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PubMed1997

Clinical response to dietary fiber treatment of chronic constipation.

OBJECTIVES: To determine the clinical outcome of dietary fiber therapy in patients with chronic constipation. METHODS: One hundred, forty-nine patients with chronic constipation (age 53 yr, range 18-81 yr, 84% women) at two gastroenterology departments in Munich, Germany, were treated with Plantago ovata seeds, 15-30 g/day, for a period of at least 6 wk. Repeated symptom evaluation, oroanal transit time measurement (radiopaque markers), and functional rectoanal evaluation (proctoscopy, manometry, defecography) were performed. Patients were classified on the basis of the result of dietary fiber treatment: no effect, n = 84; improved, n = 33; and symptom free, n = 32. RESULTS: Eighty percent of patients with slow transit and 63% of patients with a disorder of defecation did not respond to dietary fiber treatment, whereas 85% of patients without a pathological finding improved or became symptom free. CONCLUSION: Slow GI transit and/or a disorder of defecation may explain a poor outcome of dietary fiber therapy in patients with chronic constipation. A dietary fiber trial should be conducted before technical investigations, which are indicated only if the dietary fiber trial fails.

Adolescent↗
PubMed1996

[A clinical study of the use of a combination of glucomannan with lactulose in the constipation of pregnancy].

RATIONALE: Constipation is a problem frequently encountered during pregnancy as is excessive weight gain. Treatments of common use to control constipation are endowed with some drawbacks and they are not active in controlling weight increase. A preparation of lactulose and glucomannan in previous studies proved very effective and well tolerated in patients affected by stypsis and evidentiated also activity both in controlling excessive food intake and in correcting some metabolic imbalances regarding lipids and urea. MATERIAL AND METHODS: 50 pregnant females affected by constipation were treated with sachets containing a preparation of glucomannan (1.45 g) and lactulose (4.2 g) in a posology of 2 (1-4) sachets a day for 1-3 months. RESULTS: Treatment induced a return to normal frequency of weekly number of evacuations (4.9-5.8/week) and a parallel control of weight gain (within 20% of initial body weight). The latter finding seems to be related to hunger control induced by glucomannan at the gastric level which prevents an excessive food intake.

Cathartics↗
PubMedDate not supplied

[Severe chronic constipation: limitations of medical therapy and indications for surgical intervention. II].

Severe chronic constipation is a common problem in children. Most patients have functional constipation, only few (approximately 5%) have an underlying organic disease who requires surgical treatment. Anatomic problems with a painful defecation (anal rhagades, fistulas, hemorrhoids) or with difficult defecation (anal stenosis, tumor) require only a careful physical examination. Other organic problems due to neurogenic and myogenic colonic abnormalities require extensive investigations, including histological and histochemical study, for diagnosis. Ultrashort Hirschprung's disease, neuronal intestinal dysplasia type B and hypoganglionosis represent different levels of a developmental problem of the enteric nervous system. Surgical treatment is recommended in these cases. After surgery is recommended a long period of medical treatment to avoid a functional constipation.

Child↗
PubMed1997

The hypertonic rectosigmoid junction: description of a new clinicopathologic entity causing constipation.

A physiological sphincter exists at the rectosigmoid junction; this rectosigmoid sphincter (RSS) relaxes on sigmoid colon contraction and contracts on rectal contraction. Eight cases of RSS hypertonia are presented herein. Six women and two men (mean age, 44.2 +/- 10.3 years) complained of chronic constipation of 9.6 +/- 6.2 years' duration. They had had normal bowel habits before that time. Anorectal physiologic studies were performed. Intestinal transit was delayed by the accumulation of pellets in the sigmoid colon. Defecography and electromyography of the external anal sphincter and levator ani muscle were normal. The resting pressure was normal in the sigmoid colon, rectum, and rectal neck (p > 0.05) but elevated in the RSS (p < 0.01). The sigmoidorectal inhibitory and excitatory reflexes were absent. Biopsies from the sigmoid colon and rectum showed normal histologic findings, but those from the RSS were aganglionic. A diagnosis of RSS "achalasia" was made. Five of the eight patients had improvement as a result of RSS dilatation. The remaining three patients underwent sigmoidomyotomy. The eight patients are now 9 to 38 months without recurrence of constipation. Rectosigmoid junction achalasia constitutes a clinicopathologic entity that should be considered in the etiology of constipation.

