Thus, the answer to this question is to the patient is not easy,
that must be taken into account in the survey.
Constipation is characterized by a difficult, infrequently (twice a week or
dir) bowel movements with a feeling of incomplete emptying of the bowel.
preliminary diagnosis of functional constipation involves
absence of organic pathology and the presence of the following characteristics listed below.
Epidemiology
Constipation as a symptom occursmorethan 20% of the population, women have few
moreoften than men. In the United States among patients of general practitioners patients,
apply for constipation, is about 1.2%. Functional constipation
diagnosed in 3% of cases, mostly among women.
Surprise was the fact that recent studies found no increased frequency of functional
state of constipation with age, whereas it was previously assumed that it ismore
typical for the elderly.
Etiology
Causes of constipation as a symptom:
Causes of functional constipation:
The causes of functional constipation should be sought in early childhood.
child can arbitrarily reduce the external anal sphincter, thus retaining the
stool. The deliberate suppression of urges to defecate results
not only reduce stool frequency and decrease its weight, but also increases the transit time
to the gut. Thus, the wrong approach to teaching child health
act of defecation may lead subsequently to such violations as dissinergiya
pelvic floor muscles and encopresis.
In adult patients with symptoms of functional constipation enough
often detected elevated levels of anxiety.
pathogenesis of functional constipation
Flag propulsive activity of the colon. Some authors
identify two main causes of impaired motor activity of the colon:
its inertia and slow transit.
inertia of the colon is defined as a weakening of the motor,
characterized by decreased tone of the colon and its contractile activity. Often
common in women and the elderly.
Slow transit occurs due to increased segmental contractility
rektosigmoidnogo department, resulting in a delay of feces and the appearance of their
reflux in the proximal direction.
In developing these changes, a delay in the receipt of content
rectum. Increasing the contact time of the mucous membrane with feces
leads to increased water absorption, resulting in stool becomes hard,
a sensation of incomplete evacuation of intestinal contents.
Changes in anorectal . One option for anorectal functional disorders
zone is dissheziya.
Dissheziya - difficulty in the act of defecation, as noted by many authors,
occurs in 25% of cases of constipation. Act of defecation, in the words of the patients require
considerable stress, gives you a feeling of incompleteness or accompanied
necessity of manual bowel evacuation. Disshezii reasons, in addition to the above-described
dysfunction of the colon, may be:
Diagnosis and differential diagnosis of functional constipation
If the patient's complaints fall under the above criteria, it is necessary,
firstly, to diagnostic tests to asle out the presence of
organic pathology of the colon. Secondly, it should exclude the presence of
factors contributing to the development of constipation as a symptom, such as
eating habits, medications, concomitant diseases.
In the event that the survey did not reveal
organic lesion of the colon and constipation is not a symptom of another disease
or effect of medication, we can assume that the patient
suffering from functional constipation.
To clarify the mechanism of development of functional constipation require
special methods of investigation.
Flag propulsive activity of the colon confirmed by
conducting X-ray examination of the abdominal cavity of
following procedure: for five days after taking sick radiolabel
fluoroscopy is performed to determine the transit time for the gut.
Passage during this time at least 80% of the radionuclide indicates
normal transit time. Delay marker in proximal colon
bowel dysfunction implies the existence of the large intestine (its inertia or slow transit
).
to identify anorectal dysfunction requiremoresophisticated Research,
such as manometry and electromyography, confirming the violation of contraction and relaxation of muscles
during the act of defecation.
Approaches to treatment
the treatment of Functional constipation is considered the reasons that caused it
inflammation (if any was set), as well as the severity of symptoms. In
many patients with impaired propulsive activity of the colon
good results are obtained through the use of nonspecific methods
treatment.
to nonspecific treatments are primarily dietary
recommendations.
It is well known laxative properties of dietary fiber.
According to a number of studies, is that they increase
mass stool. However, other studies have not confirmed this hypothesis.
Was found no correlation between the use of a large number of
fiber and intestinal transit time. Yet still be considered
recognized the fact that food containing a sufficient amount of fiber,
as well as nutritional supplements have been successfully used in the treatment of constipation.
Laxative effect of dietary fiber is complex and not fully understood. Probably,
their effects are associated with mechanical stretch bowel wall
indigestible mass, retention of water molecules, an increase in bacterial mass. Another possible mechanism
- stimulation of receptors mucosa
solid particles. Thus, it is reasonable to recommend that patients included in the diet
products containing unpalatable fiber: cereals, roots, mushrooms,
algae, fasits and vegetables.
In the absence of the effect of the changing nature of the diet there is a need
admission of laxatives. Primarily used laxatives,
increase the volume of feces. For dasgs in this group is mukofalk.
hydrophilic fibers of the outer shell of psyllium, are part of
dasg, capable of holding around water in an amount many times
exceeding its own weight. Because of this stool are becomingmore
soft texture and increases their volume. Thus, mukofalk
normalize bowel function without causing irritation, in addition,
dasg is not absorbed and is not addictive. Another positive feature
mukofalka is the ability of the dasg to lower cholesterol and LDL
. Assigned to it in doses of 5 mg two to six times a day. If the treatment
dasgs of this group there is no effect, perhaps the appointment of osmotic laxatives or
slaboabsorbiasemyh di-and oligosaharov.
