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PubMed2004

Colonic pacing: a therapeutic option for the treatment of constipation due to total colonic inertia.

HYPOTHESIS: The treatment of constipation caused by total colonic inertia is problematic and its results are unsatisfactory. We speculated that colonic pacing would initiate electric activity in the inertial colon and effect rectal evacuation. METHODS: Nine patients with constipation due to total colonic inertia (age range, 39-52 years; 7 women, 2 men) were enrolled in the study. One pacing electrode was applied to each of the 4 potential colonic pacemaker sites, and 2 to 3 temporary recording electrodes were applied distally. A stimulator was embedded subcutaneously in the inguinal area. Home pacing was practiced after patients were trained; the recording electrodes were removed before home pacing was started. RESULTS: Colonic pacing evoked electric waves, which effected defecation in 6 of the 9 patients. Three of these 6 patients had spontaneous defecation after a few months of pacing, and their electrodes and stimulators were removed. In the other 3 of these 6 patients, the pacemakers are still in place and continue to effect rectal evacuation. Colonic pacing did not produce rectal evacuation in 3 patients and is believed to have failed because of an advanced stage of colonic inertia. CONCLUSION: Colonic pacing induced rectal evacuation in 66.6% of the patients with total colonic inertia. No complications were encountered. We suggest that colonic pacing be considered as a new therapeutic option in the treatment of total colonic inertia.

Adult↗
PubMed1986

Acetylcholinesterase and manometry in the diagnosis of the constipated child.

We studied 309 constipated infants and children who underwent rectal manometry (n = 261) and/or punch rectal biopsy, in which acetylcholinesterase histochemistry (n = 124) was compared with routine histologic examination (n = 93) for diagnostic accuracy. A 99% diagnostic accuracy was achieved with acetylcholinesterase histochemistry compared with 61% accuracy with routine hematoxylin-eosin staining on punch rectal biopsy. We recommend screening cooperative, quiet patients with rectal manometry. Most patients with abnormal manometric studies or those on whom manometry cannot be performed should have superficial punch biopsy (except those ill infants who require urgent operative intervention). This plan of management provides the least invasive but the most accurate evaluation of the constipated child. Deep rectal biopsy can be avoided except in the very rare child with hypoganglionosis or "skip-area" aganglionosis, which can be detected by manometry.

Acetylcholinesterase↗
PubMed1992

Functioning ovarian carcinoids induce severe constipation.

Five patients with ovarian carcinoid who had severe constipation for a long period preoperatively showed marked reduction of this symptom postoperatively. Because this phenomenon was believed to be caused by some biologically active substance rather than a mechanical effect of the tumor, reactivity to 17 amine and peptide hormones was studied immunohistochemically in these patients. Numerous peptide YY (PYY)-positive cells were detected, with PYY-positive cells representing more than 50% of all carcinoid tumor cells in each patient. PYY, which has a pharmacologic inhibitory action on intestinal motility, was presumably the cause of the constipation in these patients.

Adult↗
PubMed2001

What is the role of stimulant laxatives in the management of childhood constipation and soiling?.

BACKGROUND: Constipation is extremely common in childhood and may lead to overflow soiling/encopresis. Standard treatment of the more severe case is to empty the bowels of impacted faeces by the use of oral or rectal laxatives and then maintain regular bowel movements by the continuation of osmotic and stimulant laxatives. OBJECTIVES: The objective of the review was to determine the effect of stimulant laxative treatment in children with chronic constipation who may also suffer from soiling / encopresis. SEARCH STRATEGY: The Cochrane database of randomised controlled trials was searched. Additional citations were sought by hand searching of paediatric journals and from contact with known professionals in the field. SELECTION CRITERIA: All identified randomised controlled trials (RCTs) which compare the administering of stimulant laxatives to children with either placebo or alternative treatment. DATA COLLECTION AND ANALYSIS: No trials were found that met the selection criteria. MAIN RESULTS: No trials were found that adequately met the selection criteria. REVIEWER'S CONCLUSIONS: The need exists to establish a secure footing for treatment decisions and adequately sized trials are required to provide comparative data on commonly used drugs.

