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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
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Secondary constipation: hypothyroidism, hyperparathyroidism, diabetes, renal failure, pregnancy, neurologic disorders (eg,
Parkinson disease), drug side effects.
Ogilvie syndrome typically distinct entity.
Pathology
No primary colonic pathology.
Secondary pathology: melanosis coli (lipofuscin pigment in submucosal macrophages [no melanin]), colonic muscular
hypertrophy, colonic diverticulosis.
Pathophysiology: factors affecting colonic transit and evacuation:
Endoluminal factors (stool consistency).
Intrinsic factors (neuromuscular network, pacer and distention receptor function, motility).
Extrinsic factors (neural function, endocrine factors, drugs).
Evacuatory function (pelvic neuromuscular coordination).
Evaluation
REQUIRED MINIMAL STANDARD
History:
Exact analysis of patient's symptoms: number/frequency/quality of bowel movements, supportive maneuvers for
evacuation, dietary habits, past/current management (laxatives, enemas/suppositories, fibers, etc).
Associated symptoms: bleeding, abdominal distention, weight loss, pain, nausea/vomiting, prolapse? Incontinence
(fecal, gas, urine), fatigue.
List of medications (drug-induced constipation).
History of prior surgeries (adhesions, prolapse syndrome, etc).
Previous colonic evaluations (flexible sigmoidoscopy, colonoscopy, barium enema)?
Comorbidities (hypothyroidism, diabetes, coronary artery disease, COPD, liver/kidney disease, weight loss, etc).
Clinical examination: general appearance, habitus, emotional status? Abdominal exam: distention, mass, organomegaly, local
tenderness? Anorectal exam: perineal descent, vaginal, rectal or bladder prolapse, sphincter tone, stricture, rectocele, rectal
mass, fecal impaction?
Anoscopy/rigid sigmoidoscopy: morphologically distal obstruction?
Limited/full colonic evaluation: depending on risk factors and age, baseline exam prior to any other studies
rule out
morphologic cause of constipation.
Colonic transit time study: Sitzmark (or scintigraphic) study
characteristic marker distribution patterns:
– Complete elimination IBS.
– Diffusely dispersed throughout colon
slow-transit constipation (Figure 4–24).
– Distal accumulation
outlet obstruction defecating proctogram/dynamic MRI.
Figure 4–24.
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Sitzmark study in slow-transit constipation (colonic inertia).
ADDITIONAL TESTS (OPTIONAL)
Defecating proctogram (see above).
Dynamic MRI.
Urogynecologic evaluation.
Anophysiology studies (including EMG and balloon expulsion test).
Contrast enema.
Blood work: only if suspicion of endocrine imbalance (hypothyroidism, hypercalcemia, etc).
Classification
Temporary constipation without signs of chronicity.
Poor habit constipation.
Morphologic constipation.
Functional chronic constipation: slow-transit constipation, normal-transit constipation, pelvic floor dyssynergia.
Nonoperative Treatment
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General:
Dietary modification and stool regulation: increase fiber (> 25–30 g/day), increase fluid intake (> 1.5–2 L/day);
reserve sufficient time after meals for bowel movements (gastrocolic reflex); increase physical activity, avoid
constipating medications (if possible).
Laxatives (eg, polyethylene glycol [PEG], lubiprostone, lactulose, milk of magnesia, etc.)
Stool softeners.
Suppositories, enemas.
IBS: even if condition appears treatment-refractory, the management remains primarily nonoperative. Tegaserod maleate
(prokinetic 5-HT
4
receptor agonist withdrawn from US market in 2007, never approved in Europe) may be beneficial in
selected individuals.
Pelvic floor dyssynergia (anismus, levator ani syndrome, paradoxical puborectalis contraction): physical therapy/biofeedback
training.
Operative Treatment
INDICATION
Selected patients with treatment-refractory slow-transit constipation.
Correctable pelvic floor dysfunction and/or morphologic outlet obstruction.
OPERATIVE APPROACH
Slow-transit constipation: (sub-)total colectomy, antegrade irrigational stoma (MACE).
Rectocele: repair.
Pelvic floor descent/pelvic organ prolapse syndrome: organ suspension (rectopexy with/without sigmoid resection,
sacrocolpopexy, cystopexy), rectocele repair.
Outcome
Most active patients do well with medical management
Total abdominal colectomy: 85–90% satisfaction in properly selected patients, 50–60% if IBS and pelvic floor dysfunction
included; morbidity: 10–15% unsatisfactory bowel frequency and/or incontinence, recurrent bowel obstruction,
recurrent/persistent constipation.
Follow-Up
Functional reassessment (constipation/diarrhea, continence for stool/gas and urine) after 3 and 6 months.
