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PubMed1980

Irritable bowel syndrome: physiological and psychological differences between diarrhea-predominant and constipation-predominant patients.

Patients with different irritable bowel symptoms and normal subjects were compared to determine whether subtypes of irritable bowel syndrome (IBS) could be distinguished on the basis of colonic motility or psychological test scores. A provocative test involving stepwise distension of the rectosigmoid area revealed two types of colonic motility. Slow contractions having durations of at least 15 sec and occurring at irregular intervals were more frequent in IBS patients than in normals but did not differentiate constipation from diarrhea. Fast contractions having durations of less than 15 sec and occurring in runs at frequencies of 6-9 cpm were more frequent in patients with diarrhea than in normals or constipated IBS patients. Constipated patients showed no more fast contractions than normals. Severity of bowel symptoms was correlated with the overall amount of motility (motility index) in patients with diarrhea but not in patients with constipation. Patients with IBS showed significantly elevated levels on the following psychological traits: anxiety, interpersonal sensitivity, depression, hostility, and somatization of affect. However, there were no significant trait differences between patients with diarrhea and those with constipation. Also, there was no correlationbetween amount of psychopathology and either colonic motility or severity of symptoms in the whole group of IBS patients.

Adult↗
PubMed1992

Abnormal rectosigmoid myoelectric response to eating in patients with severe idiopathic constipation (slow-transit type).

Pathophysiologic mechanisms responsible for severe chronic constipation are poorly understood. In particular, most of the published studies have lumped together patients having different subtypes of constipation, with different and often conflicting results. We studied six patients complaining of severe idiopathic constipation and displaying homogeneous clinical and pathophysiologic features (i.e., patients with slow-transit type constipation) to evaluate their myoelectric spiking responses to food ingestion. Ten healthy subjects acted as controls. The constipated patients failed to show the increase in myoelectric spiking activity that was seen in controls immediately following the meals, suggesting the possibility of a neurogenic defect in this condition.

Action Potentials↗
PubMed1997

Long-term results of surgery for chronic constipation.

BACKGROUND: Developments in anorectal physiologic testing have facilitated better understanding of the process of defecation and factors that might cause chronic constipation. AIM: Patients with severe idiopathic chronic constipation were evaluated using colonic transit and pelvic floor function in an attempt to identify those patients suitable for aggressive surgical intervention. MATERIALS AND RESULTS: Among 1,009 patients studied using either a marker or scintigraphic transit technique and tests of pelvic floor function, 52 with slow-transit constipation (STC) were identified and underwent abdominal colectomy and ileorectostomy (IRA). Twenty-two patients had pelvic floor dysfunction and STC; these patients underwent initial pelvic floor retraining followed by IRA. A total of 249 patients had pelvic floor dysfunction without evidence of slow-transit and were offered pelvic floor retraining alone. The remaining 597 patients had no quantifiable abnormality of colon or pelvic floor dysfunction; these patients had normal transit constipation/irritable bowel syndrome and were treated medically. There were, thus, 74 patients operated on, 68 women, with a mean age of 53 years and a mean follow-up of 56 months. There was no operative mortality, seven patients (9 percent) had small-bowel obstruction, and nine patients (12 percent) had prolonged ileus. All patients were able to pass a stool spontaneously, 97 percent of patients were satisfied with the results of surgery, and 90 percent have a good or improved quality of life. There was no difference in the outcome of surgery in patients with STC alone compared with STC and pelvic floor dysfunction. CONCLUSION: Physiologic evaluation reliably identified patients with severe chronic constipation who might benefit from surgery. IRA is safe and effective, resulting in prompt and prolonged relief of constipation.

Adult↗
PubMed1997

Symptoms in chronic constipation.

