Under dyschezia refers to difficulty in defecation. Patients feel the presence of the chair and feel urge to defecate, but are not able to eliminate chair. This inability is due to a lack of coordination of pelvic floor muscles and anal sphincters. Diagnosis requires an anorectal examination. Treatment is difficult, however, biofeedback can have beneficial effects.
Many people mistakenly assume that a daily bowel movement is necessary and complain about constipation when bowel movements occur less frequently. Others are concerned about the appearance (size, shape, color) and the consistency of the stool. Sometimes the main Esch Pay is to dissatisfaction with the process of defecation or a feeling of incomplete evacuation after defecation. Constipation is blamed for many problems (abdominal pain, nausea, fatigue, loss of appetite), which are in fact symptoms of the underlying problem (eg. As irritable bowel syndrome or depression). Patients should not expect that all the symptoms can be alleviated only through daily bowel movement. Measures to change bowel habits should be used with caution.
From constipation refers to difficult or rare bowel movements, hard stools or a feeling of incomplete defecation. Many people mistakenly assume that a daily bowel movement is necessary and complain about constipation when bowel movements occur less frequently. Others are concerned about the appearance (size, shape, color) and the consistency of the stool. Sometimes the main Esch Pay is to dissatisfaction with the process of defecation or a feeling of incomplete evacuation after defecation. Constipation is blamed for many problems (abdominal pain, nausea, fatigue, loss of appetite), which are in fact symptoms of the underlying problem (eg. As irritable bowel syndrome or depression). Patients should not expect that all the symptoms can be alleviated only through daily bowel movement. Measures to change bowel habits should be used with caution. Compulsive patients feel that they must rid their bodies daily from “every unclean thing.” These patients often spend extremely long hours on the toilet and develop a chronic Abführmittelabusus. Etiology Acute constipation suggests an organic cause, whereas chronic constipation may be organic or functionally related (see Table: Causes of Opstipation). In many patients, the Opstipation is connected to a slow transport of stool through the colon. This delay can be obtained by drugs, organic conditions, a disturbance of function or defäkatorischen a nutritionally dependent Strörung conditionally (see table: food, which often affect the gastrointestinal function) (i.e., a dysfunction of the pelvic floor..). Patients with impaired bowel movements do not generate sufficient rectal propulsive forces and can not relax during defecation the puborectalis or the external anal sphincter, or both. In irritable bowel syndrome patients have symptoms (eg. As abdominal pain and altered bowel habits), but have usually have a normal intestinal transit and normal anorectal functions. However, at the same time be a disturbed because of irritable bowel syndrome bowel movements. Excessive effort, perhaps as a result of pelvic floor dysfunction can to anorectal pathology (. Eg hemorrhoids, anal fissures and rectal prolapse) and possibly even lead to impotence. The stalling of stool, which is the result of a Opstipation or causes this, is also prevalent in the elderly, especially with prolonged bed rest or decreased physical activity. Constipation is often the result of a Bariumeinnahme, either orally or as an enema. Causes of Opstipation causes examples Acute constipation * bowel obstruction volvulus, hernia, adhesions, Stuhleinklemmung adynamic ileus peritonitis, severe acute illness (eg. As sepsis), brain or spinal cord trauma, bed rest medicines anticholinergics (eg. As antihistamines, neuroleptics, Parkinson’s drugs, antispasmodics), cations (iron, Alumini to, Ca, barium, bismuth), opioids, Ca-channel blocker, anesthetics generally constipation shortly after the beginning of therapy Chronic with a drug constipation * colon tumor adenocarcinoma of the sigmoid colon metabolic disorders diabetes mellitus, hypothyroidism, hypocalcemia or hypercalcemia, pregnancy, uremia, porphyria CNS disorders Parkinson’s disease, multiple sclerosis, stroke, spinal cord injury disturbances de s peripheral nervous system Hirschsprung’s disease, neurofibromatosis, autonomic neuropathy Systemic diseases scleroderma, amyloidosis, dermatomyositis, myotonic dystrophy