Adult↗
PubMed1997

Diagnostic imaging in the evaluation of constipation in adults.

Acute and chronic constipation are common conditions. In most instances, a thorough history and digital rectal examination provide sufficient information to begin treatment. Occasionally, imaging studies can be useful to confirm the presence of a suspected abnormality. The acute onset of constipation suggests colonic obstruction. Plain abdominal radiographs may be sufficient to determine the level and cause of the obstruction, such as sigmoid or cecal volvulus. Barium enema radiographic examination or colonoscopy may also be useful to detect the cause of obstruction. In patients with chronic constipation, plain abdominal radiographs can be used to show the extent of fecal impaction. Colonic transit time can be assessed on serial abdominal radiographs after the patient has ingested radiopaque markers. Evacuation proctography can be used to diagnose a variety of functional disorders of the rectum and anus, such as rectocele, intussusception and abnormal perineum floor descent.

Acute Disease↗
PubMedDate not supplied

Treatment of constipation in older people.

Constipation is a common experience for a wide range of client groups. However, it is often badly managed, and research into effective treatment of constipation is sparse. This article summarises a systematic review carried out for the NHS health Technology Assessment programme. There is some evidence that laxatives can improve frequency and consistency of defecation and symptoms in older people with constipation.

Aged↗
PubMedDate not supplied

Ultrasonographic evaluation of urinary tract in children with chronic functional constipation.

Urinary tract anomalies were prospectively investigated with ultrasound in 31 children with chronic functional constipation. These children were compared with 29 healthy controls without constipation both before and after treatment. Bladder residue and upper renal tract dilatation after micturition were significantly more common in the group with constipation than in the improved after-treatment and control groups.

Adolescent↗
PubMed1998

[Measurement of colon transit time useful in the evaluation of functional constipation].

OBJECTIVE: To determine the colon transit time (CTT) in patients complaining of functional constipation and the correlation between abnormal transit times and the types of constipation and of the symptoms. DESIGN: Retrospective, descriptive. SETTING: Department of Surgery, University Hospital, Nijmegen, the Netherlands. METHOD: The signs and symptoms of 112 patients with infrequent or difficult defaecation, 93 (83%) of them women, with a median age of 42 years (range: 16-72), were recorded by means of a questionnaire. After ingestion of radiopaque markers per day for 10 days, an abdominal survey X-ray was made on day 11. The numbers of markers in the X-ray and per segment (right and left hemicolon and rectosigmoid) were counted; the CTT in hours was calculated by multiplying this number by 2.4. Slowness was defined as more than 45 h for the total CTT and as more than 15 h for the segmental CTT. RESULTS: The total CTT was normal in 33 patients (29%) and prolonged in 79 (71%). The CTT was prolonged only in the rectosigmoid in 14 patients with a normal CTT (42%) and in 50 patients with a prolonged total CTT (63%). Of the patients with a normal total CTT, 13 (39%) had a normal segmental CTT. No statistically significant correlation could be demonstrated between the presence of any symptom and a prolonged CTT. CONCLUSION: Functional constipation may be associated with a normal CTT. Disorders of colonic motility and of rectal evacuation could be distinguished by measuring the total and the segmental colonic transit times.

Adolescent↗
PubMed1997

[Value of anorectal manometry in assessment of constipation in childhood].

We studied retrospectively 210 anorectal manometries of constipated children. Of the 87 patients with an anal fissure or a functional constipation, 83 had normal sphincter relaxation. All of the 23 patients with Hirschsprung's disease lacked the sphincter relaxation, as well as 22 of the patients with a dysganglionosis. Eleven patients with innervation defects showed pathologic sphincter contractions. Anorectal manometry is a valuable tool to differentiate between innervation defects and constipation of other etiologies.

