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The First Step-by-step Plan To Cure Constipation Using A Combination Of Unique All-natural Remedies. This plan uses a strategically organized and ordered combination of the safest and most effective natural remedies for constipation. Everything used in this plan is from natures garden. No use of harmful laxatives. People who have used these swear they work Better than over-the-counter laxatives! Every strategy is carefully researched for safety and effectiveness. Each remedy builds on the last while helping out the next. The plan takes into account human physiology, anatomy, nutrition, metabolic needs and deficiencies while using specific dietary remedies and the almost always neglected but extremely powerful, mechanical remedies. All of these have been carefully planned and refined to provide you the most powerful, synergistic constipation relief plan that will relieve you of even the most stubborn of constipation episodes within as quick as 15 minutes and less than 24 Hours. More here...

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Constipation with IBS

In a patient with constipation-predominant IBS, we will attempt a high fiber diet, starting with small amounts and increasing gradually. Wheat bran, at doses of 10 to 30 g, is the best known and perhaps the most effective fiber supplement but commercial products may be more acceptable to some patients. Abdominal pain and bloating occur with fiber supplements in many IBS patients. PEG may be substituted in patients who do not tolerate fiber supplements, but we minimize the use of stimulant laxatives. Tegaserod may be useful in women with constipation-predominant IBS, although the cost of the drug far exceeds other available agents.

Management of constipation

The most important causes of constipation are immobility, poor fluid and dietary intake, and drugs, particularly opioids. Good general symptom control will minimise the first three of these, but most patients will require laxatives. The aim of laxative therapy is to achieve comfortable defecation, rather than any particular frequency of bowel movement. The choice of laxative depends on the nature of the stools, acceptability to the patient, and cost. Dose should be titrated against individual response. Clinically it is useful to divide laxatives into two groups

Normal Transit Constipation

Constipated patients with normal colon transit and normal anorectal function often misperceive bowel frequency and exhibit increased psychological distress. It is important to reassure these patients that there is no evidence of abnormal function of the colon or rectum. Patients should be educated to increase fluid and fiber intake, take advantage of gastrocolonic responses, and avoid excessive use of laxatives. We often screen these patients for underlying anxiety, depression or other psychological distress using a previously validated psychological symptom form, the SCL-90R. Pharmacotherapy to reduce underlying anxiety or depression may be helpful in some individuals. FIGURE 75-1. Diagnostic and treatment algorithm for severe constipation.

Bulk Forming Laxatives

Dietary fiber and bulk laxatives with adequate fluid intake are the most physiologic and safest of medical therapies. However, they may be counterproductive in patients with idiopathic slow transit constipation or with constipation associated with irritable bowel syndrome (IBS) because they often worsen bloating and abdominal distension in these populations.

Constipation in Pregnancy

Dietary modifications, such as increased fluid and fiber intake, are the most physiologic and safest approachs to constipation during pregnancy. As with all patients, pregnant women should be warned that fiber can cause abdominal bloating or flatulence and that sufficient amounts of fluid should be consumed daily. Fiber supplements should be started with small amounts and gradually increased as tolerated. Of the stimulant laxatives, senna is both safe and effective when combined with bulk-forming agents in pregnancy. Cascara is also mild and produces little or no colic. Although bisacodyl is safe for use in pregnancy, it tends to produce more colic than the anthraquinone laxatives, especially when administered orally. Agents to be avoided during pregnancy include castor oil, which can cause premature uterine contractions, and osmotic agents such as magnesium laxatives and phos-phosoda, which may produce sodium and water retention.

Outlet Dysfunction Constipation

In outlet dysfunction constipation, the primary failure is an inability to adequately evacuate contents from the rectum. This may be due to failure of coordinated relaxation of the striated muscles during attempted defecation (pelvic floor dyssynergia), weak expulsion forces due to pain or neuromuscular disorders, or misdirection of expulsion forces secondary to a large rectocele. We recommend biofeedback in conjunction with conservative therapy if pelvic floor dyssynergia is demonstrated with appropriate testing (Figure 75-1). The purpose is to train patients to relax their pelvic floor muscles during straining to achieve defecation. Biofeedback sessions are held weekly or more often until abnormal defecation efforts are achieved (approximately three to eight sessions). The rate of success for biofeedback has been reported to be 60 to 90 by some, but not all, investigators, but there have been no randomized controlled studies in adults and the experience in children has been...

Children with Constipation Colonic Hypomotility

In these children the motility of the colon is significantly reduced. The basis of the bowel management program is thus to teach the parents to clean the child's colon once a day with a suppository, an enema, or colonic irrigation. No special diet or medications are necessary in these cases. The fact that they suffer from constipation (hypomotility) is very helpful, as it guarantees that they will remain clean in between enemas. The real challenge is to find an enema that is capable of cleaning the colon completely. Definitive evidence that the colon is truly empty following the enema requires a plain abdominal radiograph. Soiling episodes or severe accidents occur when there is an incomplete cleaning of the bowel, with feces that progressively accumulates.

Slow Transit Constipation

In slow transit constipation (STC), there is a failure to move luminal contents through the proximal colon. This may be associated with dietary factors, such as severe caloric deficiency, with medications that alter motility or with certain neurologic, metabolic, and endocrine disorders. Attention to such factors may lead to improvement in colonic transit. Patients with idiopathic STC who fail to respond to conventional laxatives may have abnormalities of the enteric nerves, such as decreased volume of interstitial cells of Cajal and reduction of myenteric neural elements. We usually start with colon cleansing using enemas with or without mineral oil. If these are unsuccessful, a water-soluble contrast enema (Gastrografin or Hypaque) administered under fluoroscopy may be very effective. After this, the colon may be further evacuated with twice daily high volume enemas or by drinking PEG solution until cleansing is complete. The patient should then be maintained on a daily osmotic...

Surreptitious Use of Laxatives or Diuretics

Patients with a factitious cause frequently have large-volume diarrhea ( 1 L d). It should be remembered that this condition is not infrequent, occurring in 15 to 20 of patients referred to a referral center with chronic diarrhea. The primary treatment of these patients is having a high suspicion for the diagnosis because no clinical feature except for a history of psychiatric illness or macroscopic melanosis coli on sigmoidoscopy assists in the diagnosis. Some patients have a medical or veterinary background. Some laxatives increased the osmotic gap in the stool (magnesium), and its detection will help lead to the diagnosis (Phillips et al, 1995). However, with others, the osmotic gap is not increased, and only screening for laxatives in the stool or urine will establish the diagnosis. There is a chapter on managing patients with factitious or exaggerated illnesses (see Chapter 42, Exaggerated and Factitious Disease ).

Group C Sequelae of Constipation

Group C includes those patients referred to our institution because of fecal incontinence who actually had untreated severe constipation, chronic impaction, and therefore suffered from overflow pseudoincontinence. All of these patients have several factors in common. All were born with a malformation with good functional prognosis and underwent a technically correct, successful operation. Postoperatively, they all had severe constipation which was not adequately treated and developed megasigmoid and chronic fecal impac-tion. Adequate treatment of their constipation, with or without a sigmoid resection 25 , rendered them fecally continent (see Chaps. 29, 30 and 32 . Constipation is the most common functional disorder observed in patients who undergo posterior sagittal anorectoplasty 1 . Interestingly the incidence of constipation is inversely related to the frequency of voluntary bowel movements. This means that patients with the best prognosis for bowel control have the highest...


For patients with IBS and constipation, the addition of supplemental fiber may help to normalize bowel movements and alleviate related symptoms, such as tenesmus, dyschezia, and abdominal pain. There are numerous fiber supplements available over the counter the decision regarding which one to choose depends primarily on the patient's preference (ie, liquid, capsule, or wafer). It is important to instruct the patient to consume adequate amounts of water with the fiber to avoid potential side effects. If additional therapy is required, osmotic laxatives can be used safely and indefinitely. These include nonabsorbable carbohydrates (lactulose and sorbitol), milk of magnesia, magnesium citrate, or a polyethylene glycol solution (Miralax) (Table 39-3). There is a separate chapter on constipation. A more global approach to patients with the IBS and constipation utilizes the 5-HT4 agonist tegaserod (Zelnorm). Tegaserod is approved for the treatment of women with IBS whose primary bowel...


Many different laxatives exist and different groups have different effects. Laxatives should not be given indiscriminately, but only after consultation with a doctor and for short periods of time. They do speed up the passage of food through the bowel and result in defecation. If they are the only form of therapy Table 30.1 Desirable and undesirable food in the treatment of chronic constipation Table 30.1 Desirable and undesirable food in the treatment of chronic constipation used without any corresponding change in diet or lifestyle, they will not be effective in the long term. Inappropriate use may result in complications such as fluid imbalance, loss of electrolytes, and disturbances of the acid-base metabolism. If laxatives are taken to supplement the altered diet and lifestyle, they should not be stopped abruptly, but gradually phased out.

