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PubMed1998

Cholinergic stimulation and nonadrenergic, noncholinergic relaxation of human colonic circular muscle in idiopathic chronic constipation.

The aim of our study was to further investigate the pathophysiological mechanism underlying idiopathic chronic constipation (ICC), a disorder of colonic motility. A possible alteration of excitatory and inhibitory neurotransmission and also the role of inhibitory neurotransmitters such as nitric oxide (NO), 5'-adenosine triphosphate (ATP), and vasoactive intestinal peptide (VIP) has been evaluated on preparations of distal colon from patients with or without ICC. The isometric tension was recorded from isolated circular muscle strips of both experimental groups during pharmacological and electrical field stimulation (EFS). The contractile response obtained by acetylcholine (ACh 20 microM), EFS (20 Hz, 20 V, 1 msec, pulse trains lasting 1 min) and substance P (SP 1 microM) was significantly lower in ICC than in control preparations. The effect of inhibitory nonadrenergic, noncholinergic innervation was evaluated using EFS at low frequencies (0.5-8 Hz), after cholinergic and sympathetic blockade with atropine (3 microM) and guanethidine (3 microM). The maximum relaxation value expressed as percentage of inhibition of SP-induced contraction was significantly higher in ICC than in control preparations (87+/-2.4 and 67+/-6.3, respectively; P<0.05). Experiments with substances that antagonize or reduce the effect of putative inhibitory mediators (VIP 6-28, apamin and N(G)-nitro-L-arginine) suggest that an alteration in NO and ATP release is present in ICC preparations. In particular at a higher inhibitory frequency NO-mediated relaxation is enhanced in ICC vs control, supporting the hypothesis that excessive NO production may be involved in pathophysiological mechanism of constipation.

Acetylcholine↗
PubMed1991

Constipation associated with chronic spinal cord injury: the effect of pelvic parasympathetic stimulation by the Brindley stimulator.

Ten subjects with severe constipation due to complete spinal cord injury (SCI) had prolonged oro-anal transit time (p less than 0.01), diminished faecal water content (p less than 0.05) and a reduced frequency of defaecation (p less than 0.01) compared to 10 non-SCI subjects. Paraplegics with an implanted Brindley S234 anterior sacral nerve root stimulator had a significant increase in frequency of defaecation (p less than 0.01), compared to the SCI group while the faecal water content was less although not significantly so. The Brindley stimulator group also showed a more rapid colonic transit than the SCI group but this did not reach statistical significance. SCI is associated with constipation which therefore appears to be favourably influenced by the Brindley S234 anterior nerve root stimulator. The effects produced are compatible with stimulation of left colonic motility, which facilitates the emptying of the distal colon, but also suggest that part of the response restricts transit in some areas of the colon or rectum. Since the motility changes induced by the Brindley stimulator do not affect the right colon a relatively greater residence time of the faecal bolus in this part of the large bowel would enhance water absorption.

Adult↗
PubMed1997

Constipation-related symptoms and bowel program concerning individuals with spinal cord injury.

PURPOSE: To determine the prevalence of constipation-related symptoms in individuals with chronic spinal cord injury (SCI), to describe the bowel program as reported by patients and including use of bowel medications and evacuation techniques, and to examine the clinical, functional and pharmacological risks of difficulty with evacuation. PATIENTS AND METHODS: This is a cross-sectional study of all in-patients at least 3 months beyond acute injury, on the West Roxbury/Brockton VAMC SCI Service, during a 10 month period (n = 197). Clinical, functional, and medication data were abstracted from medical and nursing records. Individual interviews were conducted with all available participants (n = 161, 82%) regarding bowel-related symptoms and treatment over the previous 1 month period. The study definition of difficulty with evacuation was spending more than 1 h per episode of bowel evacuation. RESULTS: Forty-one percent of the 161 interview responders spent more than 1 h on bowel evacuation, 50% reported abdominal distension and 38% reported abdominal pain, 27% reported headaches or sweats relieved by having a bowel movement, and 33% reported fecal incontinence at least once a month. The bisacodyl suppository was the most commonly used laxative agent, while docusate was the most popular oral agent. Subjects with difficulty with evacuation (n = 66) were compared with those who spent less than 1 h on evacuation (n = 95). Factors associated with difficulty with evacuation were tetraplegia, Frankel grade A/B, laxative use, polypharmacy, previous urinary outlet surgery, and symptoms of abdominal pain and distension. CONCLUSION: Constipation-related symptoms are highly prevalent in individuals with spinal cord injury, despite considerable laxative use. Our findings suggest that difficulty with evacuation can be predicted on the basis of a patient's clinical profile.

