corazziari e. la stipsi. asmad 2016

Enrico S. CorazziariProfessore di Gastroenterologia Università “Sapienza” di Roma

[email protected]

LA STIPSI

1. Must include 2 or more of the following:

a. Straining during more than one-fourth (25%)of defecations

b. Lumpy or hard stools (BSFS 12) more thanone-fourth (25%) of defecations

c. Sensation of incomplete evacuation morethan one-fourth (25%) of defecations

d. Sensation of anorectal obstruction/blockagemore than one-fourth (25%) of defecations

e. Manual maneuvers to facilitate more thanone fourth (25%) of defecations (eg, digitalevacuation, support of the pelvic floor)

f. Fewer than 3 spontaneous bowel movementsper week

2. Loose stools are rarely present without the use of laxatives

3. Insufficient criteria for irritable bowel syndrome

a Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

Abdominal pain and/or bloating maybe present but are not predominant(iethe patient does not meet criteria forIBS) This supports the concept that FCand IBS-C are disorders that exist on acontinuous spectrum

5

THERAPEUTIC OPTIONS FOR FUNCTIONAL CONSTIPATION

DRUG

PSYLLIUM

PEG

LINACLOTIDE

PRUCALOPRIDE

LUBIPROSTONE NOT IN EU

SECOND LINE THERAPY

FIRST LINE THERAPY

Rome IV- Lacy B.E. et al Gastroenterology 2016;150:1393-1407

MacrogolPolyethylene Glycol (PEG) 3350-4000

InertNot Absorbable Not Fermentable Not Stimulant

FIRST LINE

TREATMENT

IT CAN BE USED FOR ORGANIC

AND OCCASIONAL CONSTIPATION

Pregnancy Diverticular Disease Neurological Terminal Opioids/Drugs Proctitis Diabetics

NOT INDICATED IN

THE PRESENCE OF

Obstruction Perforation

Evidence Level Recommendation Grade

1 A

Rankumar, Rao, AJGE 2005;American College GE, AJGE 2005;

CLINICAL APPROACH TO CHRONIC CONSTIPATION

Diagnostic Algorithm and Treatment

VS

Diagnostic-Therapeutic Algorithm

8

N.= 878 patients

8

20 2123

1315

1 year 2 -5 years 6-10 years 11- 20 years 20 - 30 years More 30 years

Average 17 years

ONSET OF CHRONIC CONSTIPATION (%)

Neri L. et al United European Gastroenterol J

2014;2:138-47

Chronic

Constipation

•GENETIC

•DISEASES

•STRESSORS

PATIENT BEHAVIOR

CNS

PSYCHOLOGICAL STATUS

GI PHYSIOLOGY

PHYSICIANTHERAPY

ENS

BIO-PSYCHO-SOCIO- BEHAVIORAL APPROACH

DIAGNOSTIC THERAPEUTIC ALGORITHM FOR PATIENTS WHO

REPORT THE CONTINUOUS USE OF LAXATIVES AND/OR

ENEMAS

DIAGNOSTIC ALGORITHM

BALANCE FIBRE INTAKE

REDUCE AND/OR DISCONTINUE

LAXATIVES AND ENEMAS

PEG

YESINVESTIGATE NO

CONSTIPATION

NORMAL BOWEL

MOVEMENTS UPON

DISCONTINUATION

NO

CONSTIPATION

ALARM FEATURES? CAUSES OF

CONSTIPATION?

PAIN

&CONSTIPATION

IBS-C

DIAGNOSTIC THERAPEUTIC ALGORITHM FOR PATIENTS WHO

DO NOT USE LAXATIVES OR USE CATHARTIC LAXATIVES OR

ENEMAS ON DEMAND

BALANCE FIBRE INTAKE

BOWEL RE-EDUCATION AND

PEG

ALARM FEATURES? CAUSES OF

CONSTIPATION?

YESINVESTIGATE NO

YES

FECAL IMPACTION?

