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Curriculum Vitae
Nama
Tempat & Tanggal lahir
Alamat
:
:
:
Pekerjaan
:
Riwayat pendidikan
:
Riwayat pekerjaan
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Organisasi
:
Publikasi
:
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
Current management of
chronic constipation
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
How Do We Define
Constipation?
o The American College of Gastroenterology (ACG)
definition of constipation:
o Unsatisfactory defecation characterized by infrequent
stools, difficult stool passage, or both. Difficult stool
passage includes straining, a sense of difficulty passing
stool, incomplete evacuation, hard/lumpy stools,
prolonged time to pass stool, or need for manual
maneuvers to pass stool
o The ACG Chronic Constipation Task Force also
clarified what is meant by chronic:
o Chronic constipation is defined as the presence of these
symptoms for at least 3 months
American College of Gastroenterology Chronic Constipation Task Force. Am J Gastroenterol. 2005;100(S1):1-4.
Differentiating Between
Occasional and Chronic Constipation
Occasional Constipation
Chronic Constipation
Infrequent
Present for at least 3 months
and may persist for years
Occasional or short-term
condition that may temporarily
interrupt usual routine
Long-term condition that may
dominate personal and work life
May be brought on by patient’s
behavior, change in diet, lack of
exercise, illness, or medication
Not only related to patient’s
behavior, change in diet, lack of
exercise, or medication
May be relieved by diet, exercise,
and over-the-counter (OTC)
medication
May need medical attention and
prescription medication
Overlap Between Common
Disorders
Bloating
Belching
Constipation
Chronic
Constipation
Dyspepsia
IBS
Discomfort
GERD
Heartburn
Brandt L, et al. Am J Gastroenterol. 2005;100(S1):5-22.
Abdominal
Pain
Regurgitation
Abdominal Pain: Salient Feature
Absent in Chronic Constipation
(-) Abdominal Pain
Chronic
constipation
(+) Abdominal Pain
IBS with
constipation
Presence or absence of abdominal pain is the
major differentiating feature
Brandt LJ, et al. Am J Gastroenterol. 2005;100(suppl 1):S5-S21.
Prevalence of Functional
Gastrointestinal Disorders
45
Population (%)
40
40
35
30
25
25-40
2-28
28
25
3-20
20
6-18
15
10
8
8
5
0
Chronic
DyspepsiaFunctional
GERD
Heartburn Constipation
IBS
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.
Hyper- Migraine Asthma Diabetes
tension
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.
Constipation Increases With Age
and Is More Common in Women
10
Harari, et al
Population: NHIS 1989
Criteria: self-report
8
6
4
2
25
Prevalence of
Constipation (%)
Prevalence of
Constipation (%)
12
Study 1
N = 42,375
0
Men
20
15
10
5
0
Study 2
N = 5,430
Drossman
Age Group (years)
NHIS = National Health Interview Survey
Higgins PDR, et al. Am J Gastroenterol. 2004;99:750-759.
Women
Study 3
N = 1,149
Pare
Sex
Study 4
N = 10,018
Stewart
Normal Physiology of Defecation
o Increased abdominal pressure or propulsive colorectal
contractions
o Relaxation of internal anal sphincter (autonomic)
o Relaxation of external anal sphincter (voluntary)
o Straightening of pelvic musculature (levator ani,
puborectalis)
At rest
Lembo A, Camilleri M. N Engl J Med. 2003;349:1360-1368.
Muller-Lissner S. Best Pract Res Clin Gastroenterol. 2002;16:115-133.
With straining
Chronic Constipation Interferes with
Daily Lives of the Aging Population
Constipation
No GI symptoms
Mean MOS Score
100
8
0
6
0
4
0
2
0
0
Physical
Role
Functioning Functioning
Social
Functioning
Mental
Health
Health
Perception
Bodily
Pain
MOS = medical outcomes survey
• Impact of chronic constipation on quality of life in Olmsted County, MN, residents aged ≥ 65 years
• Lower score indicates worse quality of life
Adapted from Talley NJ. Rev Gastroenterol Disord. 2004;4(suppl 2):S3-S10.
