Audit of Constipation in a Gastroenterology Referral Center

This study was designed to assess the various subtypes of functional constipation in a referral gastrointestinal center of a Latino-American country. All patients referred for evaluation of constipation during a 10-year period were audited, and those with functional constipation according to Rome I criteria classified by physiologic tests of colonic transit, as well as tests of anorectal and pelvic floor function. More than 70% of patients with functional constipation had evidence of pelvic floor dysfunction, whereas those with slow transit and constipation-predominant irritable bowel syndrome subtypes were less frequently represented. Even in a setting different from those most frequently reported in the literature, pelvic floor dysfunction represents the most common cause of functional constipation. Simple, physiologic testing is needed and useful for the diagnosis. This fact has therapeutic implications, especially because many such patients may benefit from biofeedback.     

Water load test before and after PPI therapy in patients with gastro-oesophageal reflux disease

BACKGROUND: Patients with gastro-oesophageal reflux disease may complain of epigastric pain, bloating, early satiety, epigastric fullness, epigastric burning, nausea and vomiting. AIMS: To evaluate the symptoms in response to gastric distension and its relationship to a therapeutic course in patients with gastro-oesophageal reflux disease using the water load test, compared to healthy controls. METHODS: Thirty gastro-oesophageal reflux disease patients with grade A oesophagitis (studied before and after 4 weeks of therapy with esomeprazole, 40 mg per day) and 15 patients with reflux-related symptoms demonstrated at wireless pH monitoring (non-erosive reflux disease) were compared to 30 healthy volunteers. RESULTS: Patients with grade A oesophagitis and with reflux-related symptoms ingested significantly lower water volumes than did controls, before onset of fullness, without statistically significant difference between erosive or non-erosive gastro-oesophageal reflux disease; this variable improved in patients after treatment. Nausea scores were higher basally in patients, pre- and post-therapy, and improved after therapy. Thirty-minute fullness and bloating scores improved after therapy in all gastro-oesophageal reflux disease patients compared to controls and pre-therapy. In all pre-treatment patients, a significant correlation was found only with epigastric fullness; after treatment, there was no significant relationship between the water load and the symptom scores. CONCLUSIONS: In patients with reflux-related symptoms, with or without grade A oesophagitis, the water load test is frequently abnormal, suggesting an altered gastric function. This could explain the incomplete resolution of symptoms after treatment in some patients, and should lead to additional studies aimed at exploring gastric function in gastro-oesophageal reflux disease patients.     

Gastrointestinal motility disorders in inflammatory bowel diseases

The relationship between motility and inflammatory gastrointestinal disorders is at the same time complex and intriguing since these conditions might share some genetic,environmental,immunological and microbial predisposing factors.In addition,significant symptom overlapping may occur,muddling the waters within the clinical context.Although on one hand this represents a challenge for the clinician for a potential under-or over-treatment and diagnostic delay,on the other hand it possibly represents an opportunity for the researcher to better disclose the intimate relationship between chronic(often low-grade)inflammation,motor disorders and deranged sensory function.The best example is probably represented by Crohn’s disease and ulcerative colitis.In fact,a number of gastrointestinal motor disorders have been described in association with these diseases,disorders which span from the esophagus to the anorectum,and which will be extensively covered in this review.It is conceivable that at least part of this derangement is strictly related to inflammatory cytokine trafficking and neuromuscular changes;however,given the high prevalence of functional gastrointestinal disorders in the general population,this overlap might also be serendipitous.However,it is worth noting that literature data on this topic are relatively scarce,sometimes quite outdated,and mostly focused on the interplay between irritable bowel syndrome and inflammatory bowel disease.Nevertheless,both researchers and clinicians must be aware that symptoms related to gastrointestinal motility disorders may be highly prevalent in both active and inactive inflammatory bowel disease,correlate with greater psychological comorbidity and poorer quality of life,and may negatively influence the therapeutic approaches.     

Anorectal dysfunction in constipated women with anorexia nervosa

OBJECTIVE: To evaluate anorectal and colonic function in a group of patients with anorexia nervosa complaining of chronic constipation. PATIENTS AND METHODS: Twelve women (age range, 19-29 years) meeting the criteria for anorexia nervosa and complaining of chronic constipation were recruited for the study. A group of 12 healthy women served as controls. Colonic transit time was measured by a radiopaque marker technique. Anorectal manometry and a test of rectal sensation were carried out with use of standard techniques to measure pelvic floor dysfunction. A subgroup of 8 patients was retested after an adequate refeeding program was completed. RESULTS: Eight (66.7%) of 12 patients with anorexia nervosa had slow colonic transit times, while 5 (41.7%) had pelvic floor dysfunction. Colonic transit time normalized in the 8 patients who completed the 4-week refeeding program. However, pelvic floor dysfunction did not normalize in these patients. CONCLUSIONS: Patients with anorexia nervosa who complain of constipation have anorectal motor abnormalities. Delayed colonic transit time is probably due to abnormal eating behavior.     

