROMUSCULAR DISORDER
CEREBRAL
Cerebrovasc. Acc.
Parkinson disease
Intracranial tumor
SPINAL
Cauda equina lession
Myelomeningocele
Cord injury
Multiple sclerosis
Tertiary sypilis
PERIPHERAL
D.M.
Autonomic neuropathy
Chagas disease
Hirshprungs disease
Von Recklinghousen
Stimulant laxative abuse
Vincristine

ANO-RECTAL FUNCTION

Outlet obstruction
(Anismus, obstructed
defecation, spastic pelvic
floor syndrome)

COLONIC INERTIA

Slow transit constipation

Intestinal pseudoobstruction (Ogilvies
Syndrome)

Older than 55 Y
Recent abdominal or
perineal surgery
Limited physical activity
such as bed rest
Diet less than 15 gr fiber
per day
Inadequate fluid intake
(<1000 ml)
Drug associated with
constipation (anti
cholinergic, anti emetic,
anti histamine, NSID,
hipotensive)

History chronic
constipation
History laxative abuse
Comorbid associated with
constipation (CRF,
electrolite imbalance,
spinal cord injury, IBD,
painful lesion in anorectal,
obstructing intestine,
many neurologic problem,
endocrine problem &
mental emotional problem.

Hinrichs M et al. Research based protocol. Amanagement of constipation. J Gerontological Nursing. February
2001

HISTORY
DIARY OF BOWEL MOVEMENT
CLINICAL EXAMINATION,
ENDOSCOPY
Buchmann P.
Investigation of
Anorectal Functional
Disorders 1992

ORGANIC
DISEASE

NO ORGANIC
DISEASE
TRANSIT TIME MEASUREMENT
SLOW
TRANSIT
CONSTIPATION

OUTLET
OBSTRUCTION

DEFECOGRAPHY

ABNORMALITY
OF THE RECTAL
WALL

ANISMUS
EMG

CONFIRMATION:
ANISMUS

ANORECTAL MANOMETRY

IMPAIRMENT OF
INTERNAL ANAL SPHINCTER:
HIRSPRUNG

APPLICATION OF DIAGNOSTIC METHOD IN CONSTIPATION

Constipation is not a disease, but

symptom of many diseases of
mixed origins and mechanisms

Hard stool
Diff. in evacuation
Abdominal pain
Large size stool
Obstruction of toilet
Rectal bleeding
Abdominal distention
Faecal impaction
Faecal digitation
Episodic diarrhea
Incontinence
Poor appetite
Nausea
Abdominal mass
Passage of pellete stool

98%
92%
82%

Vomiting
Abdominal tenderness
Audible borborygmi

22%
17%

History maybe
unreliable, duration
of constipation may
be variable

Diary of bowel
movement

80%
66%
64%
60%
50%
48%
44%
40%
38%
35%
27%
25%

10%

Keighley MRB, Williams NS. Surgery of

the anus, rectum and colon Sounders
1993.

Inspection on resting, squeezing and

straining: (swelling, fissure, tumor,
cicatrix, descending perineum, prolapse,
rectocele)

Rectal digital exploration: (pain, stricture,

tumor, sphincter tone, intussusceptions,
rectocele, length of anal canal)

Fist diagnostic procedure for patient with

symptom of defecation disorder
Previous digital examination is mandatory
The normal length of anal canal is 3-5 cm
Common finding related to chronic constipation is
Solitary rectal ulcer (SRU)
Anterior mucosal prolapse anterior
intussusceptions circular intussusceptions
complete rectal prolapse (all as the cause of SRU)
are difficult to be detected endoscopically
defaecography is the best mean.

SCINTIGRAPHY
Using radioisotop technetium 99m (half life
6 hours) or indium 111 (half life 3 days)

RADIOLOGIC MARKER

WMC (wireless Motility Capsule)

SCINTIGRAPH
Y
Normal: within 48
hours of
ingestion much of
the radioisotope
has been passed
from bowel

Severe
constipation due
to prolonged
transit time, over
the 4 days
radioisotope
does not
progress beyond
the thansverse
colon

Radio-opaque marker tablet

20 tablet, followed by serial
daily abdominal X-ray
Normal:
80% had passed by the end
of 5th days
TT through right colon 6.913.0 hours
TT through left colon 9.115 hours
TT through rectosigmoid 1118.4 hours
More than 40% marker
left in the colon after 5
days considered
pathology.

Colonic
inertia

Hindguti
nertia

Outlet
obstruc
tion

A condition in which large bowel becomes markedly

distended with all the symptom and sign of large bowel
obstruction but where there is no evidence of
mechanical obstruction.
Primary pseudo-obstruction: familial visceral myopathy
(normal ganglionic cells but thinning and collagen
replacement of the longitudinal muscle were found on
biopsy)
Secondary pseudo-obstruction: metabolic origin,
electrolyte disturbances, uremia, diabetes, myxoedema,
hyperparatyroidism, disturbance of the adrenopituitary
axis.