Adult↗
PubMed2001

Tegaserod, a 5-HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation.

AIM: To investigate the efficacy and safety of tegaserod, a novel 5-HT(4) receptor partial agonist, in a randomized, double-blind, placebo-controlled, 12-week treatment, multicentre study. METHODS: Eight hundred and eighty-one patients with irritable bowel syndrome, characterized by abdominal pain, bloating and constipation, received tegaserod, 2 mg b.d. or 6 mg b.d., or placebo for 12 weeks. RESULTS: Tegaserod, 2 mg b.d. and 6 mg b.d., showed a statistically significant relief of overall irritable bowel syndrome symptoms, measured by a weekly, self-administered questionnaire. At end-point, treatment differences from placebo were 12.7% and 11.8% for 2 mg b.d. and 6 mg b.d., respectively. The effect of tegaserod was noted as early as week 1, and was sustained over the 12-week treatment period. Individual irritable bowel syndrome symptoms assessed daily also showed a statistically significant improvement of abdominal discomfort/pain, number of bowel movements and stool consistency, and a favourable trend for reducing days with significant bloating. Adverse events were similar in all groups, with transient diarrhoea being the only adverse event seen more frequently with tegaserod than placebo. CONCLUSIONS: Based upon the results of this study, tegaserod offers rapid and sustained relief of the abdominal pain and constipation associated with irritable bowel syndrome. Tegaserod is also well tolerated.

Abdominal Pain↗
PubMed1999

Sensory and autonomic neuropathy in patients with idiopathic slow-transit constipation.

BACKGROUND: Slow-transit constipation (STC) is a severe disorder of unknown aetiology, which may result from an autonomic or sensory neuropathy. This study aimed to investigate patients with STC for the presence of neural dysfunction, and relate the findings to other factors, including any familial associations. METHODS: Thirty-three patients with STC were studied using standard neurophysiological tests and a range of quantitative sensory and autonomic tests. The findings were compared with those of 20 matched control subjects and nine diabetic patients with gastrointestinal symptoms. RESULTS: Twenty of the 33 patients with STC gave a family history of constipation, including an affected identical twin and Hirschsprung's disease (n = 3). None had abnormalities on neurological examination or nerve conduction studies. Fifteen of the 33 patients had abnormalities on quantitative tests, including all six who required a colectomy. Eleven patients with STC had reduced axon-reflex sweating in the presence of normal sweat gland responses (P < 0.001, all patients with STC versus controls). Twelve patients with STC had small sensory fibre dysfunction, with significantly increased thermal thresholds (cool, P < 0.05; warm, P < 0.01); these included six of nine patients with STC and rectal hyposensation. There were similar findings on quantitative testing in diabetic patients. CONCLUSION: Quantitative tests in patients with STC provide evidence of a small fibre neuropathy. The high incidence of a positive family history, particularly a possible association with Hirschsprung's disease, suggests a genetic basis, which deserves further investigation.

Adolescent↗
PubMed2001

Decreased tyrosine kinase C expression may reflect developmental abnormalities in Hirschsprung's disease and idiopathic slow-transit constipation.