OBJECTIVES: This study was designed to evaluate whether detailed symptom analysis would help to identify pathophysiologic subgroups in chronic constipation. METHODS: In 190 patients with chronic constipation (age, 53 (range, 18-88) years; 85 percent of whom were women), symptom evaluation, transit time measurement (radiopaque markers), and functional rectoanal evaluation (proctoscopy, anorectal manometry, defecography) were performed. Patients were classified on the basis of objective data from all tests in four different groups ("disordered defecation," "slow gastrointestinal transit," "disordered defecation combined with slow-transit stool," and "no pathologic finding"). RESULTS: In 59 percent of patients, disordered defecation was found, and 27 percent had slow-transit stool. In 6 percent of patients, a combination of both was found; in only 8 percent of patients, there were no pathologic findings. Straining was reported by the vast majority in all groups (82-94 percent). Infrequent bowel movements and abdominal bloating were more common in slow-transit stool (87 and 82 percent vs. 69 and 55 percent, respectively; both P < 0.01). Feeling of incomplete evacuation was more common in disordered defecation (84 vs. 46 percent; P < 0.0001). However, specificity of these symptoms was discouraging (for slow-transit stool: infrequent bowel movements had a sensitivity of 87 percent and a specificity of 32 percent and abdominal bloating had a sensitivity of 82 percent and specificity of 45 percent; for disordered defecation: feeling of incomplete evacuation had a sensitivity of 84 percent and a specificity of 54 percent). Only the sense of obstruction and digital maneuvers were acceptably specific (79 and 85 percent, respectively) for disordered defecation, but sensitivity was low. CONCLUSIONS: Definition of chronic constipation by infrequent bowel movements alone is of little value; the symptom "necessity to strain" is much better suited (94 percent sensitivity). Specificity of infrequent bowel movements for slow-transit stool was discouraging. Sense of obstruction and digital manipulation for evacuation are relatively specific for disordered defecation but insensitive. Therefore, symptoms of chronically constipated patients are not well suited to differentiate between the pathophysiologic subgroups suffering chronic constipation.

Adolescent↗
PubMed1996

Biliary dyskinesia in idiopathic slow-transit constipation.

BACKGROUND: Idiopathic slow-transit constipation may be a pangastrointestinal motility disorder. We have screened patients referred to surgery for constipation for the presence of biliary dyskinesia. METHOD: Patients had cholecystokinin-augmented trimethyl-3-bromo iminodiacetic acid scans to measure gallbladder ejection fraction. RESULTS: There is a significant difference in gallbladder ejection fraction between patients with idiopathic slow-transit constipation (median value, 28.5) compared with patients with other causes of constipation (median value, 71; Mann-Whitney, P = 0.0025). CONCLUSION: Idiopathic slow-transit constipation may be a pangastrointestinal motility disorder.

Adult↗
PubMed1995

Immunohistochemical study of the colonic muscle and innervation in idiopathic chronic constipation.

PURPOSE: This study was designed to investigate neural and muscular features of the colonic wall in patients with severe idiopathic constipation. METHODS: By using quantitative immunohistochemistry, resected specimens from 14 patients with idiopathic chronic constipation and 17 nonobstructed cancer controls were studied. RESULTS: Routine histology revealed no significant histologic abnormality throughout the colon apart from four cases of melanosis coli. Ratio of the thickness of circular to longitudinal muscle was significantly lower in the left colon in constipated subjects. The myenteric plexus appeared morphologically normal in all subjects. S-100 protein, which stains neuronal supporting tissues, demonstrated an increase in the proportion of neural tissue in the myenteric plexus. There was an increased number of PGP-9.5 immunoreactive nerve fibers in the muscularis propria in constipated patients, and this was significantly higher in the ascending and descending colon. CONCLUSION: Intractably constipated patients have alterations in the neural composition of the colonic myenteric plexus and innervation of the circular muscle.

Adolescent↗
PubMed1990

Rectal mucosal electrosensory testing--evidence for a rectal sensory neuropathy in idiopathic constipation.

Rectal sensation is usually assessed using balloon distention. The authors describe a more precise technique that avoids the variables of balloon dynamics and rectal diameter and compliance. Using both methods, rectal sensation was assessed in 13 healthy control women and 26 women with severe idiopathic constipation. Balloon distention in the rectum revealed an elevated sensory threshold (16.9 +/- 4.4 vs. 30.4 +/- 3.1 ml air, controls vs. patients, P = 0.018) and volume required to elicit a call to stool (61.1 +/- 9.1 vs. 97.5 +/- 6.4, P = 0.003) in subjects with severe constipation. The maximum tolerated volume was similar in the two groups. Rectal mucosal electrosensitivity was then tested using a bipolar ring electrode supplying a constant current. This demonstrated an elevated sensory threshold in the constipated subjects (16.3 +/- 3.0 vs. 27.4 +/- 2.1 mAmps, P = 0.005). There was a significant correlation between the sensation thresholds for balloon distention and electrical stimulation for the entire subject group (r = 0.39, P = 0.01). Two other patients with severe constipation after suspected extrinsic nerve damage were also studied and demonstrated a markedly abnormal electrical sensory threshold. Electrical testing avoided the variables inherent in balloon distention and was well tolerated, accurately quantifiable, and reproducible. The raised threshold to electrosensory mucosal testing suggests the presence of a rectal sensory neuropathy in patients with severe idiopathic constipation.

