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PubMed2000

Review of the treatment literature for encopresis, functional constipation, and stool-toileting refusal.

This review summarizes the literature on randomized, controlled, published studies involving medical, behavioral, psychological, and biofeedback treatments for encopresis/functional constipation and stool-toileting refusal in preschool-age and school-age children. Nine such studies were located in the literature involving school-age children. No randomized, controlled treatment studies involving preschool-age children have been published. This review revealed no evidence to support the routine use of psychotherapy or anal sphincter biofeedback in the treatment of pediatric fecal elimination dysfunctions, beyond those benefits derived from a comprehensive medical-behavioral intervention. Further, this review indicated that paradoxical constriction of the External Anal Sphincter does not influence the treatment outcome of either biofeedback or medical-behavioral interventions. There are remarkably few controlled treatment outcome studies in this most important clinical area. More research is needed that employs standard treatment outcome variables.

Adolescent↗
PubMed2004

Thickening of the internal anal sphincter in idiopathic constipation in children.

Thickening of the internal anal sphincter (IAS) is observed in chronic idiopathic constipation (IC) and solitary rectal ulcer syndrome (SRUS), where it has been correlated with the presence and severity of rectal intussusception. Alternatively, thickened IAS may be a feature of the obstructed megarectum in a similar way to the hypertrophy of bladder neck seen in dyssynergic bladders. The aim of this study was to investigate the significance of thickening of the IAS in children with chronic IC and to determine any association between the thickened IAS and anorectal manometry findings and patient's symptoms. A total of 144 children were admitted for investigations and treatment of chronic IC and evaluated prospectively between April 2001 and April 2003. IAS thickness was measured by endosonography using B&K axial endosonic probe type 1850 with a 10-MHz rotating transducer. The thickness of IAS was measured at 3, 6, and 9 o'clock, and the mean value of the three measurements was used for analysis. Functional assessment was done by anorectal manometry pressure studies under ketamine anaesthesia. A validated symptom score (SS) was used to assess the severity of symptoms. The sum of SS ranged between 0 and 65. Spearman's rho two-tailed test was used to correlate the thickness of IAS with patients' symptoms and anorectal manometry findings. Results were expressed as median and range and p-value of less than 0.05 was considered significant. Of 144 children, 84 were boys, median age 8.1 years (range 3.1-15). Soiling was present in 137 (94%) patients, delay in defecation in 132 (91%), and a palpable megarectum on abdominal examination in 117 (80%). The median duration of symptoms and duration of laxative treatment were 4 years (range 0.3-14.5) and 3.3 years (0.2-13.5), respectively. The average severity score for soiling, delay in defecation, palpable megarectum, and the total SS were 8 (range 0-10), 5 (0-10), 2 (0-12), and 33 (11-51), respectively. The median thickness of IAS was 0.9 mm (range 0.3-2.8) and the median resting anal sphincter pressure was 54 mmHg (19-107). The median amplitudes of rectal and anal sphincter contraction were 3 mmHg (1-25) and 9 mmHg (1-35), respectively. The thickness of IAS correlated significantly with total symptom severity score (r=0.31, p=0.0001), soiling score (r=0.28, p=0.001), megarectum score on abdominal palpation (r=0.29, p=0.001), size of megarectum on manometry (r=0.36, p=0.0001), amplitude of rectal contraction (r=0.23, p=0.007), and age of patient (r=0.55, p=0.0001). There was also a significant correlation between the amplitude of rectal and anal sphincter contraction (r=0.32, p=0.0001). There was no correlation between thickness of IAS and resting anal sphincter pressure and amplitude of anal sphincter contraction on anorectal manometry study. A total of 24 children had myectomy of thickened and overactive IAS in addition to the medical treatment of their chronic IC. The histology examination of myectomy specimen with eosin and haematoxylin staining and histochemical acetylcholine esterase staining showed smooth muscle fibres and ganglion cells. Thickening of IAS correlates significantly with duration and severity of symptoms, size of megarectum, and amplitude of rectal contraction. The pathogenesis is secondary to the continuous presence of faeces in the rectum, resulting in chronic abnormal stimulus to the IAS, which leads to hypertrophic changes in the rectum wall and IAS.