Provide a picture of the successive phases

of defecation and may reveal disorder of
defecation (outlet obstruction
constipation)

Documentation of functional and

morphological changes of anorectum and
pelvic floor during defecation

Symptoms
1.

2.
3.
4.

5.
6.
7.

Feeling of incomplete
evacuation
Blocked evacuation
Heaviness perineal mass
Heavy straining during
defaecation
Need for digital assistance
Chronic constipation
Faecal incontinence

Objective findings
1.

2.

3.

4.

Mucosal lesion of anterior

rectal wall
Rectocele of more than 2
cm on palpation
Slow transit through distal
part of colon
Intussusception as seen
by rectoscopy

Suspicion of
1.
2.
3.

Occult intussusception
Occult prolapse
Enterocele

SQUEEZING

RESTING

NORMAL APPEARANCE OF
ANORECTAL DURING RESTING,
SQUEEZING AND STRAINING
DEFAECOGRAPHY

STRAINING

The position of the anorectal junction (ARJ) with respect to the

tip of the coccyx (in cm) and values of anorectal angle (ARA) and
anal canal width (ACW) during succesive stage of defaecation

Rectal intussusception and rectal prolapse

Rectocele
Enterocele
Anismus/spastic pelvic floor syndrome
Descending perineum syndrome

Anterior mucosal prolapse

Annular intussusception
Complete rectal prolapse

Solitary ulcer
syndrome

Symmetry
anal height

Asymmetry
anal height

Rectocele: Anterior outpocketing of the rectal wall with

incomplete evacuation (usually more than 2 cm).

High incidence of ventral outpocketing some author consider normal

appearance
507 defaecografi: 66.7% outpocketing, where 89% ventral , 8% lateral
and ventral, 3% dorsal.

ENTEROCELE

Small intestine located

between vagina and
rectum. Rectum
compressed
Sigmoid (contrast +) and
small intestine located
between vagina and
rectum. Rectum
compressed

ANISMUS

Dyskinaesia of the puborectal (anismus/ spastic pelvic floor

syndrome): the muscle contracted during defaecation instead of
being relaxed incomplete evacuation

Descending
perineal syndrome
(DPS)
During straining
perineum descent
less than 2-3 cm,
more 3 cm decided
as DPS (fig. b)
Measure:
-Defaecography
-Perineometer
Clinic: Constipation
or incontinence
Etiology:
Chronic straining
chronic pudendal
neuropathy

Scematic videoproctography to measure perineal descent

Normal subject
Changes in anal canal
pressure and smooth and
striated muscle activity
during straining.
After an initial rise, the anal
canal pressure fall, and this
is associated with loss of of
the internal anal sphincter
electrical slow wave activity.
The integrated
electromyographic signal
from the striated external
anal muscle also fall

Rectoanal inhibitory reflex:

Distention of the rectum followed by relaxation of the internal
anal canal muscle. This reflex absent in Hirshprung disease

A: The striated muscle normally relax during

defecation straining, so the anal canal pressure
decrease.
B. Paradoxical contraction means striated muscle
contract during defecation straining, the anal canal
pressure increase. It is shown in anismus

Dynamic videoproctography with simultaneous rectal

and anal manometry and puborectal measurement

Especially in severely constipated woman

with slow transit problem
Test: Beck Depression Inventory,
Minnesota Multiphasic Personality
Inventory
Assess psychological factors that may
contribute the patient complaint
Administered to every patient for whom
surgical alternative is considered

HISTORY
DIARY OF BOWEL MOVEMENT
CLINICAL EXAMINATION,
ENDOSCOPY
Buchmann P.
Investigation of
Anorectal Functional
Disorders 1992

ORGANIC
DISEASE

NO ORGANIC
DISEASE
TRANSIT TIME MEASUREMENT
SLOW
TRANSIT
CONSTIPATION

OUTLET
OBSTRUCTION

DEFECOGRAPHY

ABNORMALITY
OF THE RECTAL
WALL

ANISMUS
EMG

CONFIRMATION:
ANISMUS

ANORECTAL MANOMETRY

IMPAIRMENT OF
INTERNAL ANAL SPHINCTER:
HIRSPRUNG

APPLICATION OF DIAGNOSTIC METHOD IN CONSTIPATION

Constipation consisted of 2 types: prolong transit

time and outlet obstruction.
Use algorithm for diagnosis of chronic constipation
Diary of bowel movement more reliable than recall
Colonic transit study may differentiate 2 type of
constipation
For outlet obstruction type, defecography may
identify anatomical abnormality as the cause of
constipation
Anal manometry and electromyography may
identify Hirsprung disease and anismus
Psychological test should be considered in patient
with constipation, especially whom surgical
alternative is considered