chudahman manan konstipasi

7/26/2019 Chudahman Manan Konstipasi

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Curriculum Vitae

N a m a : Dr. dr. H. CHUDAHMAN MANAN SpPD-KGEH , FINASIMTempat & Tanggal lahir : Jakarta, 1 Juni 1951Alamat : Jl. Taman Golf 6, BG 1, No. 7, Cipondoh

Tangerang. (15515)

Pekerjaan : Staf Senior Divisi Gastroenterologi, Dept. Ilmu .Penyakit .DalamFKUI/RSUPNCM,

Riwayat pendidikan :Fakultas Kedokteran UI, tahun 1976Spesialis Penyakit Dalam FKUI tahun 1986JICA Program in Gastroenterology, Tokyo,1989Konsultan Gastroentero-Hepatologi, th. 1996S3 , Sains Veteriner, IPB 2012

Riwayat pekerjaan :Kepala Puskesmas Kota Agung, Lahat, Sum-Sel 1976-1980Kepala RSUD Kabupaten Lahat, Sum-Sel 1980-1981.Pendidikan Spesialis Penyakit Dalam FKUI/RSCM, 1981-1986Spesialis P.Dalam RS Sekupang Batam 1986Koordinator Pelayanan Masyarakat, Bag.I.P.Dalam FKUI/RSCM 1998-2000Ketua Divisi Gastroenterologi, Dept.I.P.Dalam FKUI/RSUPNCM 2001-2008

Organisasi :

Anggota Ikatan Dokter Indonesia (IDI)Anggota Perhimpunan Ahli Penyakit Dalam IndonesiaAdvisory PB PGI/PEGIAnggota Perhimpunan Peneliti Hati Indonesia (PPHI)Anggota Perkumpulan Onkologi IndonesiaCouncillor Asian Pasific Association of GastroenterologyCouncillor Asian Pacific Association of Digestive EndoscopyMember OMED (Word organization of Digestive Endoscopy)

Publikasi : Dalam dan Luar Negeri


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Current management of

chronic constipation

Chudahman Manan

Indonesian Society of Gastroenterology


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EpidemiologyoConstipation problem most finding in

western country.

oIn USA constipation prevalence 2-27% with

physician consultation about 2.5 million andhospitalized patients about 100.000 pts.

oData from RSCM-Jakarta during 1998-2005,

2.397 colonoscopy exam , 216 (9%)

indication for constipation

oGender comparative women and men (4 : 1)

Sumber: buku konsensus nasional penatalaksanaan konstipasi di Indonesia oleh PGI


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How Do We DefineConstipation?

oThe American College of Gastroenterology (ACG)definition of constipation:

o Unsatisfactory defecation characterized by infrequentstools, difficult stool passage, or both. Difficult stoolpassage includes straining, a sense of difficulty passingstool, incomplete evacuation, hard/lumpy stools,prolonged time to pass stool, or need for manualmaneuvers to pass stool

oThe ACG Chronic Constipation Task Force alsoclarified what is meant by chronic:

o Chronic constipation is defined as the presence of thesesymptoms for at least 3 months

American College of Gastroenterology Chronic Constipation TaskForce.Am J Gastroenterol. 2005;100(S1):1-4.


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Differentiating BetweenOccasional and Chronic Constipation

Occasional Constipation Chronic Constipation

InfrequentPresent for at least 3 monthsand may persist for years

Occasional or short-term

condition that may temporarilyinterrupt usual routine

Long-term condition that maydominate personal and work life

May be brought on by patientsbehavior, change in diet, lack ofexercise, illness, or medication

Not only related to patientsbehavior, change in diet, lack ofexercise, or medication

May be relieved by diet, exercise,and over-the-counter (OTC)medication

May need medical attention andprescription medication


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Belching

Dyspepsia

IBS

GERD

Chronic

Constipation

Constipation

Heartburn Regurgitation

Bloating

AbdominalPain

Discomfort

Overlap Between CommonDisorders

Brandt L, et al.Am J Gastroenterol. 2005;100(S1):5-22.


7/47Brandt LJ, et al.Am J Gastroenterol. 2005;100(suppl 1):S5-S21.

