KONSTIPASIDefenisi : Gangguan BAB yg ditandai dengan feses

yang sedikit, keras, jarang dan sukar.

Parameter yang sering digunakan :

1. Frekuensi < 3 x/ minggu N : 1-2 sehari atau 2 hari sekali2. Berat < 30 gr hari N : 200 gr3. Konsistensi keras4. Straining anal & lower abd. discomfort dan perasaan tidak puas defekasi5. waktu transit di colon

Konstipasi >< Diarea

KRITERIA ROME II UNTUK DIAGNOSTIK KONSTIPASI

1. KECEMASAN / STRAINING

2. BAB KERAS

3. RASA TIDAK PUAS SETELAH BAB

4. RASA OBSTRUKTIF/BLOCKADE ANORECTAL

5. BAB < 3 MINGGU

UK : 1 % BEROBAT KE DOKTER KELUARGA

10 % MENGELUH KONSTIPASI

20 % MENGGUNAKAN LAKSANSIA

SERING PADA ♀ DAN USIA LANJUT

( BUDAYA KULTUR DAN ETNIK )( BUDAYA KULTUR DAN ETNIK )

MEKANISME AUTOMATIK DEFEKASI :MEKANISME AUTOMATIK DEFEKASI : INTEGRITAS INTEGRITAS MUKOSA REKTUM LUMBAR SPINAL CORD, SARAF PELVIC MUKOSA REKTUM LUMBAR SPINAL CORD, SARAF PELVIC DENGAN INHIBISI DARI PUSAT.DENGAN INHIBISI DARI PUSAT.

KERUSAKAN SEGMEN SAKRAL, SPINAL CORD, CAUDA KERUSAKAN SEGMEN SAKRAL, SPINAL CORD, CAUDA EQUINA ATAU SARAF ERIGENTES (TRAUMA, TUMOR) EQUINA ATAU SARAF ERIGENTES (TRAUMA, TUMOR) MENIMBULKAN KONSTIPASI DAN ATONIK BOWEL.MENIMBULKAN KONSTIPASI DAN ATONIK BOWEL.

Prevalensi :

1. SISTEMIK :

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

B. GANGGUAN ENDOKRIN DAN METABOLIK DM, PORPHIRIA, AMYLOIDOSIS, HIPOTIROIDISM, PANHIPOPITUITARISM, HIPOKALEMIA, UREMIA, HYPERKALSEMIA, PHEOKROMASITOMA, PREGNANCY

ETIOLOGI :

C. SKLEROSIS SISTEMIK DAN PENY. CONNECTIVE TISSUE

D. PENY. PSYCOLOGICAL - DEPRESI- ANOREKSIA NERVOSA -

KEBIASAAN MENAHAN BAB

E. LAIN-LAIN- KEBIASAN DIET DAN BAB YAG SALAH- USIA TUA- PERJALANAN YANG JAUH -

RENDAH SERAT - IMOBILISASI / RAWAT INAP

2. NEUROGENIK : MEKANISME BELUM JELASA. PERIPERAL:

AGANGLIONIK (HIRSCHSPRUNG’S ) TIDAK DIJUMPAI NEURON PADA DISTAL SEGMEN KOLON MENGAKIBATKAN SPASTIK KOLON. BARIUM ENEMA

TERLIHAT DILATASI PROKSIMAL KOLON (MEGA KOLON), MANOMETRI ABSEN RIFLEKS RECTO ANOINHIBITORY. BIASA USIA MUDA KONSTIPASI SEJAK LAHIR AMPULA RECTI KOSONG. AUTONOMIK NEUROPATI INTESTINAL PSEUDO - OBSTRUKSICHAGAS DISEASE

B. CENTRAL : PENYAKIT PARKINSON, TUMOR OTAK,

CEREBROVASKULER ACCIDENT KERUSAKAN DAERAH SACRAL MEDULA SPINALIS OLEH KARENA ( TUMOR,

TRAUMA, PENYAKIT DEGENERATIF, DLL ) TABES DORSALIS, MULTIPLE SCLEROSIS PARALPLEGI DLL.

