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PubMed1993

Biofeedback training in chronic constipation.

Twenty nine patients, aged 5-16 years, were studied to evaluate whether biofeedback training is effective in treating children with chronic constipation and encopresis; the clinical outcome at six weeks and 12 months was also evaluated. Patients received on average five biofeedback training sessions. The existence of external anal contraction or decreased rectal sensation in 16 (55%) and eight (27%) of the children, respectively was identified on manometry. After biofeedback training, 26 (90%) of the patients learned to relax the external anal sphincter; 18 (63%) normalised rectal sensation. The training resulted in a significant increase in defecation frequency and a significant decrease in encopresis. At six weeks, 16 (55%) of the patients were clinically symptom free. At follow up after 12 months the results were sustained. Only three patients showed a relapse within six months, of whom two were successfully treated with one extra training session. Biofeedback training might be a useful therapeutical approach in children with chronic constipation and encopresis.

Adolescent↗
PubMed1998

Rectal biopsy in the investigation of constipation.

AIMS: To develop criteria to prevent unnecessary rectal biopsies in constipated children. METHODS: A retrospective review of 186 rectal biopsies from 141 children, comparing the age at onset of symptoms with the diagnosis of Hirschsprung's disease. RESULTS: All of the 17 children with Hirschsprung's disease had the onset of symptoms before the age of 4 weeks. Twenty seven children had delayed passage of meconium (more than 48 hours) of whom 10 had Hirschsprung's disease. Three children with Hirschsprung's disease were referred after the neonatal period (2 months, 11 months, and 3 years) but all had the onset of symptoms before 4 weeks of age. CONCLUSION: If the age at onset of constipation is after the neonatal period, a rectal biopsy is unnecessary.

Age Factors↗
PubMed2004

Association of distinct alpha(2) adrenoceptor and serotonin transporter polymorphisms with constipation and somatic symptoms in functional gastrointestinal disorders.

BACKGROUND: The role of genetics in the phenotypic manifestations of irritable bowel syndrome (IBS) is unclear. Our aims were: (1) to compare the prevalence of polymorphisms of alpha 2 (alpha(2)) adrenoceptors, norepinephrine transporter, and serotonin transporter protein (soluble carrier protein member 4 (SLC6A4)) promoter in patients with lower functional gastrointestinal disorders (FGID) and in healthy controls; and (2) to test associations of these genetic variations with symptoms of IBS and high somatic symptom scores. METHODS: Validated bowel and somatic symptom questionnaires characterised the phenotype: 90 with IBS constipation (IBS-C), 128 IBS diarrhoea, 38 IBS alternating bowel function, and 20 chronic abdominal pain. Logistic regression analyses assessed associations of different polymorphisms for alpha(2) adrenoceptor and SLC6A4 with IBS or chronic abdominal pain phenotypes and high somatic score. RESULTS: Two distinct polymorphisms independently appeared to be associated with the phenotype IBS-C: alpha(2C) Del 322-325 (odds ratio (OR) 2.48 (95% confidence interval (CI) 0.98, 6.28); p = 0.05) and alpha(2A) -1291 (C-->G) (OR 1.66 (95% CI 0.94, 2.92); p = 0.08) relative to wild-type. Overall, the alpha(2C) Del 322-325 polymorphism (alone or combined with other polymorphisms) was also significantly associated with a high somatic symptom score (OR 2.2 (95% CI 1.06, 4.64); p = 0.03). Combinations of polymorphisms were also associated with high somatic scores. CONCLUSION: Functionally distinct alpha(2A) and alpha(2C) adrenoceptor and serotonin transporter polymorphisms are associated with constipation and high somatic symptoms in patients with lower functional gastrointestinal disorders, although the strength of the genetic contribution to the phenotype is unclear.

Adolescent↗
PubMed2005

A randomised controlled trial assessing the efficacy and safety of repeated tegaserod therapy in women with irritable bowel syndrome with constipation.

