Colonic transit and anorectal manometry in chronic idiopathic constipation

Twenty-one patients with refractory idiopathic constipation underwent studies of segmental colonic transit of radiopaque markers and anorectal manometry to determine the utility of these tests in planning therapy and in predicting subsequent clinical outcome. Colonic transit studies defined three groups: normal transit (n = 6), colonic inertia (n = 8), and distal slowing (n = 7). Normal transit was universally associated with evidence of psychosocial disturbances. During follow-ups ranging from 23.2 to 26.7 months, six of eight patients with colonic inertia failed to improve compared with only one of seven with distal slowing. Anorectal manometry was useful in excluding abnormalities of anorectal function. Segmental colonic transit of radiopaque markers is a simple and useful test in the evaluation of refractory idiopathic constipation and appears to have both prognostic and therapeutic utility in selected cases.     

慢性特发性便秘患者肛门直肠动力学及精神心理因素的研究

目的：研究慢性性发性便秘（CIC）患者的肛门直肠动力学及其力学及其心理的变化。方法肛门直肠测压法检测28例CIC患者肛门直肠动力学的变化,同时进行心理测试,并与24名健康者进行对照观察。结果：CIC患者年龄偏大（P＜0．05）;肛门括约肌静息压,最大缩榨压降低（P＜0．05,P＜0．005）,肛管高压带长度增加（P＜0．005）;引起直肠肛门抑制反射的最小松驰容量（MVR）增加（P＜0．005）,肛门括约肌松驰率下降（P＜0．025）;直肠内部容量刺激的排便阈值和最大耐受量均明显增加（P＜0．005,P＜0．005）;CIC患者焦虑、抑郁精神心理异常倾向的出现率明显高于对照组（P＜0．05,P＜0．01）。结论：CIC患者存在肛门直肠动力学及精神心理因素的异常。     

Colonic motility in children with constipation

Summary The predominant colonic motility pattern in constipated children with Hirschsprung's disease was hypomotile; in a small subgroup there was hypermotility. Normal motility was a feature of megacolon of other causation. Supported by S.H.E.R.T. Grant 418.     

Parameters of anorectal and colonic motility in health and in severe constipation

Anorectal function and colonic transit was assessed in 17 severely constipated patients and 15 age-matched controls. The constipated patients were divided into those who had immobile perineum (perineal descent 1.0 cm during attempted defecation) and those who had a normal descent (>1.0 cm) of the perineum. When constipation was accompanied by an immobile perineum, patients had impaired balloon expulsion, impaired and delayed artificial stool expulsion, decreased straightening of the anorectal angle, decreased descent of the pelvic floor with defecation, and prolonged rectosigmoid colon transit compared with the patients with constipation who had a mobile perineum and with normal controls. The mobile-perineum group differed from controls only in colon transit times, having prolonged total colon transit. Anal sphincter resting pressures, immediate artificial stool expulsion, resting anorectal angles, and electromyography of the external anal sphincter and puborectalis did not differentiate the constipated patients from the controls. We concluded that descent of the perineum of <1 cm was associated with impaired expulsion, an adynamic anorectal angle, and slowed distal colon transit. This simple sign of pelvic floor function distinguished constipated patients with disordered expulsion from constipated patients with normal pelvic floor function. These patients may respond poorly to surgery and conventional management and would therefore be candidates instead for pelvic floor retraining. Accurate characterization and appreciation of pelvic floor dysfunction in patients with severe chronic constipation may improve the selection for and results of surgical and nonsurgical intervention.Supported in part by Research Grants DK37990, RR585, and DK34988 from the National Institutes of Health and by the Mayo Foundation, Rochester, Minnesota.     

Colonic motility in man: features in normal subjects and in patients with chronic idiopathic constipation

The human colon is still a relatively unknown viscus, especially concerning its motor activity. However, in recent years, techniques have been perfected that allow a better understanding of colonic motility, especially through prolonged recording periods. In this way, it has been demonstrated that the viscus contracts according to a circadian trend, is responsive to physiological stimuli (meals, sleep), and features high amplitude, propulsive contractions that are part of the complex dynamic of the defecatory process. These physiological properties and their alterations in patients with chronic idiopathic constipation are reviewed in this article.     