Chronicconstipation

(-)Abdominal Pain

IBS withconstipation

(+)Abdominal Pain

Presence or absence of abdominal pain is themajor differentiating feature

Abdominal Pain: Salient FeatureAbsent in Chronic Constipation


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Prevalence of FunctionalGastrointestinal Disorders

25

25-40

40

3-20

2-28

05

10

15

20

25

30

35

40

45

DyspepsiaFunctionalHeartburn

ChronicConstipation

GERD IBS

Populatio

n(%)

28

8 8

6-18

Hyper-tension

Migraine Asthma Diabetes

Wolf-Maier K, et al. JAMA. 2003;289:2363-2369.Lawrence EC. South Med J. 2004 Nov;97(11):1069-1077.

CDC. MMWR Morb Mortal Wkly Rep. 2004;53:145-148.CDC. MMWR Morb Mortal Wkly Rep. 2003;52:833-837.

Wong WM, Fass R. Curr Treat Options Gastroenterol. 2004;7(4):273-278.Corazziari E. Best Pract Res Clin Gastroenterol. 2004;18(4):613-631.

Higgins PD, Johanson JF.Am J Gastroenterol. 2004;99(4):750-759.Brandt L, et al.Am J Gastroenterol. 2002;97(suppl11):S7-26.


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Higgins PDR, et al.Am J Gastroenterol. 2004;99:750-759.

Age Group (years)

Prevalence

of

Constipation

(%)

0

2

4

6

8

10

12

Study 1N = 42,375

Harari, et alPopulation: NHIS 1989

Criteria: self-report

NHIS = National Health Interview Survey

Constipation Increases With Ageand Is More Common in Women

Prevalence

of

Constipation

(%)

Sex

N = 5,430Drossman

N = 1,149Pare

N = 10,018Stewart

Study 2 Study 3 Study 4

Men Women

0

5

10

15

20

25


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Normal Physiology of Defecation

o

Increased abdominal pressure or propulsive colorectalcontractions

o Relaxation of internal anal sphincter (autonomic)

o Relaxation of external anal sphincter (voluntary)

o Straightening of pelvic musculature (levator ani,puborectalis)

With strainingAt rest

Lembo A, Camilleri M.N Engl J Med.2003;349:1360-1368.Muller-Lissner S. Best Pract Res Clin Gastroenterol. 2002;16:115-133.


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Chronic Constipation Interferes withDaily Lives of the Aging Population

100

8

0604020

0

MeanMOSScore

PhysicalFunctioning

HealthPerception

MentalHealth

SocialFunctioning

RoleFunctioning

BodilyPain

No GI symptoms

Constipation

Impact of chronic constipation on quality of life in Olmsted County, MN, residents aged 65 years

Lower score indicates worse quality of life

Adapted from Talley NJ. Rev Gastroenterol Disord. 2004;4(suppl 2):S3-S10.

MOS = medical outcomes survey


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Bosshard W, et al. Drugs Aging. 2004;21:911-930.Hadley S.K, et al. Journal of Am Fam Physician. 2005;72:2501-2506.

Primary Causes of Chronic constipation :

o Normal-transit constipation

o Slow-transit constipation

o Defecatory dysfunction

o IBS with constipation


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Stool Form Correlates WithIntestinal Transit Time

ODonnell LJD, et al. BMJ.1990;300:439-440.

Slow Transit

Fast Transit

Separate hard lumps

Type 2

Type 1

Type 3

Type 4

Type 5

Type 6

Type 7

Sausage-like but lumpy

Sausage-like but withcracksin the surfaceSmooth and soft

Soft blobs with clear-cut edges

Fluffy pieces with raggededges,a mushy stoolWatery, no solid pieces

The Bristol Stool Form Scale


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Primary Constipation

Slow-transit Constipation

Characterized by prolongedintestinal transit time

Altered regulation of entericnervous system

Decreased nitric oxideproduction

Impaired gastrocolic reflex

Alteration of neuropeptides(VIP, substance P)

Decreased number ofinterstitial cells of Cajal in the

colon

Irritable Bowel Syndrome(IBS) with Constipation

Alterations in brain-gut axis

Stress-related condition

Visceral hypersensitivity

Abnormal brain activation

Altered gastrointestinal

motility

Role for neurotransmitters,

hormones

Presence of non-GI sympt Headache, back pain,

fatigue, myalgia,dyspareunia,

urinary symptoms,dizziness


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Bosshard W, et al. Drugs Aging. 2004;21:911-930.Gallagher P, et al. Drugs Aging. 2008;25(10):807-821.