Cross-Reference
Colonic transit study (Sitzmark) (Ch. 2)
Defecating proctogram (defecography) (Ch. 2)
Magnetic resonane imaging (MRI) (Ch. 2)
Hemorrhoids (455.X) (Ch. 4)
Large bowel obstruction (LBO, 560.9) (Ch. 4)
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Functional disorders—irritable bowel syndrome (IBS, 564.1) (Ch. 4)
Rectocele repair (Ch. 5)
Rectal prolapse—perineal Delorme repair (Ch. 5)
(Sub-)Total colectomy, ileorectal anastomosis (open) (Ch. 5)
FUNCTIONAL DISORDERS—IRRITABLE BOWEL SYNDROME (IBS, 564.1)
Overview
IBS ("visceral hypersensitivity") is the classical example of a functional disorder, defined as nonspecific abdominal symptoms
(pain, gas formation, etc) in association with altered bowel habits (constipation, diarrhea, both), but absence of any
morphologic or biochemical abnormalities.
Pathophysiology: disturbance of brain/gut interaction results in abnormal processing of physiologic stimuli, which triggers
altered motility, increased contractility/spasticity, and visceral hypersensitivity/-algesia and is associated with a reduced
intestinal volume tolerance.
Lacking any specific tests or markers, IBS remains a diagnosis of exclusion (the term IBS generally is overused!)
Rome III
criteria (2006) are used for standardization of diagnostic criteria: Table 4–11. Important to distinguish IBS from other benign
or malignant causes of respective symptoms. Frequent overlap with other functional and personality disorders.
Table 4–11. IBS-Defining Criteria (Rome III Criteria, 2006).
Mandatory Symptoms Supportive Symptoms
Main complaint: 2 of the following symptoms:
Abdominal discomfort or
pain:
Improvement with defecation Urgency, bloating
3 days per month in at least
past 3 months
Association with change in frequency
of bowel movements
Abnormal frequency of bowel movements ( 3 per
week or > 3 per day)
Symptom onset
6 months
before diagnosis
Association with change in form of
stool
Abnormal stool quality according to Bristol Stool
Form Scale (see Table 4–12):
Lumpy/hard
Loose/watery stool
Passing of mucus
Straining or feeling of incomplete evacuation
Subtype definition only based on stool consistency: see Classification.
High probability of frustration on patient's (quality of life) and physician's side (lack of improvement), significant financial
impact on health care system.
Epidemiology
US prevalence 8–20%, of which 65% have minor symptoms with no request for treatment, 30% sporadic physician's visit,
5% severe symptoms. Mostly female predominance, but some global variability of male/female gender ratio, eg, 1:2 (US) to
4:1 (India). All ages affected, peak 20–65 years.
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Symptoms
Abdominal symptoms: pain/discomfort with relief upon defecation, bloating, heartburn, GERD, nausea, vomiting.
Stool habits: alteration with constipation, diarrhea, mixed symptoms; urgency, discharge of mucus or blood, sense of
incomplete evacuation, straining.
Frequently associated but nondiagnostic symptoms: fibromyalgia, headache, backache, genitourinary symptoms.
Psychosocial symptoms: anxiety, panic attacks, mood disorder, sleep disturbance, etc.
Differential Diagnosis
Other benign/malignant causes of abdominal pain/discomfort, eg, partial obstruction (adhesions), diverticular disease, etc.
Other benign/malignant causes of morphologic constipation/obstruction.
Other causes of functional constipation, eg, slow-transit constipation, pelvic floor dysfunction, etc.
Coexistence of IBS with any of the above.
Pathology
No primary colonic pathology.
Evaluation
REQUIRED MINIMAL STANDARD
History:
Exact analysis of patient's symptoms including stool characteristics (Table 4–12): temporal relationship between
pain/discomfort and bowel habits.
Identification of "alarm symptoms": fever, GI bleeding, weight loss, anemia, abdominal/pelvic mass.
Identification of nonintestinal pain triggers: physical activity, urination, menstruation, trauma, etc.
List of medications (drug-induced constipation).
History of prior surgeries (adhesions, prolapse syndrome, etc).
Previous colonic evaluations (flexible sigmoidoscopy, colonoscopy, barium enema)?
Comorbidities (psychiatric, hypothyroidism, diabetes, coronary artery disease, COPD, liver/kidney disease, etc).
Table 4–12. Bristol Stool Form Scale.