Cathartics↗
PubMed1986

Diagnosis and surgical management of intractable constipation.

Seventy-four patients with intractable constipation, of whom thirty-three had slow and forty-one normal intestinal transit, were investigated to determine the aetiology of their disorder and plan treatment. Patients with slow transit had a greater incidence of abdominal pain and distension (P less than 0.001) and only 9 per cent had a normal call to stool compared with 71 per cent of those with normal transit (P less than 0.001). Internal and sphincter function as assessed by sphincter pressures, length and the recto-anal inhibitory reflex did not reveal any difference between the groups and normal controls; similarly anal sensation and rectal compliance were normal. However, those with normal transit had a higher threshold of rectal sensation than controls (P less than 0.05). Slow transit patients failed to show a postprandial increase in rectosigmoid motility compared with controls (P less than 0.05). Whilst the majority failed to inhibit the external sphincter on bearing down, half of those with normal transit produced either partial or complete inhibition. Both groups were able to increase the anorectal angle on straining. Twenty-two normal transit patients had abnormal perineal descent compared with controls (P less than 0.0005). Patients with perineal descent exhibited abnormal rectal morphology. Rectal intussusception was observed in 13 of 35 evacuation proctograms. On the basis of the data presented, we could not justify internal sphincterotomy of puborectalis division. Our policy in severe slow transit constipation was to offer colectomy and ileorectal anastomosis. In five out of seven to date, a successful result has been achieved. Eight patients with rectal intussusception have undergone an abdominal rectopexy with significant improvement in three. In our hands, the evacuation proctogram and transit studies were the most useful preoperative investigations.

Anal Canal↗
PubMed1990

Disordered colorectal motility in intractable constipation following hysterectomy.

Colorectal and anal sphincter motility and electrophysiology were investigated in 14 women with profound constipation following hysterectomy and compared with an asymptomatic group of control subjects. Twelve patients complained of significant urinary symptoms. No differences in the motor function of the anal sphincters were detectable. The latency of the pudendoanal reflex was unchanged after hysterectomy. Proctometrograms demonstrated significantly increased rectal volumes and compliance in the hysterectomy group together with deficits of rectal sensory function. In the basal state a significant proximal-to-distal sigmoid colon motility gradient existed only in the control group. Following stimulation with Prostigmin, this gradient was enhanced in the control group but paradoxically reversed in the hysterectomized patients, thus constituting a functional obstruction. Denervation supersensitivity was demonstrable in two patients tested with carbachol provocation but not in control subjects. These findings suggest dysfunction in the autonomic innervation of the hindgut in some patients who had undergone hysterectomy, resulting in severe constipation.

Adult↗
PubMed1991

Anismus in patients with normal and slow transit constipation.

This study examined differences in anorectal function, with particular reference to anismus, which might explain why some patients with intractable constipation have slow and others have normal whole gut transit times. Twenty-four patients were studied; 13 with slow transit (all female, median age 32 years, range 16-52 years) and 11 with normal transit (eight women, three men, median age 37 years, range 21-60 years). Videoproctography with synchronous sphincteric electromyography and anorectal manometry was performed. There were no differences between the two groups, suggesting that slow transit constipation is not secondary to any abnormality in anorectal function and may therefore be a primary disorder of colonic motility. There was no correlation between electromyographic evidence of anismus (pelvic floor contraction on defaecation) and the ability of the patient to evacute the rectum or symptoms of obstructed defaecation. Electromyography findings alone can be misleading and should be related to proctographic evidence of incomplete rectal evacuation before functional anismus can be said to be present.

Adolescent↗
PubMed1991

Relationship between outlet obstruction constipation and obstructed urinary flow.

Ten women with symptoms and radiological features of outlet obstruction constipation underwent urodynamic bladder studies. The results were compared with ten age- and sex-matched controls. The mean (s.e.m.) peak flow rate for patients was 19.4 (6.4) ml/s compared with 32.1 (7.2) ml/s for controls (P less than 0.05). The mean (s.e.m.) voiding time for patients was 62.9 (23.7) s against a corresponding value of 15.6 (6) for controls (P less than 0.05). The mean (s.e.m.) bladder volume in patients was 482 (80) ml compared with a control value of 254 (112) ml (P less than 0.03). The mean (s.e.m.) detrusor pressure during the voiding phase was 53.3 (12) cmH2O. These results demonstrate that patients with outlet obstruction constipation have a generalized pelvic floor disorder resulting in obstructed urinary flow.