NO

PEG, LAVAGE AND/OR

ENEMA


TREAT ACCORDINGLY TREAT WITH

DIAGNOSTIC-THERAPEUTIC ALGORITHM FOR CHRONIC CONSTIPATION

ORGANIC FUNCTIONAL Rome IV Diagnostic

Criteria

REVERSIBLE IRREVERSIBLE

Neuropathies

FIRST LINE

LAXATIVE

Drugs

Stenosis

Hypothyrodism

Hypercalcemia Cognitive Impairment

Myopathies

Drugs

IF FAILURE

ENTEROKINETICS / SECRETAGOGUES ±LAXATIVES


BALANCE FIBER INTAKE

TOILET TRAINING

PEG

ALARM FACTORSI?

BOWELNORMALIZED?

YESASSESS

ALTERATIONS?

YES

TREATMENT

N

O

YES

MAINTAIN THERAPY

NO

BOWELNORMALIZED?

REFRACTORY CONSTIPATION

SECOND LINE LAXATIVE

N

O

NO

CHRONIC CONSTIPATION

YES

YESASSESS

ALTERATIONS?

YES

TREATMENT


ALARM FACTORS?

NO

FUNCTIONAL CONSTIPATION

BALANCE FIBER INTAKE

TOILET TRAINING

ETC

EUROPEAN DIAGNOSTIC THERAPEUTIC ALGORITHM FOR CHRONIC CONSTIPATION

Tack et al. Neurogastroenterol Motil 2011;

IBS-C FUNCTIONAL CONSTIPATION

NOT RESPONDING TO EMPIRIC THERAPY

INVESTIGATE ANORECTAL FUNCTION

SLOW COLONIC TRANSIT

CONSTIPATIONSLOW RECTAL TRANSIT

CONSTIPATION

«PATIENTS WHO DO NOT RESPOND TO REASONABLE TRIALS OF

EMPYRIC THERAPY SHOULD UNDERGO DIAGNOSTIC EVALUATION TO

IDENTIFY PHYSIOLOGICAL SUBGROUPS. RADIOPAQUE MARKERS CAN

BE USED TO EVALUATE COLON ( AND RECTAL) TRANSIT»

ROME IV RECOMMENDATION - Lacy B.E. et al Gastroenterology 2016;150:1393-1407

DIAGNOSTIC THERAPEUTIC ALGORITHM FOR PATIENTS WITH REFRACTORY CONSTIPATION

WITH SLOWED COLONIC TRANSIT AND NORMAL ANO-RECTAL FUNCTIONDIAGNOSTIC ALGORITHM

BULKING AGENTS

SLOWED TRANSIT CONFIRMED

NO RESPONSE

SECOND TRANSIT TIME (TT) STUDY (± BLINDING)

PSYCHIATRIC

CONSULTANCY

DIAGNOSTIC/THERAPEUTIC

ALGORITHM FOR PATIENTS

WITH NORMAL TRANSIT

YESDENIAL OF EVACUATION?

DURING TT

PEG AND/OR SECOND LINE

LAXATIVE AND/OR

ENTEROKINETICS/SECRETAGOGUES

NO RESPONSE

RESPONSE

NORMAL TRANSIT

EVALUATE

COLECTOMY

NO

EXCLUDED AND-RECTAL DYSFUNCTION

IS FUNCTIONAL CONSTIPATION NONORGANIC?