Impairment of defecation in young women with severe constipation

Anorectal manometry, radiology, and tests of simulated defecation were carried out in 14 severely constipated young women and 29 age-matched controls. The resting anal sphincter pressures were reduced in the patients, but the squeeze pressures, rectoanal inhibitory reflex, and rectal pressures upon balloon distention were all normal. At rest, the anorectal angle was more obtuse in the constipated group, but there was no overall increase in perineal descent in constipated patients compared with controls. The presence of a balloon in the rectum and the onset of pain were perceived in constipated patients at volumes that were not significantly different from those in normal volunteers. Constipated patients, however, required higher rectal volumes to induce the desire to defecate and to stimulate regular rectal contractions. Constipated patients also found it more difficult to pass simulated stools from the rectum than the normal controls and, unlike most normal controls, failed to inhibit their external anal sphincter on attempted defecation. These findings suggest that young women with severe constipation have great difficulty initiating the coordinated set of events that constitute a normal defecation response.     

Urological abnormalities in young women with severe constipation.

Anorectal and urodynamic studies were carried out in 10 young women with severe constipation and the results compared with those obtained in controls. The lowest volumes that provoked a desire to defecate (constipated 200 +/- 50 v controls 110 +/- 10 [mean +/- SEM] ml: p less than 0.05), and a desire to micturate (constipated 560 +/- 40 v controls 295 +/- 15 [mean +/- SEM] ml: p less than 0.001), were significantly greater in constipated patients compared with controls. The maximum tolerable rectal volume (380 +/- 30 v 290 +/- 20 [mean +/- SEM] ml: p less than 0.05) and the bladder capacity (720 +/- 50 v 540 +/- 10 [mean +/- SEM] ml: p less than 0.001) were also increased in the constipated subjects compared with controls. Electromyographic studies show failure of relaxation of the external anal sphincter (EAS) on attempted defecation in all 10 patients; and eight of these patients actually contracted their EAS when they strained to defecate, causing a functional outlet obstruction. Urodynamic studies showed normal urinary flow rates, normal detrusor pressures and normal radiology during voiding. Thus, these studies suggest that constipated patients have an increase in capacity and a reduction in sensitivity in the urinary bladder as well as in the rectum, but showed no evidence of obstruction to urine flow.     

Steroid hormone abnormalities in women with severe idiopathic constipation.

Patients with severe idiopathic constipation are almost exclusively women of reproductive age. To investigate the possibility of a sex hormone abnormality in this condition, we have compared a range of sex hormones during the follicular and luteal phases of the menstrual cycle in 23 healthy women (mean age 33 years) with those in 26 patients with severe idiopathic constipation (mean age 32 years, spontaneous bowel frequency less than one per week). In the patients there was a reduction in the follicular phase of progesterone (4.5 v 4 nmol/l, p = 0.006, median value, controls v patients), 17 hydroxyprogesterone (9.7 v 5.8 nmol/l, p = 0.01), cortisol (387 v 245 nmol/l, p = 0.008), testosterone (2.3 v 1.8 nmol/l, p less than 0.001), androstenedione (10.3 v 8.4 nmol/l, p = 0.02), and dehydroepiandrosterone sulphate (5.1 v 3.0 mumol/l, p = 0.03). In the luteal phase there was a reduction of oestradiol (483 v 350 pmol/l, p = 0.015), cortisol (322 v 242 nmol/l, p = 0.047), and testosterone (2.4 v 1.7 nmol/l, p = 0.003). The concentrations of sex hormone binding globulin, prolactin, luteinising hormone, and follicle stimulating hormone were not significantly different in either phase of the cycle. Women with severe idiopathic constipation have a consistent reduction in steroid hormones.     

慢性特发性便秘患者肛门直肠的动力改变

目的　测定慢性特发性便秘患者肛门直肠压力 ,探讨肛门直肠动力障碍在便秘发病机制中的作用。方法　采用美国Sandhill公司生产的BioLAB动力学参数监测系统及固态压力传感器导管 ,对 40例CIC患者进行肛门直肠压力测定 ,并与 40例正常人进行对比。结果　便秘组肛管静息压、最大缩榨压、最大缩榨间期及缩榨指数均明显低于对照组 (P <0 0 5 ,P <0 0 5 ,P <0 0l,P<0 0 1) ;模拟排便动作时肛管剩余压明显高于对照组 (P <0 0 0 1) ,肛管松弛率、排便指数均低于对照组 ,统计学处理具有显著性差异 ;初始感阈值容量大于对照组 (P <0 0 0 1) ,排便感阈值大于对照组 (P <0 0 5 ) ,最大耐受量明显低于对照组 (P <0 0 1)。结论　慢性特发性便秘病人存在肛管直肠的动力学异常及直肠敏感性降低     