BACKGROUND: It has been proposed that treatments for irritable bowel syndrome with constipation (IBS-C) should provide rapid symptomatic relief, be intermittent, and effective upon repeated use. AIMS: To evaluate the efficacy and safety of tegaserod on IBS symptoms, and its impact on quality of life and health economic measures. PATIENTS: Women (> or = 18 years of age) with IBS-C according to the Rome II criteria. METHODS: Prospective, double blind, placebo controlled, randomised trial. Women with IBS-C either received tegaserod 6 mg twice daily or placebo for one month. Patients with at least a partial response entered a treatment free interval. Upon symptom recurrence, tegaserod treated patients were re-randomised to tegaserod or placebo for an additional month. Primary efficacy variables were response (overall IBS symptoms and abdominal discomfort/pain) to first and repeated treatment. Analysis was by intention to treat. RESULTS: 2660 patients and 1191 patients were randomised for first and repeated treatment respectively. Tegaserod was superior to placebo for each primary efficacy variable (first treatment: 33.7% v 24.2% responders respectively for relief of IBS symptoms and 31.3% v 22.1% for relief of abdominal discomfort/pain; repeated treatment: 44.9% v 28.7%, and 42.4% v 27.1%, all p < 0.0001). Tegaserod was superior to placebo for every secondary efficacy variable (relief of abdominal discomfort/pain, bloating and constipation; stool frequency and consistency). A response to tegaserod was observed within the first treatment week. Tegaserod produced greater satisfaction, work productivity, and improved quality of life than placebo (p < 0.05). CONCLUSION: Tegaserod provides rapid and sustained relief of IBS-C symptoms both during first and repeated treatment.

Adolescent↗
PubMed1988

Outcome of colectomy for severe idiopathic constipation.

Severe idiopathic constipation affects predominantly young women. We have evaluated the results of colectomy in 44 women with a normal diameter colon and with a median bowel frequency of once per four weeks. The operations were done in one hospital over a 15 year period. After operation 22 patients had normal bowel frequency, 17 diarrhoea (greater than three bowel actions/day), and five persistent or recurrent constipation (interval between bowel actions at least three days). Many patients continued to experience abdominal pain (98% preoperatively v 71% postoperatively); straining and laxative use were still common after surgery. Ten patients needed psychiatric treatment for severe psychological disorders. The preoperative abnormalities of paradoxical contraction of the pelvic floor during straining and impaired rectal evacuation of a water filled balloon did not correlate with the outcome.

Adolescent↗
PubMed1988

Dynamic scanning defines a colonic defect in severe idiopathic constipation.

A technique is described in which a chemical stimulus applied to the mucosa of the right colon is used to assess colonic motor function. Peroral intubation of the right colon was achieved using a fine polyvinylchloride (PVC) tube. Bisacodyl was used to initiate colonic motor activity, and colonic transit was monitored using 99mTc-DPTA and a gamma camera. In normal subjects there was rapid movement of the radiopharmaceutical from the right colon to the rectum. In patients with severe idiopathic constipation, a spectrum of colonic abnormality was observed from slow transit involving the rectum and sigmoid only to slow transit involving the whole colon. The hepatic flexure to rectum transit time for the 'head of the isotope column' in normals ranged from 1-10 minutes (mean 5.3 minutes), whereas in patients the transit time was 14-25 minutes in four patients and radioisotope did not reach the rectum by two hours in three other patients (controls v patients, p less than 0.01). Patients also showed relatively impaired transport of the isotope 'mass'. This technique has shown that the normal colon is capable of rapid effective transport in response to a standard stimulus, and that patients with severe idiopathic constipation have a definable colonic motor disorder.

Adult↗
PubMed1988

Colonic mass movements in idiopathic chronic constipation.

As relatively little is known of human colonic motor activity either in health, or in pathological conditions, we investigated mass movements in 14 chronically constipated patients and 18 healthy volunteers. Mass movements were recorded from proximal and distal colon during 24 h (12 noon-12 noon) by a colonoscopically positioned multilumen manometric probe and low compliance infusion system. Patients and controls differed significantly in the number (mean 2.6 (0.7) v 6.1 (0.9) (SE), p = 0.02) and duration (mean 8.2 (1.6) v 14.1 (0.8) s, p = 0.04) of mass movements. The data suggest that one pathophysiological mechanism of constipation may be decreased propulsive activity. A circadian pattern, with a significant difference between day and night distribution, was documented in both groups. The patients reported decreased defecatory stimulus concomitant with the mass movements.

Adult↗
PubMed1962

The treatment of constipation in mental hospitals.

This study investigates the incidence of constipation in two representative mental institutions, and the effect, in one of the hospitals, of restricting the use of laxatives to only one drug, namely, standardized senna (Senokot). The remarkable potentiality of Senokot for long-term re-educative programmes is reflected in the reduction from 44% of 210 patients receiving various laxatives regularly at the start of the trial to 8% after three months' treatment. The special studies showed that chronic psychotics could be freed from enemas and a substantial number (17 out of 24) cured of constipation; 31 patients on insulin therapy required maintenance doses during treatment but all were subsequently cured; of 25 patients with various neurological lesions, 21 were freed of laxative treatment with four only remaining on sub-laxative doses.