Adolescent↗
PubMed1998

Currarino's triad: an unusual cause of constipation in children.

A 6-year-old girl presented with intractable constipation. On investigation, she was found to have an association of anorectal stenosis, anterior sacral defect, and anterior meningocoele (Currarino's triad). The meningocoele was excised and a Duhamel pull-through procedure performed after resection of a massively distended rectosigmoid. Post-operatively, she started having spontaneous bowel action. Early diagnosis and management is recommended to avoid the high mortality and morbidity associated with this condition.

Abnormalities, Multiple↗
PubMed2002

Chronic constipation due to Hirschsprung's disease and desmosis coli in a family.

Five members of a family are described, all of whom suffered from chronic constipation and megacolon. Detailed clinical and histologic evaluation of each member revealed that two individuals have histologic evidence of desmosis coli and three have Hirschsprung's disease, one of whom also has desmosis coli. The latter combination has never been described before, either in a family or in a single patient. Genetic studies of the family did not reveal an increase in the number of shared markers for the RET proto-oncogene, suggesting that this previously undescribed familial association is likely not caused by a mutation in the RET gene, but by other genetic abnormalities.

Chronic Disease↗
PubMed2002

Four cases of desmosis coli: severe chronic constipation, massive dilatation of the colon, and hypoperistalsis due to of changes in the colonic connective-tissue net.

We present four patients 5, 10, 12, and 17 years of age, each with a long history of severe constipation and hypoperistalsis of the gut. Three had partial or total resection of the colon, all had enterostomies, and only one maintains normal bowel function after reanastomosis. We report the clinical courses, radiologic findings, and operative procedures for all four cases. Preoperative full-thickness biopsies and the resected colon specimens revealed a complete or incomplete lack of the mesh network of collagen. The connective-tissue layer between the circular and longitudinal muscles was missing. Contrary to expectations, the enteric nervous system (ENS) was normal or near-normal in the affected areas. Hypo- and dysganglionosis was found additionally in some proximal segments of colon and/or small bowel. This combination of clinical symptoms and pathological findings is called desmosis of the colon with reference to a working hypothesis in a preliminary report by Meier-Ruge in 1998. Aplastic or hypoplastic desmosis may be the reason for the disturbed gut motility. Histologic examination should thus not only exclude changes of the ENS.

Adolescent↗
PubMed2004

Decreased interstitial cells of Cajal in the sigmoid colon of patients with slow transit constipation.

BACKGROUND AND AIMS: Slow transit constipation (STC) is a colonic motor disorder that is characterized by measurably delayed movement of materials through the colon. Although abnormalities in the neuronal networks of the colon have been demonstrated in patients with STC, the etiology of STC remains unclear. Interstitial cells of Cajal (ICC) have been shown to be the pacemaker cells of the intestine and have been implied in the pathogenesis of a number of gastrointestinal motility dysfunctions, including idiopathic STC. This study aimed to determine the normal distribution of ICC within the colon of the Chinese and also to determine if ICC are decreased in Chinese STC patients. PATIENTS AND METHODS: Twelve patients with STC and eight age-matched normal controls were studied. Specimens of sigmoid colon were obtained immediately after resection. ICC were identified with a monoclonal antibody to c-kit by an indirect immunofluorescence method. Immunostained tissues were examined with a laser scanning confocal microscope and the area occupied by ICC was calculated with an image analysis system. RESULTS: ICC were located in the external muscle layers including myenteric plexus (MP) and submucosal border (SMB). Two types of Kit-positive ICC were observed: bipolar cells characterized by one or two long processes and multipolar cells characterized by long stellate processes extending in various directions. A higher percentage of ICC was present in the MP regions and circular muscle (CM) layers compared with the SMB and longitudinal muscle (LM) layers. Tissues from STC patients showed a considerable decrease in the number of ICC located in the four regions (ICC-LM, ICC-MP, ICC-CM, ICC-SMB), especially the ICC-SMB, in which ICC almost completely disappeared. CONCLUSIONS: Similar distribution of ICC was observed in the normal sigmoid colon of the Chinese. Decreased area of c-kit+ ICC may play an important role in the pathophysiology of STC. It remains to be determined whether the loss of ICC is primary or secondary to another lesion.