功能性便秘患者肛门直肠动力学和感觉功能测定及其临床意义

目的　研究功能性便秘患者肛门直肠动力和感觉功能 ,探讨对便秘分型的临床意义。方法　 10 0例符合罗马Ⅱ诊断标准的功能性便秘患者 ,采用下消化道动力监测系统 ,通过检测肛门直肠动力和感觉功能 ,分析肛门静息压、用力排便时直肠压、肛门括约肌压及直肠 肛门括约肌压差。观察动力异常分型和感觉之间的关系。结果　① 4 2例患者肛门直肠动力正常 ,5 8例患者异常。其中Ⅰ、Ⅱ和Ⅲ型分别为 32、19和 7例。Ⅱ型组肛门静息压明显低于正常、Ⅰ和Ⅲ型组 (P <0 .0 5 )。Ⅰ、Ⅱ、Ⅲ型组的直肠 肛门括约肌压差均明显低于正常组 (P <0 .0 5 ) ,但Ⅱ型组高于Ⅰ型组 (P <0 .0 5 )和Ⅲ型组 (P <0 .0 5 ) ,Ⅲ型组压力最低。② 2 5例动力正常但感觉异常 ,37例动力和感觉均异常。 83例患者存在动力和(或 )感觉异常 ,17例动力、感觉均正常。③ 38例患者直肠感觉功能正常 ,6 2例患者异常 ,其中 4 1例感觉阈值降低 ,2 1例增高。结论　肛门直肠测压为选择正确的治疗方法提供了依据 ,对临床具有指导意义。     

功能性便秘动力学改变与情志因素的相关性

目的:分析功能性便秘(functional constipation,FC)肛肠动力学与患者生活质量及情志因素相关性.方法:患者进行肛肠动力学指标观察分析,采用生命质量调查问卷、精神心理状态评定量表问卷调查,进行动力学指标和情志因素相关性分析.结果:患者组生活质量所有8个维度的评分均低于健康对照组,存在明显的焦虑、抑郁情绪.焦虑、抑郁积分与生活质量负相关;肛肠动力学和精神心理因素相关(P<0.05),肛管缩榨压及其持续时间与抑郁自评量表(selfrating depression scale,SDS)、焦虑自评量表(selfrating anxiety scale,SAS)呈负相关;初始感觉阈值、排便感觉阈值和最大耐受容量与SAS、SDS呈正相关.结论:便秘显著损害患者的生存质量,易合并有焦虑、抑郁等情志因素的异常.焦虑、抑郁和生存质量相关,肛肠动力学和精神心理因素相关.     

Colonic mass movements in idiopathic chronic constipation.

As relatively little is known of human colonic motor activity either in health, or in pathological conditions, we investigated mass movements in 14 chronically constipated patients and 18 healthy volunteers. Mass movements were recorded from proximal and distal colon during 24 h (12 noon-12 noon) by a colonoscopically positioned multilumen manometric probe and low compliance infusion system. Patients and controls differed significantly in the number (mean 2.6 (0.7) v 6.1 (0.9) (SE), p = 0.02) and duration (mean 8.2 (1.6) v 14.1 (0.8) s, p = 0.04) of mass movements. The data suggest that one pathophysiological mechanism of constipation may be decreased propulsive activity. A circadian pattern, with a significant difference between day and night distribution, was documented in both groups. The patients reported decreased defecatory stimulus concomitant with the mass movements.     

Psychological morbidity in women with idiopathic constipation

OBJECTIVE: The aim of this study was to examine psychological morbidity in women with idiopathic constipation. METHODS: Three age-matched groups of 47 women with idiopathic constipation (excess straining or decreased bowel frequency), 28 healthy women, and 26 women with Crohn's disease completed a newly devised Perception of Female Self questionnaire, the Intimacy subscale of the Inventory of Interpersonal Problems, the Feminine Traits from the Bem Sex Role Inventory, and the General Health Questionnaire. Thirteen patients had a low bowel frequency (<2/wk), 30 had a normal bowel frequency, and four had increased bowel frequency (>3/day). Of 29 patients with a measured whole gut transit time, 19 had slow and 10 had normal transit. RESULTS: Patients with constipation had significantly increased psychological and social morbidity (anxiety, depression, and social dysfunction) (p = 0.022), increased somatization (p = 0.019), and less satisfaction in their sexual life (p = 0.001) than healthy women. Constipated women with slow transit or decreased bowel frequency did not differ significantly from those with normal transit and bowel frequency. Women with Crohn's disease did not differ significantly on any test from healthy controls. CONCLUSIONS: Women with idiopathic constipation have increased psychological morbidity, altered perception about female self, and impaired intimate relationships. These factors are not present in women with "organic" GI illness also associated with abdominal pain.     