Constipation↗
PubMed1991

Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study.

Denervation of the rectum during rectopexy has been suggested as a reason for postoperative constipation. Bowel symptoms and anorectal function have been examined in a prospective randomized study of rectopexy with (n = 14) or without (n = 12) division of the lateral ligaments. Incontinence improved in both groups of patients. Division of the lateral ligaments increased the number of patients with constipation (three before operation, ten after operation, P less than 0.01). Mean and canal pressures were higher after operation in all patients. Rectal electrical sensory threshold increased significantly in those in whom the ligaments had been divided (preoperative 27.6 mA versus postoperative 56.7 mA; P less than 0.01) but not in those in whom they were preserved (39.0 versus 34.9 mA; P greater than 0.05). Prolapse recurred in six patients who did not undergo division of the lateral ligaments, but in none of the group in whom the ligaments were divided.

Adult↗
PubMed1993

Idiopathic slow-transit constipation.

Until recently, the surgical management of idiopathic slow-transit constipation had remained unchanged since the condition was first described by Arbuthnot Lane in 1908. Although colectomy and ileorectal anastomosis is a successful treatment for the majority of patients, symptoms persist or are worse in some cases following such surgery. The previously inaccessible colon is now an area of interest in both health and disease; recent observations on aetiology, clinical investigation, neuropathology and surgical outcome lead us to question the rationale of colectomy for all patients with severe constipation.

Anastomosis, Surgical↗
PubMed1994

Antegrade enemas for the treatment of severe idiopathic constipation.

The technique of appendicocaecostomy produces a continent catheterizable channel through which colonic washouts are given. This procedure was performed on six women of mean age 33.5 years with severe idiopathic constipation (mean stool frequency less than 1 per week) resistant to medical therapy. All patients had prolonged colonic transit times, three had evidence of obstructed defaecation and all had reduced or absent voluntary anal squeeze pressure. Patients found the appendicocaecostomy and catheterization acceptable, and symptoms of abdominal distension and pain resolved. All patients were able to initiate defaecation and evacuate the colon within 1 h of irrigation, and no patient had appreciable incontinence. Irrigation was necessary every 48-72 h. Adults with intractable constipation and pelvic floor weakness would be at risk of faecal incontinence after ileorectal anastomosis; it is in these patients that appendicocaecostomy has potential for the greatest benefit.

Adult↗
PubMed2006

Tegaserod (Zelnorm) for the treatment of constipation in Parkinson's disease.

We performed a double-blind randomized placebo-controlled pilot study to determine the efficacy of tegaserod (Zelnorm) in treating constipation in 15 patients with Parkinson's disease (PD). There was a trend for improvement in the Subject's Global Assessment (SGA) of satisfaction with bowel habits (NS) and the total SGA (including abdominal discomfort, bothersome constipation, and satisfaction; NS).

Aged↗
PubMed1993

Cisapride treatment of constipation in Parkinson's disease.

Constipation, a frequent symptom in Parkinson's disease (PD), is probably caused by degeneration of the autonomic nervous system, particularly the myenteric plexus. Cisapride is a drug that causes increased release of acetylcholine in the myenteric plexus. In a pilot study, cisapride therapy was investigated in 20 PD patients, 10 women and 10 men, who suffered from delayed intestinal transit. In all cases, cisapride therapy was associated with a significant acceleration of colonic transit, as measured by radioopaque pellets viewed on radiographs. Pellet count fell from a mean of 53.8 pretreatment to 30.4 after cisapride treatment. No adverse reaction and no "overshoot affects," such as diarrhea, were seen. Our findings suggest that cisapride may alleviate the constipation associated with Parkinson's disease.

Acetylcholine↗
PubMed1997

Severe constipation in Parkinson's disease relieved by botulinum toxin.

