Scintigraphic studies of rectal emptying in patients with constipation and defecatory difficulty

We prospectively evaluated 38 adult patients with chronic constipation with and without defecatory difficulties using a newly described scintigraphic test to measure rectal emptying and compared them to 20 healthy controls. All patients underwent anorectal manometry, and 30 who complained of infrequent defecation underwent a colonic transit study using radiopaque markers. Control subjects promptly evacuated both 100 ml and 200 ml artificial stool in a characteristic fashion, but three evacuated none of the 100-ml volume and two had no evacuation of the 200-ml stool (inhibited controls). Constipated patients exhibited three patterns of emptying: (1) normal emptying of both volumes (47%); (2) poor emptying of both volumes or inhibited defecation (29%); and (3) normal emptying of the 200-ml but abnormal evacuation of the 100-ml volume (24%). An abnormal expulsion pattern during manometry occurred in 21% of patients and was strongly associated with the inhibited defecation pattern. However, defecation patterns could not be predicted on the basis of age, gender, symptoms, duration of complaints, colonic transit, or other rectal manometric parameters. Although rectal scintigraphy has potential advantages as a diagnostic test in terms of quantitation and decreased radiation exposure, the inability of the test to distinguish patients with slow transit constipation and defecatory complaints makes the potential utility of this test of uncertain value in clinical and investigative settings.     

Application of the colorectal laboratory in diagnosis and treatment of functional constipation

Defecography, pelvic floor electromyography, and segmentai colonic transit times were performed in 74 patients with functional constipation. Signs of functional outlet obstruction occurred in 74 percent. Transit times were normal in 33 percent. Measurement of colonic transit time in patients with disordered evacuation studies is useless from a clinical point of view, because abnormal segmental transit time is the result of outlet obstruction in most cases and will return to normal after adequate treatment. Only when evacuation studies are normal, or have become normal after treatment and constipation persists, are segmental transit studies indicated because they may demonstrate primary slow transit constipation. Primary slow transit constipation probably is caused by impaired motility of the whole gastrointestinal tract. As small-bowel transit time increases, defecation frequency decreases, laxatives are taken again, and abdominal pain persists. Surgery should be performed with restraint.Read at the meeting of The American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.Reprints will not be available.     

Prucalopride accelerates gastrointestinal and colonic transit in patients with constipation without a rectal evacuation disorder

BACKGROUND & AIMS: Prucalopride (PRU) is a selective benzofuran 5-hydroxytryptamine(4)-receptor agonist with gastrointestinal and colonic prokinetic activities. We evaluated the effects of PRU on gastrointestinal and colonic transit in patients with constipation. METHODS: Gastrointestinal and colonic transit were measured over 48 hours in 40 patients who fulfilled modified Rome I criteria for functional constipation. Patients had no evidence of a rectal evacuation disorder. Subjects were randomized to receive a daily dose of 2 or 4 mg PRU or placebo in a double-blind, parallel-group design. Each treatment lasted 7 days. The transit test was performed over the last 48 hours of the study. Effects on gastric emptying, small bowel transit, and colonic transit were analyzed using Kruskal-Wallis and Wilcoxon rank sum tests. RESULTS: Of 61 patients screened, 40 were eligible and randomized. Two patients withdrew because of adverse events. PRU accelerated overall gastric emptying and small bowel transit. PRU tended to accelerate overall colonic transit with significantly faster overall colonic transit and ascending colon emptying with the 4-mg dose. CONCLUSIONS: PRU accelerates transit through the stomach, small bowel, and colon in patients with constipation unassociated with a rectal evacuation disorder.     

