Chronische Obstipation: eine Erkrankung oder nur „falsche...

Chronische Obstipation: eine Erkrankung oder nur „falsche“ Ernährung?

Lukas Brügger

Universitätsklinik für Viszerale Chirurgie und Medizin

Chron. Obstipation: eine Erkrankung oder nur “ falsche“ Ernährung? / Lukas Brügger 2

Universitätsklinik für Viszerale Chirurgie und Medizin UVCM

PrevalencePrevalence• in US: 2-27%,

– Particularly age > 65y– Female predominance

• Worldwide: 12%

• In CH:– 7% frequently– 16% occasionally

– 22%

• Female predominance (5-10x)

Higgins PD. Am J Gastroenterol 2004

Wald A. Digestive Disorder Week 2006. Abstract T1255

Institut Demoscop survey 2002

Faltin DL, Int Urogynecol J 2001

Vrees MD, Clinics in Colon and Rectal Surgery 2005



What is Constipation?

• Individually different

• Frequency? – normal: Three times a day to three times a week

Rome III criteria

Pare P. Am J Gastroenterol 2001Heaton KW. Gut 1992

Longstreth GF. Gastroenterology 2006



Rome III CriteriaAt least 2 of the following criteria in at least one forth of defecation attempts during 3 months (at once orintermitting) in the last half year

–Heavy straining–Lumpy or hard stool–Feeling of incomplete defecation–Feeling of anal blockage–Manual maneuvers (Digitation, support of pelvic floor)–2 or less defecations in one week–soft, unformed stool only under laxative therapy–Criteria for irritable bowel syndrome not fullfilled

www.romecriteria.org/pdfs/ConstMode.pdfLongstreth GF. Gastroenterology 2006



Secondary Constipation

• Endocrine / metabolic disorderhypothyreoidism, hyperparathyreoidism, diabetes, uremia, hypokalemia

• DrugsOpiates, antidepressants (tricyclic), antihypertensiva(Calcium-antagonists, antidiuretics), neuroleptics, ferrum, antiparkinsonoids, antacida (aluminium)

• Neulologic / psychiatric diagnosisParkinson‘s disease, Multiple sclerosis, M. Hirschsprung, depression, anorexia nervosa, dementia

• Anatomic changesTumor, pelvic floor changes (recto-, enterocele, rectalprolapse, descensus), previous surgery



Primary functional Constipation

Normal transit Delayed transit

Normal transit(idiopatic)

constipation*

Obstructed De-fecation Syn-

drome

Slow transitconstipation

*Constipation predominant IBS






constipation*


drome



71%


rare



DiagnosticsDiagnostics ODSODS• Anamnesis

– History, drugs– Questionnaires, Scores (Rome III, Cleveland Clinic Constipation

Score...)– Urogenital symptoms– etc.

• Digital rectal examination (DRE)• Blood test (Ca, PTH, Glucose, TSH, K+)• Proctoscopy/Colonoscopy



Myths and Misconceptions About ChronicConstipation• A poor fibre diet should not be assumed to be the cause of

chronic constipation• Some patients may be helped by fibre-rich diet but many

get worse• Increasing fluid intake does not help (unless there is

dehydration)• Stimulant laxatives (in recommended doses):

–Unlikely to be harmful to the colon–Tolerance uncommon–No potential for addiction

Müller-Lissner SA. Am J Gastroenterol 2005



ConservativeConservative TreatmentTreatment• Education

adequate hydration, moderate exercise, no straining, correct position, 1 attempt/day

• High fiber diet (Metamucil®, Colosan®, Benefiber®, Normacol® etc) →20-35g/d

• Enemas, laxatives– Bulboid® supp. (Glycerin)– Osmotics

• Duphalac® (Lactulose) 10g/d• Transipeg forte®, Movicol® (Macrogol)

– Stimulants• Dulcolax® (Bisacodyl)• Darmol® (Senna)

– Paragar® (Paraffin)– Etc.

• (Biofeedback)– Manometric anal probe, baloon expulsion– Success rate 30% to >90%

Gilliland R. Br J Surg 1997Chiarioni G. Gastroenterology 2005McKee RF. Br J Surg 1999




– History, drugs– Questionnaires, Scores (Rome III, Cleveland Clinic Constipation Score)– Urogenital symptoms– etc.

