HEGAZY SURGERY

1. Functional Constipation
By
M. Osama Shetta.
Professor of Surgery
Ain Shams University

2. Definition
At least two of the following:
- Less than three bowel motions/week.
- Need in more than 25% of occasions to:
- To strain.
- To manually evacuate
- Passage of hard stool
- Sense of incomplete evacuation

3. Definition(cont.)
- These symptoms need to be chronic.
- All other aetiological causes of
constipation must be excluded
specially the organic causes.

4. Aetiology of constipation I
Dietary
Endocrine / Metabolic
Neurological
Psychogenic
Drugs & poisons
General causes

5. Drugs:
opiates
anticholinergics.
Iron therapy.
antiacids

6. Aetiology of constipation II
- Organic obstruction
- Functional constipation

7. Organic Obstruction

17. Functional Constipation
In terms of pathophysiology:
- Slow gut transit(colonic inertia).
- Rectal evacuatory dysfunction.
- Combination of both.

18. Functional Constipation
Slow transit
Outlet obstruction
–Rectocele
–Rectal prolapse, intussusception
–Anismus
–Solitary rectal ulcer syndrome
–Descending perineum syndrome
Slow transit + Outlet obstruction
Constipating form of IBS

19. Functional Constipation
Consider it when
–All other causes are excluded
–Colon looks normal on barium
enema and colonoscopy
–Rectoanal inhibitory reflex (RAIR)
is preserved
–Colon is ganglionic

20. Evaluation & Management
Initial evaluation
Initial management
Secondary management
Secondary evaluation
Tertiary management

21. Aim of Initial Evaluation
Exclude organic obstruction

22. Initial Evaluation
- History and examination
- Anorectal examination
–Inspection (rest, strain, squeeze)
–Palpation, check anal wink
–PR (rest, strain squeeze)
–Inspection of stools
–Proctosigmoidoscopy
- Routine blood investigations
- Colonoscopy + Barium enema
- More tests or consultation if history and
examination are suspicious

23. Initial Management with
Apparent cause
Treatment of the cause.

24. Initial Management
No Apparent Cause
Dietary manipulation
–Increase fluid intake
–Increase fiber in diet or by laxative
Regular exercise
Advise Never to :
–Strain
–Suppress desire
–Use stimulant laxatives
Can use supposit., lactulose, bulk
forming laxatives

25. Secondary Management
By Stimulant laxatives:

26. Aim of Secondary
Evaluation
Document the presence and the
type of functional constipation

27. Secondary Evaluation
Extensive lab. Studies
Colonic transit
Pelvic floor tests (PFT)
–Manometry (press., sens., RAIR)
–EMG
–Defecography
–Balloon expulsion test
Biopsy for ultrashort segment Hirschsprung
Psychological consultation

30. Categorization of
Functional Constipation
Anorectal physiology testing
normal transit, abnormal PFT = PF dysfunction
abnormal transit, normal PFT = slow transit constip.
abnormal transit,abnormal PFT = slow transit &PF dysf.
normal transit,normal PFT = IBS

31. Intervention in functional
constipation should be
considered only when medical
treatment consistently failed to
help the patient, constipation is
most intractable and the
patient is thoroughly
investigated

32. Treatment
Rectocele
– Surgical repair
– Biofeedback

33. Treatment
Slow transit constipation
–Total colectomy
–Segmental colectomy
–Biofeedback

34. Treatment
Complete rectal prolapse
–Rectopexy
–Resection
–Delorme

35. Treatment
Internal intussusception
–Biofeedback
–Rectopexy
–Delorme
–Rectopexy + Resection
–Other extensive operations

36. Treatment
Solitary rectal ulcer
–Biofeedback
–Excision
–Injection
–Rectopexy

37. Treatment
Anismus
–Biofeedback
–Botulinum toxin

38. Treatment
Descending perineum
–Biofeedback

39. Proper Management
Starts With Proper
Diagnosis

42. Surgical Aspects Of
Constipation
by
Ahmed A. Abou-Zeid
Professor of Surgery
Ain Shams University