Functional disorders constipation, irritable bowel syndrome, pelvic floor dysfunction (functional defecation disorders) dietary factors Low-fiber diet, low-sugar diet, chronic abuse of laxatives * There are some Überschneidun gen between the acute and chronic causes of constipation. In particular, drugs are among the most common causes of chronic constipation. Foods that often gastrointestinal function affect food with probable loss of bowel movements and / or excessive gas formation all caffeinated beverages, especially coffee with chicory peaches, pears, cherries, apples fruit juices: orange, cranberry, apple asparagus and cabbage vegetables such as broccoli, cauliflower, cabbage and Brussels sprouts Kleiemüsli, wholemeal bread, high-fiber Leb ensmittel pastries, sweets, chocolate, waffle syrup, donuts wine (> 3 glasses in sensitive individuals) milk and milk products (for lactose sensitive individuals) foods that are believed to cause constipation or loss of Darmbewegegungen contribute rice, bread, potatoes, pasta, veal, poultry, fish Cooked vegetables banana clarification history, the history of existing disease should the entire life of the patient to be a comprehensive history regarding stool frequency and consistency, they should clarify whether he must make an effort, or whether he (perineal maneuvers such. B. pressure to the perineum, buttocks area or the recto-vaginal wall) during a bowel movement applies also satisfaction should be queried after a bowel movement, including the frequency and duration of use of laxatives or enemas. Some patients deny an earlier constipation, but to specific questions they admit to use daily 15-20 min for a bowel movement. Deposits, amount and duration of blood in the stool should also be identified. In a review of organ systems of underlying medical conditions (suspected cancer) should be wanted by symptoms, including a change in stool caliber or blood in the stool. Even after systemic symptoms that suggest a chronic illness (eg. As weight loss), should be sought. The history should ask questions about known causes including previous abdominal surgery and symptoms of metabolic (z. B. hypothyroidism, diabetes mellitus) and neurological (eg. As Parkinson’s disease, multiple sclerosis, spinal cord injury) disease. The use of prescription and non-prescription medicines should be found which specifically looking anticholinergics and opioids asking ist.Körperliche investigation There is a whole-body examination carried out by focusing on signs of illness System incl. Fever and cachexia. Abdominal masses should be determined by palpation. A rectal examination should be done not only to detect fissures, strictures, blood or masses (including fecal impaction), but (the puborectalis relaxed when patients squeeze the anal sphincter) and to assess the anal resting tone, perineal reduction during simulated defecation and the rectal sensitivity. Patients with defecation disorders show increased anal resting tone (or anismus), reduced (<2 cm) or increased (> 4 cm) perineal reduction and / or a paradoxical contraction of the puborectalis muscle during simulated Stuhlentleerung.Warnhinweise Certain findings substantiate the suspicion on a more serious cause of chronic constipation: distended, tympanitic stomach vomiting blood in stool weight loss severe constipation that has recently occurred or worsened in the elderly interpretation of the findings, certain symptoms (such as a sense of anorectal blockade, prolonged or. difficult defecation), especially if they are associated with abnormal (ie increased or decreased) perineal movements during the simulated defecation, suggest a defecation. A tense, distended, tympanitic abdomen, especially if nausea and vomiting persist, suggests a mechanical obstruction. Patients with irritable bowel syndrome have abdominal pain with irregular bowel habits in general. Chronic constipation with moderate abdominal pain in a patient who uses laxatives for a long time, suggests a constipation. Acute constipation, which occurs simultaneously with the ingestion of a constipation-promoting drug in patients without suspected findings, suggests a cause of the drug. A newly emerged constipation, consisting weeks or intermittently occurring with increasing frequency and intensity, is suspect of the existence of a colon tumor or for other causes of partial intestinal obstruction in the absence of a known cause. Excessive exertion or prolonged or unsatisfactory defecation with or without anal