Adolescent↗
PubMed1998

Effect of different doses of erythromycin on colonic motility in patients with slow transit constipation.

BACKGROUND: Erythromycin has been proposed as a therapeutic agent for the treatment of functional motor disorders of the upper gastrointestinal tract. Moreover, some data exist showing a potential effect on colonic motility. AIMS: Since no data are available concerning erythromycin effects in chronically constipated patients, we investigated the effects of three different doses of the drug (50, 200, and 500 mg i. v.) on colonic intraluminal pressures in such patients. PATIENTS AND METHODS: 18 severely constipated women were studied by a colonoscopically-positioned manometric probe, and were randomized to receive one of three doses of erythromycin. Proximal and distal colonic motility was recorded basally, then during placebo infusion for 60 min and for a further 60 min after the drug had been infused. RESULTS: Analysis of the tracings showed that, except for the lowest dose in the distal colon, erythromycin failed to stimulate colonic motility in constipated patients. CONCLUSIONS: It is concluded that erythromycin cannot be considered a colokinetic agent, at least at doses commonly employed in the upper gut.

Adult↗
PubMedDate not supplied

[Use of radionuclides in the evaluation of intestinal transit time in children with idiopathic constipation].

Colonic transit times, in patients with chronic idiopathic constipation, in the past were estimated using radiopaque markers. Currently they are evaluated with colonic scintigraphy, which employs 111In DTPA orally, added to the usual children's breakfast in a 0.05 mCi dose. Anterior views of the abdomen are obtained at 6th, 24th, 30th, 48th, 54th, 72nd hour using a gamma camera on a 128 x 128 matrix and stored on hard disk. These images are processed in successive times, and the colon is divided in three main segments: right-, left- and recto-sigmoid-colon. Total and segmental percentage retentions are evaluated in each interval time. 58 children (35 males and 23 females), aged 1-12 years (mean 8.13), referred for chronic idiopathic constipation at Pediatric Surgery Department of Siena, were studied between January 1990 and September 1996. This group was compared with a control group formed by 15 patients (9 males and 6 females) aged 3-14 years (mean 8.53). Cutoff values, obtained in this control group, allowed us to distinguish, among the 58 children with idiopathic constipation, 6 symptomatic patients with normal colonic transit times and 52 symptomatic patients with pathologic ones. In this last group the evaluation of segmentary colonic transit times allowed us to identify 13 patients (25%) with increased right colonic transit time, 19 (36.5%) with increased left colonic transit time and 20 (38.5%) with increased recto-sigmoidal colonic transit time. Statistical survey allowed to distinguish significantly pathological subjects from control group ones.

Adolescent↗
PubMedDate not supplied

Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation.

BACKGROUND/AIMS: The purpose of this study was to determine the effects of a high-fiber diet and fluid supplementation in patients with functional chronic constipation. METHODOLOGY: One hundred and seventeen patients with chronic functional constipation (aged 18-50 years) were randomly divided into two treatment groups. For two months both groups consumed a standard diet providing approximately 25 g fiber per day. Group 1 (58 patients) was allowed ad libitum fluid intake, while Group 2 was instructed to drink 2 liters of mineral water per day. Compliance was monitored throughout the study and results were assessed in terms of bowel-movement frequency and laxative use. RESULTS: Fiber intake was similar in the two groups, while total daily fluid intake in Group 2 (mean 2.1 liters) was significantly greater than that of Group 1 (1.1 liters)(p < 0.001). In both groups, there were statistically significant increases in stool frequency and decreases in laxative use during the two-month trial, but both changes were greater in Group 2 (stool frequency: p < 0.001 vs. Group 1; laxative use: p < 0.001 vs Group 1). CONCLUSIONS: A daily fiber intake of 25 g can increase stool frequency in patients with chronic functional constipation, and this effect can be significantly enhanced by increasing fluid intake to 1.5-2.0 liters/day.