Stimulant Laxatives

Stimulant laxatives, such as anthraquinone compounds, diphenylmethane derivatives and may be considered in patients who fail to respond to or are intolerant of bulk or osmotic agents. These agents alter intestinal electrolyte transport and increase intestinal motor activity. They may be used intermittently or chronically when patients fail to respond adequately to bulk or osmotic laxatives. Some physicians recommend that they be taken for no longer than several weeks. However, there is no convincing evidence that chronic use of stimulant laxatives causes damage to enteric nerves or intestinal smooth muscles nor are they associated with colorectal or other cancers. Stimulant laxatives often cause superficial damage to surface epithelial cells, but this is of no functional significance and is reversible when laxatives are discontinued. A reasonable regimen is to use stimulant laxatives when no spontaneous bowel movement occurs after 48 or 72 hours. They may be used alone or combined...

Osmotic Laxatives

PEG solutions, with or without electrolytes, have been used to treat chronic constipation. A powdered form that does not contain electrolytes (MiraLax) is more palatable and may be mixed with any fluid. The amount taken daily is adjusted based on clinical response. As colonic bacteria do not hydrolyze PEG, abdominal bloating or flatulence are not as problematic as with fiber or poorly absorbed sugars. This agent is costly and, as with lactulose and sorbitol, available by prescription only.

Problemsspecial considerations

The main risk of ectopic pregnancy is sudden severe haemorrhage, which may be intra-abdominal and thus concealed until rapid decompensation and collapse occur. A common theme in deaths associated with ectopic pregnancy is the failure to consider the diagnosis before collapse. Ectopic pregnancy may present with non-specific abdominal signs including diarrhoea or constipation, thus mimicking other intra-abdominal conditions (e.g. appendicitis), although with serial measurement of plasma human chorionic gonadotrophin (hCG doubles every 2-3 days in normal pregnancy) and use of pelvic ultrasonography this should be unusual. The potential severity of the condition is not always appreciated by other hospital staff, the patient herself or her relatives. Ectopics outside the Fallopian tubes are more likely to be associated with massive haemorrhage, with abdominal pregnancies the most hazardous, especially when the placenta is removed.

Aetiological Classification

CS was first described as the triad of ARM, hemisa-crum and presacral mass 23 . The radiological aspect of the sacrum described by Currarino is the so-called sickle-shaped sacrum , which is caused by the presence of a hemisacrum with preservation of the first sacral vertebra. This finding is pathognomonic for the diagnosis CS 103 . According to Cama 16 , classification of sacral anomalies presents (1) total sacral agenesis with normal or short transverse pelvic diameter, and the defect extending to include some lumbar vertebrae, (2) total sacral agenesis with intact lumbar vertebrae, (3) partial agenesis or hypodevel-oped sacrum (preserved S1), (4) hemisacrum and (5) coccygeal agenesis. Following this classification, CS has been characterised as a type 4 sacral anomaly. Different forms of ARM can be present in CS, such as rectourethral fistula, rectovestibular fistula and rectocloacal fistula 73 . It is estimated that 29 of ARM are associated with sacral anomalies 97 . The most...

In the Twentieth Century

Distal Colostogram

Clear that different subjective criteria for grading and definitions used by various authors to assess function would make it difficult to compare results. The various studies often focused on the area specifically of interest to the surgeon who advocated the procedure. Comments like excellent, good, fair, and poor characterized the studies, and continence was assessed according to whether one was evaluating puborectalis function or other sphincter activity. Sphincter tone was frequently not mentioned. How motility was evaluated was often in question. Kelly used a scoring system with 6 as a maximum score 77 . Terms like colonic inertia appeared to address the failures and severe constipation that followed the procedure 15, 163 . In 1977, Kiesewetter noted an improvement over time from poor to good in low anomalies and from poor to fair in high anomalies, and that switching from an AP approach to an abdominosacroperi-neal or sacroperineal approach did not improve function 34 . The same...

Preparing for the Examination

Thorough bowel cleansing is essential for a sufficient endoscopic examination of the colon. The development in 1990 of a nonabsorbable electrolyte solution (polyethylene glycol, PEG) by Fordtran was a significant improvement over earlier laxatives using sodium sulfate and modified forms are still in use today. But, due to the large quantity of liquid that must be consumed (up to 4 L) and the salty taste, these solutions are not tolerated by all patients. Their effectiveness has, however, been verified by numerous studies data on sodium phosphate solutions (e.g., Fleet) and whether these are an improvement in terms of cleanliness and patient acceptability are less conclusive (8). Though they may appear to be a viable alternative for some patients, caution should be exercised if the patient has kidney insufficiency given the high phosphate content.

Preoperative abnormalities

The clinical manifestations of primary, chronic autonomic failure include the following features orthostatic hypotension, anhydrosis, heat intolerance, constipation, dysphagia, nocturia, frequency, urgency, incontinence, retention of urine, erectile or ejaculatory failure, Horner's syndrome, stridor, apnoea, Parkinson's disease, cerebellar and pyramidal features (Mathias 1997). Erythropoietin depletion may cause anaemia, particularly in diabetic neuropathy (Watkins 1998).

Clinical Manifestation

The onset ranges from insidious to abrupt. The syndrome is characterized by a history of constipation (defined as three or more days without bowel movement) followed by a subacute progression of bulbar and extremity weakness (within four to five days) manifest in inability to suck and swallow, weakened voice, ptosis, hypotonia, that may progress to generalized flaccidity and respiratory compromise. There is, however, a broad clinical spectrum of IB. The mild end of the spectrum appears to be represented by infants who never require hospitalization but who have feeding difficulties, mild hypotonia, and floppy neck, and failure to thrive, while the severe end of the spectrum may be characterized by a presentation resembling sudden infant death syndrome (SIDS) (26), and these patients require hospitalization for treatment of their respiratory and feeding difficulties. The main clinical feature of the syndrome is constipation which occurs in about 95 of patients (16,27). Botulism is...

Abdominal Rectal Prolapse Repair

Most authors advocate complete posterior mobilization of the rectum to the coccyx, and some recommend partial anterior mobilization as well. The extent of lateral mobilization has been debated and there is little data reported in the literature. It has been found in patients undergoing posterior mesh rectopexy for prolapse that division of lateral ligaments may contribute to the development of onset constipation. A marked increase of constipation has been found in patients who had undergone Wells rectopexy with division of lateral ligaments, when they were compared

Signs symptoms diagnosis and investigations

In patients with cancer, compression of the bowel lumen develops slowly and often remains partial. As a consequence of the partial or complete occlusion to the lumen and or dysmotility, the accumulation of the unabsorbed secretions produces nausea, vomiting, intermittent or complete constipation, pain, and colicky activity to surmount the obstacle that causes colicky pain. Abdominal distension may be absent in high obstruction that is, of the duodenum or proximal jejunum and when the bowel is plastered down by extensive mesenteric spread.

Long Term Bowel Function During Childhood

Traditionally, the long-term results of low malformations are considered to be good in the great majority of patients (Table 28.1) 4,17,31,32,55 . The poor results have been considered to be related to neurological damage and mental retardation 56 or insufficient long-term care of the patients 3,32 . Recently, more critical and comprehensive analyses have demonstrated clearly a significant number of patients with functional aberrations, especially chronic constipation (Table 28.1). In the series of Yeung and Kiely 23 , 15 of 32 children with a follow-up between 1 and 7 years had normal bowel function. Of the remaining 17 patients, all had constipation and 9 occasional or frequent soiling requiring treatment. Rintala et al. 57 used a scoring system to compare the bowel function of 40 children with low anomalies with that of healthy children. Only 52 of their patients had scores within the range of healthy children constipation was found in 42 and soiling in 10 of the patients. Ong and...

Functional Outcome After Rectal Prolapse Surgery

The frequency of postoperative constipation varies greatly between studies. Some studies report increased incidence (Graf et al, 1996 Aitola et al, 1999), whereas others report an unchanged (Tjandra et al, 1993), or decreased (Roberts et al, 1988 Winde et al, 1993) incidence. Possible reasons for postoperative constipation include colonic den-ervation, rectal denervation by division of the lateral ligaments, or a redundant sigmoid that may contribute to rectosigmoid kinking.