The role of pelvic floor dysfunction and slow colonic transit in adolescents with refractory constipation

OBJECTIVE: Although pelvic floor dysfunction (PFD) is recognized as a cause of refractory constipation in adults, this diagnosis is not frequently considered in children and adolescents with refractory constipation. The purpose of this study was to examine the symptoms and colonic transit in adolescents with constipation evaluated for a disorder in pelvic floor function. METHODS: Adolescents with refractory constipation who had undergone anorectal manometry (ARM) and balloon expulsion test (BET) were identified by retrospective review of records. Initial symptoms and the clinician's assessment were used to categorize patients by pediatric Rome II criteria, that is, functional constipation (FC), constipation-predominant irritable bowel syndrome (C-IBS) or functional fecal retention (FFR). Results of scintigraphic colonic transit studies were evaluated. A chi2 test was used to assess the association between individual clinical symptoms and Rome II criteria. RESULTS: Sixty-seven adolescents underwent evaluation of pelvic floor function by tests for PFD: BET was abnormal in 42%. There was no underlying disease or alternative diagnosis to account for the constipation in these patients. Among the 41 patients who also underwent scintigraphic colonic transit, 30% had slow transit constipation and 12% had both slow colonic transit and abnormal BET. Patients classified as C-IBS were more likely to report weight loss (p = 0.03), bloating (p = 0.04), and incomplete rectal evacuation (p = 0.03). CONCLUSION: Abnormal pelvic floor function and delayed colonic transit are demonstrable as single or combined problems in adolescents with refractory constipation.     

Functional defecation disorder as a clinical subgroup of chronic constipation: analysis of symptoms and physiological parameters

Objective. Patients with functional constipation can be classified according to symptoms and physiological parameters as either having a disorder of defecation or having normal defecation. It is hypothesized that the disordered defecation, where it exists, is a causative factor of the constipation. However, the utility of this classification has yet to be proven in terms of predicting response to therapy. The definitions are non-specific and based on tests that are done in an artificial setting and with derived normal ranges. It is therefore possible that the symptoms and physiological parameters of a defecatory disorder may occur as a continuous spectrum in these patients, rather than defining a discrete entity or subtype. The aim of this study was to use cluster analysis and factor analysis of defecatory symptoms and physiological parameters to look for evidence of subgroups in patients with functional constipation. Material and methods. Consecutive patients presenting to a specialist constipation clinic and satisfying the inclusion criteria were assessed to determine the severity of defecatory symptoms, and underwent isotope defecating proctography and the Sitzmark transit study. Assessments were made contemporaneously and results of any test not performed within 6 weeks of the initial assessment were excluded. Principle components analysis and cluster analysis were performed to look for evidence of subgroups. Relationships between evacuatory symptoms, index parameters, and test results were explored. The detailed and unselected nature of the analyses produced hundreds of test results, and statistically significant results were critically evaluated in this context. Results. A total of 116 patients were studied (age range 18-73 years, mean 40.5 years). Based on the results of the transit study and proctography, 38% of patients showed evidence of slow transit constipation, 20% FDD (functional defecation disorder), 29% both, and 12% neither. Principle components analysis did not demonstrate an obvious dimension reduction for the variables tested. Cluster analysis (over 150 solutions tested) failed to show evidence of clustering. There were no useful predictive relationships between evacuatory symptoms, index parameters and test results. Conclusions. We used multiple statistical analyses to look for clustering and predictive relationships between clinical and physiological parameters in consecutive patients with functional constipation and found no evidence of the existence of a subgroup of patients with a defecatory disorder. This may be due to weaknesses in the study design, poor validity of the assessments performed, or that defecatory features do not identify a distinct pathophysiological entity, but rather are manifested variably as a continuous spectrum.     

Constipation

Chronic constipation is a common disorder manifested by a variety of symptoms. Assessments of colonic transit and anorectal functions are used to categorize constipated patients into three groups, i.e., normal transit or irritable bowel syndrome, pelvic floor dysfunction (i.e., functional defaecatory disorders) and slow transit constipation. 'Slow transit' constipation is a clinical syndrome attributed to ineffective colonic propulsion and/or increased resistance to propagation of colonic contents. Defaecatory disorders are caused by insufficient relaxation of the pelvic floor muscles or a failure to generate adequate propulsive forces during defaecation. Colonic transit is often delayed in patients with functional defaecatory disorders. Normal and slow transit constipation are generally managed with medications; surgery is necessary for a minority of patients with slow transit constipation. Functional defaecatory disorders are primarily treated with pelvic floor retraining using biofeedback therapy.     

