Boehringer Simp Obst Kronik Ukrida 070413 (Chudahman Manan)
Boehringer Simp Obst Kronik Ukrida 070413 (Chudahman Manan)
Boehringer Simp Obst Kronik Ukrida 070413 (Chudahman Manan)
Nama Tempat & Tanggal lahir Alamat Pekerjaan Riwayat pendidikan : : : : : Dr. dr. H. CHUDAHMAN MANAN SpPD-KGEH , FINASIM Jakarta, 1 Juni 1951 Jl. Taman Golf 6, BG 1, No. 7, Cipondoh Tangerang. (15515) Staf Senior Divisi Gastroenterologi, Dept. Ilmu .Penyakit .Dalam FKUI/RSUPNCM, Fakultas Kedokteran UI, tahun 1976 Spesialis Penyakit Dalam FKUI tahun 1986 JICA Program in Gastroenterology, Tokyo,1989 Konsultan Gastroentero-Hepatologi, th. 1996 S3 , Sains Veteriner, IPB 2012 Kepala Puskesmas Kota Agung, Lahat, Sum-Sel 1976-1980 Kepala RSUD Kabupaten Lahat, Sum-Sel 1980-1981. Pendidikan Spesialis Penyakit Dalam FKUI/RSCM, 1981-1986 Spesialis P.Dalam RS Sekupang Batam 1986 Koordinator Pelayanan Masyarakat, Bag.I.P.Dalam FKUI/RSCM 1998-2000 Ketua Divisi Gastroenterologi, Dept.I.P.Dalam FKUI/RSUPNCM 2001-2008 Anggota Ikatan Dokter Indonesia (IDI) Anggota Perhimpunan Ahli Penyakit Dalam Indonesia Advisory PB PGI/PEGI Anggota Perhimpunan Peneliti Hati Indonesia (PPHI) Anggota Perkumpulan Onkologi Indonesia Councillor Asian Pasific Association of Gastroenterology Councillor Asian Pacific Association of Digestive Endoscopy Member OMED (Word organization of Digestive Endoscopy) Dalam dan Luar Negeri
Riwayat pekerjaan
Organisasi
Publikasi
Chudahman Manan
Indonesian Society of Gastroenterology
Epidemiology
oConstipation problem most finding in western country. oIn USA constipation prevalence 2-27% with physician consultation about 2.5 million and hospitalized patients about 100.000 pts. oData from RSCM-Jakarta during 1998-2005, 2.397 colonoscopy exam , 216 (9%) indication for constipation oGender comparative women and men (4 : 1)
Sumber: buku konsensus nasional penatalaksanaan konstipasi di Indonesia oleh PGI
Infrequent
Occasional or short-term condition that may temporarily interrupt usual routine May be brought on by patients behavior, change in diet, lack of exercise, illness, or medication May be relieved by diet, exercise, and over-the-counter (OTC) medication
Discomfort
IBS GERD
Abdominal Pain Regurgitation
Heartburn
Chronic constipation
35
30 25 20 15 10
8 8 25-40 2-28 25 3-20 6-18 28
5
0
Chronic DyspepsiaFunctional GERD Heartburn Constipation IBS Hyper- Migraine Asthma Diabetes tension
Wong WM, Fass R. Curr Treat Options Gastroenterol. 2004;7(4):273-278. Corazziari E. Best Pract Res Clin Gastroenterol. 2004;18(4):613-631. Higgins PD, Johanson JF. Am J Gastroenterol. 2004;99(4):750-759. Brandt L, et al. Am J Gastroenterol. 2002;97(suppl11):S7-26.
Wolf-Maier K, et al. JAMA. 2003;289:2363-2369. Lawrence EC. South Med J. 2004 Nov;97(11):1069-1077. CDC. MMWR Morb Mortal Wkly Rep. 2004;53:145-148. CDC. MMWR Morb Mortal Wkly Rep. 2003;52:833-837.
8 6 4 2 0
10
Study 1 N = 42,375
25 20 15 10
Men
Women
5
0
N = 5,430 Drossman
Study 2
N = 1,149 Pare
Study 3
N = 10,018 Stewart
Study 4
Sex
Lembo A, Camilleri M. N Engl J Med. 2003;349:1360-1368. Muller-Lissner S. Best Pract Res Clin Gastroenterol. 2002;16:115-133.
Social Functioning
Mental Health
Health Perception
Bodily Pain
o Slow-transit constipation
o Defecatory dysfunction o IBS with constipation
Bosshard W, et al. Drugs Aging. 2004;21:911-930. Hadley S.K, et al. Journal of Am Fam Physician. 2005;72:2501-2506.