Onki CheungMD and Arnold WaldMD

Constipation is one of the most common digestive complaints in the general population. Over 2.5 million people consult a physician and hundreds of millions of dollars are spent on laxatives each year. Although constipation is often defined as a frequency of defecation twice weekly or less, constipated patients may complain of excessive straining with defecation, passage of hard or small stools, difficulty TABLE 75-1. Laxatives Used in the Treatment of Constipation TABLE 75-1. Laxatives Used in the Treatment of Constipation Laxatives *Bulk-forming laxatives Bran Saline laxatives Magnesium sulfate Magnesium citrate *Stimulant laxatives (oral) Senna Cascara Bisacodyl *In each category, laxatives are listed with the most preferred at the top and least preferred at *In each category, laxatives are listed with the most preferred at the top and least preferred at initiating evacuation, or a feeling of incomplete evacuation. Physicians should therefore not rely only on the criteria of...

Hirschsprungs Disease

The coincidence of HD and ARM is not easily determined. In the aforementioned extensive series of lesions associated with ARM, the incidence of classically proven HD was thought to be very low 9 . Hy-poganglionosis of the terminal gut has been observed in cases of ARM where it was felt to be a result of the etiologic factors producing the ARM rather than due to a de novo failure of ganglion cell migration 13,14 . It has been suggested that the terminal bowel in cases of high ARM be biopsied and that the aganglionic or hypoganglionic segments be resected during the pull-through 15 , but most surgeons now feel that the association between HD and ARM is sufficiently rare that biopsy sampling is unnecessary. Constipation following repair of an ARM is unlikely to be due to HD and can be managed by ensuring patency of the anus and attention to dietary factors. More recently, the subject of NID and the occurrence of classical HD in the presence of low ARM have entered the complex picture of...

GI Complications Starvation

Gastric emptying of solids, and possibly of liquids, is delayed in patients with AN (Dubois et al, 1979 Ricci and McCallum, 1988). This phenomenon presumably contributes to complaints of early satiety and fullness and may normalize more slowly than other markers of starvation, such as bradycardia and hypotension. Transaminase elevations are not uncommon in starved anorectic patients and often worsen transiently with refeeding. Compared with controls, patients are more likely to suffer from constipation and to demonstrate delayed whole gut and colonic transit times (Chun et al, 1997 Kamal et al, 1991).As with other eating disorder-related GI problems, slowed transit times resolve with weight restoration.

Core Characteristics Of The Disease

The extrapyramidal features appear similar to those in PD, including bradykinesia with rigidity, postural instability, hypokinetic speech, and occasionally tremor, usually with a poor or unsustained response to chronic levodopa therapy. The signs of cerebellar dysfunction include disorders of extraocular movements, ataxic speech, and ataxia of limb movements and gait resulting in postural instability and frequent falls. Autonomic insufficiency results in orthostatic hypotension, urinary retention or incontinence, and impotence, often accompanied by constipation and decreased sweating. Parkinsonian, cerebellar, and autonomic features often occur in combination in MSA, but one or, in some patients, two features may predominate.

Functional Problems During the First Years of Life

Constipation is a major problem with patients who have had PSARP or anal transposition for rectoves-tibular fistula 2,8,11,21 . Constipation may develop secondary to untreated anal stenosis, but more commonly is a consequence of disordered colonic motility 8,22 . Constipation may begin early after the operation, and its severity is related to the degree of the initial dilatation of the rectal blind pouch 8,21 . Constipation is also the most common early functional problem in patients with low anomalies 2,23 . Severe soiling with low anomalies is rare and is caused by operative sphincter damage or severe sacral defects.

Hydroxytryptamine Agonists

Tegaserod (Zelnorm) (Novartis Pharmaceutical Company) is the most recently approved prokinetic agent. It has recently been FDA-approved for treatment of women with constipation-predominant irritable bowel syndrome (IBS). It is a partial and selective 5-HT4 receptor agonist that possesses GI stimulatory effects from the esophagus to the rectum. Animal and human studies have shown stimulatory motor effects throughout the digestive tract, and it has been shown by Prather and colleagues (2000) to accelerate orocecal transit in patients with IBS. There are data showing improved gastric emptying times in patients with gastroparesis and clinical trials in this subgroup of patients are ongoing. Dosing is recommended as 6 mg po twice daily but in our experience dosing up to 4 times daily is well tolerated without loose stools. We will especially consider introducing this therapy for patients who complain of constipation in addition to their symptoms of gas-troparesis. Tegaserod does not have...

Therapeutic principles of management

For most patients the management of cachexia requires insight and enthusiasm from the physician, surgeon, general practitioner, nurse specialist, and dietician with whom the patient may come into contact. Cachexia is a chronic problem for which there is no quick fix and which requires repeated reevaluation as the clinical condition of the patient changes. Once signs of cachexia are evident patients generally have two to six months to live. Early recognition and prophylactic measures are better than trying to reverse an advanced situation. Good clinical judgment is paramount to identify all reversible factors that may be contributing to the patient's wasting syndrome. In particular, if nausea and vomiting can be controlled with regular antiemetics (or surgery if there is a defined mechanical obstruction), malabsorption treated with enzyme supplements, constipation treated with laxatives, pain well controlled with the minimum of sedation, and depression treated with antidepressants then...

Anorectal Physiology in Health and with Inflammation

The complex physiology of the anorectum is adversely influenced by inflammation with increased sensitivity to sensation and an amplification of muscular responses stimulated by stool in the rectum. Tenesmus is the sensation of incomplete evacuation of the rectum or nonproductive straining to defecate. It occurs when rectal contraction is accompanied by internal anal sphincter relaxation. In the presence of inflammation, there is sensitivity to lower than normal volumes of balloon distention and exaggerated relaxation of the internal anal sphincter (IAS). The sensations accompanying this response are perceived rectal fullness, urgency to defecate and a sense of incomplete evacuation. Occasionally, tenesmus continues when visible inflammation is no longer present. When this occurs, treatment for microscopic inflammation or pharmacologic manipulation of rectal contractility and IAS relaxation improves these symptoms. In addition to the influence of rectal inflammation on anorectal...

Citrus aurantium L Fam Rutaceae

For abdominal distension and pain, constipation, belching with a fetid odor due to stagnation of undigested food, it is used with Fructus Crataegi (Shan Zha) and Fructus Hordei Germinatus (Mai Ya). For constipation and abdominal distension due to accumulation of Heat, it is used with Cortex Magnoliae Officinalis (Hou Po) and Radix et Rhizoma Rhei (Da Huang). For abdominal distension after meals caused by Spleen Deficiency, it is used with Rhizoma Atractylodis Macrocephalae (Bai Zhu). For diarrhea with tenesmus due to the accumulation of Damp Heat, it is used with Radix et Rhizoma Rhei (Da Huang), Rhizoma Coptidis (Huang Lian), and Radix Scutellariae (Huang Qin) in The Pills of Aurantii Immaturus for Removing Stagnancy (Zhi Shi Dao Zhi Wan).

Opioid receptor antagonists

Activation of peripheral m-opioid receptors present in the enteric nervous system increases tone and phasic contractility leading to compromised motility throughout the GI tract. Opioid-induced bowel dysfunction is a condition for which no adequate treatment is currently available and, moreover, activation of opioid receptors might be a contributory factor to the development of post-operative ileus (POI). A peripheralized opioid receptor antagonist, which does not interfere with analgesia represents a possible treatment for these conditions. Methylnaltrexone 11 is a quaternary analogue of the m-opioid antagonist naltrexone, which does not cross the blood-brain barrier and has limited oral absorption. After parenteral administration, methylnaltrexone reversed motility impairments caused by opioids in healthy volunteers and chronic methadone users 30 . The compound is presently in clinical development for various conditions associated with opioid-induced constipation. Alvimopan 12 is a...

Preoperative Evaluation

The patient history should include preoperative constipation and incontinence symptoms, bowel frequency, obstetric history, and other associated pelvic floor disorders, such as co-existing urinary incontinence or genital prolapse. Patients with rectal prolapse are at an increased risk for other concomitant pelvic floor abnormalities.

The Acute Porphyrias Diagnosis

Several signs and symptoms may occur during an acute porphyric attack, reflecting widespread involvement of the nervous system. The most frequent is abdominal pain which is caused by an autonomic neuropathy. Other features of autonomic neuropathy are tachycardia, hypertension, constipation, and urinary retention. Peripheral neuropathy may develop as the attack progresses and can lead to paralysis in its most severe form. Central nervous system manifestations include organic brain syndrome, depression, and seizures.

Phenotypic Features of MEN Type IIB

MEN type IIB patients can also develop ganglioneuromas of the intestine in the submucosal and myenteric plexus. Intestinal dysfunction from ganglioneuromatosis may manifest early in life with poor feeding, failure to thrive, constipation, or pseudo-obstruction. Adults with this disorder may have dysphagia from esophageal dysmotility. Rarely, a patient can present with toxic megacolon. Neonates and infants with severe intestinal gan-glioneuromatosis have a clinical course similar to that of Hirschsprung's disease.