Treatment of severe and intractable constipation

Opinion statement A careful clinical evaluation, exclusion of secondary causes (eg, colonic obstruction, metabolic conditions [hypothyroidism, hypercalcemia], and drug-induced constipation), and assessments of colonic transit and rectal evacuation are necessary to ascertain whether constipation is attributable to normal colonic transit, delayed colonic transit (ie, slow-transit constipation), or a rectal evacuation disorder (with or without delayed colonic transit). Idiopathic slow-transit constipation is a clinical syndrome predominantly affecting women and is characterized by intractable constipation and delayed colonic transit. This syndrome is attributed to disordered colonic motor function and spans a spectrum of variable severity ranging from patients who have relatively mild delays in transit, but are otherwise indistinguishable from irritable bowel syndrome, at one extreme to patients with colonic inertia or chronic megacolon at the other extreme. Most patients are treated with one or more pharmacological agent. A subtotal colectomy is effective and occasionally indicated for patients with medically refractory severe slow-transit constipation, provided that pelvic floor dysfunction has been excluded or treated. Pelvic floor dysfunction can be diagnosed by the clinical features and anorectal testing. Most patients with pelvic floor dysfunction will respond to pelvic floor retraining by biofeedback therapy.     

Functional defecation disorder as a clinical subgroup of chronic constipation: Analysis of symptoms and physiological parameters

Objective. Patients with functional constipation can be classified according to symptoms and physiological parameters as either having a disorder of defecation or having normal defecation. It is hypothesized that the disordered defecation, where it exists, is a causative factor of the constipation. However, the utility of this classification has yet to be proven in terms of predicting response to therapy. The definitions are non-specific and based on tests that are done in an artificial setting and with derived normal ranges. It is therefore possible that the symptoms and physiological parameters of a defecatory disorder may occur as a continuous spectrum in these patients, rather than defining a discrete entity or subtype. The aim of this study was to use cluster analysis and factor analysis of defecatory symptoms and physiological parameters to look for evidence of subgroups in patients with functional constipation. Material and methods. Consecutive patients presenting to a specialist constipation clinic and satisfying the inclusion criteria were assessed to determine the severity of defecatory symptoms, and underwent isotope defecating proctography and the Sitzmark transit study. Assessments were made contemporaneously and results of any test not performed within 6 weeks of the initial assessment were excluded. Principle components analysis and cluster analysis were performed to look for evidence of subgroups. Relationships between evacuatory symptoms, index parameters, and test results were explored. The detailed and unselected nature of the analyses produced hundreds of test results, and statistically significant results were critically evaluated in this context. Results. A total of 116 patients were studied (age range 18–73 years, mean 40.5 years). Based on the results of the transit study and proctography, 38% of patients showed evidence of slow transit constipation, 20% FDD (functional defecation disorder), 29% both, and 12% neither. Principle components analysis did not demonstrate an obvious dimension reduction for the variables tested. Cluster analysis (over 150 solutions tested) failed to show evidence of clustering. There were no useful predictive relationships between evacuatory symptoms, index parameters and test results. Conclusions. We used multiple statistical analyses to look for clustering and predictive relationships between clinical and physiological parameters in consecutive patients with functional constipation and found no evidence of the existence of a subgroup of patients with a defecatory disorder. This may be due to weaknesses in the study design, poor validity of the assessments performed, or that defecatory features do not identify a distinct pathophysiological entity, but rather are manifested variably as a continuous spectrum.     

Constipation: evaluation and treatment of colonic and anorectal motility disorders

This article focuses on the colonic and anorectal motility disturbances that are associated with chronic constipation and their management. Functional chronic constipation consists of three overlapping subtypes: slow transit constipation, dyssynergic defecation, and irritable bowel syndrome with constipation. The Rome criteria may serve as a useful guide for making a clinical diagnosis of functional constipation. Today, an evidence-based approach can be used to treat patients with chronic constipation. The availability of specific drugs for the treatment of chronic constipation, such as tegaserod and lubiprostone, has enhanced the therapeutic armamentarium for managing these patients. Randomized controlled trials have also established the efficacy of biofeedback therapy in the treatment of dyssynergic defecation.     