Adolescent↗
PubMed2001

Colectomy for slow-transit constipation: preoperative functional evaluation is important but not a guarantee for a successful outcome.

PURPOSE: This study was designed to assess the results of preoperative functional evaluation of patients with severe slow-transit constipation in relation to functional outcome. METHODS: Four hundred thirty-nine patients with chronic intractable constipation were evaluated by marker studies. Twenty-one patients underwent colectomy and ileorectal anastomosis for slow-transit constipation. Mean colorectal transit time was 156 hours (normal, <45 hours). Small-bowel transit time was normal in ten patients and delayed in five patients. Six were nonresponders. Morbidity was 33 percent. Small-bowel obstruction occurred in six patients; relaparotomy was done in four patients. Follow-up varied from 14 to 153 (mean, 62) months. RESULTS: After three months, defecation frequency was increased in all. Mean stool frequency improved from one bowel movement per 5.9 days to 2.8 times per day. Sixteen patients felt improved after surgery. Seventeen continued to experience abdominal pain, and 13 still used laxatives and enemas. Satisfaction rate was 76 percent (16 patients). After one year, defecation frequency was back at the preoperative level in five patients. An ileostomy was created in two more patients because of incontinence and persistent diarrhea. Eleven patients (52 percent) still felt improved. A relation between small-bowel function and functional results could not be demonstrated. CONCLUSIONS: Preoperative evaluation is important but not a guarantee for, successful outcome. Colectomy remains an ultimate option for patients with disabling slow-transit constipation, but patients should be informed that, despite an increased defecation frequency, abdominal symptoms might persist. Any promiscuous use of colectomy to treat constipation should be discouraged.

Anastomosis, Surgical↗
PubMed2001

Cecal access for antegrade colon enemas in medically refractory slow-transit constipation: a prospective study.

PURPOSE: The current surgical treatment for therapy-resistant slow-transit constipation consists of either subtotal colectomy or ileostomy. This prospective study was performed to examine the creation of an access enabling antegrade enemas of the colon as an alternative to these interventions. Development of symptoms associated with constipation was also a study subject. METHODS: Twelve patients with a median defecation frequency of once a week were evaluated preoperatively, using marker-transit studies, defecography, manometry, and colonoscopy. All patients subsequently received an enema access, placed in the lower right abdomen. The appendix (available in seven cases) was laparoscopically fixed to the abdominal wall and served as a stoma, a procedure that required a conversion in one case. In five previously appendectomized cases, the terminal part of the ileum was transected, the distal side fixed to the abdominal wall to serve as a stoma, and the proximal side anastomosed to the ascending colon. Quality-of-life-assessment was included. This consisted of Nottingham Health Profile, State Trait Anxiety Inventory, and Zung tests, as well as disease specific questions. Besides perioperative and out-patient evaluations, patients were asked about and scored on constipation associated symptoms. RESULTS: Twelve patients (8 female) with a mean age of 43 (17-66) years were treated. Using various enema regimes, frequency of defecation (median one daily) without major complications was established. In four cases, a subtotal colectomy was required in the long run. Two of these four patients needed an ileostomy after for persisting symptoms. State Trait Anxiety Inventory and Zung results improved, as did several associated symptoms. Overall, constipation scores dropped from a median of 21.5 to 5.5. CONCLUSION: Cecal access for antegrade colon enemas in medical therapy-resistant slow-transit constipation is a minimally invasive procedure with promising results. In case of failure, further surgery is not compromised by this procedure.

Adolescent↗
PubMed2001

Effect of subtotal colectomy on gastric emptying of a solid meal in slow-transit constipation.