A parkinsonian patient with severe outlet-type constipation was treated with injection of botulinum toxin into the puborectalis muscle. A total of 30 units (Botox) was injected in two sites. Resting anal pressure, maximum voluntary contraction, and pressure on straining were evaluated before treatment and 4, 8, 12, and 16 weeks afterward. Pressure values declined following treatment, the decline of pressure on straining ending by week 12. Proctography performed 8 weeks after treatment showed improvement in the anorectal angle and evacuation of barium paste. The clinical benefit lasted for approximately 12 weeks. The present data show that botulinum toxin is a promising tool for treating outlet-type constipation in Parkinson's disease.

Anti-Dyskinesia Agents↗
PubMed1990

Neuronal dysplasia. Considerations for the pathogenesis and treatment of primary chronic constipation in adults.

Intestinal muscle and the autonomic nervous system constitute a neuromuscular unit. A clinical study was undertaken to seek neurogenic causes of impaired motility affecting the rectosigmoid junction and rectum. Patients with primary chronic constipation were shown by enzyme-histochemical examination of biopsies to have neuronal colonic dysplasia of the rectosigmoid, whereas the latter was normally innervated in healthy controls. The present investigations provide a fresh insight, underpinned by histological findings, into the aetiology of chronic constipation and make a contribution to its operative treatment.

Adult↗
PubMed1993

The effect of preliminary bowel preparation on a simple test of colonic transit in constipated subjects.

The abdominal distribution of orally ingested radioopaque markers is used to assess total and segmental colonic transit in constipated patients, but interpretation may depend on whether studies are carried out on a full colon or one cleared of faeces. We asked 25 severely constipated patients (age 18-74; 22 F, 3 M) to ingest 50 polyethylene markers (4 mm x 2 mm) at breakfast on 2 occasions 1 month apart. No bowel preparation was used for study 1 but for the second study 2 doses of Sodium Picosulphate (2 x 10 mg) were taken 3 days before ingestion of the markers. All subjects reported a good result which had ceased a day before taking the markers. Marker distribution was assessed by a plain abdominal film taken 72 hours after ingestion. All 25 subjects had more than 50% of markers present at 72 h in study one. Of these 4 showed evidence of outlet obstruction with more than 50% of ingested markers in the rectum. In the remaining 21 subjects markers were distributed throughout the colon in a pattern indicating colonic inertia. Following the administration of purgative there was no significant change in the mean number of markers retained but patterns of marker distribution for individual subjects did alter. Of the 21 patients who previously had colonic inertia, 3 showed outlet obstruction and 1 showed no evidence of delayed transit. Of the 4 patients with a pattern of outlet obstruction in the first study, 2 showed no evidence of delayed transit after Picolax.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1984

Colon motility and colo-anal reflexes in chronic idiopathic constipation. Effects of a novel enterokinetic agent cisapride.

Motor activity of the colon and reflex behaviour of the anal sphincters in normal subjects and in patients with idiopathic constipation were studied using a novel probe with 5 open-end tips to measure pressures, and 3 balloons for stimulation of the distal colon. Constipation appeared to be associated with an increased threshold of the inhibitory relaxation reflex of the internal anal sphincter (41.7 in normals and 65.7 in patients), and in particular with a blunted sensation of the defaecation urge (51.0 in normals and 112.8 in patients). Single-blind comparison with a placebo showed that cisapride, a new gastrointestinal prokinetic substance, had a significant effect on the sensation threshold, which normalized or improved in 15 out of the 16 patients studied.

Adult↗
PubMed1991

Left hemicolectomy with rectal excision for severe idiopathic constipation.

The standard surgical therapy for severe idiopathic constipation is total colectomy with ileorectal anastomosis, but this results in intractable diarrhoea in a third of the patients and recurrent constipation in another 10%. Studies which employ either radio-isotopes or radio-opaque markers permit the delineation of regional delay in colonic transit. Based on these studies, and evidence that the rectum is also abnormal in these patients, we have performed a left hemicolectomy with rectal excision in 2 patients with proven left colonic delay. After 2 and 3 years of follow-up, both patients have normal frequency, transit studies and anorectal physiology studies. Segmental resection based on physiological studies may offer better relief of symptoms with a lower chance of side effects in selected patients.

Adult↗