Adult↗
PubMed2005

Role of pelvicography and colpocystodefecography in diagnosis of outlet obstructive constipation.

AIMS: The aim was to research the changes in pelvic floor morphology and corresponding visceras in patients with outlet obstructive constipation (OOC). PATIENTS AND METHODS: Thirty-eight patients with OOC and 12 healthy volunteers were enrolled in this study. With simultaneous pelvicography and colpocystodefecography (PCCD), including pelvicography, vaginal opacification, voiding cystography and defecography, pelvic floor morphology was observed and the anorectal angle, the level of the perineum, peritoneum and bladder were measured. RESULTS: Thirty-seven cases of internal rectal prolapse (IRP), 5 cases of rectocele (RC) and 5 cases of spastic pelvic floor syndrome SPFS were diagnosed by PCCD. 12 IRP, 4 RC and 1 SPFS were detected by common physical examination. All of these were confirmed by PCCD. Moreover, PCCD found 9 pelvic floor hernia or peritoneoceles, 6 cystoceles, 3 descending perineum syndromes and 10 uterine prolapses. Compared with controls, OOC patients had a significantly large anorectal angle during defecation, abnormal descending of the perineum at rest and during defecation, and a deep pouch of Douglas during defecation. Some patients with urinary system symptoms may have had an abnormal descent of the bladder during rest and defecation. CONCLUSION: Simultaneous PCCD has a higher positive ratio than the common physical examination in diagnosing IRP and RC, and provides information for the diagnosis of pelvic floor hernia or peritoneocele, cystocele or uterine prolapse. PCCD is helpful in the selection of a proper surgical procedure.

Adult↗
PubMed1998

Abnormalities of nerve fibers in the circular muscle of patients with slow transit constipation.

Abnormalities of the enteric nervous system are thought to explain the pathophysiology of motility disorders. Our aim was to determine if particular classes of enteric neurons are affected in slow transit constipation (STC). Specimens were taken from the terminal ileum and ascending, transverse and descending colon of patients undergoing subtotal colectomy for STC. Immunohistochemistry was performed using antisera to neuron-specific enolase, tachykinin, leu-enkephalin, choline acetyltransferase, vasoactive intestinal peptide, nitric oxide synthase, tyrosine hydroxylase and neuropeptide Y. The density of nerve fibres labelled with these antibodies in each layer was compared with age-matched controls. The density of nerve fibres with tachykinin and enkephalin immunoreactivity was reduced in the colonic circular muscle of the 15 patients with STC, whereas innervation of all other layers was normal. This reduction of tachykinin-immunoreactive nerve fibres also occurred in nine of the 12 specimens of terminal ileum examined. No difference was detected in the density or distribution of nerve fibres using the other antisera. Excitatory nerve fibres are present in the circular muscle in STC but they are deficient in tachykinins and enkephalin.

Adult↗
PubMed2000

Rectal pacing in patients with constipation due to rectal inertia: technique and results.

In a previous study we determined the rectal pacing parameters needed for rectal evacuation in patients with rectal inertia. Here we investigated the effect of rectal pacing on rectal myoelectric activity, motility, and evacuation in ten patients with constipation due to rectal inertia. A pacemaker was implanted in a subcutaneous pocket above the inguinal area, with a lead threaded in the anal submucosa to be hooked at the rectosigmoid junction. The effect of rectal pacing on rectal electric activity was investigated by inserting two recording electrodes to the rectal mucosa. The patients were then trained for home pacing. No waves were recorded from the rectum at rest. On rectal pacing, slow waves or pacesetter potentials (mean frequency 2.3+/-1.1 cpm, amplitude 0.86+/-0.1 mV, velocity 3.4+/-1.6 ms) were registered after a latency period of 5.2+/-1.6 min. Rectal evacuation, on pacing, occurred in seven of the ten patients. The three who showed no significant response exhibited low wave parameters. Three of seven patients were able to evacuate spontaneously without pacing after having performed daily pacing for 5-6 months. The pacemaker was removed in six patients (three failures and three after spontaneous defecation). Thus rectal pacing succeeded in inducing rectal evacuation in 70% of the patients. The procedure failed in three patients. Three had spontaneous defecation after a few months of rectal pacing. No complications were encountered, and the method was tolerated and acceptable. Further studies on a large group of patients are required.