Primary Constipation(1):

Normal-transit ConstipationIntestinal transit and stool frequency are within the

normal range

Most frequent type of constipation


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Lembo A, Camilleri M. N Eng J Med. 2003;349:1360-1368.


Slow-transit ConstipationCharacterized by prolonged intestinal transit timeAltered regulation of enteric nervous system

Decreased nitric oxide productionImpaired gastrocolic reflexAlteration of neuropeptides (VIP, substance P)Decreased number of interstitial cells of Cajal in the

colon


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Bosshard W, et al. Drugs Aging. 2004;21:911-930.Hadley S.K, et al. Journal of Am Fam Physician. 2005;72:2501-2506.


Defecatory DysfunctionMore common in older womenchildbirth

traumaPelvic floor dyssynergiaContributing factors include anal fissures,

hemorrhoids, rectocele, rectal prolapse,posterior rectal herniation

Excessive perineal descent

Pathogenesis may be multifactorialstructuralproblem

Abnormal anorectal manometry and/ordefecography


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Videlock E, Chang L. Gastroenterol Clin N Am. 2007;36:665-685.Hadley SK, et al. Journal of Am Fam Physician. 2005;72:2501-2506.


Irritable Bowel Syndrome (IBS) withConstipation

Alterations in brain-gut axis

Stress-related conditionVisceral hypersensitivityAbnormal brain activationAltered gastrointestinal motilityRole for neurotransmitters, hormonesPresence of non-GI symptoms

Headache, back pain, fatigue, myalgia, dyspareunia,urinary symptoms, dizziness


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Rome III Criteria for IBS-C

Recurrent abdominal pain or discomfort (anuncomfortable sensation not described as pain) at least3 days per month in the last 3 months associated with 2or more of the following:

1. Improvement with defecation2. Onset associated with a change in frequency of

stool3. Onset associated with a change in form of stool

Criteria must be fulfilled for the last 3 months, withsymptom onset at least 6 months prior to diagnosis

In pathophysiology research and clinical trials, a pain/discomfort frequency ofat least 2 days a week during screening for patient eligibility

Longstreth G, et al. Gastroenterology. 2006;130:1480-1491.


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Manualmaneuversto facilitatedefecations

Manualmaneuversto facilitatedefecations

Sensation ofanorectal

obstruction/blockage

Loose stools are rarely present without the use of laxatives

Insufficient criteria for irritable bowel syndrome

Longstreth GF, et al. Gastroenterology. 2006;130:1480-1491.

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

During at least 25% of defecations

Sensationof

incompleteevacuation

Sensationof

incompleteevacuation

StrainingStrainingLumpy or

hardstools

Lumpy orhard

stools

< 3defecations

per week

Rome III Diagnostic Criteria*for Functional Constipation

Chronic constipation must include 2 or more of the following:


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Patient Care :

oThrough patient historyoPhysical/abdominal/digital rectal examso

Evaluate symptoms in terms of diagnosticcriteria Chronic constipation/IBS-CoAssessment for red flags/alarm featuresoNeed for additional testing

oTreatment/Management plan


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Ask the Right Questions

o Define the meaning of constipationo How long have you experienced these

symptoms?

o Frequency of bowel movements?

o

Abdominal pain?o Other symptoms?

o What is most distressing symptom?

o Manual maneuvers to assist with defecation?

o

Any limitation of daily activities?o Are you taking any medications?

o What treatment have you tried?

o What investigations have been done?

Locke GR III, et al. Gastroenterology. 2000;119:1761-1778.


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Pare P, et al.Am J Gastroenterol. 2001;96:3130-3137.