Colonic motility studies in severe chronic constipation: an organic approach to a functional problem

Abstract Chronic constipation is one of the more frequent functional gastrointestinal symptoms. The more severe cases not infrequently undergo a major surgical approach. However, there is still a need for a better diagnostic and therapeutic approach, since the results are still unpredictable, probably due to a poor selection of candidates. This article focuses on the current diagnostic approach to chronic constipation, with an emphasis on the possible role of colonic manometry to help better choose those patients that may benefit from surgery.     

老年特发性便秘直肠肛门压力测试59例分析

目的　探讨老年慢性特发性便秘 (CIC)患者直肠肛门运动功能变化 ,　 方法 　采用瑞典Medtronic公司生产的 8通道水灌注式消化道压力检测系统对 5 9例老年CIC患者及 36例老年对照者进行直肠肛门压力测定。　 结果 　老年CIC患者最大缩榨压、模拟排便时肛管压力变化低于老年对照组 (P <0 0 5 ) ,直肠初始感觉阈值、排便阈值和最大耐受容量均高于老年对照组 (P <0 0 5 ) ,2 8例 (47 5 % )老年CIC患者模拟排便时出现肛管压力异常升高。　 结论 　老年CIC与直肠低敏感、高耐受及排便时直肠肛管运动不协调有关     

Ultrasonography shows no abnormality of pelvic structures in women with severe idiopathic constipation.

Patients with severe idiopathic constipation are almost exclusively women. Common presenting features include lower abdominal pain, irregular and painful menstruation, and a past history of gynaecological surgery. Pelvic ultrasonography was undertaken in 26 patients with severe idiopathic constipation and 21 age matched control women to detect any gynaecological abnormality. No difference was found in ovarian, uterine or pelvic vein morphology or size. The abdominal pain in these patients is related to the bowel disorder, and minor abnormalities of pelvic morphology on ultrasound are probably incidental findings.     

老年特发性便秘患者结肠、直肠和肛门动力学变化

目的　探讨老年慢性特发性便秘 (CIC)患者结肠、直肠和肛门运动功能变化。方法　应用不透 X线标记物法 ,采用 8通道水灌注式消化道压力检测系统 ,对 5 9例老年慢性特发性便秘 (CIC)患者及 36例对照者进行结肠通过时间检查及直肠肛门压力测定。结果　 1老年 CIC组全结肠及分段结肠通过时间较对照组明显延长(P<0 .0 5 ) ;2长期服用泻药的老年 CIC患者其全结肠通过时间较间断服药和不服药组明显延长 (P<0 .0 5 ) ;3老年 CIC患者最大缩榨压、模拟排便时肛管压力变化低于对照组 (P<0 .0 5 ) ,直肠初始感觉阈值、排便阈值和最大耐受容量均高于对照组 (P<0 .0 5 ) ,并有 2 8例 (4 7.5 % )老年 CIC患者模拟排便时出现肛管压力异常升高。结论　老年 CIC患者存在结肠动力学异常 ,与直肠低敏感、高耐受及排便时直肠肛管运动不协调有关     

Physiological studies in young women with chronic constipation

Manometric, radiological and neurophysiological investigations were performed on 34 women, aged between 14 and 53, who suffered with chronic constipation refractory to treatment, and on 27 agematched normal female control subjects. The constipated patients had more difficulty in evacuating simulated stools than control subjects and 13 out of 19 patients tested obstructed defaecation by contracting the external sphincter during straining. The constipated group required a greater degree of rectal distension than control subjects to induce rectal contractions, anal relaxation and a desire to defaecate. Other modalities of rectal sensation were normal in the constipated subjects. Compared with controls, constipated patients had significantly lower anal pressures, an abnormal degree of perineal descent on straining and an obtuse anorectal angulation at rest. These results were compatible with weakness of the pelvic floor and neuropathic damage to the external sphincter. Mouth to anus transit time was abnormally prolonged in 60% of constipated patients, but was within the normal range in the remainder. Anorectal function in patients with slow transit was not significantly different from that in patients with a normal transit time. The mouth to caecum transit time of a standard meal was prolonged in constipated patients irrespective of the duration of the whole gut transit. Gastric emptying was not significantly prolonged.