KONSTIPASI

Defenisi : Gangguan BAB yg ditandai dengan feses yang sedikit, keras, jarang dan sukar. Parameter yang sering digunakan : 1. 2. 3. 4. Frekuensi < 3 x/ minggu N : 1-2 sehari atau 2 hari sekali Berat < 30 gr hari N : 200 gr Konsistensi keras Straining anal & lower abd. discomfort dan perasaan tidak puas defekasi 5. waktu transit di colon Konstipasi >< Diarea

KRITERIA ROME II UNTUK DIAGNOSTIK KONSTIPASI

1. KECEMASAN / STRAINING
2. BAB KERAS 3. RASA TIDAK PUAS SETELAH BAB

4. RASA OBSTRUKTIF/BLOCKADE ANORECTAL

5. BAB < 3 MINGGU

Prevalensi :
UK : 1 % BEROBAT KE DOKTER KELUARGA 10 % MENGELUH KONSTIPASI

20 % MENGGUNAKAN LAKSANSIA
SERING PADA DAN USIA LANJUT ( BUDAYA KULTUR DAN ETNIK ) MEKANISME AUTOMATIK DEFEKASI : INTEGRITAS MUKOSA REKTUM LUMBAR SPINAL CORD, SARAF PELVIC DENGAN INHIBISI DARI PUSAT. KERUSAKAN SEGMEN SAKRAL, SPINAL CORD, CAUDA EQUINA ATAU SARAF ERIGENTES (TRAUMA, TUMOR) MENIMBULKAN KONSTIPASI DAN ATONIK BOWEL.

ETIOLOGI :
1. SISTEMIK : A. OBAT 2AN: AL ( ANTASIDA ), ANALGETIK (CODEIN,
OPIAT) OBAT ANASTESI, ANTIKOLINERGIK, ANTIKONVULSAN, ANTI DEPRESANT / TRISIKLIK, BARIUM SULFAT, BISMUTH, BENZODIAZEPIN, DIURETIK, SITOTOKSIK, ANTI PARKINSON, GANGLION BLOKERS, SUPLEMENT BESI, ANTI HIPERTENSI, LAKSAN, MUSCLE RELAKSAN, MAO INHIBITOR, INTOKSIKASI METALIK ( ARSENIK, BESI, MERKURI )

B. GANGGUAN ENDOKRIN DAN METABOLIK

DM, PORPHIRIA, AMYLOIDOSIS, HIPOTIROIDISM, PANHIPOPITUITARISM, HIPOKALEMIA, UREMIA, HYPERKALSEMIA, PHEOKROMASITOMA, PREGNANCY

C. SKLEROSIS SISTEMIK DAN PENY. CONNECTIVE TISSUE D. PENY. PSYCOLOGICAL - DEPRESI - ANOREKSIA NERVOSA - KEBIASAAN MENAHAN BAB E. LAIN-LAIN - KEBIASAN DIET DAN BAB YAG SALAH - USIA TUA - PERJALANAN YANG JAUH - RENDAH SERAT - IMOBILISASI / RAWAT INAP

2. NEUROGENIK : MEKANISME BELUM JELAS

A. PERIPERAL: AGANGLIONIK (HIRSCHSPRUNGS ) TIDAK DIJUMPAI NEURON PADA DISTAL SEGMEN KOLON MENGAKIBATKAN SPASTIK KOLON. BARIUM ENEMA TERLIHAT DILATASI PROKSIMAL KOLON (MEGA KOLON), MANOMETRI ABSEN RIFLEKS RECTO ANOINHIBITORY. BIASA USIA MUDA KONSTIPASI SEJAK LAHIR AMPULA RECTI KOSONG. AUTONOMIK NEUROPATI INTESTINAL PSEUDO - OBSTRUKSI CHAGAS DISEASE B. CENTRAL : PENYAKIT PARKINSON, TUMOR OTAK, CEREBROVASKULER ACCIDENT KERUSAKAN DAERAH SACRAL MEDULA SPINALIS OLEH KARENA ( TUMOR, TRAUMA, PENYAKIT DEGENERATIF, DLL ) TABES DORSALIS, MULTIPLE SCLEROSIS PARALPLEGI DLL.