N = 1149

Stoolcannot

bepassed

PercentofPatients

Physicians think:

< 3 BM per week

Straining Hard orlumpystools

Incompleteemptying

Abdominalfullness orbloating

< 3 BMper

week

Need topress on

anus

81

72

54

3937 36

28

0

10

20

30

40

50

60

7080

90

Common Patient Descriptionsof Constipation


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Sumber: konsensus nasional penatalaksanaan konstipasi di Indonesia oleh PGI

Supportive exam :

Colonoscopy


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Any Alarm Symptoms?Are Diagnostic Tests Needed?

Locke GR III, et al. Gastroenterology. 2000;119:1761-1778.Brandt LJ, et al.Am J Gastroenterol. 2005;100(suppl 1):S5-S21.

o Hematochezia

o Family history of colon cancer

o Family history of inflammatory bowel disease

o Anemia

o Positive fecal occult blood test

o Unexplained weight loss 10 pounds

o

Severe, persistent constipation that isunresponsive to treatment

o New-onset constipation in an elderly patient


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Mediators of Gl Function

Visceral SensitivitySerotoninTachykininsCalcitonin gene-related peptideNeurokinin A

EnkephalinsCorticotropin releasing factor

Kim DY, Camilleri M.Am J Gastroenterol. 2000;95(10):2698-2709.

SecretionSerotonin

Acetylcholine

MotilitySerotonin

AcetylcholineNitric oxideSubstance P

Vasoactive intestinal peptideCholecystokininCorticotropin releasing factor


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Combined Risk Factors forConstipation in the Elderly Populationo

Reduced fiber intakeo Reduced liquid intakeo Reduced mobility associated with functional declineo Decreased functional independenceo Pelvic floor dysfunctiono

Chronic conditions Parkinsons disease Dementia Diabetes mellitus Depression

o Polypharmacy (both over the counter andprescription medications, such as NSAIDs, antacids,antihistamines, iron supplements, anticholinergics,opiates, Ca channel blockers, diuretics,antipsychotics, anxiolytics, antidepressants)


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Common Changes with Aging that Increasethe Risk for Constipation

Gallagher P, et al. Drugs Aging. 2008;25(10):807-821.Schiller L. Gastroenterol Clin N Am. 2001;30:497-515.

o Decreased total body water

o Decreased colonic motility*

o Deterioration of nerve function

o Increased pelvic floor descent

o Decreased rectal compliance

o Decreased rectal sensation

o Age-related changes to the internal and externalanal sphincter

*Demonstrated in some, but not all studies


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Consider Secondary Causes

Constipation

GastrointestinalColorectal: neoplasm,ischemia, volvulus,

megacolon,diverticular disease

Anorectal: prolapse,rectocele, stenosis,

megarectum

Drugs

OpiatesAntidepressantsAnticholinergicsAntipsychotics

Antacids (Al, Ca)Ca channel blockersIron supplements

Metabolic/EndocrineHypercalcemia

HyperparathyroidismDiabetes mellitusHypothyroidismHypokalemia

UremiaAddisonsPorphyria

PsychologicalDepression

Eating disorders

NeurologicalParkinsons

Multiple sclerosisAutonomic neuropathy

Aganglionosis(Hirschsprungs, Chagas)

Spinal lesionsCerebrovascular disease

LifestyleInadequate fiber/fluid

Inactivity

SurgicalAbdominal/pelvic surgeryColonic/anorectal surgery

SystemicAmyloidosisSclerodermaPolymyositisPregnancy

Candelli M, et al. Hepatogastroenterology. 2001;48:1050-1057.Locke GR, et al. Gastroenterology. 2000;119:1761-1766.


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Chronic Constipation Secondary to Diabetes

Special Considerationso Constipation occurs in 20% of patients with diabeteso Related to duration of diabetes > 10 yearso Diabetic autonomic neuropathyo Gastrocolic reflex may be absent, delayed, blunted

o Constipation may be severe and can lead tomegacolon

Treatment Strategy*1. Optimize diabetes care2. Stepwise pharmacologic therapy

Exclude slow transit Bulking agents, osmotic laxatives, Cl channel activators,

stimulant laxatives

Verne GN, et al. Gastroenterol Clin North Am.1998;27:861-874.