Functional constipation can progress to organic

constipation

Fecal stasis can cause organic lesions

MEGACOLON

SILENT CONSTIPATION

Fecal stasis and no referred bowel symptoms

COGNITIVE IMPAIRMENT, PSYCHO, ERRONEOUS

BELIEFSClinical presentationAbdominal Distension/Pain

Onset with Complications Children/ElderlyObstruction/perforation

Megarectum/Megacolon

Volvulus

Fecal Incontinence

Urinary Retention

Psycho-motor agitation

DiagnosisBristol stool form type 1 & 2

Rectal examination

Abdominal physical examination: palpable fecal masses

Scout film of the abdomen

ABDOMINAL PAIN. REDUCED BOWEL

FREQUENCY AND PERSISTENT FECAL STASIS

IDROCOLON

SILENT CONSTIPATIONUse of laxatives

PSYCHO, ERRONEOUS BELIEFS

Clinical presentation

Unaware or denied use of laxatives

Abdominal Distension/Pain

Bristol stool form type 6 & 7

Cramps

Astenia

Fecal Incontinence

DiagnosisBristol stool form type 6 & 7

Rectal examination

Scout film of the abdomen

Hypokalemia

Stop Laxatives and bowel diary

ENVIRONMENTAL &

PSYCHOLOGICAL CONDITIONS

Stool retention and bowel postponement

Incorrect beliefs

Dietetic constipation

Psychological Alterations

Anxiety and Stressful events

Depression

Anorexia & Bulimia

Obsessive -Compulsive ritual to defecate

Surreptitious constipation

Factitious constipation

SILENT/SYMTOMATIC FUNCTIONAL ORGANIC CONSTIPATION

SILENT CONSTIPATION SYMPTOMATIC CONSTIPATION

NO SYMPTOMS

BLOATING

DYSPEPSIA

ABDOMINAL PAIN

FECAL STASIS

COMPLICATEDFECALOMA

OBSTRUCTION

PERFORATION

MEGARECTUM

MEGACOLON

FECAL STASIS

HARD STOOLS <25 %REDUCED BOWEL FREQUENCY STRAINING

AT STOOLS

INCOMPLETE EVACUATION

DIGITAL FACILITATIONS

SENSATION OF ANORECTAL OBSTRUCTION

DIAGNOSIS OF GASTROENTEROLOGICAL CONDITIONS IN PREGNANCY

%

HYPEREMESIS GRAVIDARUM 15.1

GASTROESOPHAGEAL REFLUX 14.3

CONSTIPATION 13.0

HEMATOCHEZIA 5.1

NEW GI SYMPTOMS 35.4

WORSENING OF PRE-EXISTING CONDITION 24.4

PREGNANCY-RECURRENT SYMPTOMS 15.1

Saha et al J Women Health 2011

T Poskus, et al. BJOG 2014;121:1666-1672

RISK FACTORS FOR RECTOANAL PATHOLOGY AND

DYSFUNCTIONS AFTER PREGNANCY

DETECT FECAL STASIS AND PREVENT

CONSTIPATION SYMPTOMS AND

COMPLICATIONS

Suspect condition in

Diverticular Disease

Opioids/Drugs

Care Homes

Bed-ridden

Neurological

Terminal

Proctitis

Pregnancy

CHECK-LIST FOR PREVENTION AND TREATMENT OF

FECAL STASIS AND CONSTIPATION

PREDISPOSING

CONDITIONS- Drugs

- Neuropathies

- Cognitive Impairment

- Mobility

-Pregnancy

DEFECATORY PATTERN- Straining

- Bowel Frequency BRISTOL STOOL FORM SCALE

- Use of Laxatives/Enemas

Rectal Examination

CONCLUSIONS

Diagnose and treat symptomatic chronic constipation

from the very beginning of the clinical work out

Suspect silent constipation in the presence of

predisposing conditions. A scout film of the abdomen is

simple, cheap and useful (except in pregnancy)