Type Description of Stool Label
1 Separate hard lumps (difficult to pass) Constipation
2 Lumpy, sausage-shaped
3 Sausage with cracks on surface Normal
4 Smooth and soft sausage/snake
5 Soft blobs with clear-cut edges (passed easily)
6 Fluffy pieces (mushy) Diarrhea
7 Watery/liquid without solid pieces
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Clinical examination: general appearance, habitus, emotional status? Abdominal exam: unspecific findings, possibly
tenderness to palpation (occasionally disproportionate emotional reaction to exam), absence of true morphologic pathology.
Anoscopy/rigid sigmoidoscopy: rule out distal morphologic pathology?
Limited/full colonic evaluation: depending on age and risk factors serves as baseline exam prior to any other studies to rule
out morphologic cause of constipation.
Colonic transit time study: complete elimination of Sitzmark indicative of normal-transit constipation, consistent with IBS-C.
ADDITIONAL TESTS (OPTIONAL)
Stool examination: fecal occult blood, stool leukocytes, O&P (eg, Giardia lamblia, ameba, etc).
Other imaging modalities: defecating proctogram, dynamic MRI, small bowel follow-through, etc.
Anophysiology studies.
Classification
IBS-C: IBS with constipation hard/lumpy stools 25%, loose/watery stools < 25%.
IBS-D: IBS with diarrhea loose/watery stools 25%, hard/lumpy stools < 25%.
IBS-M: IBS with mixed symptoms hard/lumpy stools 25%, loose/watery stools 25%.
IBS-U: undefined IBS absence of sufficient abnormality in stool consistency.
IBS-A: IBS with alternating symptoms symptom fluctuance over time.
Nonoperative Treatment
General
Even treatment-refractory IBS primarily nonoperative management:
Reassurance, counseling, education.
Dietary modification: elimination of triggers, increased fluid intake (> 1.5–2 L/day).
Stool regulation: > 25–30 g bulking fibers per day, but risk of increased flatulence!
Psychosocial "hygiene," psychological support.
Acupuncture?
Probiotics?
Pain
Uncertain benefit from smooth muscle relaxants for pain relief?
Potentially low-dose antidepressant medication.
Constipation
Laxatives (eg, polyethylene glycol [PEG], lubiprostone, lactulose, milk of magnesia, etc).
Stool softeners.
Prokinetics, eg, tegaserod maleate (5-HT
4
receptor agonist, withdrawn from US market in 2007, never approved in
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Europe).
Diarrhea
Drug therapy: loperamide, diphenoxylate/atropine, cholestyramine, alosetron (selective serotonin 5-HT
3
receptor
antagonist, risk of intestinal ischemia).
Operative Treatment
INDICATION
Almost never indicated, unless specific target with high probability of functional improvement (caveat: unnecessary
operations!).
Resective surgery for normal-transit constipation (eg, subtotal colectomy) associated with high probability of failure
(patient satisfaction, quality of life, recurrent bowel obstructions, diarrhea).
OPERATIVE APPROACH
Not applicable.
Outcome
Persistent or recurrent symptoms expected, but with guidance and supportive measures most patients can be maintained
in a functional condition.
Follow-Up
Functional reassessment (pain, constipation/diarrhea, quality of life, triggering factors) at regular intervals.
Cross-Reference
Constipation (Ch. 1)
Diarrhea (Ch. 1)
Pain, abdominal (Ch. 1)
Colonic transit study (Sitzmark) (Ch. 2)
Defecating proctogram (defecography) (Ch. 2)
Magnetic resonance imaging (MRI) (Ch. 2)
Large bowel obstruction (LBO, 560.9) (Ch. 4)
Functional disorders—chronic constipation (564.0X) (Ch. 4)
(Sub-)Total colectomy, ileorectal anastomosis (open) (Ch. 5)
FUNCTIONAL ANORECTAL PAIN—LEVATOR ANI SYNDROME (569.42)
Overview
Levator ani syndrome comprises a not entirely homogenous collection of painful conditions (pain, pressure, discomfort,
burning) in the rectum, sacrum, and/or anococcygeal area that is often aggravated by long periods sitting or upright position
and is not associated with visible pathology. However, the condition may initially have been triggered by local pathology but
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now runs detached in an autonomous pain cycle.
Several synonyms: chronic proctalgia, levator ani spasm, puborectalis syndrome, pyriformis syndrome, pelvic tension
myalgia, coccygodynia, proctodynia.
Definition by Rome III criteria (2006): three mandatory criteria (preferably but not necessarily for > 3 months):
Chronic or recurrent rectal pain/aching.
Duration of episodes > 20 minutes.
Exclusion of other causes of rectal pain.
Epidemiology
Exact incidence unknown; estimated 3–6% of adults affected, one-third of whom are seeking medical attention.