*Treatment strategy based on clinical experience


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Myths and Misconceptions AboutChronic Constipation

Misconception Reality

Diseases arise fromautointoxication byretained stools

No evidence to support this theory

Fluctuations in hormonescontribute to constipation

Fluctuations in sex hormones during the menstrualcycle have minimal impact on constipation, but are

associated with changes in other GI symptomsChanges in hormones during pregnancy may playa role in slowing gut transit

A diet poor in fiber causes

constipation

A low fiber diet may be a contributory factor in asubgroup of patients with constipation

Some patients may be helped by an increase in

dietary fiber, others with more severe constipationmay get worse symptoms with increased dietaryfiber intake

Increasing fluid intake is asuccessful treatment forconstipation

No evidence that constipation can be treated successfullyby increasing fluid intake unless there is evidence ofdehydration

Muller-Lissner S, et al.Am J Gastroenterol. 2005;100:232-242.Heitkemper M, et al.Am J Gastroenterol. 2003;98(2):420-430.


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More Misconceptions About ChronicConstipation

Muller-Lissner S, et al.Am J Gastroenterol. 2005;100:232-242.

Misconception RealityStimulant laxatives

damage the enteric

nervous system and

increase the risk of

cancer

Unlikely that stimulant laxatives at recommended

doses are harmful to the colon

No data support the idea that stimulant laxatives are

an independent risk factor for colorectal cancer

Laxatives cause

electrolyte

disturbances

Laxatives can cause electrolyte disturbances, but

appropriate drug and dose selection can minimize

such effects

Laxatives induce

tolerance

Tolerance is uncommon in most laxative users,

however tolerance to stimulant laxatives can occur in

patients with severe constipation and slow colonictransit

Laxatives are

addictive

No potential for addiction to laxatives, but laxatives

may be misused


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Modification Targeted Mechanism Efficacy

Increase fluidintake

Increase stool volume by augmentingluminal fluid

Limited; majority of fluidis absorbed beforereaching the colon and isexpelled via urine

Increase exercise Improve motility by decreasing transit timethrough the GI tract

Moderate; someevidence suggests this isbeneficial; however, notsufficient to treat

Increase dietaryfiber

Increase water and bulk stool volume Limited benefit comparedwith placebo

Lifestyle Modifications

Chung BD, et al. J Clin Gastroenterol. 1999;28:29-32.

Dukas L, et al.Am J Gastroenterol. 2003;98:1790-1796.ACG Chronic Constipation Task Force.Am J Gastroenterol.2005;100(suppl 1):S1-S4.


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Ineffective Reliefof Constipation

Johanson JF and Kralstein J.Aliment Pharmacol Ther. 2007;25:599-608.

Ineffective Relief ofMultiple Symptoms

Lack ofPredictability

Ineffective Reliefof Bloating

D

issatisfiedPatients(%)

OTC laxatives Prescription laxatives Fiber(n = 268)(n = 42)(n = 146)

44

60

7167

50 50

75

5250

66

79 80

0

20

40

60

80

100

Are Patients Satisfied WithLaxatives and Fiber?


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Treating Constipation With Laxatives

Laxative Description

Bulking Agents

Absorbs liquids in the intestines and swells to form a soft, bulkystool; the increase in fecal bulk is associated with acceleratedluminal propulsion

Osmotic

Laxatives

Draws water into the bowel from surrounding body tissuesproviding a soft stool mass and improved propulsion

[saline, poorly absorbed mono- and disaccharides, polyethyleneglycol]

StimulantLaxatives

Cause rhythmic muscle contractions in the intestines, increaseintestinal motility and secretions

LubricantsCoats the bowel and the stool mass with a waterproof film; stoolremains soft and its passage is made easier

Stool Softeners

Helps liquids mix into the stool and prevent dry, hard stool masses;has been said not to cause a bowel movement but instead allowsthe patient to have a bowel movement without straining

Combinations

Combinations containing more than 1 type of laxative; for example,a product may contain both a stool softener and a stimulantlaxative

Gallagher P, et al. Drugs Aging. 2008;25:807-821.