Prevent complications of chronic constipation

Master ECM in Gastroenterologia 2016

QUESTIONARIO DI VALUTAZIONE FINALE25 Novembre 2016

NORMAL INHIBITION DYSSYNERGIA

MANOMETRIC ANAL BEHAVIOUR

DURING STRAINING TO DEFECATE

Pelvic DyssynergiaRepeated straining

HemorrhoidFecal

incontinence

BEHAVIOUR, ORGANIC & FUNCTIONAL DISORDER INTERACTION LEADING TO IMPAIRED DEFECATION &

RECTO-ANAL COMPLICATIONS

Solitary rectal ulcer

Mucosal intussusception

Rectocele

Rectal prolapse

Pudendal nerve injury

Perineal descent

Pelvic floor dyssynergia

TITOLO


CONCLUSIONS

ANORECTAL DYSFUNCTION AND PATHOLOGY

DEVELOPING DURING PREGNANCY AND POSTPARTUM

can be prevented or minimized detecting and treating

1) INTESTINAL DYSFUNCTION PRECEDING PREGNANCY

2) PREGNANCY DE NOVO CONSTIPATION AND

ALTERED DEFECATION

4) EXCESSIVE DURATION OF DELIVERY

5) DELIVERY LESIONS

• Inserire

• 1. le sequele della gravidanza

• 2. la stipsi come fattore di rischio delle sequele post partum

• 3.diap del behaviour organic- functionaldeterminants of complications

SILENT

CONSTIPATION

SYMPTOMATIC

CONSTIPATION

HARD STOOLS

REDUCED BOWEL FREQUENCY

STRAINING AT STOOLS


DIGITAL FACILITATION

SENSATION OF ANAL BLOCKADE

DEFECATORY

ALTERATIONS

NORMAL OR LOOSE STOOLS

REPETITIVE DEFECATIONS

NO SYMPTOMS

BLOATING

ABDOMINAL PAIN

COMPLICATED

FECALOMA

OBSTRUCTION

PERFORATION

SILENT

CONSTIPATION

SYMPTOMATIC

CONSTIPATION

HARD STOOLS


STRAINING AT STOOLS




DEFECATORY

ALTERATIONS



NO SYMPTOMS

BLOATING

ABDOMINAL PAIN

COMPLICATED

FECALOMA

OBSTRUCTION

PERFORATION

SILENT

CONSTIPATION

FECAL STASIS

SILENT CONSTIPATION

NO

SYMPTOMATIC

CONSTIPATION

HARD STOOLS


STRAINING AT STOOLS




DEFECATORY

ALTERATIONS



NO SYMPTOMS

BLOATING

ABDOMINAL PAIN

COMPLICATED

FECALOMA

OBSTRUCTION

PERFORATION

REFERRED CONSTIPATION ABDOMINAL PAIN

AND USE OF LAXATIVES

WITHDRAW LAXATIVES

NO PAINNO CONSTIPATION

DIARY

IBS-C PAINLESS CONSTIPATION


Asymptomatic (silent) constipation

Symptomatic constipation

Functional constipation

IBS-constipation type

Altered Defecatory Pattern

Happy period constipation

Psychosocial Factors

Patient’s behavior

Abdomino-pelvic dyssynergia

Hard Pellety like stools

Fecal retention

Altered pre-defecatory motor pattern

Rectocele/intussusception

Altered ano-rectal sensitivity

SUSPECT ANORECTAL

PATHOLOGY IN DEFECATORY

ALTERATIONS

RECIPROCAL CAUSAL ASSOCIATION

WITH DEFECATORY STRAINING

HemorrhoidsAnal Fissure

Rectal Prolapse

Rectocele

Solitary Rectal Ulcer

SILENTE

PREVENZIONE

COMPLICANZE

NO

PRESENTAZIONE STIPSI CRONICA

SI

USO CONTINUO LAX/CLIST?

RIFERITA

HA I CRITERI

DIAGNOSTICI ROMA III?

RIDURRE

SOSPENDERE

LAX / CLIS

NO SI

NON STIPSI STIPSI CRONICA

COMPLICATA

55

12

88

Sì

No

Valori %

2. Il paziente ha episodi di diarrea ?

Solo in occasione

dell’assunzione di lassativi

3. Il paziente ha dolore o fastidio addominale

ricorrente (almeno 3 gg al mese negli ultimi 3 mesi)?

61

39

Sì No

Base: 878 pazienti

4. A quale delle seguenti caratteristiche si associa il

dolore\fastidio del paziente ? Il dolore\fastidio…

82

38 37

…migliora in seguito a defecazione

…viene indotto o aggravato

dall'assunzione di cibo

...è il sintomoprevalente

manifestato dalpaziente

Dati clinici del paziente con stipsi cronica

Diagnostic Criteriaa for IBS-C

Recurrent abdominal pain at

least 1 day weekly for the last 3

months, and 2 or more of the

following:

Related to defecation

Associated with reduced bowel movements (fewer

than 3/week)

Associated with hard or lumpy stools

Diagnostic Criteriaa for Functional Constipation

Presence of 2 or more of the following:

Straining in at least 25% of bowel movements.

Hard stools in at least 25% of bowel movements.

Sensation of incomplete evacuation in at least 25% of bowel

movements.

Sensation of anorectal blockage in at least 25% of bowel

movements.

Manual maneuvers to facilitate defecation in at least 25% of

bowel movements.

Fewer than 3 bowel movements per week.