Primary Causes of Chronic constipation :
o Normal-transit constipation
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.
Stool Form Correlates With
Intestinal Transit Time
The Bristol Stool Form Scale
Slow Transit
Type 1
Separate hard lumps
Type 2
Sausage-like but lumpy
Type 4
Sausage-like but with
cracks
in the surface
Smooth and soft
Type 5
Soft blobs with clear-cut edges
Type 3
Type 6
Fast Transit
Type 7
O’Donnell LJD, et al. BMJ. 1990;300:439-440.
Fluffy pieces with ragged
edges,
a mushy stool
Watery, no solid pieces
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
Lembo A, Camilleri M. N Eng J Med. 2003;349:1360-1368.
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.
Rome III Criteria for IBS-C
Recurrent abdominal pain or discomfort (an
uncomfortable sensation not described as pain) at least
3 days per month in the last 3 months associated with 2
or more of the following:
1. Improvement with defecation
2. Onset associated with a change in frequency of
stool
3. Onset associated with a change in form of stool
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.
Rome III Diagnostic Criteria*
for Functional Constipation
Chronic constipation must include 2 or more of the following:
During at least 25% of defecations
Straining
Lumpy or
hard
stools
Sensation
of
incomplete
evacuation
Sensation of
anorectal
obstruction/
blockage
Manual
maneuvers
to facilitate
defecations
<3
defecations
per week
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
Longstreth GF, et al. Gastroenterology. 2006;130:1480-1491.
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
Ask the Right Questions
o Define the meaning of “constipation”
o How long have you experienced these
symptoms?
o Frequency of bowel movements?
o Abdominal pain?
o Other symptoms?
o What is most distressing symptom?
o Manual maneuvers to assist with defecation?
o Any limitation of daily activities?
o Are you taking any medications?
o What treatment have you tried?
o What investigations have been done?
Locke GR III, et al. Gastroenterology. 2000;119:1761-1778.
90
Percent of Patients
80
Common Patient Descriptions
of Constipation
81
72
70
60
Physicians think:
< 3 BM per week
54
50
39
40
37
36
28
30
20
10
0
Straining
Hard or Incomplete Stool Abdominal < 3 BM
lumpy emptying
per
cannot fullness or
stools
bloating
week
be
passed
N = 1149
Pare P, et al. Am J Gastroenterol. 2001;96:3130-3137.
Need to
press on
anus
Supportive exam :
Colonoscopy
Sumber: konsensus nasional penatalaksanaan konstipasi di Indonesia oleh PGI
Any Alarm Symptoms?
Are Diagnostic Tests Needed?
Hematochezia
Family history of colon cancer
Family history of inflammatory bowel disease
Anemia
Positive fecal occult blood test
“Unexplained” weight loss ≥ 10 pounds
Severe, persistent constipation that is
unresponsive to treatment
o New-onset constipation in an elderly patient
o
o
o
o
o
o
o
Locke GR III, et al. Gastroenterology. 2000;119:1761-1778.
Brandt LJ, et al. Am J Gastroenterol. 2005;100(suppl 1):S5-S21.
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
Kim DY, Camilleri M. Am J Gastroenterol. 2000;95(10):2698-2709.
Combined Risk Factors for
Constipation in the Elderly Population
Reduced fiber intake
Reduced liquid intake
Reduced mobility associated with functional decline
Decreased functional independence
Pelvic floor dysfunction
Chronic conditions
– Parkinson’s disease
– Dementia
– Diabetes mellitus
– Depression
o Polypharmacy (both over the counter and
prescription medications, such as NSAIDs, antacids,
antihistamines, iron supplements, anticholinergics,
opiates, Ca channel blockers, diuretics,
antipsychotics, anxiolytics, antidepressants)
o
o
o
o
o
o
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
*Demonstrated in some, but not all studies
Gallagher P, et al. Drugs Aging. 2008;25(10):807-821.
Schiller L. Gastroenterol Clin N Am. 2001;30:497-515.