• Digital rectal examination (DRE)• Blood test (Ca, PTH, Glucose, TSH, K+)• Proctoscopy/Colonoscopy• Anorectal manometry, balloon expulsion• (MR)-Defecography• (Uro)-Gynecologic examination (POP-Q)• Transit time






constipation*


drome






ObstructedObstructed DefecationDefecation Syndrome (ODS)Syndrome (ODS)• Paradoxical puborectalis contraction

(PPC)Anismus, Pelvic floor dyssynergia / dysfunction, Nonrelaxing PuborectalisSyndrome, Spastic pelvic floorsyndrome, dyschezia…

• Outlet obstruction– Rectoanal intussusception/prolapse

(Solitary rectal ulcer syndrome)– Rectocele– Pelvic organ prolapse, Enterocele,

Sigmoidocele

• Segmental aganglionosis

ManometryBaloon expulsion

Defecography

DefecographyGynecolog.examination

ManometryEndoscopy



S.T.A.R.R. (S.T.A.R.R. (StapledStapled transanaltransanal rectalrectal resectionresection))



S.T.A.R.R.S.T.A.R.R.



STARR: STARR: OutcomesOutcomes

Boccasanta(n=90)

Renzi(n=68)

Excellent 52.2% 53.3%

Good 37.8% 36.7%

Fairly good 5.6% 5.6%

Poor 4.4% 4.4%

6 months follow upBoccasanta et al. Dis Colon Rectum 2004Renzi. Int J Colorectal Dis 2005



STARR: STARR: overalloverall patientpatient satisfactionsatisfaction

1Month

3Months

6Months

12months

Excellent 35.5% 43.3% 52.2% 53.3%

Good 46.7% 43.3% 37.8% 36.7%

Fairly good 12.2% 7,8% 5.6% 5.6%

Poor 5.6% 5.6% 4.4% 4.4%

n = 90Boccasanta et al. Dis Colon Rectum 2004



ContourContour®®TranstarTranstarTMTM



MeshMesh SacrocolpopexySacrocolpopexy (and (and ResectionResection RectopexyRectopexy))

Aus Corman ML. Colon & Rectal Surgery. Lippincott Williams & Wilkins, Philadelphia 2005



Lim M. Dis Colon Rectum 2007

Pelvic Floor Distress Inventory (PFDI)

Pelvic

Organ P

rolap

se

Distres

s Inven

tory

Colorec

tal-A

nal

Distres

s Inven

tory

Urinary

Distres

s

Inven

tory

p<0.05



SacralSacral nerve nerve stimulationstimulation (SNS)(SNS)

Temporäre Elektrode permanente Elektrode



Holzer B. Dis Colon Rectum 2008



Jarret MED. Br J Surg2004

Cochrane Database of Systematic Reviews 2007



Conservativetreatment

Paradoxe puborectalis contr.

failure

Permanentcolostomy

IntussusceptionRectocele

Pelvic organ prolapseEnterocele

Treatment Treatment modalitiesmodalities ODSODS

BiofeedbackSNS

(Botox)

STARR STARR/Resectionrecto-

pexySakrokolpopexy






constipation*


drome







– History, drugs– Questionnaires, Scores (Rome III, Cleveland Clinic Constipation Score)– Urogenital symptoms– etc.

• Digital rectal examination (DRE)• Blood test (Ca, PTH, Glucose, TSH, K+)• Proctoscopy/Colonoscopy• Anorectal manometry, balloon expulsion• (MR)-Defecography• (Uro)-Gynecologic examination (POP-Q)• Transit time



Surgery for slow transit constipationExclusion of general slow transit (small intestine): Szintigraphy

Total colectomy with ileorectal anastomosis

• Success rate: 39-100%– Proven slow transit: 90% (median)– Incomplete investigation of transit: 67%

(median)

• Stool frequency: 2.8-5x/day

• QOL: 77% improvement

Knowles CH, Ann Surg 1999 (Review)

Wong SW, ANZ J Surg 2007 (Review)

Zutshi M, Int J Colorectal Dis 2007



Conclusion

• Constipation: rather syndrome than illness• Change of habits (fibers) may help in certain types• Conservative treatment always comes first• Laxatives are not so bad• Surgery is effective in selected patients

Chronische Obstipation: eine Erkrankung oder nur „falsche...

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