3. LARGE BOWEL ORIGIN: LAKUKAN COLOK DUBUR / RT

A. ORGANIK OBSTRUKSI: LESI KOLON SEBELAH KIRI.TUMOR COLON, STRIKTURA, VOLVULUS KRONIK,

HERNIA, PROLAPSUS REKTAL, STENOSIS ANAL, INFEKSI KRONIS (AMUBIASIS, SYPHILIS, TUBERCULOSIS), ISKEMIK KOLITIS, ENDOMETRIOSIS, ENEMA KOROSIV, OPERATIF.B. ABNORMALITAS DARI FUNGSI OTOT :

IBS / ORANG MUDA , DIVERTIKEL SINDROME, DILATASI SEGMENTAL KOLON, MYOTONIK DISTROPI, SKLEROSIS SISTEMIK.C. GANGGUAN RECTAL, ANAL DAN PELVIC BAGIAN BAWAH PROKTITIS ULSERATIF, FISSURE ANAL, PROLAPS MUKOSA, HEMORRHOID, ABSES PERIANAL, ANUS ECTOPIK ANTERIOR

4. IDIOPATIK : MARKER RADIO OPAQUE

A. DELAYED TRANSIT (COLONIC KONSTIPASI) LAZY BOWEL, KONSTIPASI KLONIK BERAT,

WANITA DEWASA BAB 1X SEMINGGU KELOMPOK INI TIDAK RESPON TERHADAP DIET TINGGI SERAT.

B. NORMAL TRANSIT TIME, ABNORMALLY LONG STORAGE OF STOOL.

C. KOMPONEN PSIKOLOGI TRANSIT TIME NORMAL

DIAGNOSIS

1. KLINIS A. ANAMNESE: DITANYA TENTANG :

- KONSTIPASI ? DIAGNOSIS ? - SEJAK KAPAN ? - SEJAK ANAK HIRCHSPRUNG’S TIBA-TIBA DEWASA ( TUMOR?, OBAT2AN, PASCA

OPERASI ) - DIET SERAT ?

B. PEM FISIK: - ANOREKTAL FISSURA, HEMORHOID, ABSCES

PERIANAL, RECTOCELE, NEOPLASMA. RECTAL TOUCHE TINJA NYEMPROT HIRCHSPRUNG’S

- KONSTIPASI NEUROLOGIK SENSORI KUTANEUSSEKITAR ANUS

2. PEMERIKSAAN LABORATORIUM :- DARAH RUTIN, ELEKTROLIT, UREUM, KALSIUM

SERUM TSH.

3. PEMERIKSAAN PENUNJANG :A. BARIUM ENEMA :

- KONTRAS GANDA NEOPLASMA- HIRSCHSPRUNH’SKOLON SEMPIT, PANJANG DAN DILATASI PROKSIMAL.- KONSTIPASI KRONIS KOLON LEBAR & PANJANGB. KOLONOSKOPI : KADANG KELAINAN (-)

NEOPLASMA, ULKUS SOLITER RECTUM, MELANOSIS COLI, ULSERATIVE PROKTITIS

BIOPSI KONFIRMASI HIRSCHSPRUNH’S DISEASE DAN ULKUS SOLITER

C. COLONIC TRANSIT TIME :

MENELAN 20 POTONG MARKER RADIO OPAQUE, KEMUDIAN FOTO ABDOMEN FOLLOW UP 5 HARI, JIKA < 80% YANG DIKELUARKAN KONSTIPASI

D. ANORECTAL MANOMETRY :

MENGEVALUASI ADANYA PENYAKIT HIRSCHSPRUNG’S DAN COLORECTAL MOTILITY

E. ELEKTROMIOGRAFI :

MENILAI FUNGSI SPINCTER ANI DAN FUNGSI MUSCLE PUBORECTALIS.