Consider Secondary Causes
Psychological
Depression
Eating disorders
Surgical
Abdominal/pelvic surgery
Colonic/anorectal surgery
Lifestyle
Inadequate fiber/fluid
Inactivity
Metabolic/
Endocrine
Hypercalcemia
Hyperparathyroidism
Diabetes mellitus
Hypothyroidism
Hypokalemia
Uremia
Addison’s
Porphyria
Drugs
Opiates
Antidepressants
Anticholinergics
Antipsychotics
Antacids (Al, Ca)
Ca channel blockers
Iron supplements
Constipation
Gastrointestinal
Neurological
Parkinson’s
Multiple sclerosis
Autonomic neuropathy
Aganglionosis
(Hirschsprung’s, Chagas)
Spinal lesions
Cerebrovascular disease
Candelli M, et al. Hepatogastroenterology. 2001;48:1050-1057.
Locke GR, et al. Gastroenterology. 2000;119:1761-1766.
Systemic
Amyloidosis
Scleroderma
Polymyositis
Pregnancy
Colorectal: neoplasm,
ischemia, volvulus,
megacolon,
diverticular disease
Anorectal: prolapse,
rectocele, stenosis,
megarectum
Chronic Constipation Secondary to Diabetes
Special Considerations
o Constipation occurs in 20% of patients with diabetes
o Related to duration of diabetes > 10 years
o Diabetic autonomic neuropathy
o Gastrocolic reflex may be absent, delayed, blunted
o Constipation may be severe and can lead to
megacolon
Treatment Strategy*
1. Optimize diabetes care
2. Stepwise pharmacologic therapy
– Exclude slow transit
– Bulking agents, osmotic laxatives, Cl channel activators,
stimulant laxatives
*Treatment strategy based on clinical experience
Verne GN, et al. Gastroenterol Clin North Am. 1998;27:861-874.
Myths and Misconceptions About
Chronic Constipation
Misconception
Reality
Diseases arise from
autointoxication by
retained stools
• No evidence to support this theory
Fluctuations in hormones
contribute to constipation
• 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 diet poor in fiber causes
constipation
• 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
Increasing fluid intake is a
successful treatment for
constipation
• No evidence that constipation can be treated successfully
by increasing fluid intake unless there is evidence of
dehydration
Muller-Lissner S, et al. Am J Gastroenterol. 2005;100:232-242.
Heitkemper M, et al. Am J Gastroenterol. 2003;98(2):420-430.
More Misconceptions About Chronic
Constipation
Misconception
Reality
Stimulant laxatives
damage the enteric
nervous system and
increase the risk of
cancer
• 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 cause
electrolyte
disturbances
• Laxatives can cause electrolyte disturbances, but
appropriate drug and dose selection can minimize
such effects
Laxatives induce
tolerance
• Tolerance is uncommon in most laxative users,
however tolerance to stimulant laxatives can occur in
patients with severe constipation and slow colonic
transit
Laxatives are
addictive
• No potential for addiction to laxatives, but laxatives
may be misused
Muller-Lissner S, et al. Am J Gastroenterol. 2005;100:232-242.
Lifestyle Modifications
Modification
Targeted Mechanism
Efficacy
Increase fluid
intake
Increase stool volume by augmenting
luminal fluid
Limited; majority of fluid
is absorbed before
reaching the colon and is
expelled via urine
Increase exercise
Improve motility by decreasing transit time
through the GI tract
Moderate; some
evidence suggests this is
beneficial; however, not
sufficient to treat
Increase dietary
fiber
Increase water and bulk stool volume
Limited benefit compared
with placebo
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.
Are Patients Satisfied With
Laxatives and Fiber?
Dissatisfied Patients (%)
100
OTC laxatives
(n = 146)
Prescription laxatives
(n = 42)
80
66
71
75
Fiber
(n = 268)
80
79
67
60
60
50
50
52
50
44
40
20
0
Ineffective Relief Ineffective Relief of
of Constipation Multiple Symptoms
Lack of
Predictability
Johanson JF and Kralstein J. Aliment Pharmacol Ther. 2007;25:599-608.