Long-Term Study on the Effects of Visual Biofeedback and Muscle Training as a Therapeutic Modality in Pelvic Floor Dyssynergia and Slow-Transit Constipation

PURPOSE: Biofeedback training has been shown as an effective therapeutic measure in patients with pelvic floor dyssynergia, at least in the short term. Long-term effects have received less attention. Moreover, its effects in patients with slow-transit constipation have been scarcely investigated. This study was designed to assess in an objective way the medium- and long-term effects of biofeedback and muscle training in patients with pelvic floor dyssynergia and slow-transit constipation. METHODS: Twenty-four patients (14 with pelvic floor dyssynergia and 10 with slow transit) meeting the Rome II criteria for constipation, and unresponsive to conventional treatments, entered the study. Clinical evaluation and anorectal manometry were performed basally and three months after a cycle of electromyographic biofeedback and muscle training; moreover, a clinical interview was obtained one year after biofeedback. Patients with slow-transit constipation also had colonic transit time reassessed at one year. RESULTS: Clinical variables (abdominal pain, straining, number of evacuations/week, use of laxatives) all significantly improved in both groups at three-month assessment; anorectal manometric variables remained unchanged, apart from a significant decrease of sensation threshold in the pelvic floor dyssynergia group and of the maximum rectal tolerable volume in the slow-transit constipation group. At one-year control, 50 percent of patients with pelvic floor dyssynergia still maintained a beneficial effect from biofeedback, whereas only 20 percent of those complaining of slow-transit constipation did so. Moreover, the latter displayed no improvement in colonic transit time. CONCLUSIONS: In our experience, patients with pelvic floor dyssynergia are likely to have continued benefit from biofeedback training in the time course, whereas its effects on slow-transit constipation seems to be maximal in the short-term course.     

A practical approach to diagnosis and management of functional constipation in adults

Chronic constipation is a frequently complained condition in clinical practice and may be primary (idiopathic) or due to secondary causes. The definition of the various forms of constipation is presently made according to the Rome III criteria, which recently incorporated also specific diagnostic algorithms. The diagnosis of constipation relies on the patient’s history, including use of drugs, physical examination, and specific investigations (transit time, anorectal manometry, balloon expulsion test, defecography). These will often be useful to start a targeted therapeutic schedule that may include fibres, laxatives, biofeedback training and, in extreme cases, a surgical approach. This review will analyse the clinical and diagnostic aspects of chronic constipation in adult patients, with emphasis on recent therapeutic approaches.     

Intact colonic motor response to sudden awakening from sleep in patients with chronic idiopathic (slow-transit) constipation

PURPOSE: There are few data about the relationships between colonic motor behavior and higher brain functions, such as sleep. Previous studies were done in healthy subjects, and it is unknown whether patients with functional motor disorders of the colon behave differently. This study was designed to characterize colonic motor activity in patients with constipation, both during sleep and after sudden awakening, and to compare it with that of healthy subjects. Our working hypothesis was that patients with constipation would have an impaired response to sudden awakening. PATIENTS AND METHODS: Twelve chronically constipated women, 22 to 49 years old, were recruited for the study, and their data were compared with those obtained from 12 healthy female volunteers, 21 to 38 years old. Manometric studies were performed in the descending and sigmoid colon for 30 minutes during sleep (immediately before awakening) and 30 minutes after being awakened suddenly. A motility index was calculated before and after the stimulus. RESULTS: In both groups motility in the descending and the sigmoid colon was almost absent during sleep and significantly increased after sudden awakening. No difference in postawakening values was found between patients with constipation and controls. CONCLUSIONS: In patients with chronic constipation, the brain-gut control of some fundamental mechanisms governing colonic motility is preserved. These data suggest that the alterations of colonic motility described in chronic constipation may be caused by an intrinsic dysfunction of the viscus.     

Esophageal Manometric Abnormalities in Parkinson's Disease

The gastrointestinal tract, and especially the esophagus, is frequently involved in neurological diseases; however, objective studies of gut motor function are few. We carried out an esophageal manometric study in 18 patients with various stages of Parkinson's disease (4 stage I, 4 stage II, 7 stage III, and 3 stage IV) to evaluate the function of the viscus in this disease. Clinical assessment showed that 61% complained of esophageal symptoms such as dysphagia, acid regurgitation, pyrosis, and noncardiac chest pain. Manometric abnormalities were documented also in 61% patients, and were represented by repetitive contractions, simultaneous contractions, reduced LES pressure, and high-amplitude contractions. However, only 33.3% of patients had both symptoms and manometric abnormalities. We conclude that esophageal motor abnormalities are frequent in Parkinson's disease, and may appear at an early stage of the disease.     

Colonic motility and gastric emptying in patients with irritable bowel syndrome effect of pretreatment with octylonium bromide

This study was undertaken to evaluate (1) the colonic response to eating for a prolonged time in healthy subjects and patients with the irritable bowel syndrome (IBS); (2) the effect of octylonium bromide, a new smooth muscle relaxant acting by interfering with calcium ion mobilization, on the postprandial colonic motility; and (3) whether chronic gastric stasis could be responsible for both the dyspeptic symptoms often complained of by IBS patients and the faulty colonic response to eating. The colonic response to a 1000-kcal mixed meal in ten healthy subjects was characterized by two transient (from 0 to 60 and from 120 to 150 min postprandially, respectively) increases in colonic motor activity; ten IBS patients showed a continuous postprandial increase in colonic motor activity that was not terminated 180 min after eating. Treatment of IBS patients with octylonium bromide (80 mg, qid,per os) for 5–7 days reduced their colonic response to eating to a very short increase in colonic motor activity limited to the first 30 min. Finally, gastric emptying was not different in the two groups.     

Manometric investigation of the entire esophagus in healthy subjects and patients with high-amplitude peristaltic contractions

Normal esophageal motor parameters and nuteracker esophagus have never been well characterized in Italy. For this reason, we investigated 33 patients with nutcracker esophagus and compared them with 34 age- and sex-matched volunteers. Esophageal manometry revealed that lower esophageal sphincter pressure and contraction amplitude at 3, 8, 13, and 18 cm above the lower esophageal sphincter were significantly higher in patients (p<0.05). In addition, bi- and tripeaked waves were significantly increased in the patients at all esophageal recording levels. No significant differences were found between the 9 patients and 17 controls who were also evaluated for upper esophageal sphincter pressure.