Chronic Disease↗
PubMed1962

Redundant colon as a cause of constipation.

The authors present evidence to show that a long colon is associated with constipation. In certain cases of intractable constipation associated with a long colon they recommend surgical treatment.

Colon↗
PubMed1989

Ultrasonography shows no abnormality of pelvic structures in women with severe idiopathic constipation.

Patients with severe idiopathic constipation are almost exclusively women. Common presenting features include lower abdominal pain, irregular and painful menstruation, and a past history of gynaecological surgery. Pelvic ultrasonography was undertaken in 26 patients with severe idiopathic constipation and 21 age matched control women to detect any gynaecological abnormality. No difference was found in ovarian, uterine or pelvic vein morphology or size. The abdominal pain in these patients is related to the bowel disorder, and minor abnormalities of pelvic morphology on ultrasound are probably incidental findings.

Adolescent↗
PubMed1990

Evidence for motor neuropathy and reduced filling of the rectum in chronic intractable constipation.

Subtotal colectomy with ileorectal anastomosis is now frequently offered to patients with slow transit constipation who have severe symptoms and no response to more conventional medical treatment. If this operation is to be successful, the underlying problem should be delay in the progress of contents through the colon but no mechanical or functional obstruction in the small bowel or rectum. We have used a recently described technique of prolonged ambulant manometry and electromyography to investigate anorectal function in these patients. Pressure data were collected using a 2 mm diameter intrarectal probe carrying microtransducers, and external anal sphincter activity was assessed by a pair of silver-silver chloride surface electrodes. Fourteen control subjects and eight patients with colonic inertia were studied. Sampling reflexes, indicative of rectal filling, occurred at mean (SEM) rates of 7.4 (2.0)/hour in controls but were significantly reduced in patients (2.4 (0.3)/hour (p less than 0.01]. Recurrent rectal motor complexes were seen to occur in both groups at intervals of 76 (1.8) minutes in controls and 64.9 (7.2) minutes in patients (p less than 0.1), and with amplitudes of 42.4 (2.1) mmHg and 9.2 (0.7) mmHg (p less than 0.001), respectively. External sphincter electromyographic spike activity did not differ between groups. Our results support the concept of reduced transit of faeces to the rectum from the colon over a 24 hour period in slow transit constipation and suggest that a motor neuropathy may also be present in the rectum.

Adult↗
PubMed1993

Radioisotope determination of regional colonic transit in severe constipation: comparison with radio opaque markers.

Radio-opaque markers have a well established role in distinguishing between patients with normal and those with slow intestinal transit, but in the latter group their accuracy in defining the region of delay has not been established. To study regional colonic transit accurately the transit of a radioisotope labelled meal was determined and findings were compared with those of simultaneously ingested radio-opaque markers. Twelve healthy controls (mean age 33 years) and 12 severely constipated women (mean age 36 years, bowel frequency < once per week) were studied On day 1, a meal containing 10 MBq 111In bound to 0.7 mm resin microspheres was ingested. Subjects also ingested a set of radiologically distinguishable markers on three successive days. Abdominal scans were obtained three times daily for 7 days. Abdominal radiographs were obtained after 72 or 96 hours and again at 144 or 168 hours. Eight 'regions of interest' were created--one for the small bowel, six for the colon, and one for excreted stool. The constipated patients all showed colonic transit outside the normal range, with a variable site of delay demonstrated by time activity curves for each region. To provide a different measure of the effectiveness of colonic transport, the movement of the 'centre of mass' for the radioisotope and for the markers was then determined. The radioisotope and radiopaque marker methods gave similar results. At all times between 24 and 144 hours there was no significant difference for the position of the centre of mass between the radio-opaque and marker methods. At all times, however, the mean difference between the markers and the radioisotopes was positive, indicating that the center of mass of the markers was always head of that of the radioisotope. The mean difference between the methods was never greater than one region of interest, and ranged from 12 to 72% of one region of interest in the colon. The difference between these two methods could reach up to two colonic segments in certain patients at one time. Radioisotope ingestion provides accurate information about the transit through individual colonic regions because of the possibility of frequent observations and the clear delineation of the entire colon. Although these features were not obtained with radio-opaque markers, they are suitable as a screening test for the presence and pattern of colonic delay.