BACKGROUND: Some patients with Hirschsprung's disease have refractory constipation following excision of aganglionic bowel, as do patients with idiopathic slow-transit constipation (STC). Gut motility depends on enteric neuronal development in response to expression of trophic factors and their receptors. Recent studies indicate the importance of neurotrophin 3 (NT-3) and its high-affinity receptor tyrosine kinase C (trk C) in enteric neuronal development. METHODS: Blinded quantitative immunohistochemical analysis of colon from patients with Hirschsprung's disease (aganglionic, hypoganglionic and normoganglionic) (n = 5), STC (n = 6) and appropriate age-matched control tissues (n = 5) was performed for NT-3 and trk C. Sural nerve morphometry and immunostaining were undertaken in three patients with STC who had abnormalities on limb autonomic and sensory testing. RESULTS: A significantly higher proportion of submucous plexus neurones was trk C immunoreactive in control infant than adult colon (mean(s.e.m.) 73(9) versus 16(3) per cent of the total; P < 0.001), in accord with a role in development. The proportion of submucous plexus trk C-immunoreactive neurones was reduced in colon from patients with Hirschsprung's disease (28(7) per cent of total in normoganglionic Hirschsprung's disease; P < 0.007 versus infant controls) and STC (10(1) per cent of total; P = 0.053 versus adult controls). No abnormalities of STC sural nerves were detected by morphometry or immunostaining. CONCLUSION: Decreased trk C expression may reflect developmental abnormalities in Hirschsprung's disease and idiopathic STC. Trk C activation by NT-3 or drugs may provide novel treatments. Presented in abstract form to the Pacific Association of Pediatric Surgeons, Las Vegas, Nevada, USA, May 2000

Adult↗
PubMed2002

Idiopathic slow transit constipation and megacolon are not associated with neurturin mutations.

Chronic idiopathic slow-transit constipation (ISTC) and idiopathic megacolon (IMC) are early-onset gastrointestinal motility disorders of unknown aetiology. The gene encoding the neurotrophic factor neurturin may be a candidate for these disorders, as neurturin-deficient mice have a similar enteric phenotype. In the present study, we tested this hypothesis. Genomic DNA from 26 cases of chronic idiopathic STC [with a family history of constipation in 15 (58%) and Hirschsprung's disease in two (8%)], and five cases of IMC [two familial (40%)] was screened by direct DNA sequencing using the fluorescent dideoxy terminator method. Results were compared with published sequence data and 24 control DNAs. Our results revealed several previously unreported common sequence polymorphisms, but overall frequencies were comparable between patients and controls. We conclude that mutation of neurturin is not a frequent cause of ISTC or IMC.

Adult↗
PubMed2002

Surgical management of constipation.

There are many recognised causes of constipation in the cat and the management of the condition depends on the clinician's ability to recognise the appropriate aetiology in each case. Most surgery therapies for constipation in the cat are related to the management of idiopathic megacolon, although causes such as pelvic outlet obstruction, complications of neutering surgery, perineal herniation, and malunion pelvic fractures may also require surgical intervention. Currently, the surgical management of megacolon consists of subtotal colectomy with the recommendation that the ileocolic junction be preserved. The procedure, in general, is associated with few life-threatening complications although the majority of individuals will experience a transient period of loose stool formation in the immediate post-operative period. In the majority of cases, the long-term outcome following subtotal colectomy is considered excellent.

Animals↗
PubMed2002

Signs and symptoms of slow-transit constipation versus functional retention.

BACKGROUND/PURPOSE: Slow-transit constipation (STC) has been described recently in children. This retrospective study correlated symptoms, signs, transit times, and immunohistochemistry to determine the diagnostic differences between STC and functional fecal retention (FFR). METHODS: One hundred eighty children with intractable constipation underwent clinical assessment, nuclear transit study (NTS), with or without laparoscopic colonic muscle biopsy. Patients were divided by NTS into those with STC and those with FFR. Parents completed questionnaires on presenting symptoms. RESULTS: In 161 patients with STC and 19 with FFR, there were no differences in gender, gestation, or timing of symptom onset. Over 20% had the first meconium delayed more than 24 hours after birth even in FFR (4 of 19). Bloating and soiling were more common in STC. There were no differences between patients with STC but different histology on biopsy. More STC patients had soft stools (39%) than FFR (16%), and a lower stool frequency of less than once a week (STC 26% compared with 11% FFR). FFR was managed more often with medication or diet alone (53%) compared with STC (29%), where enemas, lavage, or surgery were more common. CONCLUSIONS: Children with STC showed similar symptoms and signs to those with FFR, but more had bloating and soiling, softer stools, and longer intervals between bowel actions. Delayed meconium stool beyond 24 hours after birth was common in both groups. Diagnosis of STC or FFR required NTS and was not possible on symptoms alone.