Laxatives


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LaxativesLaxative

TypeGeneric Name Brand Name(s)

Bulk-forming

Methylcellulose Citrucel

Polycarbophil FiberCon, Fiber-Lax

Psyllium Metamucil, Konsyl

Lubricating

Glycerin Glycerin suppository (generic)

Mineral oil Mineral oil (generic)

Magnesium hydroxide (milk of magnesia) and mineral

oil Phillips

M-O

StoolSofteners

Docusate sodiumColace, DulcolaxStool Softener, PhillipsLiqui-Gels

Saline Magnesium hydroxide (milk of magnesia)Ex-LaxMilk of Magnesia Laxative/AntacidPhillipsChewable TabletsPhillipsMilk of Magnesia

Stimulant

Bisacodyl Ex-Lax Ultra, Dulcolax Bowel Prep Kit

Sodium bicarbonate and potassium bitartrate Ceo-Two Evacuant

Sennosides Ex-LaxLaxative Pills

Castor oil Purge

Senna Senokot

Osmotic Polyethylene glycol 3350 GlycoLax

, MiraLAX

Lactulose Kristalose


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Aim of bisacodyl study:

oTo observe Complete Spontaneous Bowel

Movements (CSBM) every week during 4 weeks

treatment

o

Two condition related to bowel movement : Spontaneous Bowel Movement (SBM):

spontaneous defecation

Complete Spontaneous Bowel Movement (CSBM):

spontanneous defecation with good sensation


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Material & Method :

oAdult patients total 368 ptso Diagnosis chronic

constipationo Bisacodyl tab (Dulcolax)Rvs.

placebo; during 4 weeks

o Center of study Germany &UK


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Study result:Complete Spontaneous bowel movement at first day

& 4 weeks after treatment :

Placebo Bisacodyl

Total patients 117 239

First step evaluation 1.1 1.1

4 weeks evaluation 2.0 5.2

Different result between

bisacodyl & placebo

3.3

95% Confidence interval (2.6 , 4.0)

p-value


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Result :Complete spontaneous bowel movement after 4 weeks

**

** ** **

Significant diff in CSBM between Bisacodyl mand placebo

R l


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Result :

**

**

**

**

Avarage Spontaneous Bowel Movement after 4 weeks

Significant diff between Bisacodyl & plasebo to increase SBM


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Patients self assesment for quality of life (QOL)

Bisacodyl increase QOL from patients with constipationrecovery bowel habit every day . 80% patients have satisfied withBisacodyl.

0

10

20

30

40

50

60

Good Satisfactory Not

satisfactory

Bad

Percen

tageofpatients

PBO

BIS


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Patients symptoms improvement afterbisacodyl treatment

o Regular bowel habit everyday

o Decreased constipation symptoms

o Decreased bloating symptoms

o Decreased abdominal discomfort

Bisacodyl relief clinical symptoms due to constipation


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No AlarmSymptoms

AlarmSymptoms

Directed testing

Refer to a specialistas needed

Continue

regimen

+ Response

Suggested Management Algorithm forChronic Constipation

OTC = over-the-counter therapies (probiotics, herbal medications, stool softeners

[docusate sodium], psyllium, methylcellulose, calcium polycarbophil, bisacodyl, senna)

Bleeding, anemia,weight loss,sudden change instool caliber,abdominal pain

No response

Lifestyle, OTC, stimulant laxative


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Summary

o Chronic constipation is a commoncondition mostly in the elderly

o Quality of life pts with constipationespecialy in elderly patients is

negatively affected by the symptomsof chronic constipation

o Identify risk factors and secondary

causes for constipationo Be vigilant for red flags or alarm

symptoms; directed tested may benecessary


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Summary contd

o Main objective of treatment forchronic constipation is to improvepatients symptoms, restore normal

bowel function ( 3 bowelmovements per week), improvequality of life

o Bisacodyl have good therapeuticeffect and minimal side effect withgood safety profile


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hank you very muchhank you very much

for your kind attentionor your kind attention

chudahman manan konstipasi

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