Digivolution suggests a defecation. Patients with Stuhleinklemmung show spasms and disposal of aqueous mucus or stool components that have formed around the impacted stool mass and diarrhea pretend (paradoxical diarrhea) .Testverfahren The study is based on the clinical appearance and the nutritional history of the patient. Constipation with a clear cause (drugs, trauma, bed rest) can be treated symptomatically without further investigation. Patients with symptoms of intestinal obstruction require a plain abdominal lying and standing, possibly an enema with a water soluble contrast agents for the evaluation of colonic obstruction, and possibly a CT or Bariumkontrastdarstellung of the small intestine (bowel obstruction: diagnosis). Most patients with no clear etiology require a colonoscopy and a laboratory examination (examination of the blood count, TSH, fasting glucose, electrolytes and calcium). Further investigations are reserved with pathological results of the above discussed tests or those who do not respond to symptomatic treatment usually patients. If the main complaint image are irregular Defäkationen that colonic transit using radioresistant contrast agents (based markers) or scintigraphy should be determined. If the main complaint image include difficulty in defecation, anorectal manometry and rectal Ballonexpulsion should be made. In patients with chronic constipation, it is important to distinguish between slow transit constipation (abnormal radiation-resistant seat marker contrast study) and dysfunction of the pelvic floor muscles (the contrast medium is only in the distal colon withheld) to distinguish. Therapy may discontinuation of the causative drugs (some may be necessary) increase in fiber intake if necessary Experiment with a short application osmotic laxatives Each identified cause should be treated See Table substances for the treatment of constipation for a summary. Laxatives should be used judiciously. Some (eg., Phosphate, bran, cellulose) bind drugs and interfere with their absorption. A fast passage of stool may limit the optimal absorption of medicines and food. Contraindications laxative exist in acute abdominal pain of unknown origin, inflammatory bowel disease, intestinal obstruction, gastrointestinal bleeding and Stuhleinklemmung. Diet and behavior The diet should contain a sufficient amount of fiber (typically 15 to 20 g / day) in order to ensure an adequate amount of stool. Vegetable fiber, which is non-digestible and non-resorbable in the majority, increase the amount of stool. Determine components of dietary fiber absorb liquid to soften the stool and facilitate passage. Fruits and vegetables are highly recommended as a dietary fiber, in addition, also contain cereals, bran. The additional fiber intake is particularly effective in the treatment of normal transit constipation, but is not very effective in slow transit constipation or defecation. Lifestyle changes can be helpful. Patients should try to defecate daily at the same time, preferably 15-45 minutes after breakfast because the food intake increases intestinal motility. Initial efforts to establish a regular, moderate defecation by glycerol-containing suppositories can be supported. The informed consent discussion is important, but it is difficult to convince compulsive patients that their attitude to bowel movement is abnormal. The doctor must explain that daily bowel movements are not essential to the gut the ability to function by itself must be given, and that the frequent use of laxatives or enemas (more than once in three days) the gut robbed this possibility. Drugs for the treatment of constipation drug dose side effects of fiber bran * Up to 1 cup / day bloating, flatulence, iron and Kalziumalabsorption psyllium up to 10-15 g / day in single doses of 2.5 to 7.5 g bloating, flatulence methylcellulose Up to 6-9 g / day in divided doses of 0.45 to 3 g less inflation than other fiber calcium polycarbophil 2-6 tablets / day bloating, flatulence emollients docusate sodium 100 mg 2 or 3 times per day ineffective in severe constipation glycerin 2-3 g suppository once daily. irritation of the rectal mucosa Mineral oil 15-45 ml p.o. once daily. grease pneumonia, malabsorption of fat soluble vitamins, dehydration, fecal incontinence osmotic substances sorbitol 15-30 ml p.o. of a 70% solution of 1 to 2 times a day. 120 ml rectally a 25 to 30% solution Temporary abdominal cramps, flatulence lactulose 10-20 g (15-30 ml), 1 to 4 times a day. Temporary abdominal