Adolescent↗
PubMed2001

Outlet Dysfunction Constipation.

The diagnosis of outlet dysfunction constipation in patients with idiopathic constipation that responds poorly or not at all to conservative measures, such as fiber supplements, fluids, and stimulant laxatives, is based upon diagnostic testing. These tests include colonic transit of radio-opaque markers, anorectal manometry or electromyography, barium defecography, and expulsion of a water-filled balloon. The literature suggests that conditions such as pelvic floor dyssynergia exist but may be over-diagnosed as a laboratory artifact. In our laboratory, we screen patients with balloon expulsion studies, and then test for dyssynergia only if the result of the balloon expulsion test is abnormal. In my opinion, anal sphincter electromyogram and manometry are equivalent in establishing the diagnosis. Barium defecography is helpful in making a diagnosis of a rectocele, but I prefer to document that vaginal pressure on the rectocele significantly improves rectal evacuation. Manometry also helps to establish the presence of megarectum, hypotonia, and weak expulsion efforts. Conceptually, biofeedback training, which incorporates simulated defecation, is the most logical approach to pelvic floor dyssynergia. It incurs no risk and benefits 60% to 80% of patients. The drawbacks are the time-intensive nature of the therapy and the short-term costs, which are offset if there is sustained benefit. There is no evidence that biofeedback is helpful in children with constipation. Habit training has established benefits, but recurrences are frequent and long-term reinforcement is helpful to maintain success. Laxatives and enemas are adjunctive therapies in both habit training and biofeedback. Surgery is effective in those uncommon patients with physiologically significant rectoceles, but surgical division of the puborectalis muscle is risky and unproven. Likewise, botulinum toxin injection into the puborectalis is unproven, but the effects are rarely permanent should incontinence occur. Diagnostic measures and therapeutic success are enhanced when patients are seen in centers experienced with the evaluation of these disorders.

Journal Article↗
PubMed2004

Treatment Options for Primary Constipation.

Patients suffering from primary constipation often show symptom improvement with increased intake of fiber. Bulk laxatives are a core component of treatment if dietary fiber is unsuccessful in alleviating symptoms. Although there are a number of commercial laxative preparations available, only polyethylene glycol (PEG), an osmotic laxative, should be used on a daily basis. For the elderly, saline laxatives may be used on a regular basis, provided there are no cardiac or renal comorbid contraindications. Tegaserod, a 5-HT(4) partial receptor agonist, is approved for the treatment of constipation in female patients. The appropriate role of biofeedback remains to be determined. Surgery should be reserved for patients with slow transit constipation refractory to medical therapy. Patients being considered for surgery should be evaluated at institutions with substantial expertise in the investigation and management of this population.

Journal Article↗
PubMed2001

Long-term outcome after colectomy in severe idiopathic constipation.

OBJECTIVE: The specific aim of the investigation was to assess the long-term results of subtotal colectomy with ileorectal anastomosis in patients with severe idiopathic constipation. PATIENTS AND METHODS: 40 patients with severe idiopathic constipation were operated on between 1981 and 1993. Patients were accepted for a colectomy and an ileo-rectal anatomosis after a thorough gastro-intestinal investigation. Pre-operative bowel frequency was less than 2 movements per week, and slow transit was documented. Postoperative complications occurred in eight patients. Early re-operation was performed in 2 patients for small bowel obstruction. RESULTS: Mean follow-up was 11 (range 5-16) years. The defaecation frequency at follow-up was 3.0 +/- 1.9 per day. Twenty-nine patients stated that they were satisfied and 11 were dissatisfied with the procedure. The outcome did not correlate with observed signs of outlet obstruction, blunted rectal sensation or presence of a psychiatric diagnosis. At 5-16 years after the procedure 33 patients still retain the ileo-rectal anastomosis. Seven patients have had further procedures: Five patients have an ileo-anal pouch, one has a continent ileostomy and one has a conventional ileostomy. Small bowel obstruction was encountered in 17 patients, in 10 of these surgical treatment was necessary. CONCLUSION: It is concluded that colectomy and ileorectal anastomosis for the treatment of severe idiopathic constipation causes an increase in the number of bowel motions, but is deemed successful only by 3 out of 4 patients. Secondary morbidity is considerable.