Biopsy↗
PubMed2001

Clostridial constipation's broad pathology.

Clostridia are normally found in the healthy colon, where their numbers are kept in check by other bacteria. However, when they establish themselves in the ileum they become formidable foes. They produce medium-length fatty acids that increase water absorption, causing hypertension and drying up the feces, causing constipation.Furthermore, they can deconjugate bile (impaired fat absorption), metabolyze tryptophan (the most scarce of the essential amino acids), digest fiber (so that the more fiber the patient takes, the more the constipation is exacerbated), digest lecithin, produce carcinogenic metabolites and copious amounts of extremely foul smelling gas, etc. They can also prevent vitamin B12 absorption in the ileum, causing anemia. The synthetic sugar lactulose, which can only be digested by lactobacilli, can help displace the clostridia and resolve the constipation by causing the lactobacilli to produce short fatty acids that have the opposite effect to that of the medium fatty acids produced by clostridia and their accomplices: they cause water retention in the intestines.

Carbohydrate Metabolism↗
PubMed1999

[Giant fecaliths in habitual constipation].

HISTORY AND FINDINGS: A 17-year old adolescent with chronic constipation developed fecal incontinence with liquid, fetid stool. He had had variable bowel symptoms since early childhood, but not in his infancy. Since several years he had undergone psychotherapeutic treatment for depression due to a familial conflict situation. Abdominal palpation revealed the presence of a large, hard mass in the lower abdomen, measuring about 20 cm in diameter. INVESTIGATIONS: A defecography verified the presence of a huge obstructing fecalith in the rectum, with massive dilation and elongation of the antecedent rectum and colon (megarectum and megacolon). Neither endoscopy nor radiological imaging revealed a narrow bowel segment. In sequential biopsies, no indication of aberrant innervation was found. The recto-anal inhibitory reflex could be elicited. TREATMENT AND COURSE: Restoration of the rectal passage was achieved by manual disimpaction in numerous sessions, supported by repeated rectal enemas. Subsequently, the patient had normal daily bowel movements for a few days. However, he had to be readmitted three weeks later because again a fecalith had formed, measuring 15 cm in diameter. A few days after discharge the patient hat not followed the exhortation to void ad least once per day. After renewed disimpaction he was referred to a psychosomatic clinic. CONCLUSION: Voluntary withholding of defecation can eventuate massive coprostasis and the development of megacolon and megarectum. In theses instances the major complaint may not be constipation but paradoxical diarrhea. A number of conditions have to be excluded before the diagnosis idiopathic megacolon can be confirmed. Treatment ist difficult and often necessitates prolonged and repetitious interventions.

Adolescent↗
PubMed1992

Manometric evaluation of children with chronic constipation using a suction-stimulating electrode.

Thirteen children with chronic constipation (8 males and 5 females, aged 1 month to 9 years) were evaluated manometrically. A suction-stimulating electrode was used to induce the rectoanal reflex electrically so as to examine the threshold voltage and latency of this reflex. The rectoanal reflex was induced in all patients by balloon dilatation of the rectum. However, electrical stimulation of the rectal mucosa triggered a reflex in only nine of them and the threshold voltage and latency was 22.2 +/- 3.6 volts (mean +/- SD, n = 9) and 2.04 +/- 0.38 seconds (n = 9), respectively. Hence, it is suggested that a suction-stimulating electrode is a useful supportive tool in manometric anorectal studies, and that disturbances in the rectal nervous system might be one of the causative factors in chronic constipation in childhood.

Anal Canal↗
PubMed1998

Desmosis of the colon: a working hypothesis of primary chronic constipation.