BACKGROUND: Idiopathic slow-transit constipation is considered a panenteral disease in which patients may have delayed gastric emptying. The effects of total abdominal colectomy and ileorectal anastomosis on upper gut motility are unknown. The aim of this study was to evaluate gastric emptying in patients with idiopathic slow-transit constipation before and after subtotal colectomy. METHODS: Gastric emptying of a solid meal was studied by scintigraphic technique in 11 patients with idiopathic slow-transit constipation. The total colonic transit time was more than 72 hours in all patients studied, with delay in transit in all segments of the colon. The gastric emptying test was repeated 3 to 6 months after total abdominal colectomy and ileorectal anastomosis in ten of these patients. Before and after surgery, patients filled out a questionnaire to record upper gut symptoms. RESULTS: Solid gastric emptying was delayed (T1/2 > upper limit of normal) in 7 of 11 patients with idiopathic slow-transit constipation. Gastric emptying T1/2 was almost similar before and after surgery. Mean +/- standard deviation was 142 +/- 91 minutes before surgery and 146 +/- 67 minutes after surgery. Symptoms of vomiting and belching improved significantly after surgery. Symptoms of nausea, bloating, and pyrosis also decreased, but these changes failed to reach statistical significance. CONCLUSION: Despite a reduction in upper gut symptoms, total abdominal colectomy and ileorectal anastomosis does not improve delayed gastric emptying in patients with idiopathic slow-transit constipation.

Adult↗
PubMed1998

Patterns of colonic motility as recorded by a sham fecaloma reveal differences among patients with idiopathic chronic constipation.

BACKGROUND: By using a technique designated sham fecaloma, we were able to identify two types of segmentary motor phenomenon: displacement motor phenomena and nondisplacement motor phenomena. The aim of the study contained herein was to evaluate for identification of patients with different types of slow-transit constipation. METHODS: Studies were performed in healthy subjects (n = 5; colonic transit time <30 hours) and in constipated patients (n = 6; colonic transit time >125 hours; normal rectoanal manometry). A Foley-type recording probe with two perfused catheters (proximal and distal) was used. A rigid sigmoidoscope was used to place the probe at the sigmoid colon. Values recorded by the distal catheter were subtracted (point by point) from the values recorded by the proximal catheter. Subtraction curves were analyzed to quantify characteristics of displacement motor phenomena (an anally directed pressure gradient) and nondisplacement motor phenomena (an orally directed pressure gradient). RESULTS: All healthy subjects had contractions during the recording session. Displacement motor phenomena were predominant (displacement motor phenomena/30 minutes = 21.2 +/- 13.2; range, 3-39). Constipated patients yielded two different patterns: three patients had a very small number of contractions, and three patients had a prevalence of nondisplacement motor phenomena, with numbers similar to numbers of displacement motor phenomena in healthy subjects. A comparison of the patterns of constipated patients revealed a statistically significant difference (P = 0.039). CONCLUSION: Sham fecaloma is a simple and safe test. Constipated patients in this study had two different patterns of colonic motility: scarce activity without haustration and normal activity without displacement motor phenomena. This method might be useful as a diagnostic tool for clarification of the pathophysiology of severe colonic motor disorders.

Adult↗
PubMed1998

Which physiologic tests are useful in patients with constipation?

PURPOSE: Physiologic tests such as manometry, colonic transit times, balloon compliance, defecography, pudendal nerve latency, and electromyography are used to evaluate patients with severe constipation. Patients referred because of severe constipation between 1991 and 1996 were studied to examine the role that physiologic testing played in making a diagnosis and directing treatment. METHODS: Of 139 patients referred for severe idiopathic constipation, physiologic testing was recommended in 127, and 104 patients underwent the studies. The pretesting impression was noted, and test results were evaluated to determine diagnostic accuracy. If a specific initial impression was documented, tests were classified as refuting it, confirming it or confirming and adding significant information. If there was no clear pretest impression, tests were evaluated for their ability to indicate a diagnosis. The patient's history also was evaluated to determine what information was most useful in making a diagnosis. Historical features including duration of constipation, symptoms consistent with outlet obstruction or dysmotility, age, associated urinary incontinence, and prior hysterectomy were analyzed. Data were collected prospectively, then reviewed by an independent observer. RESULTS: Ninety-eight study patients remained after 29 were excluded who did not undergo the recommended studies (19) or because no initial impression was documented (10). In 43 patients (44 percent), testing did not provide additional useful information. In 8 patients, testing confirmed the initial impression and added information impacting the treatment plan. Test results clearly refuted the initial impression in only one patient. In 46 (47 percent) patients the initial impression was uncertain, and in 43 (94 percent) of these, testing aided in making the diagnosis. In three cases, the diagnosis remained uncertain after testing. Prior hysterectomy (P = 0.003), urinary incontinence (P < 0.001), and symptoms of pelvic outlet obstruction (P = 0.03) were associated with a high incidence of rectocele. Defecography and transit times were the most useful tests. Surprisingly, symptoms of outlet obstruction or dysmotility did not show an overall correlation with transit times. CONCLUSIONS: In one-half of these patients with severe constipation, physiologic testing added significant information, leading to a specific diagnosis. Pretesting history and symptoms did not predict which patients were most likely to benefit from these studies.