3. LARGE BOWEL ORIGIN: LAKUKAN COLOK DUBUR / RT

A. ORGANIK OBSTRUKSI: LESI KOLON SEBELAH KIRI. TUMOR COLON, STRIKTURA, VOLVULUS KRONIK, HERNIA, PROLAPSUS REKTAL, STENOSIS ANAL, INFEKSI KRONIS (AMUBIASIS, SYPHILIS, TUBERCULOSIS), ISKEMIK KOLITIS, ENDOMETRIOSIS, ENEMA KOROSIV, OPERATIF. B. ABNORMALITAS DARI FUNGSI OTOT : IBS / ORANG MUDA , DIVERTIKEL SINDROME, DILATASI SEGMENTAL KOLON, MYOTONIK DISTROPI, SKLEROSIS SISTEMIK. C. GANGGUAN RECTAL, ANAL DAN PELVIC BAGIAN BAWAH PROKTITIS ULSERATIF, FISSURE ANAL, PROLAPS MUKOSA, HEMORRHOID, ABSES PERIANAL, ANUS ECTOPIK ANTERIOR

4. IDIOPATIK : MARKER RADIO OPAQUE

A. DELAYED TRANSIT (COLONIC KONSTIPASI) LAZY BOWEL, KONSTIPASI KLONIK BERAT, WANITA DEWASA BAB 1X SEMINGGU KELOMPOK INI TIDAK RESPON TERHADAP DIET TINGGI SERAT.

B. NORMAL TRANSIT TIME, ABNORMALLY LONG STORAGE OF STOOL. C. KOMPONEN PSIKOLOGI TRANSIT TIME NORMAL

DIAGNOSIS
1. KLINIS A. ANAMNESE: DITANYA TENTANG : - KONSTIPASI ? DIAGNOSIS ? - SEJAK KAPAN ? - SEJAK ANAK HIRCHSPRUNGS TIBA-TIBA DEWASA ( TUMOR?, OBAT2AN, PASCA OPERASI ) - DIET SERAT ? B. PEM FISIK: - ANOREKTAL FISSURA, HEMORHOID, ABSCES PERIANAL, RECTOCELE, NEOPLASMA. RECTAL TOUCHE TINJA NYEMPROT HIRCHSPRUNGS - KONSTIPASI NEUROLOGIK SENSORI KUTANEUS SEKITAR ANUS

2. PEMERIKSAAN LABORATORIUM : - DARAH RUTIN, ELEKTROLIT, UREUM, KALSIUM SERUM TSH. 3. PEMERIKSAAN PENUNJANG : A. BARIUM ENEMA : - KONTRAS GANDA NEOPLASMA - HIRSCHSPRUNHSKOLON SEMPIT, PANJANG DAN DILATASI PROKSIMAL. - KONSTIPASI KRONIS KOLON LEBAR & PANJANG B. KOLONOSKOPI : KADANG KELAINAN (-) NEOPLASMA, ULKUS SOLITER RECTUM, MELANOSIS COLI, ULSERATIVE PROKTITIS BIOPSI KONFIRMASI HIRSCHSPRUNHS DISEASE DAN ULKUS SOLITER

C. COLONIC TRANSIT TIME :

MENELAN 20 POTONG MARKER RADIO OPAQUE, KEMUDIAN FOTO ABDOMEN FOLLOW UP 5 HARI, JIKA < 80% YANG DIKELUARKAN KONSTIPASI
D. ANORECTAL MANOMETRY : MENGEVALUASI ADANYA PENYAKIT HIRSCHSPRUNGS DAN COLORECTAL MOTILITY E. ELEKTROMIOGRAFI : MENILAI FUNGSI SPINCTER ANI DAN FUNGSI MUSCLE PUBORECTALIS.

PENGOBATAN :

1. GENERAL
A. ATASI PENYAKIT SISTEMIK & PENYAKIT ORGANIK YANG MENYEBABKAN KONSTIPASI

B. STOP OBAT2AN DAN LAKSANSIA KUAT

C. DIET TINGGI SERAT, BANYAK MINUM & BULKING AGENT (BAGI YANG TIDAK AMPU MENGKOMSUMSI DIET SERAT ) D. BIASAKAN BAB YANG BAIK (SEGERA BAB JIKA SUDAH ADA DESAKAN, BERI WAKTU YANG CUKUP UNTUK BAB) E. MOBILITAS / OLAH RAGA TERUTAMA INDIVIDU YANG SEHARIANNYA DUDUK ATAU TIDUR.