INTRODUCTION: Over the last few years, resected specimens of colon from children and young adults have been systematically studied with regard to the vegetative innervation of the colon and its net of stabilizing connective tissue in the muscularis propria. From the basic investigations of Goerttler, it is known that this connective tissue net has important functions in the coordinated movement of longitudinal and circular muscles. The present study reports on cases of chronic constipation, which showed in most cases histopathologically a normal number of nerve cells and ganglia in the myenteric plexus, but abnormalities in the connective tissue net (desmosis). SUBJECTS AND METHODS: Over 6 years, 236 cases (12 +/- 8 years of age), which were treated surgically for an aganglionosis, hypoganglionosis, hypoperistalsis syndrome and megacolon development, were histopathologically investigated. All surgical specimens were native, caudo-cranially coiled, and were cut 15 microns (equiv. to 4-5 microns paraffin sections) by a cryostat. The vegetative nervous system of the gut was stained with acetylcholinesterase and dehydrogenase reactions. The tissue was also fixed in formalin, embedded in paraffin, and 4 microns sections were stained with hematoxylineosin and picric acid/sirius red. Collagen III; S 100 and PGP 9.5 immunohistochemical reactions were performed. RESULTS: 14 surgical specimens (6%) showed total or focal lack of the connective tissue net in the vicinity of the myenteric plexus. Between the connective tissue net of circular and longitudinal muscles, a continuous connection was missing. These cases were mainly characterized by a hypoperistalsis syndrome or a megacolon without any anomaly of the vegetative innervation. 222 cases (94%) were treated for Hirschsprung's disease or hypoganglionosis without any anomaly of the connective tissue of the muscularis propria. CONCLUSION: The missing continuity of the connective tissue net in the muscularis propria seems to abolish coordinated alternative movement of circular and longitudinal muscles. Therefore, the lack of coordinated propulsive activity of the colon results in a therapy-resistant chronic constipation, with a hypoperistalsis syndrome.

Adolescent↗
PubMed2001

Percutaneous colonoscopic cecostomy for management of chronic constipation in children.

BACKGROUND: Chronic constipation and encopresis are common problems in children with spina bifida and anorectal anomalies. Commonly used therapies include complicated bowel regimens and antegrade continence enemas delivered via surgically placed appendicostomies and radiologically placed cecostomies. METHODS: A technique is described for percutaneous placement of cecostomies for the delivery of continence enemas or venting. RESULTS: Percutaneous cecostomies were placed in 12 patients. Improvement in bowel management occurred in all patients. CONCLUSIONS: Percutaneous endoscopic cecostomy is a safe and effective method for the treatment of intractable constipation.

Adolescent↗
PubMed2000

Constipation presenting as recurrent vulvovaginitis in prepubertal children.

Vulvovaginitis is the most common gynecologic problem in premenarcheal girls. We describe 3 patients with recurrent vulvovaginitis caused by bacterial infection who responded to treatment of constipation with resolution of the vulvovaginitis. There were no recurrences during the follow-up period of 15 to 36 months. We propose that underlying constipation should be added to the list of possible causes of recurrent vulvovaginitis.

Child, Preschool↗
PubMed1975

Simple chronic constipation: pathophysiology and management.

Chronic constipation is not a simple problem. It is often related to fundamental beliefs and habits. Once it has been established that the cause is not an organic disorder, the physician must take pains to explore with the patient other possible causes. Simple, inorganic constipation can usually be traced to poor diet or poor habits. The physician should provide simple explanations of the mechanisms involved in the act of elimination and detailed instructions on appropriate food and water intake and the development of regular habits. Laxatives should be prescribed only if absolutely necessary and if the patient taking them can be carefully observed.

Antacids↗
PubMed1983

Chronic constipation. Important aspects of workup and management.

Constipation is at best an annoying problem and at worst an incapacitating one. Two common causes are a faulty diet and inactivity. Drs Nivatvongs and Hooks propose a trial of dietary fiber for patients in whom an organic cause for constipation cannot be found. Such a trial may prove to be not only diagnostic but also therapeutic. They also discuss the proper use of laxatives, enemas, and surgical procedures.

Adolescent↗
PubMed1995

Constipation in the elderly.

Management is not as straightforward as it appears. Patients often have associated conditions that predispose to or result from constipation. An OTC laxative habit may confound the workup and frustrate treatment. Overall evaluation is required, lest constipation progress to a medical crisis that requires hospital admission.

Aged↗