Adult↗
PubMed1995

Relationships between defecographic findings, rectal emptying, and colonic transit time in constipated patients.

The relations between defecographic findings, rectal emptying, and colonic transit time were analysed in 80 constipated patients (median age 49 years, range 22-87). Patients were classified into three clinically defined groups (slow transit, outlet obstruction, and a mixed group). Rectal evacuation was evaluation was evaluated by computer-based area calculation. There were no differences in defecographic findings except that evacuation was less efficient in the slow transit group compared with the mixed group (p < 0.01) and with the outlet obstruction group (P < 0.05). Transit time was prolonged in the slow transit and mixed groups compared with the outlet group (p < 0.001). Prominent impression of the puborectalis muscle during straining and the size of a rectocoele correlated with rectal emptying (p < 0.01). Perineal descent, anorectal angles, enterocoele, or intussusception were not significantly related to emptying. Prominent impression of the puborectalis muscle (p < 0.05) and impaired rectal emptying (p < 0.05) were more frequent in patients with prolonged transit time (six or more days). There was no significant correlation between transit time and rectal evacuation in the total study population. There was, however, an inverse relation between these variables (r = 0.40, p < 0.02) when all patients who claimed infrequent defecation (two or fewer/week) were analysed separately. These results did not confirm a direct relation between rectal evacuation and colonic transit time in constipated patients overall. The results are consistent with the suggestion that impaired colonic function may develop secondary to outlet obstruction in some patients.

Adult↗
PubMed1999

Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation.

BACKGROUND: Polyethylene glycol (PEG) 3350 is a non-absorbable, non-metabolised osmotic agent used in lavage solutions for gut cleansing. AIMS: To compare the efficacy of PEG and lactulose in chronic constipation. METHODS: A total of 115 patients with chronic constipation entered a multicentre, randomised, comparative trial. They initially received two sachets containing either PEG (13 g/sachet) or lactulose (10 g/sachet) and were given an option to change the dose to one or three sachets/day, depending on response. RESULTS: Ninety nine patients completed the trial. After four weeks, patients in the PEG group (n=50) had a higher number of stools and a lower median daily score for straining at stool than patients in the lactulose group (n=49). Overall improvement was greater in the PEG group. Clinical tolerance was similar in the two groups, but flatus was less frequently reported in the PEG group. The mean number of liquid stools was higher in the PEG group but the difference was significant only for the first two weeks. There were no serious adverse events and no significant change in laboratory tests in either group. At the end of the study, the number of sachets used by the patients was 1.6 (0.7)/day in the PEG group and 2.1 (0.7)/day in the lactulose group. Sixty one patients completed a further two months open study of one to three sachets PEG daily; there was no loss of efficacy and no serious toxicity. CONCLUSION: Low dose PEG 3350 was more effective than lactulose and better tolerated.

Adult↗
PubMed2001

Response to a behavioural treatment, biofeedback, in constipated patients is associated with improved gut transit and autonomic innervation.

BACKGROUND: Although behavioural treatment (biofeedback) successfully treats the pelvic floor abnormalities in patients with idiopathic constipation, many patients also normalise their impaired bowel frequency. We postulated that a response may be associated with altered cerebral outflow via extrinsic autonomic nerves to the gut. We investigated whether treatment changes extrinsic innervation, using mucosal laser Doppler flowmetry, whether autonomic changes are gut specific, and whether it changes gut transit. MATERIALS AND METHODS: Forty nine patients (44 female, mean age 39 years) with idiopathic constipation were studied before and after biofeedback treatment (mean five sessions). Rectal mucosal blood flow was measured by laser Doppler flowmetry to assess direct extrinsic gut nerve autonomic activity. To assess general autonomic activity, RR (interval between successive R waves on the electrocardiogram) variability, Valsalva ratio, orthostatic adjustment ratio, and phase II:IV blood pressure ratio (II:IV) of the Valsalva manoeuvre were measured. All autonomic tests were compared with those of 26 healthy volunteers (19 female, mean age 37 years). RESULTS: Twenty nine of 49 patients were symptomatically improved. Treatment reduced those with < or =3 bowel actions per week (27 v 9, pre v post), need to strain (26 v 9), and laxative or suppository use (34 v 9). Biofeedback reduced retained markers by 32% in those with slow transit and by 20% in those with normal transit. Twenty two had slow transit before treatment-14 felt symptomatic improvement of whom 13 developed normal transit. There was a significantly greater increase in rectal mucosal blood flow in patients who subjectively improved compared with those who did not (29% v 7%; p<0.03) and in those with improved bowel frequency (33% v 9%, increased v unchanged bowel frequency; p<0.05). Thirty five patients had abnormal RR variability and 33 an abnormal Valsalva ratio; one had an abnormal orthostatic adjustment ratio and one an abnormal II:IV ratio. None of the general cardiorespiratory autonomic reflexes was changed by treatment. CONCLUSIONS: Biofeedback treatment affects more than the pelvic floor. Successful outcome after biofeedback treatment is associated with improved activity of the direct cerebral innervation to the gut and improved gut transit. This effect is gut specific; cardiovascular autonomic reflexes were not altered.