PENGOBATAN :

1. GENERAL

A. ATASI PENYAKIT SISTEMIK & PENYAKIT ORGANIK YANG MENYEBABKAN KONSTIPASI

B. STOP OBAT2AN DAN LAKSANSIA KUAT

C. DIET TINGGI SERAT, BANYAK MINUM & BULKING AGENT (BAGI YANG TIDAK AMPU MENGKOMSUMSI DIET SERAT )

D. BIASAKAN BAB YANG BAIK (SEGERA BAB JIKA SUDAH ADA DESAKAN, BERI WAKTU YANG CUKUP UNTUK BAB)

E. MOBILITAS / OLAH RAGA TERUTAMA INDIVIDU YANG SEHARIANNYA DUDUK ATAU TIDUR.

2. SERAT : TINGGI SERAT ( BRAN & CEREAL BUKAN SAYUR & BUAH) OBAT KONSTOPASI TANPA KOMPLIKASI. PEMBERIAN SECARA BERTAHAP SAMPAI DEFEKASI NORMAL TERCAPAI DAN MAINTENANCE. BILA KELUHAN BERTAMBAH BIASA PADA KONSTIPASI SPASTIK SLOW TRANSIT PEMBERIAN SERAT DI STOP.

3. BULKING AGENT

METIL SELULOSA (METAMUSIL DAN SEJENISNYA DIGUNAKAN PD KONSTIPASI ). MEKANISME MENARIK AIR & MENAMBAH DEFEKASI DPT DIPAKAI SEBAGAI PENGGANTI SERAT BAGI YG TIDAK RESPON THD SERAT.

4. MEDIKAMENT

SECARA UMUM LAKSANSIA TDK DIANJURKAN JANGKA PANJANG. BAHAN INI GANGGUAN ABSORBSI DAN

FARMAKOKINETIK OBAT, BERIKATAN FISIKAL DAN CHEMIKAL TRANSIT TIME

A. LUBRICANT LAXATIVELIQUID PARAFIN EFEK SAMPING ASPIRASI PNEUMONITIS + GGN ABSORBSI VIT. LARUT LEMAK TDK DIGUNAKAN LAGI.

B. FAECAL SOFTENER ( PELUNAK TINJA ) MENURUNKAN TEGANGAN PERMUKAAN DAN MENARIK AIR MASUK KE TINJA DIOCTYL SODIUM SULPHOSUCCINATE (CLOXYL/DIALOSET PLUS FISURA ANI, HEMOROID, UNSTABLE ANGINA / MCI

C. OSMOTIK LAXATIVE MAGNESIUM SULFAT, LACTULOSE, POLYTHYLENE GLYCOL, ELECTROLYTE SODIUM.

MEKANISME MENARIK AIR & MENGELUARKAN

GUT HORMON/KOLESISTOKININPERISTALTIK BEKERJA

CEPAT PROSEDUR DIAGNOSTIK ( BARIUM

ENEMA / KOLONOSKOPI DAN TINDAKAN OPERASI. HATI-

HATI PD ORG TUA (GGK, GGJ, LAKTULOSA

ENSEPALOPATI HEPATIK ( MENURUNKAN KADAR

AMONIA DLM KOLON)

D. STIMULANT LAXATIVE ANTHRAQUINONE, POLYPHENOLS(PHENOFHALEIN, BISACODYL, PHENASETIN) DAN CASTOR OIL. MEKANISME IRITASI MUKOSA USUS, STIMULASI DIREK NEURONAL SUB MUKOSA PLEKSUS MYENTRIKUS MENIMBULKAN KERAM PERUT, TIDAK DIPAKAI PADA OBS.USUS, PEMAKAIAN KRONIK ATONIK KOLON, MELANOSIS COLI. OXYPHENATOIN PADA HERBAL TRADISIONAL KERUSAKAN HATI KRONIK

E. SUPPOSITORIA&ENEMAPHENOLPHTALEIN TIMBUL RASH, ALBUMINURIA DAN HEMOGLOBINURIA

F. PROKINETIK EGENT CISAPRIDE

5. PSYCOLOGICAL,BEHAVIOURAL & BIO-FEEDBACK TERAPI:

- KONSTIPASI + IBS PSIKOTERAPI / HYPNOTISM. BEHAVIOUR TERAPI LATIHAN BAB PADA ANAK-ANAK KOMBINASI DENGAN TINGGI SERAT

- BIO FEED BACK TERAPI KOMPLEKS BERMANFAAT PADA PELVIC FLOOR SYNDROMA

6. SURGERY : KONSTPASI SECARA UMUM DPT DITATALAKSANAKAN SECARA KONSERVATIF & MEDIKAMEN

TUMOR COLON, HIRSCHSPRUNG’S DISEASE, PENYAKIT ORGANIK YANG MENYEBABKAN OBSTRUKTIF PADA COLON DAN SEVERE SLOW TRANSIT CONSTIPATION SUB TOTAL KOLEKTOMI DGN ILEORECTAL ANASTOMOSIS.