Patients with FC should not meet IBS

criteria, although

abdominal pain and/or bloating may be

present but are not predominant

symptoms

4

4

4

3

7

4

5

6

5

6

7

7

11

11

24

18

15

36

24

36

59

48

13

18

14

18

19

18

21

23

25

22

17

20

27

30

31

32

23

27

35

21

29

20

11

17

30

27

28

24

21

22

19

11

14

12

6

8

20

14

13

12

11

9

5

5

4

4

3

2

4

5

Non indica 0 Assente 1 Leggero 2 Moderato 3 Forte 4 Molto forte

Fare sforzi o spingere molto

Perdita di sangue/taglietti all'ano

Gonfiore

Feci piccole

Sensazione di evacuazione incompleta

Feci dure

Dolori andando di corpo

Dolori alla pancia

Dover andare di corpo

senza riuscire

Bruciore all'ano

Fastidio all'addome

Crampi allo stomaco

Valori %Base: 878 pazienti 27

Quanto è stato forte ciascuno di questi disturbi nelle ultime 2 settimane

L’intensità e la tipologia di disturbi

1Pare

et a

l. Am

J G

astro

ente

rol2001;9

6:3

130

THIS IS THE SYMPTOM USUALLY INQUIRED

BY PHYSICIANS

Re

sp

on

de

rs(%

)

SYMPTOMATIC PRESENTATION


THE CONSTIPATION UNIVERSE

Rey E et al. Am J Gastroenterol, 4 March 2014;doi:10.1038/ajg.2014.18

D60D60

Relationship between Functional constipation and

Abdominal pain/bloating

Functionalconstipation

IBS –C

Abdominal pain / Bloating

-+

Nor functional constipation nor

IBS

IBS FLOW CHARTfurther diagnostic evaluation

Prevalence of abnormal response on straining

V.P. Suttor, et al. Dis Colon Rectum 2010;53:156-160

AGE RELATED FUNCTIONAL CONSTIPATION

Pediatric 10% Defecatory Alterations

Adult 10-20% Female-Male 4:1Slow Transit & Defecatory Alterations

Old Age 20-30% Defecatory AlterationsPrevail

Effetto della ritenzione fecale sul dolore addominale nel bambino

81% 57%

Dolore addominale

Dolore addominale alleviato

dall’evacuazione

CORAZZIARI et al. 1998

Diagnostic Criteria a for IBSRecurrent abdominal pain at



following:


Associated with reduced bowel movements

(fewer than 3/week)


Diagnostic Criteria a for Functional ConstipationPresence of 2 or more of the following:




movements.

Sensation of anorectal blockage in at least 25% of bowel movements.

Manual maneuvers to facilitate defecation in at least 25% of bowel

movements.


Diagnostic Criteria for Functional Defecation

Disorders1. The patient must satisfy diagnostic criteria for functional

constipation and/or irritable bowel syndrome with constipation

2. During repeated attempts to defecate, there must be features

of impaired evacuation, as demonstrated by 2 of the following

3 tests:

a. Abnormal balloon expulsion test

b. Abnormal anorectal evacuation pattern with manometry or

anal surface EMG

c. Impaired rectal evacuation by imaging

Diagnostic Criteria a for Functional Abdominal

Bloating/DistensionMust include both of the following:

1. Recurrent bloating and/or distention occurring, on average, at

least 1 day per week; abdominal bloating and/or distention

predominates over other symptoms.b

2. There are insufficient criteria for a diagnosis of irritable bowel

syndrome, functional constipation,

ROME IV DIAGNOSTIC CRITERIA

IBS-C vs CCA SINGLE WELL CAMOUFLAGED CONDITION

SEVERE ABDOMINAL SYMPTOMS

IN IBS-C PATIENTS

S. Satish, et al. Clinical Gastroenterology and Hepatology 2014;12:616-623

Colonic Transit Time in Functional Constipation and IBS-

C PatientsFunctional Constipation

Italian Coop Study on Constipation*

Normal Transit 17 %

Slowed transit 83 %

*Corazziari et al 1982

IBS-C

Several Studies

Slowed transit 23-47 %

Ansari et al 2010 ; Manabe et al 2010; Tornblon et al 2012; Mertz et al 1999

titolo

S. Satish, et al. Clinical Gastroenterology and Hepatology 2014;12:616-623

IBS AND PELVIC FLOOR DYSFUNCTIONS

IBS

Does not cause Pelvic Floor Alterations

May be caused by Pelvic Floor Dysfunctions (e.g. fecal retention)