Adolescent↗
PubMed1987

Stimulation of colonic peristalsis by vasopressin: electromyographic study in normal subjects and patients with chronic idiopathic constipation.

The effects of vasopressin on colonic motility were investigated in 6 healthy subjects and 10 patients with chronic idiopathic constipation. Recordings of the colonic myoelectric spiking activity were performed by means of 50-cm long silastic tube, equipped with four bipolar ring electrodes fixed at 10-cm intervals, which was introduced by flexible colonoscopy into the left colon. Tracing were obtained for 1 h in the fasting state and for another hour after an intramuscular injection of a pharmacological dose of vasopressin (0.3 U/kg). The different types of spike bursts generated by the colonic smooth muscle were compared before and after vasopressin injection. In both controls and patients, the tracing showed (i) rhythmic stationary spike bursts (RSB) that were seen at only one electrode site; and (ii) sporadic bursts that were either propagating over all four electrodes (SPB) or nonpropagating (SNPB). Injection of vasopressin in controls was followed for 30 min by a significant increase in the number of propagating bursts from 2.7 +/- 0.6 (mean +/- SEM) to 5.2 +/- 1.4 bursts (p less than 0.05); RSB and SNPB were not altered by vasopressin. In the constipated patients, the number of propagating bursts during the control period was significantly lower (0.8 +/- 0.2 bursts/30 min) than in the volunteers (p less than 0.05). After vasopressin, there was a significant increase to 3.6 +/- 0.8 bursts/30 min (p less than 0.001); RSB and SNPB also did not show significant alteration after vasopressin. Finally, 4 out of the 10 patients passed stools during the recording session.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

Constipation: a physiological approach.

The first step in managing a patient with constipation is to understand the precise nature of the complaint. Is the onset recent? What are the frequency and form of the stools, and how much effort is required to defecate? Is constipation steady or alternating as in irritable bowel syndrome? Are there structural, metabolic or pharmacological confounders? Is the patient depressed? Has dietary fibre been tried at a sufficient dose? What are the patient's understanding and beliefs about the symptoms? Has there been sufficient and appropriate investigation? Armed with the answers to these questions, physicians can help most patients through lifestyle, dietary and pharmacological adjustments, along with supplementary fibre. Some patients may require regular doses of an osmotic laxative. Those few that fail these measures should have their transit time estimated while on a high fibre diet; if it is normal, further testing is unlikely to help. The above efforts should be re-emphasized, and reassurance should be offered. Some patients may require a psychological assessment. If transit time is prolonged and the patient may benefit from surgery for colonic inertia or biofeedback for anismus, then colon and anorectal function should be assessed. The decision to perform further tests should be made carefully, and unrealistic expectations should be discouraged. Before surgery is offered, the patient should have the benefit of receiving an expert opinion. Biofeedback helps some patients with isolated anorectal dysfunction.

Cathartics↗
PubMed1999

Abdominal massage therapy for chronic constipation: A systematic review of controlled clinical trials.

Abdominal massage therapy was once an accepted treatment for constipation. Subsequently interest faded, but recent years have seen a revival of interest in massage. It is therefore timely to ask whether or not it is an effective form of treatment for this condition. Computerized literature searches were carried out to retrieve all controlled clinical trials. Data were extracted in a standardized, pre-defined fashion. Four studies met the inclusion/exclusion criteria. None of the four studies is free of methodological flaws. They are heterogeneous in terms of trial design, patient sample and type of massage used. Nonetheless the results of these trials collectively imply that massage therapy could be a promising treatment for chronic constipation. Future, more rigorous trials should evaluate its true value.

Abdomen↗