UNDERLYING DISEASES STATES ASSOCIATED WITH CONSTIPATION

MECHANICAL OBSTRUCTION

COLON CANCER

EXTERNAL COMPRESSION OF THE INTESTINE

STRICTURES : DIVERTICULAR, POST ISCHEMIC, POST

SURGICAL

CROHN’S DISEASE ADHESIONSINTUSSUSCEPTIONSCOLONIC VOLVULUSENDOMETRIOSISHERNIARECTAL PROLAPSE, OCCULT OR COMPLETE

METABOLIC DISEASESDIABETES MELLITUSHYPOTHYROIDISMHYPERCALEMIAHYPERPARATHYROIDISM HYPOPITUITARISMPHEOCHROMOCYTOMAHYPOKALEMIAHYPOMAGNESEMIAUREMIAHEAVY METAL POISONINGPORPHYRIA

NTESTINAL MYOPATHIESAMYLOIDOSISSCLERODERMAMIXED CONNECTIVE TISSUE DISEASEMYOPATHIC PSEUDO-OBSTRUCTION CHAGAS’ DISEASE

INTESTINAL NEUROOPATHIES PARKINSON’S DISEASESPINAL CORD INJURY OR TUMORCEREBRAL VASCULAR DISEASEMULTIPLE SCLEROSISNEUROPATHIC PSEUDO-OBSTRUCTIONHIRSCHSPRUNG'S DISEASE

OTHER CONDITIONDEPRESSIONANOREXIA NERVOSA

AUTONOMIC NEUROPATHYIMMOBILITYDEMENTIACARDIAC DISEASEPREGNANCYIDIOPATHIC MEGA COLONPAINFUL ANAL DISEASE (INFLAMED HEMORRHOID,

FISSURE, ABSCESS)RECTOCELEIRRITABLE BOWEL SYNDROME

ADDITIONAL CAUSES OF CONSTIPATION IN CHILDREN

ANORECTAL MALFORMATIONS

STRICTURE DUE TO NECROTISING ENTEROCOLITIS

CYSTIC FIBROSIS

NEUROLOGICAL MALFORMATIONS : SPINA BIFIDA, MYELOMENINGOCELE

RECKLINGHAUSEN’S DISEASE

INTESTINAL NEURONAL DYSPLASIA

ABNORMAL ABDOMINAL MUSCULATURE : GASTROSHISISM PRUNEBELLY, DOWN’S SYNDORME

VITAMIN D INTOXICATION

FUNCTIONAL FECAL RETENTION

INFANT DYSCHEZIA

DRUGS THAT MAY CAUSE CONSTIPATION

OPIATES

ANTICHOLINERGICS

TRCYCLIC ANTIDEPRESSANTS

CALCIUM CHANNEL BLOCKERS

ANTIPSYCHOTICS

ANTIPARKINSONIAN DRUGS

ANTICONVULSANTS

GANGLIONIC BLOCKERS

DIURETICS

ANTIHISTAMINES

ANTACIDS

CALSIUM SUPPLEMENTS

IRON SUPPLEMENTS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)