Diabetic autonomic neuropathy

Atic DPN can vary from mild to severe. Cardiac symptoms include fixed tachycardia, orthostatic postprandial hypotension, arrhythmias, and in severe cases, sudden cardiac death. Gastrointestinal symptoms include constipation, nightime diarrhea and gastroparesis with early satiety, nausea and vomiting. Genitourinary symptoms are common in men, with impotence present in nearly all males after 25 years of diabetes. Urinary retention occurs in men and women. Abnormal pupillary responses and abnormal sweating occurs, with anhydrosis of the feet and hands, and gustatory sweating in more severe cases. Abnormal neuroendocrine responses likely contribute to hypoglycemic un-awareness in type 1 patients.

Hospitals And Clinical Medicine

Some doctors were known for the huge fortunes they had acquired, whereas a few were remembered for establishing hospitals and charitable clinics. Most experts in medical ethics argued that it was appropriate to charge fees for treating the sick. The physician needed to earn enough to marry and educate his children, without having to engage in work that would interfere with the study of science. Thus, it was important for the rich to pay large fees so that the doctor could care for the poor without charge. Dressed in his white shirt and cloak, distinctive doctor's turban, carrying a silver-headed stick, perfumed with rose-water, camphor, and sandalwood, the physician was an impressive figure. However, despite the honors accorded to scholar-physicians, skepticism about medical practitioners remained strong. In many popular stories, the Devil appears disguised as a physician, or the physician kills his patient through ignorance or treachery. In one such story, a physician murdered his...

Disease Activity Assessment

Pregnant women by nature may have intermittent abdominal discomfort from the enlarging gravid uterus, preexisting fibroids, changing bowel habits particularly constipation, bladder compression and gastroesophageal reflux. Other more serious causes of accelerating abdominal pain include cholelithiasis or choledocholithiasis, sphincter of oddi dysfunction, intra-abdominal or retroperitoneal abscess, and toxemia of pregnancy.

Embryogenesis of Primary Rectal Ectasia

In 1984, Upadhyaya suggested a similar cause of mid-anal sphincteric defect as the possible cause of constipation in anterior perineal anus 22 . It may also be possible that not much attention has been given to this entity so far and many more cases may be diagnosed in future. This possible cause also explains the clinically and radiologically evident posterior rectal shelf in a few cases of primary rectal ectasia.

Symptoms of Pheochromocytoma

Moregulatory, dissipating heat that was acquired during prolonged vasoconstriction during a paroxysm. Constipation is common, and toxic megacolon has rarely occurred. Many patients have visual changes during acute attacks. Paroxysms usually begin abruptly and subside slowly. The episodes may not recur for months or may recur many times daily. Each patient tends to have a particular pattern of symptoms, with the frequency or severity of episodes usually increasing over time. Attacks can occur without provocation or may occur with certain activities, such as bending, rolling over in bed, exertion, abdominal palpation, or micturition (with bladder paragangliomas). The interindividual variability in manifestations is striking most patients have dramatic symptoms, but others with incidentally discovered secretory pheochromocytomas are completely asymptomatic. Patients who develop pheochromocytomas as part of multiple endocrine neoplasia (MEN) type II are especially prone to be normotensive...

Neuroendocrine Tumors of the Rectum

Approximatively 50 of patients with rectal tumors are asymptomatic. Other patients mainly present with rectal bleeding, constipation, rectal syndrome, or rectal pain. Carcinoid syndrome is very rare because it is very unusual for the tumors to release serotonin into the circulation, despite their capacity to synthesize this amine. About 75 of the lesions are within 8 cm of the anal verge and are possible to reach with digital palpation. Luckily, only about 14 of patients with rectal carcinoids present with metastasis. Local excision or transanal resection is recommended for tumors measuring 1 cm in diameter because these tumors are at low risk for recurrence or metastasis ( 2 ). For tumors between 1 and 2 cm in size (10 of cases) without evidence of lymph node metastasis, wide excision with a meticulous evaluation to exclude muscular invasion is usually recommended. Transanal endosonography may be particularly useful in this intermediate group to assess tumor extension. In doubtful...

Clinical Presentations Diarrhea

Chronic GVHD affects 40 to 50 of SCT patients, occurring most often in those who have had acute GVHD, but can arise de novo. In contrast to acute GVHD, which is typified by mucosal injury in the gut, chronic GVHD in the gut is characterized by the presence of fibrosis and atrophy, leading to GI dysmotility syndromes such as gastropare-sis or constipation. Bacterial overgrowth may complicate small bowel dysmotility. Chronic GVHD usually does not induce inflammatory changes in the mucosa, making mucosal biopsies seldom useful in making the diagnosis. However, upper endoscopy or colonoscopy is sometimes performed to evaluate for other causes of gastric outlet obstruction, diarrhea, or new onset constipation.

Stephens Secondary Pull Through [12

In all patients who need a sacroperineal or sacroab-dominoperineal reexploration and levator repair, magnetic resonance imaging (MRI) and a cinedefe-cography should be performed before the secondary repair. Prior to intended repair, defecography indicates whether there is complete or partial loss of ano-rectal angulation and movement so that the incontinence is indeed due to muscle inaction rather than to some simply correctable factor such as constipation.

Neurophysiological Techniques

Also helps to identify patients in whom incontinence may develop or worsen following surgery. Anal sphincter EMG is generally better tolerated, and yields identical results (50). In at least 80 of patients with MSA, EMG of the external anal sphincter reveals signs of neuronal degeneration in Onuf's nucleus with spontaneous activity and increased polyphasia (103-105). However, these findings do not reliably differentiate between MSA and other forms of APD. An abnormal anal sphincter examination was present in 5 of 12 (41.6 ) PSP patients (106). Furthermore, neurogenic changes of external anal sphincter muscle have also been demonstrated in advanced stages of PD by several investigators (107,108). Also chronic constipation, previous pelvic surgery, or vaginal deliveries can be confounding factors to induce nonspecific abnormalities (109). In summary, in patients with probable MSA, abnormal sphincter EMG, as compared to control subjects, has been found in the vast majority of patients,...

Pharmacologic Therapy of Chronic Pain

Patients with functional constipation as they can increase bowel movements and even cause diarrhea. However, they have been less well evaluated in the management of pain per se than TCAs at the present time, the literature suggests the efficacy of these agents for chronic pain is equivocal at best. Newer antidepressants the serotonin norepinephrine reuptake inhibitors such as venlafaxine (Effexor) hold more promise in this regard but have not been subjected to extensive testing in this setting. An older agent in the same class, trazadone (Desyrel), has been used with good effect in patients with noncardiac chest pain although it does not have the usual side effects of the TCAs, it is more sedating and can cause priapism in males.

Interventions Aimed at the Removal of the Pruritugens

Based on the assumption that the pruritogen(s) is excreted in bile, cholestyramine powder (4 g dose) mixed with some fluid can be prescribed right before and after breakfast to take advantage of the pouring of the gall bladder contents into the small bowel after breaking the overnight fast. When the first 2 doses are not associated with relief of pruritus, the dosage can be increased by adding 4 g at lunch and at dinnertime. It is recommended that 16 g per day not be exceeded. The most common side effects of resin treatment are bloating and constipation. Malabsorption of fat-soluble vitamins, a complication of cholestasis (see below), may arise or may be worsened by resin treatment accordingly, follow up of the prothrom-bin time (PT) and serum concentration of fat-soluble vitamins is prudent while these resins are prescribed for chronic use. Patients who take medications need to space out their intake at least 2 hours from the dose of the resin to assure drug absorption. Well-informed...

Management And Prognosis

Maintenance of adequate nutrition and hydration is of outmost importance. Parenteral nutrition is usually required because of the likely length of the disease and the undesirability of oral or nasogastric feedings. Adequate nutritional support can minimize weight loss, maintain electrolyte balance, and improve management of arrhythmias. Attention must be paid to skin care, and excretory functions must be monitored closely for urinary retention or serious constipation. Patients must be immunized with tetanus toxoid to prevent further disease. Tracheostomy may be required to prevent laryngospasm, which greatly increases the mortality rate of the disease.