2. SERAT : TINGGI SERAT ( BRAN & CEREAL BUKAN SAYUR & BUAH) OBAT KONSTOPASI TANPA KOMPLIKASI. PEMBERIAN SECARA BERTAHAP SAMPAI DEFEKASI NORMAL TERCAPAI DAN MAINTENANCE. BILA KELUHAN BERTAMBAH BIASA PADA KONSTIPASI SPASTIK SLOW TRANSIT PEMBERIAN SERAT DI STOP. 3. BULKING AGENT METIL SELULOSA (METAMUSIL DAN SEJENISNYA DIGUNAKAN PD KONSTIPASI ). MEKANISME MENARIK AIR & MENAMBAH DEFEKASI DPT DIPAKAI SEBAGAI PENGGANTI SERAT BAGI YG TIDAK RESPON THD SERAT.

4.

MEDIKAMENT SECARA UMUM LAKSANSIA TDK DIANJURKAN JANGKA PANJANG. BAHAN INI GANGGUAN ABSORBSI DAN FARMAKOKINETIK OBAT, BERIKATAN FISIKAL DAN CHEMIKAL TRANSIT TIME

A. LUBRICANT LAXATIVELIQUID PARAFIN EFEK SAMPING ASPIRASI PNEUMONITIS + GGN ABSORBSI VIT. LARUT LEMAK TDK DIGUNAKAN LAGI.
B. FAECAL SOFTENER ( PELUNAK TINJA ) MENURUNKAN TEGANGAN PERMUKAAN DAN MENARIK AIR MASUK KE TINJA DIOCTYL SODIUM SULPHOSUCCINATE (CLOXYL/DIALOSET PLUS FISURA ANI, HEMOROID, UNSTABLE ANGINA / MCI

C. OSMOTIK LAXATIVE MAGNESIUM SULFAT, LACTULOSE, POLYTHYLENE GLYCOL, ELECTROLYTE SODIUM. MEKANISME MENARIK AIR & MENGELUARKAN

GUT HORMON/KOLESISTOKININPERISTALTIK
BEKERJA CEPAT PROSEDUR DIAGNOSTIK ( BARIUM ENEMA / KOLONOSKOPI DAN

TINDAKAN OPERASI. HATI-HATI PD ORG TUA

(GGK, GGJ, LAKTULOSA ENSEPALOPATI HEPATIK ( MENURUNKAN KADAR AMONIA DLM

KOLON)

D. STIMULANT LAXATIVE ANTHRAQUINONE, POLYPHENOLS(PHENOFHALEIN, BISACODYL, PHENASETIN) DAN CASTOR OIL. MEKANISME IRITASI MUKOSA USUS, STIMULASI DIREK NEURONAL SUB MUKOSA PLEKSUS MYENTRIKUS MENIMBULKAN KERAM PERUT, TIDAK DIPAKAI PADA OBS.USUS, PEMAKAIAN KRONIK ATONIK KOLON, MELANOSIS COLI. OXYPHENATOIN PADA HERBAL TRADISIONAL KERUSAKAN HATI KRONIK E. SUPPOSITORIA&ENEMAPHENOLPHTALEIN TIMBUL RASH, ALBUMINURIA DAN HEMOGLOBINURIA F. PROKINETIK EGENT CISAPRIDE

5. PSYCOLOGICAL,BEHAVIOURAL & BIO-FEEDBACK TERAPI:

KONSTIPASI + IBS PSIKOTERAPI / HYPNOTISM. BEHAVIOUR TERAPI LATIHAN BAB PADA ANAK-ANAK KOMBINASI DENGAN TINGGI SERAT BIO FEED BACK TERAPI KOMPLEKS BERMANFAAT PADA PELVIC FLOOR SYNDROMA

6. SURGERY : KONSTPASI SECARA UMUM DPT DITATALAKSANAKAN SECARA KONSERVATIF & MEDIKAMEN
TUMOR COLON, HIRSCHSPRUNGS DISEASE, PENYAKIT ORGANIK YANG MENYEBABKAN OBSTRUKTIF PADA COLON DAN SEVERE SLOW TRANSIT CONSTIPATION SUB TOTAL KOLEKTOMI DGN ILEORECTAL ANASTOMOSIS.