DISTURBANCES OF COLONIC OR ANORECTAL FUNCTION IN CONSTIPATION

COLONIC DYSFUNCTION

INCREASE IN NON PROPULSIVE COLONIC CONSTRACTIONS

DECREASE IN PROPULSIVE COLONIC CONSTRACTIONS

SLOW TOTAL OR SEGEMENTAL COLONIC TRANSIT

ANORECTAL DYSFUNCTION

ELEVATED ANAL PRESSURE

DISTURBED PERINEAL MOVEMENT

DISTURBED RECTAL SENSATION

INCREASED RECTAL COMPLIANCE

FEATURES OF FUNCTIONAL FECAL RETENTION (FFR) AND COLONICNEUROMUSCULAR DISORDERS (CNR) IN CHILDREN

FEATURE FFR CNR

FECAL SOILING COMMON FLARE

OBSTRUCTIVE SYMPTOMS FLARE COMMON

LARGE – CALIBER STOOLS COMMON FLARE

STOOL WITHHOLDING COMMON FLARE BEHAVIOR

ENTEROCOLITIS NEVER POSSIBLE

UPPER GI SYMTOMS NEVER COMMON

SYMPTOMS FROM BIRTH FLARE COMMON

LOCALIZATION OF STOOLS RECTUM RECTUM

AND COLON

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

COLONIC STENOSIS OR SLOW TRANSITHARD AND SMALL STOOLSINFREQUENT DEFECATIONABSENCE OR URGE TO DEFECATE

ANOREACTAL DYSFUCTION THIN STOOLSFEELING OF RESISTANCE TO DEFECATIONSTRAINING AT DEFECATIONFEELING OF INCOMPLETE DEFECATIONPAIN WITH DEFECATIONDIGITAL SUPPORT OF PERINEUM OR ANTERIOR RECTAL WALLDIGITAL EVACUATIONINCOMPLETE OR NO EMPTYING WHEN ENEMA APPLIED

IRRITABLE BOWEL SYNDROMESMALL STOOLSPAIN RELEIVED BY DEFECATION INTTERMITENT DIARRHEAFEELING OF INCOMPLETE DEFECATIONSTRAINING AT DEFECATION

POSSIBLE PHYSICAL FINDINGS IN CONSTIPATION

INSPECTIONABDOMINAL DISTENTION

PERINEAL FISSURE, INFLMMATION, OR SCAR

PERINEAL DESCENT

DECREASED MOBILITY OF THE PERINEUM

DIGITAL OR MANUAL EXAMINATIONADOMINAL MASS OR TENDERNESS

FECAL IMPACTION

ANAL STRICTURE

INCREASED ANAL CANAL TONE DURING REST OF SQUEEZE

PAINFUL EXAMINATION OF THE ANAL CANAL

PAIN AT THE RIM OF THE PUBORECTALIS MUSCLE

RECTAL MASS

RECTOCELE

INDICATION FOR RETERRAL FOR SPECIALIZED GASTROENTEROLOGIC EVALUATION

RECENT ONSET OF CONSTIPATION

CHRONIC CONSTIPATION WITH CHANGE IN STOOL FROM OR FREQUENCY

WEIGHT LOSS

ANEMIA, BLOOD PER RECTUM, OCCULT BLEEDING

ABDOMINAL PAIN OR TENDERNESS

FAMILY HISTORY OF COLON CANCER

PERSISTING PALPABLE TUMOR

OLDER THAN 40 YEARS AT ONSET OF SYMPTOMS

TREATMENT FAILURE;FAILURE TO IMPROVE WITH ROUTINE THERAPY OR CHRONIC NEED FOR HIGH DOSES OF ANY

LAXATIVE

THREE TREATMENT APPROACHES FOR CONSTIPATION BASED ON CLINICAL SUSPICION OR PROOF OF ONE OF THREE POSSIBLE GROUPS OF FUNCTIONAL DISORDERS

ANORECTAL DYSFUNCTION DECREASE FIBER IN DIETINCREASE STOOL WATER CONTENT WITH SALINE LAXATIVESRETRAIN PELVIC FLOOR FUNCTIONUSE GLYCERIN SUPPOSITORIES IF NEEDEDUSE BIOFEEDBACK TECHNIQUES IF THE ABOVE APPROACHES

ARE UNSECESSFULAFTER SUCCESSFUL ACHIEVEMENT OF REGULAR BOWEL

HABITS, REINTRODUCE FIBER - RICH DIETSLOW COLONIC TRANSIT

INCREASE FIBER IN DIET ; FIBER SUPPLEMENTSSALINE LAXATIVESCISAPRIDESURGERY IN SEVERE CASES AND FOR PATIENTS RESISTANT TO

MEDICAL THERAPYIRRITABLE BOWEL SYNDROME

FIBER RICH DIET IF TOLERATED BY THE PATIENTSALINE LAXATIVESANTISPASMODIC USED ONLY WQITH CAUTIONTRICYCLIC ANTI DEPRESSANTS IN CASES OF IBS IN WHICH PAIN

IS A PROMINENT SYMPTOM