Download - Bahan_kuliah Konstipasi.ppt
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