UNDERLYING DISEASES STATES ASSOCIATED WITH CONSTIPATION

MECHANICAL OBSTRUCTION COLON CANCER EXTERNAL COMPRESSION OF THE INTESTINE STRICTURES : DIVERTICULAR, POST ISCHEMIC, POST SURGICAL CROHNS DISEASE ADHESIONS INTUSSUSCEPTIONS COLONIC VOLVULUS ENDOMETRIOSIS HERNIA RECTAL PROLAPSE, OCCULT OR COMPLETE

METABOLIC DISEASES DIABETES MELLITUS HYPOTHYROIDISM HYPERCALEMIA HYPERPARATHYROIDISM HYPOPITUITARISM PHEOCHROMOCYTOMA HYPOKALEMIA HYPOMAGNESEMIA UREMIA HEAVY METAL POISONING PORPHYRIA NTESTINAL MYOPATHIES AMYLOIDOSIS SCLERODERMA MIXED CONNECTIVE TISSUE DISEASE MYOPATHIC PSEUDO-OBSTRUCTION CHAGAS DISEASE

INTESTINAL NEUROOPATHIES PARKINSONS DISEASE SPINAL CORD INJURY OR TUMOR CEREBRAL VASCULAR DISEASE MULTIPLE SCLEROSIS NEUROPATHIC PSEUDO-OBSTRUCTION HIRSCHSPRUNG'S DISEASE
OTHER CONDITION DEPRESSION ANOREXIA NERVOSA AUTONOMIC NEUROPATHY IMMOBILITY DEMENTIA CARDIAC DISEASE PREGNANCY IDIOPATHIC MEGA COLON PAINFUL ANAL DISEASE (INFLAMED HEMORRHOID, FISSURE, ABSCESS) RECTOCELE IRRITABLE BOWEL SYNDROME

ADDITIONAL CAUSES OF CONSTIPATION IN CHILDREN ANORECTAL MALFORMATIONS STRICTURE DUE TO NECROTISING ENTEROCOLITIS CYSTIC FIBROSIS NEUROLOGICAL MALFORMATIONS : SPINA BIFIDA, MYELOMENINGOCELE RECKLINGHAUSENS DISEASE INTESTINAL NEURONAL DYSPLASIA ABNORMAL ABDOMINAL MUSCULATURE : GASTROSHISISM PRUNEBELLY, DOWNS SYNDORME VITAMIN D INTOXICATION FUNCTIONAL FECAL RETENTION

INFANT DYSCHEZIA

DRUGS THAT MAY CAUSE CONSTIPATION

OPIATES ANTICHOLINERGICS TRCYCLIC ANTIDEPRESSANTS CALCIUM CHANNEL BLOCKERS ANTIPSYCHOTICS ANTIPARKINSONIAN DRUGS ANTICONVULSANTS GANGLIONIC BLOCKERS DIURETICS ANTIHISTAMINES ANTACIDS CALSIUM SUPPLEMENTS IRON SUPPLEMENTS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)

DISTURBANCES OF COLONIC OR ANORECTAL FUNCTION IN CONSTIPATION

COLONIC DYSFUNCTION
INCREASE IN NON PROPULSIVE COLONIC CONSTRACTIONS DECREASE IN PROPULSIVE COLONIC CONSTRACTIONS SLOW TOTAL OR SEGEMENTAL COLONIC TRANSIT

ANORECTAL DYSFUNCTION
ELEVATED ANAL PRESSURE DISTURBED PERINEAL MOVEMENT

DISTURBED RECTAL SENSATION

INCREASED RECTAL COMPLIANCE

FEATURES OF FUNCTIONAL FECAL RETENTION (FFR) AND COLONICNEUROMUSCULAR DISORDERS (CNR) IN CHILDREN
FEATURE
FECAL SOILING OBSTRUCTIVE SYMPTOMS LARGE CALIBER STOOLS STOOL WITHHOLDING BEHAVIOR ENTEROCOLITIS