Nutritional care of the patient with constipation

Chronic constipation is defined as a symptom-based disorder based on the presence for at least 3 months in the last year of unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both. On the other hand, the presence of clinically important abdominal discomfort or pain associated with constipation defines irritable bowel syndrome (IBS) with constipation. Intake of dietary fibre and bulking agents (psyllium) may be effective in alleviating chronic constipation in patients without slow colonic transit or disordered constipation. On the other hand, fibre may improve stool consistency in patients with IBS with constipation, but it is considered to be not effective in improving abdominal pain, distension or bloating. Probiotics may be effective in relieving constipation; however, the effect of lactic acid bacteria ingestion may be dependent on the bacterial strain used and the population being studied. Lactulose, which is a substrate for lactic acid bacteria (prebiotic), is effective to treat patients with chronic constipation.     

Results of colectomy for severe slow transit constipation

PURPOSE: This study assesses the outcome of a standardized operation performed by two surgeons for severe idiopathic slow transit constipation that was resistant to laxative treatment. METHODS: Fifty-nine consecutive patients, 4 men and 55 women, with a mean age of 42.3 years, underwent colectomy with ileorectal anastomosis. Slow colonic transit was demonstrated in each case. Fifty-two patients were available for follow-up, with median time to follow-up being 42 (range, 3–81) months. RESULTS: Median bowel frequency was 4 per 24 hours. Sixty-nine percent had four or less bowel movements daily. Ten percent used antidiarrheal medication regularly. One patient had a stoma for recurrent severe constipation. Mean continence score was 1.8 (on a scale of 0–20); six patients were incontinent, and four of these six had normal preoperative anal manometry. Fourteen patients (27 percent) had difficulty with rectal evacuation. Preoperative defecating proctography was a poor predictor of postoperative evacuation difficulties. Twenty-seven patients (52 percent) had persisting abdominal pain, but there was a significant improvement in the degree of pain (P <0.00001). Forty-seven patients (90 percent) were satisfied with the outcome of the operation (and would elect to have it done again). Dissatisfied patients had recurrent constipation or diarrhea and incontinence. CONCLUSION: Colectomy with ileorectal anastomosis produces a satisfactory functional outcome in the majority of patients undergoing surgery for severe constipation with proven slow colonic transit.Supported by the Division of Surgery and the Colorectal Research Fund.Read at the meeting of the Royal Australasian College of Surgeons, Perth, Australia, May 1995.     

Difficult defecation: difficult problem assessment and management; what really helps?

Difficult defecation is a common and perhaps underrecognized cause of chronic constipation. While the history and a careful digital rectal examination are very useful for diagnosing defecatory disorders, the diagnosis needs to be confirmed by anorectal tests. Anorectal manometry and a rectal balloon expulsion test generally suffice to diagnose defecatory disorders; barium or MR defecography may necessary in selected cases. Colonic transit is normal or slow in patients with defecatory disorders. Pelvic floor retraining by biofeedback therapy is superior to laxatives for managing defecatory disorders.     

Discriminant value of psychological distress, symptom profiles, and segmental colonic dysfunction in outpatients with severe idiopathic constipation.

Severe idiopathic constipation can be categorised based on physiological testing into subgroups including slow transit constipation and pelvic floor dysfunction. This study aimed to determine if colonic and psychological symptoms, or rectosigmoid transit times, could discriminate among these subgroups. Patients, categorised according to total colonic transit times and pelvic floor function testing, completed a self report questionnaire that recorded symptoms and psychological distress. Patients with normal transit constipation (n = 60) had significantly increased depression scores compared with those who had slow transit constipation (n = 70) or pelvic floor dysfunction (n = 30). The general severity index (GSI, a measure of overall psychological distress) negatively but weakly correlated with total colonic transit (r = -0.26, p < 0.01). A feeling of anal blockage was the only symptom that was associated with pelvic floor dysfunction (v normal transit constipation). Only a more regular defecation pattern, utilisation of different postures to defecate, and a feeling of incomplete evacuation were associated with slow v normal transit constipation. Psychological or colonic symptoms were not, however, significant discriminators in a multivariate analysis. Rectosigmoid transit times at 80% sensitivity had very poor specificity for discriminating pelvic floor dysfunction from other subgroups. It is concluded that clinical symptoms, psychological distress, and rectosigmoid transit times cannot be used to identify subgroups of patients with intractable constipation.     