cramping, flatulence polyethylene glycol 17 g daily. fecal incontinence (dose dependent) magnesium MgCl2 or Mg-sulfate tablets 1-3 g 4 times a day magnesium milk 30-60 ml / day magnesium citrate 150-300 ml / day (up to 360 ml) of magnesium toxicity , Deh ydrierung, abdominal cramps, fecal incontinence, diarrhea sodium phosphate 10 g p.o. once as colonic irrigation Rare cases of acute renal failure stimulants anthraquinones Depending on the used Abdominal brand cramps, dehydration, melanosis coli, malabsorption, possibly adverse effects on intramural nerves bisacodyl 10 mg suppositories up to 3 times / week 5-15 mg / Tag po Fecal incontinence, hypokalemia, abdominal cramps, burning sensation in the rectum with daily use of suppositories linaclotide 145-290 micrograms p.o. once / day for at least 30 minutes before the first meal of abdominal pain, bloating, contraindicated in children <6 years avoided in children <17 years lubiprostone 24 mcg p.o. 2 times daily. With food nausea, especially on an empty stomach enemas Mineral oil / olive oil retention 100-250 ml / day rectal fecal incontinence, mechanical trauma tap water 500 ml rectally mechanical trauma phosphate 60 ml rectally accumulation of injury to the rectal mucosa, hyperphosphatemia, mechanical trauma Soapy water 1500 ml rectally accumulation of injuries to the rectal mucosa, mechanical trauma * The dose of dietary fiber supplements should be gradually increased over several weeks up to the recommended dose. lubiprostone is available by prescription only and is approved for long-term use. Mod after Romero Y, JM Evans, Fleming KC, Phillips SF. Constipation and fecal incontinence in the elderly population. Mayo Clinic Proceedings 71: 81-92, 1996; by kind. Approval. Types of laxatives filling substances (eg psyllium, calcium polycarbophil, methylcellulose.) Act slowly and gently and represent the safest substances for the stimulation of defecation The correct application includes a slow increase of the dose -. Three ideally to four times daily with a sufficient amount of liquid (. for example, 500 ml / day additional fluid) taken to prevent a hardening - is formed to softer and bulkier chair. Flatulence can be reduced by gradually increasing the amount of fiber to the recommended dose, or by switching to a synthetic fiber preparation, such as methyl cellulose. Osmotic agents contain heavy absorbable polyvalent ions (eg., Magnesium, phosphate, sulfate), polymers (eg., Polyethylene glycol), or carbohydrates (for. Example, lactulose, sorbitol) which remain in the intestine, thereby increasing the intraluminal osmotic pressure and pull in this way water into the intestine. The correspondingly increasing volume of the intestinal contents stimulates peristalsis. These substances act usually within 3 hours. In general, osmotic laxatives are reasonably safe even when used regularly. However, sodium phosphate should not be used as a preparation for colon cleansing, since it can come in a single application to acute kidney failure in rare cases themselves. These events occurred primarily in the elderly, specifically those with pre-existing kidney disease and those taking medications that affect renal perfusion or function (eg. As diuretics, ACE inhibitors, angiotensin II receptor blockers) , Also, magnesium and phosphate are partially absorbed and (z. B. in renal failure) may be detrimental under certain conditions. Sodium (in some applications) may worsen heart failure. In large and frequent doses, these drugs can disrupt the fluid balance and electrolyte balance. Another approach to colon cleansing for diagnostic examinations, preoperative or possibly also in chronic constipation provide large volumes of balanced osmotic substances is (polyethylene glycol electrolyte solution) that are given orally or via a feeding tube. Secretory or stimulant laxatives (z. B. phenolphthalein, bisacodyl, castor oil, anthraquinones) act via an irritation of the intestinal mucosa or via a direct stimulation of submucosal and myenteric plexus. Although phenolphthalein was withdrawn from the US market after animal studies suggesting the suspicion that the connection is carcinogenic, it is for humans no epidemiological evidence. Bisacodyl is an effective drug for the treatment of chronic constipation. The anthraquinones senna, cascara sagrada, aloe and rhubarb are common ingredients of herbal and over the counter laxatives. You arrive unchanged in the colon where they are converted by the bacterial metabolism into active