Symptoms
Anorectal and (high) rectal discomfort, occasionally with radiation into gluteal muscles and lower extremities dull ache,
sensation of constant rectal pressure ("ball") or heaviness, occasional burning. Potential worsening with bowel movements.
Differential Diagnosis
Anal fissure, thrombosed external hemorrhoid, abscess and fistular disease, prostatitis, coccygodynia, proctalgia fugax, HIV-
associated ulcer, malignancy-associated lesion (cancer, melanoma, leukemia, lymphoma, etc), ischemia, IBD, cryptitis.
Pathology
Lack of visible pathology.
Evaluation
REQUIRED MINIMAL STANDARD
History: onset/pattern of symptoms, lack of specific symptoms (prolapse, lump/bump, bleeding, fevers/chills, etc)? Previous
evaluations and treatments? Stool quality, bowel habits? Emotional condition: psychological distress, tension, anxiety?
Clinical examination including anoscopy/rigid sigmoidoscopy: absence of any other painful lesions in anorectum, except
laterally: tender levator muscles
local digital pressure triggering patient's discomfort.
Full/partial colonic evaluation as per general screening guidelines.
ADDITIONAL TESTS (OPTIONAL)
Anophysiology testing, including balloon expulsion test and EMG.
Defecating proctogram.
Classification
Levator ani syndrome.
Unspecified functional anorectal pain (lack of tenderness on levators).
Nonoperative Treatment
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Maintaining stool regularity (supplemental fibers, fluid intake, stool softener, etc).
Warm sitz baths
general and pelvic floor relaxation.
Physical therapy, biofeedback training, digital massage of levator ani muscles.
Electrogalvanic stimulation (EGS): low-frequency oscillating current
induction of muscle fasciculation and fatigue break
and desensitization of spastic muscle contraction cycles.
Muscle relaxants: hyoscyamine, topical nitroglycerine, calcium antagonists.
Acupuncture?
Uncertain benefit: injection of botulinum toxin A.
Psychotherapy?
Operative Treatment
INDICATION
Surgery to be avoided.
OPERATIVE APPROACH
Not applicable.
Outcome
Combined efforts should result in 50–75% improvement.
Follow-Up
Recheck patient after 4–6 weeks of initiated treatment.
Cross-Reference
Constipation (Ch. 1)
Pain, perirectal (Ch. 1)
Anophysiology studies (Ch. 2)
Defecating proctogram (defecography) (Ch. 2)
Magnetic resonance imaging (MRI) (Ch. 2)
Anal fissure (565.0) (Ch. 4)
Functional disorders—chronic constipation (564.0X) (Ch. 4)
Functional anorectal pain—proctalgia fugax (569.42) (Ch. 4)
FUNCTIONAL ANORECTAL PAIN—PROCTALGIA FUGAX (569.42)
Overview
Proctalgia fugax comprises sporadic sudden attacks of severe anorectal pain (acute muscle spasm) lasting several seconds or
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minutes with subsequent complete resolution. Attacks lack a morphologic pathology, may occur during sleep and wake the
patient up. Occurrence overall infrequent with < 5 episodes per year in 50% of patients.
Definition by Rome III criteria (2006): 3 mandatory criteria (preferably but not necessarily for > 3 months):
Recurrent episodes of anal or lower rectal pain.
Duration of episodes: seconds to minutes.
Absence of anorectal pain between episodes.
Epidemiology
Exact incidence unknown, estimated 5–15% of adults sporadically affected, of whom < 20% seek medical attention. Equal
gender distribution.
Symptoms
Sharp and severe anorectal and low rectal pain.
Differential Diagnosis
Anal fissure, thrombosed external hemorrhoid, abscess and fistular disease, prostatitis, levator ani syndrome, coccygodynia,
HIV-associated ulcer, malignancy-associated lesion (cancer, melanoma, leukemia, lymphoma, etc), ischemia, IBD, cryptitis.
Pathology
Lack of visible pathology.
Evaluation
REQUIRED MINIMAL STANDARD
History: characteristic description of attacks (time, duration, frequency)? Lack of specific anorectal/pelvic symptoms:
prolapse, lump/bump, bleeding, fevers/chills, etc? Previous evaluations and treatments? Stool quality, bowel habits?
Emotional condition: psychological distress, tension, anxiety?
Clinical examination including anoscopy/rigid sigmoidoscopy: intervals of complete absence of any pathology or pain.
Full/partial colonic evaluation as per general screening guidelines.
ADDITIONAL TESTS (OPTIONAL)
Only if clinical diagnosis is in doubt:
Anophysiology testing, including balloon expulsion test and EMG.
Defecating proctogram.
Classification
Sporadic form.
Familial form.
Nonoperative Treatment