Pilot Study of Pathophysiology of Constipation Among Community Diabetics

We aimed to compare gastrointestinal transit anddefecatory function in a random sample of people with orwithout diabetes mellitus in a US community who reportedconstipation or laxative use. In this pilot study we measured: gastric, small bowel, andcolonic transit by scintigraphy; vector manometry ofanal sphincters at rest and during squeeze; defecatorydynamics by balloon expulsion test; and scintigraphic measurement of anorectal angle at rest andduring defecation. Autonomic function tests wereperformed in diabetics. Diabetics with constipation hada higher prevalence of abnormal evacuation or prolonged colonic transit during the first 24 hr thancontrols (P = 0.07): three had prolonged 24-hr colonictransit, and three abnormal evacuation. Amongconstipated controls, only one had anismus. Overall,diabetics had slower colonic transit during the first 24hr than nondiabetics (P < 0.05). Community diabeticswho experience constipation or use laxatives have agreater prevalence of delayed 24-hr colonic transit or evacuatory dysfunction than communitycontrols.     

The surgical treatment of chronic constipation

Constipation rarely requires surgical treatment. The common causes are degenerative neurological disease, impaired rectal evacuation and functional bowel disease with features of the irritable bowel syndrome. Psychogenic factors should be investigated and any underlying bowel condition identified. The role of anorectal physiology is discussed. The results of surgical resection for slow transit constipation and poor unless patients are carefully selected. Anismus is difficult to treat successfully by surgery. Recently, colonic conduit has been proposed for obstructed defaecation. Received: 27 August 1999 / Accepted: 22 November 1999     

Contributions of evacuation proctography and anorectal manometry to evaluation of adults with constipation and defecatory difficulty

We prospectively evaluated 36 patients who complained of chronic constipation and/or defecatory difficulties to determine the role of anorectal manometry and evacuation proctography in delineating the pathogenesis of these complaints. Twenty patients with constipation also underwent a colonic transit study with radioopaque markers, which identificd one group with normal transit (N=10) and another with slow transit (N=10). Nine of 36 patients (25%) had inappropriate puborectalis muscle contraction or exhibited weak expulsion efforts during evacuation proctography, and these correlated highly with poor rectal emptying of barium paste (20±6% vs 61±5% in patients with normal relaxation; P<0.01). However, poor rectal emptying did not correlate with the presence of high-grade intussusceptions, large rectoceles, anorectal angles at rest or with straining, rectal diameter, clinical features, or colonic transit. Moreover, abnormal expulsion patterns as seen with anorectal manometry correlated poorly with the presence of inappropriate puborectalis contraction and decreased rectal emptying by proctography. Although anatomic abnormalities occurred frequently in patients with constipation and/or defecatory difficulties, they were also prevalent in asymptomatic controls. In view of these findings, surgical intervention to correct anatomic abnormalities in patients with constipation and/or defecatory difficulties should be considered only with great caution.     

Measuring colonic transit time in chronic idiophatic constipation.

INTRODUCTION AND OBJECTIVES: Colonic transit time can define three types of delay: right colon (colonic inertial), left colon and recto sigmoid. The aim of this study is to compare clinic characteristics and manometric results among the different groups with segmental colonic transit disorder. PATIENTS AND METHODS: 61 subjects were included in our study (5 men and 56 women) with and average age of 47.5 years (range: 17-84 years). We carried our a study of segmental and total colonic transit time, with the use of radio-opaque markers and sequential abdominal X-rays. We considered that transit time was prolonged when it was longer than 72 hours, and segmental transit time, when right colon was longer than 22 hours, left colon 37.2 hours and recto-sigmoid 37.2 hours. We included different clinic data: age, sex, place of residence stool frequency, abdominal pain, painful evacuation, incomplete evacuation, evacuation desire, dietary fibre intake, use of laxatives. We practised anorectal manometry in 20 patients. RESULTS: The average total colonic transit time was 38.2 hours in normal transit and 103 hours with disorder. The frequency in the three colonic segments, when there was a long total colonic transit time, was: 40% in the left colon, 33% in the recto-sigmoid and 27% in the right colon. We analysed the clinical characteristics of these three groups, finding more frequency of painful evacuation and defecation desire and lower dietary fibre intake in recto sigmoid. The most important abnormality in anorectal manometry was the hiposensitivity in the anorectal area, that only appeared in subjects with long segmental transit time in the right colon (colonic inertia), statistically significant. CONCLUSIONS: The measurement of colonic transit time with radio-opaque markers is a simple technique that allows for the objective detection of the different groups of patients with chronic idiopathic constipation. The exact typification of the abnormality is important for the individualization of each treatment.     