forms. Side effects include allergic reactions, electrolyte imbalance, melanosis coli and a cathartic colon. Melanosis coli refers to a brownish-black colorectal pigmentation of unknown composition. The cathartic colon refers to changes in the colon anatomy as they show up in patients with chronic laxative use in the Bariumkontrastdarstellung. It is unclear whether the cathartic colon, which was attributed to a destruction of the neurons of the myenteric plexus by anthraquinones, by currently available substances or other neurotoxic agents (e.g., B. podophyllin) which are no longer available, is caused. It seems to be connected to a long-term Anthrachinoneinsatz no increased risk of colon cancer. It can enemas, incl. Mains water and commercially available hypertonic solutions are applied. Emollient substances (eg. B. docusate, mineral oil) cause a slow softening of the chair and thus facilitate the passage. However, they are not effective stimulators of defecation. Docusate is a surface-active substance, which allows water to be absorbed by the stool and softens the mass in this way and vermehrt.Stuhleinklemmungen Stuhleinklemmungen are initially with enemas of tap water, followed by small inlets (100 mL) of commercially available hypertonic solutions. If these measures do not work, a manual crushing and exposing the stool mass is necessary. This procedure is painful, so the perirectal and intrarectal administration of local anesthetics (eg. As lidocaine 5% or 1% dibucaine) is recommended. Some patients require sedation. Geriatric basics constipation in the elderly used due to low fiber diet, lack of exercise, comorbidities and use of drugs with obstipierender side effect. Many older people have misconceptions regarding the normal bowel activity and regularly use laxatives. Other changes that the elderly predispose to constipation include increased rectal compliance and impaired rectal sensation stimulus (so that larger quantities in the rectum are required to trigger the desire for defecation). Key points Drug causes are common (eg. As chronic abuse of laxatives, use of anticholinergic drugs or opioids). An intestinal obstruction is to think always when an acute and severe constipation is present. Symptomatic treatment is appropriate in the absence of suspicious findings and after exclusion of pelvic floor dysfunction. Dyschezia (Impaired defecation; dysfunction of pelvic floor and anal sphincters; functional defecation; dyssynergia) Under dyschezia is understood difficulty in defecation. Patients feel the presence of the chair and feel urge to defecate, but are not able to eliminate chair. This inability is due to a lack of coordination of pelvic floor muscles and anal sphincters. Diagnosis requires an anorectal examination. Treatment is difficult, however, biofeedback can have beneficial effects. Normally the etiology is increased defecation of rectal pressure, while relaxation of the external anal sphincters. This process may be influenced by one or more disorders (eg. B. limited rectal contraction, excessive contraction of the abdominal wall, paradoxical anal contraction, failure of the anal relaxation) of unknown etiology. Functional defecation disorders manifest at any age. In contrast, the Hirschsprung's disease, which is characterized by the absence of rektoanalen inhibitory reflex is almost always in childhood or in adolescence diagnostiziert.Symptome and complaints has the patient or does not feel that stool in the rectum is. Despite prolonged effort defecation is tedious, if not impossible, this is true even for soft chairs or enemas. Patients complain of anal blockage and remove digital chair from her rectum or manipulate manually perineum or vagina to empty chair. Die tatsächliche Stuhlfrequenz kann oder kann nicht herabgesetzt sein.Diagnose Untersuchungen des Rektums und des Beckens können eine Hypertonie der Beckenbodenmuskulatur und des Analsphinkters aufdecken. Bei der Abklärung zeigen die Patienten unter Umständen nicht die erwartete anale Erschlaffung oder perianale Senkung. Durch übermäßiges Drücken prolabiert die Rektumvorderwand bei Patienten mit eingeschränkter analer Entspannung in die Vagina; solche Rektozelen sind in der Regel eher eine sekundäre als eine primäre Störung. Eine lange bestehende Dyschezie mit chronischem Drücken beim Stuhlgang kann ein solitäres Geschwür oder einen Rektumprolaps unterschiedlicher Ausprägung, eine exzessive perianale Senkung oder eine Enterozele hervorrufen. Eine anorektale Manometrie