Adolescent↗
PubMed1998

Pelvic floor function in patients with clinically complete spinal cord injury and its relation to constipation.

PURPOSE: Constipation is a common problem in patients with spinal cord injury. The aim of this study is to analyze the role of pelvic floor dysfunction in the development of constipation. METHODS: Twenty-five patients with clinically complete supraconal spinal cord injury were studied by means of colonic transit time, anal manometry, electrophysiologic testing, and sensory-evoked potentials. RESULTS: Sixteen patients had prolonged total and segmental colonic transit times (Group C), and nine patients had normal colonic transit times (Group NC). Basal pressure and anal pressure during coughing, Valsalva's maneuver, and rectal distention were diminished in all patients, but no differences were observed between Group C and Group NC. Rectal sensation was preserved in eight patients, but this was not related to the absence of constipation. In seven of these eight patients, somatosensory-evoked potentials could be recorded, which indicated an incomplete cord lesion. Synergic relaxation of the pelvic floor during straining was never observed; dyssynergia was seen in ten (7 in Group C and 3 in Group NC; P = not significant) patients. Associated peripheral nerve damage was present in 40 percent of patients but did not predispose these patients to constipation. CONCLUSIONS: Loss of rectal sensation, dyssynergic pelvic floor contraction during straining, associated peripheral nerve damage, and insufficient rise of intraabdominal pressure could not be held responsible for constipation as a result of spinal cord injury. A prolongation of the colonic transit time is the most important mechanism, and therapy should be directed toward it.

Adolescent↗
PubMed1995

Dermatoglyphic patterns in children with chronic constipation.

Analysis of the fine ridge configurations on the digits of the palms and soles (dermatoglyphics) may sometimes help in the diagnoses of certain medical disorders. Dermatoglyphic patterns have been reported to be associated with congenital anomalies, such as congenital heart disease, duodenal ulcer, abdominal pain, and constipation. The palmar dermatoglyphic patterns of 77 children with constipation (39 functional and 38 organic constipation) were recorded. The control group consisted of 84 children with inguinal hernia. Those patients with at least one arch identified on any digit of either hand were termed arch positive. There was no significant correlation between arch positivity and constipation (functional or organic), or inguinal hernia (chi square, P = 0.9211). Therefore, the presence of palmar arches cannot be used as a screening device for children with chronic constipation, especially of organic etiology.

Child↗
PubMed1998

[Evacuation defecography and defecoflometry in diagnosis of chronic constipation. A prospective comparative study of 49 patients].

Chronic constipation can be divided in two large groups: slow-transit constipation, caused by pathological intestinal transit, and obstructive defecation disorder, caused by pelvic and rectal wall abnormalities. Videodefecography and defecoflowmetry are methods used to study dynamic evacuation of the rectum. Videodefecography also enables visual estimation of rectal evacuation. Defecoflowmetry allows analysis of anal and rectal pressures. Within this prospective study we utilized and compared these methods in 19 patients with slow transit and 30 patients with obstructive disease. In patients with slow transit, both investigations demonstrated a significantly higher defecation rate than in obstructive defecation disorder (slow transit: defecoflowmetry 65%, videodefecography 80%; obstructive defecation disorder: 50% and 58%). The evacuation time was pathologically prolonged in both types of constipation, with a range of 43-55 s. Rectoceles are demonstrated in 94% of cases with slow transit and in 72% with obstructive defecation disorder. Also, we often found obstructive components in slow-transit constipation patients. Normal defecography or defecoflowmetry can rule out obstructive defecation disorder. We conclude that videodefecography and defecoflowmetry are important items in the complex diagnostic regimen needed in evaluation of chronic constipation.

Adult↗
PubMed2006

Systematic assessment of constipation on plain abdominal radiographs in children.