May be the cause of

Chronic Pelvic Pain

Urgency

Incontinence

CAUSES OF DEFECATORY SYMPTOMS

DEFECATORY SYMPTOMS Sense of Incomplete

Evacuation Straining at Stools Loss of defecatory

stimulus Frequent and fractional

evacuation Anal Blockade

Hard Pellety like stools Fecal retention Weak Propulsion Megarectum Dyssynergia Altered predefecatory

motor colon pattern Rectocele/intussusseption Loss of, or increased

threshold for, defecatorystimulus

Hypersensitive rectum Up-regulation of central

urge perception

FINAL CLINICAL CONSIDERATIONS ON CONSTIPATION

ROME CRITERIA

Categorize the major functional GI syndromes

Cannot identify all subtypes of patients

IBS-C AND FUNCTIONAL CONSTIPATION BELONG TO THE SAME SPECTRUM OF CLINICAL SYNDROMES CHARACTERIZED BY THE VARIABLE ASSOCIATION BETWEEN DIFFERENT MODALITIES OF GI TRANSIT AND VISCERAL SENSITIVITY

IN CLINICAL PRACTICE IDENTIFY THE SUBTYPES OF CONSTIPATION WITH OR

WITHOUT ABDOMINAL PAIN THAT CAN FAVORABLY RESPOND TO A TREATMENT ABLE TO NORMALIZE THE SLOWED TRANSIT AND REDUCE THE VISCERAL SENSITIVITY

IBS FLOW CHARTfurther diagnostic evaluation

75Valori %

3. Da quanto tempo il paziente soffre di stipsi cronica ?

Base: 878 pazienti

8

20 2123

1315

Fino a 1 anno 2 -5 anni 6-10 anni 11- 20 anni 20 - 30 anni Oltre 30 anni

In media da 17 anni

11. Ha mai subito un intervento chirurgico per la stipsi cronica ?

6

93

1

SìNoNon indica

Hanno subito intervento chirurgico n=49

S.T.A.R.R. 39%

Emorroidi / Milligan Morgan 18%

Rettocele/enterocele 8%

Plastica perineale 8%

Prolasso rettale 6%

Neurostimolazione sacrale 4%

Resezione del sigma 4%

Altri interventi (colposacropessia, emicole,

laparoscopia, intussuscezione…) 12%

Dati clinici del paziente con stipsi cronica

Rome IV. Lacy B.E. et al Gastroenterology 2016;150:1393-1407

DIAGNOSTIC-THERAPEUTIC ALGORITHM FOR CHRONIC CONSTIPATION

ORGANIC FUNCTIONAL Rome IV Diagnostic Criteria

REVERSIBLE IRREVERSIBLE

Neuropathies

FIRST/SECOND

LINE LA Drugs

Stenosis

Hypothyrodism

Hypercalcemia Cognitive Impairment

Myopathies

Drugs

IF FAILURE

TREAT ACCORDINGLY TREAT WITH

Diagnostic Criteria for IBSRecurrent abdominal pain at



following:


Associated with reduced bowel movements

(fewer than 3/week)


Diagnostic Criteria for Functional ConstipationPresence of 2 or more of the following:




movements.

Sensation of anorectal blockage in at least 25% of bowel movements.

Manual maneuvers to facilitate defecation in at least 25% of bowel

movements.


Diagnostic Criteria for Functional Defecation

Disorders1. The patient must satisfy diagnostic criteria for functional

constipation and/or irritable bowel syndrome with constipation

2. During repeated attempts to defecate, there must be features

of impaired evacuation, as demonstrated by 2 of the following

3 tests:

a. Abnormal balloon expulsion test

b. Abnormal anorectal evacuation pattern with manometry or

anal surface EMG

c. Impaired rectal evacuation by imaging

Diagnostic Criteria a for Functional Abdominal

Bloating/DistensionMust include both of the following:

1. Recurrent bloating and/or distention occurring, on average, at

least 1 day per week; abdominal bloating and/or distention

predominates over other symptoms.

2. There are insufficient criteria for a diagnosis of irritable bowel

syndrome, functional constipation,

ROME IV DIAGNOSTIC CRITERIA

corazziari e. la stipsi. asmad 2016

Health & Medicine