Type 1 Type 2
Type 3
Type 4 Type 5 Type 6
Fast Transit
Type 7
Primary Constipation
Slow-transit Constipation
Characterized by prolonged intestinal transit time Altered regulation of enteric nervous system Decreased nitric oxide production Impaired gastrocolic reflex Alteration of neuropeptides (VIP, substance P) Decreased number of interstitial cells of Cajal in the colon Irritable Bowel Syndrome (IBS) with Constipation Alterations in brain-gut axis
Stress-related condition Visceral hypersensitivity Abnormal brain activation Altered gastrointestinal motility Role for neurotransmitters, hormones Presence of non-GI sympt Headache, back pain,
fatigue, myalgia, dyspareunia, urinary symptoms, dizziness
Primary Constipation(1):
Normal-transit Constipation
Intestinal transit and stool frequency are within the normal range Most frequent type of constipation
Bosshard W, et al. Drugs Aging. 2004;21:911-930. Gallagher P, et al. Drugs Aging. 2008;25(10):807-821.
Primary Constipation(2):
Slow-transit Constipation
Characterized by prolonged intestinal transit time Altered regulation of enteric nervous system Decreased nitric oxide production Impaired gastrocolic reflex Alteration of neuropeptides (VIP, substance P) Decreased number of interstitial cells of Cajal in the colon
Primary Constipation(3):
Defecatory Dysfunction
More common in older women childbirth trauma Pelvic floor dyssynergia Contributing factors include anal fissures, hemorrhoids, rectocele, rectal prolapse, posterior rectal herniation Excessive perineal descent Pathogenesis may be multifactorial structural problem Abnormal anorectal manometry and/or defecography
Bosshard W, et al. Drugs Aging. 2004;21:911-930. Hadley S.K, et al. Journal of Am Fam Physician. 2005;72:2501-2506.
Primary Constipation(4):
Irritable Bowel Syndrome (IBS) with Constipation Alterations in brain-gut axis
Stress-related condition Visceral hypersensitivity Abnormal brain activation Altered gastrointestinal motility Role for neurotransmitters, hormones Presence of non-GI symptoms Headache, back pain, fatigue, myalgia, dyspareunia,
urinary symptoms, dizziness
Videlock E, Chang L. Gastroenterol Clin N Am. 2007;36:665-685. Hadley SK, et al. Journal of Am Fam Physician. 2005;72:2501-2506.
Criteria must be fulfilled for the last 3 months, with symptom onset at least 6 months prior to diagnosis
In pathophysiology research and clinical trials, a pain/discomfort frequency of at least 2 days a week during screening for patient eligibility
Longstreth G, et al. Gastroenterology. 2006;130:1480-1491.
Straining
Loose stools are rarely present without the use of laxatives Insufficient criteria for irritable bowel syndrome
*Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis
Patient Care :
o Through patient history o Physical/abdominal/digital rectal exams o Evaluate symptoms in terms of diagnostic criteria Chronic constipation/IBS-C o Assessment for red flags/alarm features o Need for additional testing o Treatment/Management plan
90 80 Percent of Patients 70 60 50 40 30 20 10 0
39
37
36 28
Straining
Hard or Incomplete Stool Abdominal < 3 BM lumpy emptying per cannot fullness or stools bloating week be passed
Supportive exam :
Colonoscopy
Mediators of Gl Function
Motility Visceral Sensitivity
Serotonin Acetylcholine Nitric oxide Substance P Vasoactive intestinal peptide Cholecystokinin Corticotropin releasing factor Serotonin Tachykinins Calcitonin gene-related peptide Neurokinin A Enkephalins Corticotropin releasing factor
Secretion
Serotonin Acetylcholine
Common Changes with Aging that Increase the Risk for Constipation
o o o o o o o Decreased total body water Decreased colonic motility* Deterioration of nerve function Increased pelvic floor descent Decreased rectal compliance Decreased rectal sensation Age-related changes to the internal and external anal sphincter
Gallagher P, et al. Drugs Aging. 2008;25(10):807-821. Schiller L. Gastroenterol Clin N Am. 2001;30:497-515.