The surgical management of constipation.

The anal physiology laboratory plays a very important role in the selection of patients for surgical treatment for constipation. Any report which does not include reference to these methods of evaluation will not be helpful since there are several causes of constipation. The current recommended treatment for slow transit constipation is still total abdominal colectomy with ileorectal anastomosis. Treatment of pelvic floor outlet obstruction seems to be best accomplished using muscle/sensory retraining techniques since this is a functional disorder rather than an anatomical or physiological disorder. Combinations of colonic inertia, pelvic floor outlet obstruction and internal intussusception should be treated to correct the pelvic floor outlet obstruction initially, followed by correction of the colonic inertia. In this way failure will be avoided at the time of surgical treatment of the constipation.     

Study on functional constipation and constipation‐predominant irritable bowel syndrome by using the colonic transit test and anorectal manometry

OBJECTIVE: To investigate the visceral perception, anorectal pressure and colonic transit time (CTT) in patients with functional constipation and constipation‐predominant irritable bowel syndrome (C‐IBS), and to study the manometric abnormalities of these two conditions. METHODS: The CTT in patients with functional constipation and C‐IBS was studied by using radiopaque markers. Rectal visceral perception thresholds, rectal compliance and anorectal pressure were examined by electric barostat. RESULTS: The CTT in both groups of constipated patients was abnormal. A lot of radiopaque markers remained in the right colon in C‐IBS patients, whereas in patients with functional constipation, the radiopaque markers remained in each segment of the colon. The anorectal resting pressure, squeezing pressure and relaxation pressure were normal in both groups. Rectal compliance and defecation thresholds were much higher compared with controls, and the rectal visceral perception of functional constipation was also abnormal. CONCLUSIONS: The motility abnormalities of functional constipation and C‐IBS occurred in different colonic segments. Results suggest that CTT measure­ment and anorectal manometry could be helpful in the differential diagnosis of these two conditions.     

Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy?

PURPOSE: Treatment of severe constipation caused by combined colonic inertia and nonrelaxing pelvic floor is controversial. This study is designed to evaluate the outcome of preoperative biofeedback and subtotal colectomy for patients with combined colonic inertia and nonrelaxing pelvic floor. METHODS: One hundred six patients who underwent subtotal colectomy for intractable constipation from 1982 through 1995 answered a detailed questionnaire regarding postoperative bowel function, symptoms of abdominal pain and bloating, and degree of satisfaction after the operation. Sixteen of these patients had a combination of colonic inertia and nonrelaxing pelvic floor diagnosed by transit marker study, electromyography, and defecography. These patients completed preoperative biofeedback training. RESULTS: Electromyographic relaxation of pelvic floor musculature was demonstrated after the biofeedback treatment in all patients, but symptoms of difficult evacuation persisted. Postoperatively, seven patients (43 percent) had complete resolution of symptoms of constipation or difficult evacuation. Six patients still complained of incomplete evacuation that was severe in two and unresponsive to postoperative biofeedback. Three patients (18 percent) complained of diarrhea (>5 bowel movements per day) and incontinence of liquid stools (at least one episode a week). Nine patients (56 percent) were satisfied despite persistent symptoms. CONCLUSIONS: Subtotal colectomy can improve some symptoms in patients with slow transit constipation and nonrelaxing pelvic floor. However, incomplete evacuation persists in a significant number of patients and almost one-half of patients are dissatisfied with their surgery.