Benefits Versus Toxicity And Risks Of Therapy

Chemotherapy can be divided into those of the CMF-like regimens and those of the doxoru-bicin regimens. All chemotherapies used as adjuvant treatment cause significant myelosup-pression, with leukopenia generally clinically more significant than anemia or thrombocy-topenia. In the NSABP trials of classic CMF x 6, the incidence of neutropenia less than 2,000 was 10 percent and severe infection about 1 percent.21 With AC x 4, it is 4 percent severe neutropenia and 2 percent severe infec-tion.21 With 6 months of CAF, the risk of leukopenia and infection is higher. Thrombocy-topenia is seen in less than 1 percent of patients in most regimens.21 Doxorubicin-containing regimens are more emetogenic than CMF however, the incidence of severe vomiting is rapidly dropping with the introduction of serotonin antagonists. Alopecia is nearly universal with doxorubicin and is seen in about 40 percent of CMF patients.21 Diarrhea is rarely seen with either regimens the use of serotonin antagonist...

Dynamic Graciloplasty

Unfortunately many complications with this new technique have also been reported. Da Silva et al. 45 compared 2 groups of patients, 11 had an artificial bowel sphincter and 5 had the gracilis neosphincter. Complications occurred in six patients (50 ), including three with fecal impaction (all artificial sphincter), three with device migration (two gracilis neosphincter, one artificial bowel sphincter), and in two patients with concomitant wound infection (one gracilis, one artificial sphincter). None of the patients had the device explanted. The quality of life scales increased with both the artificial and the gracilis sphincter.

Management of Diabetic Diarrhea Clinical Examination and Routine Tests

Incontinence should be sought in history. Oral medications used for glycemic control, such as metformin (Avandemet) and acarbose (Precose), are often associated with bloating, diarrhea, and other gastrointestinal side effects. Other medications may cause diarrhea, including laxatives and proki-netics. The clinical examination should include a thorough neurological evaluation, with the search for signs suggesting autonomic neuropathy (such as orthostatic hypotension, lack of pupillary response to light, response of pulse and blood pressure to the Valsalva maneuver and absence of sweating), or malabsorption, such as anemia, edema, and clubbing.

Information Sources About CAM

There are a variety of valuable information sources available for physicians, although none of them are specifically focused on GI disease. Patients should not rely too heavily on the advice or recommendations provided by employees of health food stores or other stores selling herbal and nutritional supplements (Verhoef et al, 2002). Often only the owner or the manager of the store has much experience and knowledge about the therapies. Other employees may have relatively little training and may not be able to distinguish between treatments that are safe and appropriate for a given condition and those more commonly used for other GI complaints. General intestinal remedies sold at health food stores often contain laxatives.

Fathia GibrilMD and Robert T JensenMD

In this chapter, treatment of SD is briefly reviewed. Not discussed are diarrheal diseases with a secretory component included in other chapters in this volume, including (1) infectious diarrheas, (2) diarrheas owing to bile salts or fatty acids, and (3) diarrhea owing to inflammatory diseases such as inflammatory bowel disease. This chapter focuses on the treatment of the remaining causes of SD, including those owing to hormone-related diarrhea, surreptitious use of laxatives, and SD of unknown origin.The hormone-related diarrheas include vasoactive intestinal secreting tumors (VIPomas), gastrinomas causing ZollingerEllison syndrome, glucagonomas, somatostatinomas, medullary thyroid cancer, and systemic mastocytosis.

Clinical Presentation Diagnosis

Foot Malformations

Closed spinal dysraphism reveals itself through skin abnormalities in 50 to more than 80 of cases 1518 . In the context of ARM, vascular nevus, lumbo-sacral subcutaneous mass, skin dimple and deviation of the natal cleft should be searched for. The manifestations of tethered cord have rightfully been called protean by Hoffman and coworkers in 1976 19 . Presenting symptoms may include motor and sensory deficits in the lower extremities, gluteal and genital region, leg or back pain (especially in older children and adults), foot deformities, leg length discrepancies and scoliosis (neuro-orthopaedic syndrome) or bladder and bowel dysfunction (Fig. 18.1). The majority of our patients had abnormal findings in one or several of these aspects (27 35), but only a minority (6 35) presented with clear-cut progressive symptoms. Most authors agree, that faecal incontinence and urinary abnormalities are more common in patients with tethered cord 2,5,20 , whereas constipation is more common in ARM...

Rectourethral Fistulas

Rectourethral Fistula Bulbar

The bands that are divided around the rectum are actually vessels and nerves. One would think that this denervation would provoke dysmotility, which leads to the problem of constipation in these patients. Thus, patients with higher malformations (which require more dissection) would be expected to suffer from more severe constipation. However, the opposite is true in that patients with lower defects suffer more severe constipation than patients with higher defects 10 . The explanation for the observed dysmotility remains elusive 12 .

Vacterl Syndrome Life Expectancy

Vacterl Syndrome Life Expectancy

Anorectal malformations (ARM) and cloacal anomalies are rare and complex malformations of the lower gastrointestinal and genitourinary tract. They affect approximately 1 3,500-1 5,000 live births 1 . They may occur in isolation or in association with abnormalities of the urogenital, cardiovascular and skeletal systems as well as with the vertebral, anal, cardiac, tracheoesophageal, renal and limb abnormalities (VACTERL) association. Treatment has traditionally focussed on achieving urinary and faecal continence with preservation of renal function. Diversion of the bowel may be required. It will often be possible to create a continent bladder, though emptying may require intermittent catheterisation. A continent rectum is more difficult and many children remain clean only by a process of controlled constipation or continue with a colostomy 2 . Faecal continence remains a challenge and is achieved in about 60 of patients.

Chronic Pancreatitis And Urinary Retention

Fistulotomy Wound

Complications include urinary retention, urinary tract infection, bleeding, anal stenosis, incontinence, fecal impaction, infection, and fistula formation. Local infection and fistula formation are quite uncommon, easily recognized, and generally treated in the office with drainage or superficial fistulotomy. Urinary retention is generally secondary to both local pain and the amount of intravenous fluids received intraoperatively. Rates up to 17 have been reported (25), but the incidence can be minimized by limiting intraoperative fluids to less than 300 cm3. Bleeding can be immediate, i.e., in the recovery room, or delayed, at between 7-16 d postoperatively (25). If hemodynamically significant, this must be addressed in an operating room with suture ligation or cautery. Anal stenosis and incontinence are both the result of overzealous excision-stenosis from the failure to preserve native tissue between excision sites and incontinence from excision of sphincter muscle fibers with the...

Postoperative Management and Colostomy Closure

After the colostomy is closed, the patient usually has multiple bowel movements and may develop per-ineal excoriation. A constipating diet may be helpful in the treatment of this problem. After several weeks, the number of bowel movements decreases and most patients then start to have constipation. After 3 months, the patient develops a more regular bowel movement pattern. A patient who has one to three bowel movements per day, remains clean between bowel movements, and shows evidence of a feeling or pushing during bowel movements, has a good bowel movement pattern and is usually able to potty train. A

Prokinetic Agent Target Classes 21 Dopamine D2 receptor antagonists

Fosita Pilonidal

Prucalopride 5 is a selective 5-HT4 agonist which when dosed once daily for 4 weeks showed significant improvements compared to placebo in stool softening, decreased straining and time to first stool in patients with chronic constipation, who were refractory to laxatives. However, further development of this compound is on hold due to carcinogenicity issues 12 . Tegaserod 6 is a 5-HT4 receptor agonist which has been approved by the FDA for IBS-C and chronic idiopathic constipation and is marketed in the US and elsewhere. Tegaserod is rapidly absorbed in man and shows linear pharmacokinet-ics in a 2-12 mg oral dose range, with no significant differences found between healthy volunteers, young or elderly IBS patients 13 . In clinical phase III studies for IBS-C conducted in predominantly female patients, tegaserod b.i.d. at 6mg for 12 weeks compared to placebo demonstrated significant improvements in self-reported symptom scores including abdominal pain, bloating and bowel function....

Clinical Features


The most common symptom is refractory constipation, either primarily or persistent after successful reconstructive surgery for a known ARM. Rectal ectasia predisposes to ampullary overloading and constipation. Patients usually present after 6 months of age, the most common period being around 1-3 years. On per rectal examination, ballooning of the posterior rectal shelf may be found, in which the finger in the rectum can be brought very close to the perineum with very little intervening tissue. Typically, the child presents with chronic constipation, straining at stool, and only able to pass small amounts of hard fecal matter by rubbing the bottom against the floor toilet seat.

Intrinsic Malformations of the Anorectum

Absent Ganglion Cells

These data suggest that anomalies of the intramural nerve plexus are less important for chronic constipation than is malformation or damage to the extramural cholinergic nerve fibers. In addition, biopsy samples of the rectal wall in 25 patients with severe postoperative constipation investigated by Holschneider et al. revealed no correlation between histomorphological findings and the clinical symptoms. Only four out of nine patients with agan-glionosis and two out of eight children with hypogan-glionosis suffered from severe chronic constipation. However, all patients without histological abnormalities showed normal bowel evacuations 7,13 . Therefore, aganglionosis, hypoganglionosis, and IND of the most distal part of the rectal pouch and in the fistula may represent a normal situation.