Action Potentials↗
PubMed2003

Bleeding, incontinence, pain and constipation after STARR transanal double stapling rectotomy for obstructed defecation.

BACKGROUND: The STARR double stapling procedure (DSP), i. e. transanal anteroposterior rectotomy, has been recently reported as a low-morbidity and effective operation for the treatment of rectocele and internal rectal mucosal prolapse (R-IMP) causing obstructed defecation. We report the postoperative complications and recurrence of symptoms following this novel operation. PATIENTS AND METHODS: Fourteen chronically constipated women with RIMP, aged 36-72 years, presented with either severe complications or recurrence of symptoms following DSP performed by means of two circular staplers. All were followed for a median period of 12 months (range, 2-24) after DPS. RESULTS: Severe rectal bleeding occurred in two cases postoperatively. Persistent severe anal pain was reported by seven patients, all presenting with anxiety. Four of them were multiparous. Three patients had fecal incontinence, both had vaginal deliveries. R-IMP recurred in six, obstructed defecation in seven cases. Four patients needed reintervention, one for suturing the bleeding area, one excising the recurrent prolapse, one for colpocele and one for rectal stricture. Four patients required biofeedback training for non-relaxing puborectalis and two needed psychotherapy. CONCLUSION: Parity, spastic floor syndrome and psychoneurosis seem to be the risk factors predisposing to failure of DSP, which may be followed by severe complications and early recurrence of symptoms requiring reoperation.

Adult↗
PubMed2005

Increased beta-adrenergic sensitivity correlates with visceral hypersensitivity in patients with constipation-predominant irritable bowel syndrome.

Autonomic imbalance has been proposed to be a pathophysiological factor for irritable bowel syndrome (IBS). The aim of this study was to assess beta-adrenergic abnormalities in IBS and to evaluate their relationship to visceral hypersensitivity and other symptoms of IBS patients. Sixteen IBS patients and 16 control subjects were recruited into this study. Participants were asked to complete a questionnaire regarding bowel symptoms, and in order to study beta-adrenergic sensitivity, isoproterenol stimulation tests were performed and visceral hypersensitivity was evaluated by barostat test. Results showed that beta-adrenergic activity and rectal sensitivity were more pronounced in IBS patients than in normal control patients (P < 0.01). Although both IBS subgroups also exhibited more pronounced beta-adrenergic sensitivity than did the controls (P < 0.05), a significant correlation between beta-adrenergic activity and maximally tolerable pressures on the barostat test was found only in IBS-C patients (P = 0.03, R = 0.855). In addition, patients with "hard or lumpy" stools exhibited a higher degree of beta-adrenergic activity (P = 0.00). We conclude that increased beta-adrenergic activity significantly correlated with visceral hypersensitivity in constipation-predominant IBS and symptoms of hard or lumpy stools in IBS patients.

Adrenergic beta-Agonists↗
PubMed2006

Irritable bowel syndrome and chronic constipation: emerging drugs, devices, and surgical treatments.

Irritable bowel syndrome (IBS) and chronic constipation (CC) are two of the most common functional disorders of the gut. CC and IBS are estimated to affect up to 20% and 27% of the North American population respectively. Although not life-threatening, CC and IBS can profoundly and negatively affect quality of life and are associated with a significant economic burden related to direct and indirect annual health-care costs. Possible etiologies for IBS and CC include alterations in visceral sensation and gastrointestinal motility. IBS may be caused by disturbances in brain-gut interactions affecting gastrointestinal motility and visceral sensitivity. Research efforts in CC have begun to identify abnormalities in myenteric neurons, alterations in neurotransmitters and their receptors, and incoordination of the muscles of the pelvic floor or anorectum. Both disorders may be influenced by genetic predisposition, environmental factors, and stress. In this article, the safety and efficacy of traditional and emerging therapies for CC and IBS are examined. In addition, their pathophysiology and symptoms are briefly reviewed.