BACKGROUND: Constipation in childhood is common and its clinical assessment is often difficult. Plain abdominal radiography is simple and used to quantify constipation. Three scoring systems, those of Barr et al., Leech et al. and Blethyn et al., have been developed to quantify fecal loading on the abdominal radiograph. OBJECTIVE: In order to determine which method is the most useful in clinical practice, we assessed the reproducibility of the three scoring systems. MATERIALS AND METHODS: Plain abdominal radiographs from 40 clinically constipated children were retrospectively reviewed by two paediatric radiologists on two separate occasions. The radiographs were scored according to three different systems developed by Barr et al., Leech et al., Blethyn et al. Intraobserver variability and interobserver reproducibility were determined for each system. Kappa coefficients were calculated as indicators of inter- and intraobserver agreement for categorical outcome variables. RESULTS: The Leech score showed the highest reproducibility: the intraobserver agreement was high for both observers (kappa values of 0.88 and 1.00, respectively, P<0.05). Furthermore, the interobserver agreement was also high: kappa 0.91 in the first round and 0.84 in the second. CONCLUSIONS: The Leech score proved to be a highly reproducible tool for assessment of childhood constipation and is of value in clinical practice for systematic assessment of constipation on plain abdominal radiographs in children.

Child↗
PubMed2006

Transient ventriculoperitoneal shunt malfunction after chronic constipation: case report and review of literature.

BACKGROUND: Significant constipation in patients with shunt-dependent hydrocephalus may often be enough to bring a subclinical shunt malfunction to clinical attention or even to be the cause of temporary distal peritoneal shunt malfunction. The treatment of the constipation may address the symptomatic shunt dysfunction so as to avoid operative intervention. The pathogenesis of distal shunt malfunction and its management in such a situation are discussed, and the relevant literature is briefly reviewed. CASE REPORT: A 16-year-old young boy had shunt-dependent hydrocephalus secondary to prematurity and intraventricular hemorrhage at birth. He was chronic flaccid paraplegic and had a neurogenic bladder and bowel involvement. He presented with acute dull aching intermittent headaches, nausea, and constipation of short duration. There was no underlying shunt infection. CT brain showed dilated lateral ventricles. Shunt survey revealed a convoluted course and kink in the distal peritoneal catheter. After administration of a bowel enema, the headaches and nausea resolved over the next few hours, and the posttreatment CT showed significant decrease in ventricular size. CONCLUSION: Chronic constipation is an important predisposing factor for distal malfunction in shunt-dependent hydrocephalus and should be ascertained in evaluation of a ventriculoperitoneal shunt malfunction. Appropriate treatment of significant constipation can relieve shunt malfunction and reestablish cerebrospinal fluid circulation. A shunt exploration can be avoided in such a situation. A close neurological monitoring of the patient is essential during the course of treatment. An interdisciplinary approach between concerned medical specialties and enhanced awareness is mandatory to ensure appropriate bowel management.

Adolescent↗
PubMed2003

The constipated child: how likely is Hirschsprung's disease?

The incidence of Hirschsprung's disease (HD) was determined in children who presented with constipation to a specialist paediatric surgical unit. During a 5-year period, 355 rectal biopsies were performed on 182 neonates, infants and children presenting with chronic constipation or intestinal obstruction: 25 (14%) were diagnosed HD. One hundred and four patients had suction and 78 had full-thickness rectal biopsies. Haematoxylin-eosin (HE) staining and acetylcholinesterase (AChE) histochemistry was used. In 13 cases (8%) of suction and 2 cases (2.5%) of full thickness rectal biopsies, specimens were inadequate to diagnose HD. The mean age of all patients was 2.9 years and that of patients diagnosed with HD was 3.64 months. Nineteen patients with HD were diagnosed in the first month, 5 in 1-12 months and 1 at 4 years of age (Fig. 1). The authors found that along with onset of constipation convincing indications for rectal biopsy to exclude HD were as follows: those infants and children who do not pass meconium within 48 hours, have low intestinal obstruction of unknown cause, severe constipation, chronic abdominal distension and failure to thrive. A diagnostic accuracy of 94% was achieved with AChE histochemistry for suction rectal biopsy. After this review, referring paediatricians were advised that screening of other common organic causes of constipation with the least invasive investigations, including laboratory, dietary and paediatric gastroenterology advice, should be undertaken to avoid unnecessary rectal biopsy to exclude HD and related disorders.

Acetylcholinesterase↗