Interventional techniques in gynaecological malignancy

Superior Hypogastric Plexus Block

Where standard routes of analgesic administration have failed, the epidural route using a percutaneous epidural catheter can provide optimal analgesia. The benefits of opioid administration by the spinal route have been acknowledged for some time and there is clear evidence that some patients find epidural analgesia of a higher quality with a diminished incidence of unwanted side effects such as nausea, drowsiness and constipation. Epidural catheters can be inserted percutaneously and brought out through the skin or attached to a number of subcutaneous administration devices (Figure 2). Subcutaneous pumps have been used to facilitate epidural and spinal analgesia, as have subcutaneous ports through which opiates can be given on a daily or more frequent basis.

The Holschneider Score

Nor the current score systems are suitable for comparative postoperative studies. The authors suggested renouncing the assessment of fecal continence, taking chronic constipation into account. With regard to three subgroups, the types of partial continence, but not the degrees of continence, are differentiated. The authors used their score in 78 patients and postulated that with regard to therapeutic conclusions, the results were more evident and more correct as compared to other scores.

Vomiting Laxative and Diuretic Abuse

GI complaints associated with the abuse of laxatives, particularly the stimulant laxatives, such as bisacodyl and phe-nolphthalein, and the anthracene derivatives (senna, cascara, danthron), include nonspecific complaints such as constipation, diarrhea, abdominal cramping or pain, nausea and vomiting, and distention and bloating. Other sequelae of laxative abuse include steatorrhea, protein-losing enteropathy, osteomalacia and melanosis coli. Rectal prolapse secondary to severe laxative abuse can also be seen in eating disorder patients.

Determination of the Laxative Requirement in a Disimpacted Patient

Once the patient has been disimpacted, an arbitrary amount of laxative is started, usually a senna derivative. The initial amount is based on the information that the parents give about the previous response to laxatives, and the subjective evaluation of the megasig-moid on the contrast enema. The empiric dose is given and the patient is observed for the next 24 h. If the patient does not have a bowel movement in the 24 hours after giving the laxative, it means the laxative dose was not enough, and it must be increased. An enema is also required in order to remove the stool produced during the previous 24 h. Stool in these extremely constipated patients should never remain in the rectosigmoid for more than 24 h. The routine of increasing the amount of laxatives and giving an enema, if needed, is continued every night until the child has a voluntary bowel movement and empties the colon completely. The day that the patient has a bowel movement (which is usually with diarrhea), a...

Womans Nature And Women Doctors

Acute ovaritis, prolapsus uteri, anemia, constipation, headaches, hysteria, neuralgia, and other horrors. The ''intellectual force'' expended by girls studying Latin or mathematics destroyed significant numbers of brain cells in addition to decreasing fertility. Educated women who escaped sterility would face dangerous pregnancies and deliveries because they had smaller pelvises and their babies had bigger brains. They would be unable to nurse their own babies, because they had ''neither the organs nor nourishment requisite.'' As evidence, Clarke presented the sad case of the flat-chested Miss D., who entered Vassar at 14. By the time she graduated, she was the victim of dysmenorrhea, hysteria, nervousness, headaches, chronic invalidism, and constipation. Another unfortunate student died soon after graduation the postmortem revealed a worn-out brain. Even Martha Carey Thomas (1857-1935), founder and president of Bryn Mawr College, remembered being terrified when she read such warnings...

Qualityof Life Measurements

Quality of life is a multidimensional concept, which includes, but is not limited to, the social, physical, and psychological functioning of the individual. Validated instruments are supposed to objectively measure the domains of quality of life, and to exclude observer bias. The relevance of quality-of-life assessment in children with ARM was confirmed in an early study by Ditesheim and Templeton 4 , who used a questionnaire scoring system that included items such as school attendance, social relationships, and physical capacities. Today it is well known that children and adolescents with fecal incontinence may suffer from emotional problems, internalizing behavior problems, and depressive symptoms. Various measures of quality of life have been used for quantitative and qualitative scoring of children and adolescents with fecal incontinence and constipation. However, the results presented below are not conclusive and none of the suggested instruments has been generally accepted.

Anoderm Skin of the Anal Canal

Fecal incontinence in patients having undergone PSARP repair for ARM improves at adolescence, as constipation disappears. Continence was ameliorated in 14 out of 22 children followed up by Rintala et al. after puberty 49 . Constipation improved in 13 out of 15 patients and only 2 needed a regular enema regimen after puberty. This improvement with time is probably related to a reinforced sphincter function and an increasing use of gluteal and pelvic floor muscles, and is a manifestation of the adaptation and adjustments made by the patient himself to achieve a socially acceptable status.

Tethered Cord Surgery

Expanding intrapelvic meningocele or detection of an inclusion tumour are additional reasons for prophylactic surgery in ventral sacral meningoceles. Constipation is not an indication for surgery, at least in our experience, since we never saw improvement after untethering plus closure or removal of the me-ningocele.

Continence Function HAQL

In the outcome classification of Krickenbeck, three domains are separately evaluated voluntary bowel movement, soiling and constipation. With the data of our survey we obtain from the simplified definition of voluntary bowel movement according krickenbeck-agreement (Table 37.3), because we see inconsistency in this item. But ist was possible to operationalise the soiling domain with data from the HAQL. The constipation domain of the new Krickenbeck classification works with several assumptions. For instance, that the constipation is treated and that the order of treatment is observed (diet medication irrigation). However, some parents perform colonic irrigation as preventive therapy as well as to manage soiling. This has to be considered, if judgements with this assessment method are made.

Psychotropic Medications

When choosing an antidepressant for therapy, the side effect profile should be used to the patient's advantage. In IBS patients with diarrhea,a TCA would be more appropriate given its side effect of constipation. Conversely, an SSRIshould be chosen in IBS patients with constipation. When choosing a specific TCA, use a secondary amine with fewer overall side effects such as nortriptyline (Pamelor) instead of its precursor amitriptyline (Elavil) or desipramine (Norpramin) instead of imipramine (Tofranil). Low doses of the TCAs between 10 and 25 mg are used initially with the maximum benefit usually occurring at a dose of 50 mg d (see Table 39-1). Little data are currently available about the SSRI antidepressant medications. However, preliminary studies have suggested possible efficacy with the use of paroxetine (Paxil) (Creed et al, 2001), as well as fluoxetine (Prozac) (Kurken et al, 2002). Standard antidepressant doses of these SSRI medications may be necessary. Preliminary evidence...

Incontinence Requiring Reoperation

Essentially resulted in loss of the rectosigmoid. These patients do not suffer from constipation. Instead they suffer from increased colonic motility and a tendency to diarrhea. It took several years to recognize this specific group of patients, and today revisional surgery is not offered to them, because it is clear that they never regain bowel control. Fortunately, endorectal pull-throughs are no longer performed for ARM and it is rather unusual to see these patients.

Chronic Neuropathic Ulcer With Osteomyelitis

Osteomyelitis Foot

A 46-year-old male patient with type 1 diabetes diagnosed at the age of 27 years was referred to the outpatient diabetes foot clinic because of a chronic ulcer under his right fifth metatarsal head. He had acceptable diabetes control (HBA1c 7.7 ), pro-liferative diabetic retinopathy treated with laser in both eyes, but no nephropathy. He complained of muscle cramps during the night and chronic constipation interrupted by episodes of nocturnal diarrhea. The patient had a history of painless diabetic foot ulceration for 3 years under his right foot after a burn injury. He had attended the surgery department of a country hospital,

Results from Clinical Trials with cf1520 OnyxOl 5 or CI1042

Intraperitoneal, intraarterial, and intravenous administration were also remarkably well tolerated in general. Intraperitoneal administration was feasible at doses up to 1013 particles divided over 5 days 50 . The most common toxicites included fever, abdominal pain, nausea vomiting, and bowel motility changes (diarrhea, constipation). The severity of the symptoms appeared to correlate with tumor burden. Patients with heavy tumor burdens reached a maximally tolerated dose at 1012 particles (dose-limiting toxicities were abdominal pain and diarrhea), whereas patients with a low tumor burden tolerated 1013 without significant toxicity.