FFR
COMMON FLARE COMMON COMMON NEVER

CNR
FLARE COMMON FLARE FLARE POSSIBLE

UPPER GI SYMTOMS
SYMPTOMS FROM BIRTH LOCALIZATION OF STOOLS

NEVER
FLARE RECTUM

COMMON
COMMON RECTUM AND COLON

SYMPTOMS IN THREE GROUPS OF COLONIC AND ANORECTAL CAUSES OF CHRONIC CONSTIPATION

COLONIC STENOSIS OR SLOW TRANSIT
HARD AND SMALL STOOLS INFREQUENT DEFECATION ABSENCE OR URGE TO DEFECATE

ANOREACTAL DYSFUCTION
THIN STOOLS FEELING OF RESISTANCE TO DEFECATION STRAINING AT DEFECATION FEELING OF INCOMPLETE DEFECATION PAIN WITH DEFECATION DIGITAL SUPPORT OF PERINEUM OR ANTERIOR RECTAL WALL DIGITAL EVACUATION INCOMPLETE OR NO EMPTYING WHEN ENEMA APPLIED

IRRITABLE BOWEL SYNDROME

SMALL STOOLS PAIN RELEIVED BY DEFECATION INTTERMITENT DIARRHEA FEELING OF INCOMPLETE DEFECATION STRAINING AT DEFECATION

POSSIBLE PHYSICAL FINDINGS IN CONSTIPATION

INSPECTION
ABDOMINAL DISTENTION PERINEAL FISSURE, INFLMMATION, OR SCAR PERINEAL DESCENT DECREASED MOBILITY OF THE PERINEUM

DIGITAL OR MANUAL EXAMINATION

ADOMINAL MASS OR TENDERNESS FECAL IMPACTION ANAL STRICTURE INCREASED ANAL CANAL TONE DURING REST OF SQUEEZE PAINFUL EXAMINATION OF THE ANAL CANAL PAIN AT THE RIM OF THE PUBORECTALIS MUSCLE RECTAL MASS RECTOCELE

INDICATION FOR RETERRAL FOR SPECIALIZED GASTROENTEROLOGIC EVALUATION

RECENT ONSET OF CONSTIPATION
CHRONIC CONSTIPATION WITH CHANGE IN STOOL FROM OR FREQUENCY WEIGHT LOSS

ANEMIA, BLOOD PER RECTUM, OCCULT BLEEDING

ABDOMINAL PAIN OR TENDERNESS FAMILY HISTORY OF COLON CANCER

PERSISTING PALPABLE TUMOR

OLDER THAN 40 YEARS AT ONSET OF SYMPTOMS TREATMENT FAILURE;FAILURE TO IMPROVE WITH ROUTINE THERAPY OR CHRONIC NEED FOR HIGH DOSES OF ANY LAXATIVE

THREE TREATMENT APPROACHES FOR CONSTIPATION BASED ON CLINICAL SUSPICION OR PROOF OF ONE OF THREE POSSIBLE GROUPS OF FUNCTIONAL DISORDERS
ANORECTAL DYSFUNCTION DECREASE FIBER IN DIET INCREASE STOOL WATER CONTENT WITH SALINE LAXATIVES RETRAIN PELVIC FLOOR FUNCTION USE GLYCERIN SUPPOSITORIES IF NEEDED USE BIOFEEDBACK TECHNIQUES IF THE ABOVE APPROACHES ARE UNSECESSFUL AFTER SUCCESSFUL ACHIEVEMENT OF REGULAR BOWEL HABITS, REINTRODUCE FIBER - RICH DIET SLOW COLONIC TRANSIT INCREASE FIBER IN DIET ; FIBER SUPPLEMENTS SALINE LAXATIVES CISAPRIDE SURGERY IN SEVERE CASES AND FOR PATIENTS RESISTANT TO MEDICAL THERAPY IRRITABLE BOWEL SYNDROME FIBER RICH DIET IF TOLERATED BY THE PATIENT SALINE LAXATIVES ANTISPASMODIC USED ONLY WQITH CAUTION TRICYCLIC ANTI DEPRESSANTS IN CASES OF IBS IN WHICH PAIN IS A PROMINENT SYMPTOM