Surgical
Lifestyle
Opiates Antidepressants Anticholinergics Antipsychotics Antacids (Al, Ca) Ca channel blockers Iron supplements
Drugs
Constipation
Neurological Gastrointestinal
Colorectal: neoplasm, ischemia, volvulus, megacolon, diverticular disease Anorectal: prolapse, rectocele, stenosis, megarectum
Metabolic/ Endocrine
Parkinsons Multiple sclerosis Autonomic neuropathy Aganglionosis (Hirschsprungs, Chagas) Spinal lesions Cerebrovascular disease
Systemic
Amyloidosis Scleroderma Polymyositis Pregnancy
Exclude slow transit Bulking agents, osmotic laxatives, Cl channel activators, stimulant laxatives
Reality
No evidence to support this theory Fluctuations in sex hormones during the menstrual cycle have minimal impact on constipation, but are associated with changes in other GI symptoms Changes in hormones during pregnancy may play a role in slowing gut transit A low fiber diet may be a contributory factor in a subgroup of patients with constipation Some patients may be helped by an increase in dietary fiber, others with more severe constipation may get worse symptoms with increased dietary fiber intake No evidence that constipation can be treated successfully by increasing fluid intake unless there is evidence of dehydration
Reality
Unlikely that stimulant laxatives at recommended doses are harmful to the colon No data support the idea that stimulant laxatives are an independent risk factor for colorectal cancer Laxatives can cause electrolyte disturbances, but appropriate drug and dose selection can minimize such effects Tolerance is uncommon in most laxative users, however tolerance to stimulant laxatives can occur in patients with severe constipation and slow colonic transit No potential for addiction to laxatives, but laxatives may be misused
Lifestyle Modifications
Modification
Increase fluid intake
Targeted Mechanism
Increase stool volume by augmenting luminal fluid
Efficacy
Limited; majority of fluid is absorbed before reaching the colon and is expelled via urine Moderate; some evidence suggests this is beneficial; however, not sufficient to treat Limited benefit compared with placebo
Increase exercise
Chung BD, et al. J Clin Gastroenterol. 1999;28:29-32. Dukas L, et al. Am J Gastroenterol. 2003;98:1790-1796. ACG Chronic Constipation Task Force. Am J Gastroenterol. 2005;100(suppl 1):S1-S4.
80
66 60 50 44 50 50
60
40
20
0
Ineffective Relief Ineffective Relief of of Constipation Multiple Symptoms Lack of Predictability Ineffective Relief of Bloating
Description
Absorbs liquids in the intestines and swells to form a soft, bulky stool; the increase in fecal bulk is associated with accelerated luminal propulsion Draws water into the bowel from surrounding body tissues providing a soft stool mass and improved propulsion [saline, poorly absorbed mono- and disaccharides, polyethylene glycol] Cause rhythmic muscle contractions in the intestines, increase intestinal motility and secretions Coats the bowel and the stool mass with a waterproof film; stool remains soft and its passage is made easier Helps liquids mix into the stool and prevent dry, hard stool masses; has been said not to cause a bowel movement but instead allows the patient to have a bowel movement without straining Combinations containing more than 1 type of laxative; for example, a product may contain both a stool softener and a stimulant laxative
Combinations
Laxatives
Laxative Type
Methylcellulose
Generic Name
Citrucel
Brand Name(s)
Bulk-forming
FiberCon, Fiber-Lax Metamucil, Konsyl Glycerin suppository (generic) Mineral oil (generic) Phillips M-O
Lubricating
Stool Softeners
Saline
Docusate sodium
Magnesium hydroxide (milk of magnesia) Bisacodyl Sodium bicarbonate and potassium bitartrate
Stimulant
Osmotic
Study result:
Complete Spontaneous bowel movement at first day & 4 weeks after treatment :
Placebo Total patients 117 Bisacodyl 239
1.1
2.0 3.3
1.1
5.2
Significant difference the end result from 2 groups , bisacodyl more superior than placebo
Result :
Complete spontaneous bowel movement after 4 weeks
** ** ** **
Result :
Avarage Spontaneous Bowel Movement after 4 weeks
**
**
** **
Bisacodyl increase QOL from patients with constipation recovery bowel habit every day . 80% patients have satisfied with Bisacodyl.
o Regular bowel habit everyday o Decreased constipation symptoms o Decreased bloating symptoms o Decreased abdominal discomfort
Alarm Symptoms
Continue regimen
No response
Summary
o Chronic constipation is a common condition mostly in the elderly o Quality of life pts with constipation especialy in elderly patients is negatively affected by the symptoms of chronic constipation o Identify risk factors and secondary causes for constipation o Be vigilant for red flags or alarm symptoms; directed tested may be necessary
Summary contd
o Main objective of treatment for chronic constipation is to improve patients symptoms, restore normal bowel function ( 3 bowel movements per week), improve quality of life o Bisacodyl have good therapeutic effect and minimal side effect with good safety profile