Indications and Contraindications

An assessment of the condition of the colonic mucosa is important where there are clinical indications of colitis, i. e., abdominal pain, diarrhea, malabsorption, perianal bleeding as a result of possible intestinal ischemia, inflammation, erosions and ulcers of various geneses, polyps and tumors, diverticula, or vascular malformations. Changes in bowel habits and an increasing tendency toward constipation are cause for performing an endoscopic search for a stricture in the intestinal lumen, e. g., due to neoplasia, diverticular myochosis (thickening of the circular muscle layer), or postinflammation stricture (Tab. 1.1). Constipation Diarrhea Abdominal pain

Bowel Management Program

It is important to differentiate real fecal incontinence from overflow pseudoincontinence. In patients with real fecal incontinence, the normal mechanism of bowel control is deficient for the reasons described. Pseudoincontinence occurs when a patient behaves like they are fecally incontinent, but really have severe constipation and overflow soiling. Once the disimpaction is treated and the patient receives enough laxatives so as to avoid constipation, he she becomes continent. This patient group is described in Chaps. 29 and 30. It is extremely important to distinguish between real incontinence and pseudoincontinence in order to identify the origin of the problem and consequently to plan the best treatment. Of all children with ARM who have undergone a correct and successful operation, 75 have voluntary bowel movements after the age of 3 years 2 . About half of these patients soil their underwear on occasion. Those episodes of soiling are usually related to constipation. When the...

Direct Inguinal Hernia

The neck of the hernial sac is wide, the risk of incarceration is low. On standing, the hernial sac is felt as a diffuse medial outpouching over the inguinal canal, which is not controlled by digital pressure applied immediately proximal to the femoral artery. Direct inguinal hernia is a less common type ofhernia, is age related, usually affects men over age 40, and is rare in women. It is an acquired condition associated with obesity, constipation, and benign prostatic hypertrophy. It is usually asymptomatic and is even less noticeable than the indirect type. This type of hernia is not contained in the spermatic cord, and unless the hernial sac is large it rarely extends to the scrotum or major labium. The hernial sac protrudes anteriorly and pushes the side of the examiner's index finger forward. Both direct and indirect inguinal hernia may protrude on each side of the inferior epigastric vessels as pantaloon hernia.

Familial Visceral Myopathy

Familial visceral myopathy or hollow visceral myopathy are believed to be the most common causes of primary disease (Faulk et al, 1978). Clinically affected family members may be asymptomatic or suffer from abdominal pain, dysphagia, abdominal distension, constipation, early satiety, nausea, and vomiting. Radiographic demonstration of intestinal distension via plain films or barium studies further supports the diagnosis. Involvement of the bladder and ureter commonly occurs. Gross and microscopic features, as described by Mitros and colleagues (1982), include dilatation of various segments of the intestinal tract, most commonly the duodenum (leading to megaduodenum) and microscopic changes, including fibrosis and muscle cell degeneration.

Management options

Initial management includes simple analgesics such as paracetamol and nonsteroidal anti-inflammatory drugs. Constipation (which causes straining) should be prevented if possible by avoiding opioids such as codeine or by offering lactulose. Although dehydration can exacerbate the headache, there is no evidence that overhydration has a beneficial effect. Other medical management includes oral caffeine 150-300 mg 6-8 hourly, which has been shown to improve the symptoms although not cure them. Caffeine may cause nausea and vomiting in overdosage and has been implicated in convulsions occurring after dural puncture. Successful use of the anti-migraine serotonin-receptor agonist sumatriptan (6mg subcutaneously) has been described anecdotally, as has adrenocorticotrophic hormone (ACTH 1-5mU kg in 1000-2000ml saline given intravenously over one hour). However, despite anecdotal reports of ACTH's synthetic analogue Synacthen being successful, a randomised controlled trial found no benefit of...

Difficulties for the Gastroenterologist in Engaging and Maintaining Patients in Treatment

Because patients with AN and BN are strongly ambivalent about giving up dieting behavior, gastroenterologists may find themselves unwitting accomplices of patients looking to feel better rather than to get better. Complaints about bloating, early satiety, constipation, nausea, reflux, and abdominal pain may prompt expensive, often invasive diagnostic or therapeutic procedures, the vast majority of which are unnecessary distractions from the task of behavioral change and recovery, which usually results in the resolu

Supplemental Reading

Locke GR III, Pemberton JH, Phillips SF. AGA technical review on constipation. American Gastroenterological Association review . Gastroenterology 2000 119 1766-78. Wald A. Slow transit constipation. Curr Treat Options Gastroenterol 2002 5 279-83. Wald A. Constipation, diarrhea and symptomatic hemorrhoids during pregnancy. Gastroenterol Clin North Am 2003 32 301-22. Wald A. Anorectal manometry. In Schuster M, Crowell M, Koch K, editors. Schuster atlas of gastrointestinal motility, 2nd ed. Hamilton (ON) BC Decker Inc 2002. p. 289-303. Wald A, Hinds JP, Caruana BJ. Psychological and physiological characteristics of patients with severe idiopathic constipation. Gastroenterology 1989 97 932-7. Wald A. Is chronic use of stimulant laxatives harmful to the colon. J Clin Gastroenterol 2003 36 386-9. Wald A. Approach to the patient with constipation. In Yamada T, editor. Textbook of gastroenterology, 4th ed. Philadephia Lippincott, Williams and Wilkins 2003. p. 894-910. Wald A. Outlet...

Theory of Traditional Chinese Medicine

High fever, irritability or coma, thirst, abdominal pain, constipation or diarrhea, vomiting Slow, deliberate movement, withdrawn manner, white face, fear of cold, cold limbs, pain lessened by warmth, watery stool, clear urine, no thirst or a desire for hot liquids Quick, agitated movement, extroverted manner, red face and eyes, high fever, irritability, thirst and desire for cold liquids, constipation, dark urine Frail and weak movement, ashen pale, or sallow face, shallow breathing, pain that is relieved by pressure, spontaneous sweating, copious urination or incontinence High fever, aversion to heat, constipation, red tongue with yellow coating, upper body symptoms such as red tip, toothache, blood-shot eyes, dry mouth and throat, convulsion, stiff neck, various bleeding, mania, insomnia, restlessness, and unconsciousness

Conclusion Of Anorectal Malformation

Chronic constipation with overflow incontinence is more frequent after PSARP than it is after ab-dominoperineal pull-through procedures, which more frequently lead to stool incontinence. 6. In constipated children one should always be aware of associated malformations of the intramural plexus. In addition, malformations of the smooth and striated muscle fibers and Cajal's cells could be present. In cases of severe chronic constipation, suction, or even full-thickness biopsy samples should be taken.

Psychiatric Treatment of Eating Disorders Outpatient Treatment

Effective treatment depends on setting clear behavioral guidelines (eg, binging and vomiting decrement of 50 over 3 to 4 weeks, weight gain of 1 to 2 lbs week on a prescribed diet). The patient should be weighed at the beginning of each session and be instructed to maintain a daily food log and record of abnormal behaviors, such as vomiting or use of laxatives. Triggers for eating disordered behavior and situations that sustain it are discussed and alternate thoughts and behaviors are explored. The therapeutic approach is cognitive-behavioral and fairly directive, with the therapist playing an active role in helping the patient problem solve, develop healthier behaviors, and challenge irrational beliefs. Although the standard course of cognitive behavioral treatment for uncomplicated BN is brief, on the order of 16 to 20 weeks, persuading patients with AN to gain weight as outpatients is difficult, and outpatient psychotherapy for AN may be more protracted.

Preparing dogs for space travel

The far more difficult challenge with the sanitation device was getting the dogs to actually use it. Nature had accustomed them to adopt a certain position to urinate and defecate, and now they had to be reprogrammed to do it differently. Initially, the dogs retained all wastes rather than use the unfamiliar device. Even the use of laxatives did not encourage them. Only slow and consistent training finally acclimatised them to the novelty of this new approach 14 .

Nonstimulant Medications for ADHD

Timothy Wilens and colleagues (2002) recommended that dosing with TCAs should start with 25 mg daily with a gradual increase to a maximum of 5 mg per kg of patient weight per day, except for nortriptyline, whose dosing should be limited to a maximum of 2 mg per kg per day. Often responses to TCA treatment are not very noticeable until the regimen has been continued for three to five weeks. Adverse effects with TCAs may include sedation, weight gain, dry mouth, constipation, and sexual dysfunction. Usually nortriptyline produces fewer adverse effects than do the other TCAs.

Clinical Manifestations

Groans refer to the gastrointestinal manifestations of hypercalcemia, seen in 15 of primary hyper-parathyroidism. Patients can present with anorexia, constipation, weight loss, nausea and vomiting, and, peptic ulcer disease. Up to 10 of patients with parathyroid carcinoma can present with acute pancreatitis or recurrent severe pancreatitis. Unfortunately, the degree of anorexia, decreased fluid intake, and vomiting seen with untreated parathyroid carcinoma only aggravates the underlying intravascular depletion caused by hyperparathyroid-induced hypercalcemia.