Journal Article↗
PubMedDate not supplied

[Role of anorectal manometry in the differential diagnosis of chronic constipation in children]

OBJECTIVES: 1. To evaluate the role of anorectal manometry in recognizing patients with histological abnormalities of the myenteric plexus as the cause of chronic constipation. 2. To correlate clinical features with the etiology of the constipation.METHODS: The etiology of the constipation was identified retrospectively from the medical records of 57 patients submitted to anorectal manometry. The test was performed in the Pediatric Gastroenterology Laboratory of the University Hospital of the State University of Campinas Medical School. The procedure was performed using a single-balloon system in which a water-perfused pressure transducer was interfaced with a polygraph and displayed on a computer screen. Manometry was performed in patients who, after 6 to 23 months of intense medical treatment using osmotic laxatives and dietary fibres (20 g/d), continued to develop fecal impaction and/or needed evacuatory enema. Regularization of bowel movements during at least 24 months follow-up or the visualization of abnormalities in myenteric plexus in rectal biopsy were used as reference points for the definitive diagnosis.RESULTS: Rectoanal reflex was present in 44 of the 57 patients (77%). Thirteen patients with a negative reflex underwent rectal biopsy which showed abnormalities of the ganglion cells in 10. Subsequent manometry performed on those three patients revealed a normal rectoanal reflex. Sensitivity, specificity, positive and negative predictive values of the manometric test were 1.0, 0.94, 0.77 and 1.0, respectively.CONCLUSIONS: Anorectal manometry is a diagnostic technique with very small possibility of error in differential diagnosis between constipation of a chronic functional nature and that which is secondary to ganglion cell abnormalities.

Journal Article↗
PubMedDate not supplied

[Clinical and alimentary history of children attending a pediatric gastroenterology outpatient clinic with functional chronic constipation and its possible complications].

In order to better understand the natural history of chronic functional constipation, a questionnaire was applied to 163 children and infants, before beginning standardized treatment. Median age (range) at start was 3 mo(0-108 mo) but age at arrival at the Pediatric Gastroenterology Unit was 53 mo(2-146 mo). In 62.4% of the cases symptoms began before or up to 3 mo after cow's milk introduction and rarely around (-/+ 6 mo) toilet training. Possible complications appeared progressively, often at preschool or school age or as the first noticeable manifestation: recurrent abdominal pain (61.1%), fecal soiling (45.4%), fecal blood (35%), enuresis (23.3%), vomiting (19%), urinary infection (17.9%), urinary retention (8.6%). Abdominal distension was rarely detected on physical examination and was usually discrete. In conclusion, children attended in Botucatu begin their constipation at an early age, frequently associated with weaning,and important complications may ensue along years. This evolution should be avoided by prevention and early treatment of constipation.

English Abstract↗
PubMed2002

[Adolescence. Chronic functional constipation. Is this a question of education for health?].

Chronic functional constipation is a problem whose frequency in consultation is increasing at adolescent ages, in spite of the family's lack of knowledge of the intestinal habits of their children in these age groups. It normally results in a high number of different complementary tests, the use of medicines, at times in a continuous way, hospital admissions and high costs. It is essential to make a detailed clinical history (in order to look for the underlying causes that produce constipation), to realise an exhaustive physical examination in search of any sign of associated pathology, and to apply effective and satisfactory therapeutic actions. Preventive measures must be a priority; hence educational norms, dietetic norms--while the problem persists--and apprenticeship in health self-care are included. Pharmacological treatment should never be the definitive solution to constipation, nor should it be used in a continuous way.

English Abstract↗