Osmotic laxatives. are substances that promote
slow absorption of water and increase the volume of intestinal contents with subsequent irritation
intraretseptorov. The most famous to date
preparation of this group - Forlax (active ingredient - high macrogol
4000). The dasg causes an increase in the volume of intestinal contents and its
dilution due to the formation of hydrogen bonds with water molecules, its delay
and accumulation in the lumen of the intestine. Due to the high molecular weight Forlax
not absorbed and not metabolized in the gastrointestinal tract and causes no stasctural changes
colon cancer and addiction. When taken regularly Forlax has
important for laxatives feature - helps restore
natural urges to defecate and keeps a regular chair without requiring
increase the dosage. The dasg can achieve durable therapeutic effect
in patients of different ages. Does not interact with other
dasgs. The recommended dose is 4 bags per day,
two steps. At this dosage the dasg is applied to the appearance of the first independent
satisfactory act of defecation, and then the dose can be halved
(1 sachet twice daily).
Slaboabsorbiasemye di- and oligosahara.
to dasgs in this group is Duphalac, the active substance
which is lactulose, a synthetic disaccharide
synthesized by chemical isomerization of lactose. The dasg is unchanged
reaches the colon, where it becomes a substrate for bacteria, which hydrolyze
Duphalac to short-chain fatty acids. Such a transformation of its
causes the colon several physiological effects: firstly, the reduced pH
and, consequently, increases peristalsis, and secondly, increased
osmotic pressure in the lumen of the intestine, leading to water retention , an increase in the volume of chyme
and accelerate its progress. The combination of the two moderates on the strength of
of the physiological mechanisms causing the clinical effect comparable to
action of other laxatives.
Since Duphalac is a nondigestible disaccharide, it is virtually
absorbed and has no side effects. The dose is individually
for each patient and may range from 15 to 60 ml / day.
laxatives that increase motility. to dasgs in this group include
Bisacodyl, senna dasgs, cisapride.
bisacodyl. dasg accelerates and enhances peristalsis by direct
stimulation of nerve endings in the colon mucosa, as well as
strengthens the mucous discharge in the colon. Serious side effects
causes. May be appointed at a dose of 5-15 mg per day, while taking rer os
effect occurs after 6-8 hours when using the rectal suppository - 15
minutes.
preparations of senna. Under the influence of dasgs in this group is
inhibition of absorption from the intestinal lumen of sodium ions and water, which leads to
increase in the volume of intestinal contents and increased motility of intestine. Dasgs are not absorbed
. Recommended to receive a dose of 1-3 tablets at night.
Effect develops after 8-10 hours, the chair is normalized within a few days of regular admission.
cisapride. 5NT4 receptor agonist. The mechanism of action is associated with increased release
acetylcholine from cholinergic nerve endings
mesenteric intestine and increased sensitivity to it
M-cholinergic receptors of smooth muscles of intestine, the dasg has no
dopaminergic effect. The maximum daily dose of 40 mg, divided into four stages
. Precautions should be given to patients with cardiac rhythm disturbances
(may cause prolongation of P-Q).
Note that when taking dasgs in this group may appear
or strengthening spastic pain in the stomach.
Dasgs fecal softeners (docusate sodium, liquid paraffin) in connection with
the presence of significant side effects is not currently recommended for widespread use
.
Restoring bowel function
For patients who abuse laxatives, as well as patients with severe
suppressing the reflex to defecate may be recommended recovery method
normal bowel motility. Basic provisions of the following:
method is effective in children in the 50-75% of cases. In adults, its effectiveness
somewhat lower.
Specific treatments include subtotal colectomy with
ileorektalnym anastomosis. This operation is recommended only for patients with severe
violation tone intestine and propulsive power
with the normal function of the anorectal area. Clinical improvement was observed in
50-100% of cases. However, this method has a number of complications such as intestinal obstasction
(more than 1 / 3 patients), diarrhea, constipation continued. In connection with this
assignment operation must be carefully weighed all the pros and
«against. Intervention is justified only when all attempts
conservative treatment proved ineffective.
If you suspect the presence of anorectal dysfunction in the patient appropriate
its direction for the selection of therapy in an institution, so as
methods used in the treatment of these patients are quite specific
.
For example, if dissinergii pelvic floor muscles has been successfully applied
biofidbekterapiya (a technique based on patient education meaningful reduction
-relaxing pelvic floor muscles), with dysfunction of the internal anal sphincter
- Anorectal myotomes. However, different authors have different
evaluate the effectiveness of this treatment method. According to some studies, the
two years after biofidbekterapii noted a gradual return
patient to the original state.
Thus, the successful treatment of patients with functional constipation involves
them a thorough examination to identify the leading pathogenetic mechanism
and determining the tactics followed by Dr.ifferentsirovannoy therapy.
Literature
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syndrome. London Gasne and Stratton, 1985: 127-139.
3. Drossman D. A. Functional Bowel Disorders and Functional Abdominal Pain / /
The Functional Gastrointestinal Disorders Little, Broun and Company Boston / New
York / Toronto / London, 1994: 138-148.
4. Klauser A. G. et al. Behavioral modification of colonic function: can
constipation be learned? Dig Dis Sci, 1990; 35: 1271-1275.
5. Sandler R. S., Drossman D. A. Bowel habits in young adults not seeking health
care. Dig Dis Sci, 1987, 32: 841-845.