Medicine In The Roman World


Serving the Roman legions gave Dioscorides the opportunity to travel widely and study many novel plant species, hundreds of which were not known to Hippocrates. An acute observer and keen naturalist, Dioscorides provided valuable information about medically useful plants, their place of origin, habitat, growth characteristics, and proper uses. He also described remedies made from minerals and animals. Pharmacologists who have examined the text have found recipes for valuable therapeutic agents, including analgesics, antiseptics, emetics, laxatives, strong purgatives, and so forth.

Darifenacin Urinary Incontinence [1518

Darifenacin demonstrates greater effect on tissues in which the predominant receptor type is M3 rather than Ml or M2. In vitro darifenacin inhibits carbachol-induced contractions with greater potency in isolated guinea-pig bladder (M3) than in guinea-pig atria (M2) or dog saphenous vein (Ml). In animal models, it shows greater selectivity for inhibition of detrusor contraction over salivation or tachycardia. The synthesis of darifenacin involves the coupling of 5-(2-bromoethyl)-2, 3-dihydrobenzofuran with as a key step. The latter intermediate is prepared from 3-(R)-hydroxypyrrolidine in a five-step sequence involving N-tosylation, Mitsunobu reaction to introduce a tosy-loxy group in the 3-position with stereochemical inversion, anionic alkylation with diphenylacetonitrile, cleavage of the N-tosyl protecting group with HBr, and conversion of the cyano group to a carboxamide. Darifenacin is supplied as a controlled release formulation, and the recommended dosage is 7.5 mg once, daily....

Clinical Presentation

A cross-sectional analysis by Mann and colleagues (1997) demonstrated that the median age of symptom onset was 17 years with a range of 2 weeks to 59 years (11 males, 9 females). The frequency and severity of symptoms may vary remarkably depending upon the section and the extent of the GI tract involved. The most common symptoms included pain (80 ), vomiting (75 ), constipation (40 ), and diarrhea (20 ) (Stanghellini et al, 1987).When the esophagus is involved, decreased esophageal motility and lower esophageal sphincter (LES) tone may lead to complaints of dysphagia and reflux symptoms. The complete absence of bowel movements or flatus indicates complete obstruction as opposed to the more common finding of constipation. However, diarrhea may also occur in patients with CIP and is likely secondary to intestinal stasis promoting bacterial overgrowth. Some suffer from malabsorption and develop nutritional deficiencies secondary to bacterial overgrowth. Loss of appetite and weight loss...

Hemorrhoids Anal Fissures and Rectal Ulcers

The anorectum is a frequent source ofsignificant lower GI bleeding. It frequently manifests with small amounts of bright red blood noted on the toilet paper, coating the stool, or dripping into the toilet bowl. Many causes of anorectal bleeding, such as hemorrhoids and fissures, are recurrent. Constipation occasionally causes stercoral ulcers due to fecal impaction or the solitary rectal ulcer syndrome from mucosal trauma, rectal prolapse, or direct digital

Cirsium setosum Willd MB Fam Asteraceae

Cirsium Setosum

For constipation due to Dry Intestine, it is used with Fructus Cannabis Sativae (Huo Ma Ren) and Lignum Aquilariae Resinatum (Chen Xiang) in the Moisten the Intestine Pill (Run Chang Wan). Contraindicated in patients with hyperactive Kidney Fire, loose stools due to Spleen Deficiency, and constipation due to Excess Heat.

Rimantadine hydrochloride amethyl1adamantanemethylamine hydrochloride

High fever and constipation followed by diarrhea. Mortality may exceed 90 . Inflammation and ulceration of the whole alimentary tract is the main pathological lesion, but patchy pneumonia may occur. Transmission is by direct contact and outbreaks usually start by the introduction of an infected animal with up to 100 infection of the affected herd. Control is by slaughter and use of tissue-culture-attenuated vaccines, which generate life-long immunity. The virus is closely similar in structure to Measles and Canine distemper virus and contains cross-reacting antigens. Serum from rinderpest virus-infected cattle prevents hemagglu-tination by Measles virus. Several live virus-attenuated vaccines are available and a global rinderpest eradication campaign coordinated by the Food and Agriculture Organization of the United Nations (FAO) is underway. Synonyms cattle plague virus peste bovina peste bovine.

Multidisciplinary Behavioral Treatment

In the Nijmegen behavioral treatment protocol, developed at the Radboud University Nijmegen Medical Centre, defecation problems are considered to be the result of a dysfunctional interaction between the organ, which is impaired by the ARM, and behavioral factors 13 . To have a bowel movement, there has to be rectal filling. In healthy children this will lead to a sense of urge, which induces a defecation reflex and results in an empty bowel. For children to become continent, there has to be an interaction between the organ and the behavior of the child. The child has to perceive a sense of urge and to learn to react by withholding defecation for a short while, to go to the toilet or potty for voluntary evacuation. This will not only lead to an empty bowel, but also to empty diapers or trousers. In this learning process, several things can go wrong. For instance, a child who experiences pain with defecation will react to a sense of urge by withholding instead of relaxation. This will...

Pathogen Specific Therapy Bacterial Pathogens

Nontyphoidal species of Salmonella cause approximately 1.4 million cases of gastroenteritis and diarrhea annually. Contaminated meat, poultry, and eggs are common sources of infection, although bean sprouts, tomatoes, and orange juice have also been linked to outbreaks of salmonellosis. Other than diarrhea, clinical features may include abdominal pain, fever, and chills. Grossly bloody diarrhea is uncommon. Patients may carry Salmonella in their stools for weeks after symptoms resolve and 0.2 to 0.6 of patients may carry Salmonella over 1 year (long term carriers). The majority of cases in healthy adults are self-limited and do not require antibiotics. However, Salmonella can invade vascular sites and cause systemic toxicity in compromised hosts. Therapy (see Table 49-2) is indicated for patients with systemic toxicity or bacteremia, aged under 6 months or over 50 years, and in patients with prosthetic joints, heart valves or vascular grafts, severe atherosclerosis, malignancy, HIV...

What foods can I eat to assure that Im getting enough calcium

For example, too much fiber in your diet can slow the rate at which calcium is absorbed by your body. However, a high-fiber diet has also been associated with healthful changes, such as decreased risks of breast and colon cancer. Increasing fiber in your diet can also decrease the constipation associated with calcium carbonate. Dividing the amount of calcium that you need into smaller doses to take throughout the day may provide better absorption and fewer side effects of bloating and gas.

Predisposing Conditions And Pathophysiology

Excretion of the organism has persisted for as long as 158 days after the onset of constipation, well after clinical recovery had occurred. The syndrome has occurred in both breast-fed and bottle-fed infants, and the role of type of feeding is yet unsettled (16). Risk factors for IB are multifactorial and include breastfeeding, and the introduction of first-formula feeding, consumption of honey, and residence in a region of high spore density and soil disruption (13). Constipation appears to be a risk factor but also is an early manifestation of intoxication (17). Preformed toxin has not been identified in food ingested by the infants, but the organism has been identified in honey, vacuum cleaner, dust, and soil. C. botulinum organisms, but no preformed toxin, were identified in six different honey specimens fed to three California patients with IB, as well as from 10 (9 90) of honey specimens studied (23). By food exposure history, honey was significantly associated with type B IB....

Serotonin Antagonists

The use of ondansetron at doses of 4 mg orally 3 times a day in patients with PBC was associated with a decrease in fatigue scores as assessed by the Fisk Fatigue Impact Score (FFIS), as published in abstract form. Headache and constipation were the most common side effects associated with ondansetron. These preliminary results may support the idea that altered serotoninergic neurotransmission contributes to the pathogenesis of fatigue in liver disease. Table 122-2 summarizes the experience with ondansetron in the treatment of fatigue to date.

Parkinson Disease

James Parkinson first described Parkinson disease (PD), a neurodegenerative disorder with an incidence range from 4.9 to 26 per 100,000 and prevalence of approximately 200 per 100,000, in 1817 in his monograph Essay on the Shaking Palsy. Parkinson termed the disease paralysis agitans and reported resting tremor, festinant gait, flexed posture, dysarthria, dysphagia, insomnia, and constipation as the hallmarks of the condition. Charcot subsequently used the term Parkinson's disease, and differentiated the resting tremor of PD from the cerebellar outflow action tremor seen in multiple sclerosis. He also noted that tremor was not always present in all PD cases, and that cognitive decline may also be a part of the disease. In 1893 researchers discovered that the substantia nigra was abnormal in those afflicted with PD. Subsequent examinations of the brains of patients dying with idiopathic PD demonstrated

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Natural Remedies For Constipation
Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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