Constipation↗
PubMed1981

Paradoxical instruction in the treatment of encopresis and chronic constipation: an experimental analysis.

The purpose of the present single-case experimental investigation was to examine the efficacy of paradoxical instruction in the treatment of exacerbation-based discontinuous encopresis and chronic constipation. The subject, a 9-yr old male, complained of infrequent bowel movements and daily soiling. In addition, toileting and related activities appeared to cause considerable anxiety. An ABAB reversal design with 1-yr follow-up was used as a means of evaluating treatment effectiveness. Dependent measures included weekly parental records of soiling and appropriate bowel movements. Results indicated a clear demonstration of functional control and consistent improvement in the encopretic disturbance. These findings were maintained at 1-yr follow-up.

Behavior Therapy↗
PubMed1992

An alternative biofeedback-based behavior modification treatment for a case of chronic constipation.

A 31-year old female with chronic constipation was referred for treatment of a paradoxical contraction of the external anal sphincter (EAS) muscle during straining to defecate. The patient was dependent on laxative use and the digital removal of feces. The present program emphasized biofeedback training of the EAS utilizing the inexpensive, noninvasive procedure of disposable surface electrodes placed on the anal verge. Outcome of treatment resulted in an 89% decrease in laxatives used, complete termination of the digital removal of feces, and a notable decrease in EAS tension. The patient was able to maintain these gains at an 8 month follow-up.

Adult↗
PubMed1993

Severe constipation with diffuse intestinal myenteric hyperganglionosis.

The authors report a case of neuronal intestinal dysplasia in a 6-year-old girl. The disease is characterized by hyperplastic ganglia throughout the large and small intestine, associated with severe constipation. To better understand the pathophysiology of this disease the authors investigated the histopathologic, ultrastructural, and immunohistochemical characteristics of the intestinal tissue in this case. The hyperganglionosis was associated with immunohistochemical findings of intact expression of the neuropeptides controlling the peristaltic reflex, through lower expression of calcitonin-gene related peptide. With the recent progress in our understanding of the neural regulation of gastrointestinal function, it may now be possible to begin to understand the complex pathophysiological mechanisms underlying gastrointestinal motility disorders.

Calcitonin Gene-Related Peptide↗
PubMed1992

Oral naloxone reduces constipation but not antinociception from oral morphine in the rat.

Oral administration of naloxone (10 mg/kg) antagonized the slowing of the intestinal transit caused by oral morphine (1, 2.5 and 5 mg/kg) in rats. Oral administration of naloxone (10 mg/kg) did not prevent the antinociceptive effect of orally administered morphine (2.5 mg/kg) in the tail-flick test carried out on rats. It is concluded that oral naloxone locally blocks the constipating effect of morphine, while it fails to reduce the central action of morphine due to extensive metabolization after oral administration.

Administration, Oral↗
PubMed1989

Primary constipation: an underlying mechanism.

Primary (simple) constipation is a consequence of habitual bowel elimination on common toilet seats. A considerable proportion of the population with normal bowel movement frequency has difficulty emptying their bowels, the principal cause of which is the obstructive nature of the recto-anal angle and its association with the sitting posture normally used in defecation. The only natural defecation posture for a human being is squatting. The alignment of the recto-anal angle associated with squatting permits smooth bowel elimination. This prevents excessive straining with the potential for resultant damage to the recto-anal region and, possibly, to the colon and other organs. There is no evidence that habitual bowel elimination at a given time each day contributes considerably to the final act of rectal emptying. The natural behavior to empty the bowels in response to a strong defecation reflex alleviates bowel emptying by means of the recto anal inhibitory reflex.

Constipation↗