Ineffective Relief
of Bloating
Treating Constipation With Laxatives
Laxative
Description
Bulking Agents
Absorbs liquids in the intestines and swells to form a soft, bulky
stool; the increase in fecal bulk is associated with accelerated
luminal propulsion
Osmotic
Laxatives
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]
Stimulant
Laxatives
Cause rhythmic muscle contractions in the intestines, increase
intestinal motility and secretions
Lubricants
Coats the bowel and the stool mass with a waterproof film; stool
remains soft and its passage is made easier
Stool Softeners
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
Combinations containing more than 1 type of laxative; for example,
a product may contain both a stool softener and a stimulant
laxative
Gallagher P, et al. Drugs Aging. 2008;25:807-821.
Laxatives
Laxative
Type
Bulk-forming
Lubricating
Stool
Softeners
Saline
Stimulant
Osmotic
Generic Name
Brand Name(s)
Methylcellulose
Citrucel®
Polycarbophil
FiberCon®, Fiber-Lax®
Psyllium
Metamucil®, Konsyl®
Glycerin
Glycerin suppository (generic)
Mineral oil
Mineral oil (generic)
Magnesium hydroxide (milk of magnesia) and mineral
oil
Phillips’® M-O
Docusate sodium
Colace®, Dulcolax® Stool Softener, Phillips’
Liqui-Gels®
Magnesium hydroxide (milk of magnesia)
Ex-Lax® Milk of Magnesia Laxative/Antacid
Phillips’® Chewable Tablets
Phillips’® Milk of Magnesia
Bisacodyl
Ex-Lax Ultra, Dulcolax Bowel Prep Kit
Sodium bicarbonate and potassium bitartrate
Ceo-Two Evacuant®
Sennosides
Ex-Lax® Laxative Pills
Castor oil
Purge®
Senna
Senokot®
Polyethylene glycol 3350
GlycoLax®, MiraLAX
Lactulose
Kristalose®
Aim of bisacodyl study:
oTo observe Complete Spontaneous Bowel
Movements (CSBM) every week during 4 weeks
treatment
oTwo condition related to bowel movement :
 Spontaneous Bowel Movement (SBM):
spontaneous defecation
Complete Spontaneous Bowel Movement (CSBM):
spontanneous defecation with good sensation
Material & Method :
o Adult patients total 368 pts
o Diagnosis chronic
constipation
o Bisacodyl tab (Dulcolax)R vs.
placebo; during 4 weeks
o Center of study Germany &
UK
Study result:
Complete Spontaneous bowel movement at first day
& 4 weeks after treatment :
Placebo
Bisacodyl
Total patients
117
239
First step evaluation
1.1
1.1
4 weeks evaluation
2.0
5.2
Different result between
bisacodyl & placebo
3.3
95% Confidence interval
(2.6 , 4.0)
p-value
<0.0001
Significant difference the end result from 2 groups , bisacodyl
more superior than placebo
Result :
Complete spontaneous bowel movement after 4 weeks
**
**
**
**
Significant diff in CSBM between Bisacodyl mand placebo
Result :
Avarage Spontaneous Bowel Movement after 4 weeks
**
**
**
**
Significant diff between Bisacodyl & plasebo to increase SBM
Patients self assesment for quality of life (QOL)
Percentageof patients
60
50
40
PBO
BIS
30
20
10
0
Good
Satisfactory
Not
satisfactory
Bad
Bisacodyl increase QOL from patients with constipation
recovery bowel habit every day . 80% patients have satisfied with
Bisacodyl.
Patients symptoms improvement after
bisacodyl treatment
o Regular bowel habit everyday
o Decreased constipation symptoms
o Decreased bloating symptoms
o Decreased abdominal discomfort
Bisacodyl relief clinical symptoms due to constipation
Suggested Management Algorithm for
Chronic Constipation
Bleeding, anemia,
weight loss,
sudden change in
stool caliber,
abdominal pain
Alarm
Symptoms
No Alarm
Symptoms
Lifestyle, OTC, stimulant laxative
Directed testing
Refer to a specialist
as needed
+ Response
Continue
regimen
No response
OTC = over-the-counter therapies (probiotics, herbal medications, stool softeners
[docusate sodium], psyllium, methylcellulose, calcium polycarbophil, bisacodyl, senna)
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 cont’d
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
Thank you very much
for your kind attention