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PubMed2006

Megacolon: constipation or volvulus?

Pediatric abdominal complaints are common presentations in emergency departments, and emergency physicians are challenged every day with a vast array of gastrointestinal disorders. Differentiating the child with a benign abdominal process from the child with a more serious condition can be difficult. We report a case of massive dilatation of the colon due to fecal impaction. Means for distinguishing constipation from alternative diagnoses are discussed.

Abdominal Pain↗
PubMed1987

Idiopathic slow-transit constipation: whole gut transit times, measured by a new simplified method, are not shortened by opioid antagonists.

A simplified method for measuring mean whole gut transit time has been validated which avoids stool collection and is suitable for out-patients. Radio-opaque markers are swallowed daily for 14 days and the mean whole gut transit time is derived directly from an abdominal X-ray. Using this new technique, neither nalmefene (in a double-blind study of six patients) nor naloxone (in an open study of four patients) shortened mean whole gut transit time in idiopathic slow-transit constipation.

Adult↗
PubMed1997

Laparoscopic-assisted compared with open total colectomy in treating slow transit constipation.

BACKGROUND: Total colectomy is the procedure of choice when slow transit constipation (STC) can be confidently diagnosed. A laparoscopic-assisted technique (LTC) may be potentially advantageous over traditional open technique (OTC) in the treatment of this benign condition. METHODS: A historical control (non-randomized) study was performed on patients diagnosed to have STC after clinical, anorectal physiologic and transit marker studies. All earlier consecutive patients underwent OTC and the latter consecutive patients underwent LTC. The intra-operative time, blood loss, postoperative ileus recovery, duration of hospitalization and complications were recorded. A bowel function and patient satisfaction questionnaire was administered on follow-up. RESULTS: Twenty-four of 411 patients were found to have STC; 17 (2 men, 15 women; mean age, 40 (standard error of mean [SEM] 5) years) underwent OTC and 7 (2 men, 5 women; mean age, 39.5 (SEM 6) years) underwent LTC. There were significant improvements in the stool frequency, need for assisted evacuation and abdominal distension (P < 0.05) after both procedures; 96% were fully satisfied with the resulting bowel function. However, OTC patients were less satisfied with the cosmetic outcome (P < 0.05). Intra-operative time for LTC was longer by a mean 74 min (P < 0.05). Postoperative blood loss, recovery of ileus and hospitalization time were the same in both groups. There were no deaths. The complication rates were 43% for LTC and 24% for OTC. The predominant complication was bowel obstruction for which two patients (both OTC) required adhesiolysis. CONCLUSIONS: Both OTC and LTC improve bowel function for STC;LTC gives a better cosmetic result, but takes longer to perform.

Adult↗
PubMed2006

Rectal sensation, pelvic floor function and symptom severity in Hispanic population with irritable bowel syndrome with constipation.

OBJECTIVE: In patients with irritable bowel syndrome with constipation (IBS-C, Rome II) we determined if pelvic floor function correlates with rectal sensitivity and tone, and if the pelvic and rectal measurements correlate with symptoms. PATIENTS AND METHODS: Sensory thresholds and tone in fasting and postprandial states were evaluated with an electronic barostat in 34 patients and 10 normal controls. The pelvic floor was assessed by defaecography. RESULTS: Pain threshold to rectal distension was lower in IBS-C patients (P = 0.007). Postprandially, IBS-C patients showed lower values for sensation of gas, perception of urge, and pain threshold compared with controls. In IBS-C the anorectal angle widened less and showed less perineal mobility during defecation; the rectal tone in fasting IBS-C patients correlated with the angle at rest (P = 0.04) and with the perineal descent at rest (P = 0.01). The severity of abdominal discomfort or pain, and abdominal fullness correlated with the anorectal angle. The duration of symptoms and frequency of bowel movements correlated with perineal descent. Straining, mucus expulsion, and the feeling of incomplete evacuation correlated with rectal sensitivity variables. CONCLUSION: Patients with IBS-C have lowered sensory thresholds for noxious and non-noxious stimuli, increased visceral sensitivity after food, less perineal mobility during defecation, and symptoms that correlate with rectal sensitivity and pelvic floor parameters.

Adult↗
PubMed1978

Lactulose syrup assessed in a double-blind study of elderly constipated patients.

The laxative effects of 50% lactulose syrup and 50% glucose syrup were compared in a 12-week, double-blind study of 47 elderly constipated patients living in a nursing home. The dosage was 30 ml daily taken at bedtime; it was reduced to 15 ml if the initial dosage produced two or more bowel movements daily. The number of bowel movements during treatment in comparison to pretreatment was significantly increased in the 42 patients (19 lactulose, 23 glucose) who completed at least 8 weeks of the study. Laculose was superior to glucose in the mean number of bowel movements per day (p less than 0.02) and in the percentage of days in which at least one bowel movement occurred (p less than 0.05). Reduction in the severity of each 5 symptoms (cramping, griping, flatulence, tenesmus, bloating) was greater with lactulose. For relief of all 5 symptoms, lactulose was significantly more effective than glucose (p less than 0.04). The striking reduction in the number of fecal impactions (only 6 in the lactulose patients vs 66 in the controls) was highly significant (p less than 0.015). The lactulose patients needed fewer enemas than did the controls. No abnormal values were observed in laboratory tests.

Aged↗
PubMed1999

Colonic motility in man: features in normal subjects and in patients with chronic idiopathic constipation.

The human colon is still a relatively unknown viscus, especially concerning its motor activity. However, in recent years, techniques have been perfected that allow a better understanding of colonic motility, especially through prolonged recording periods. In this way, it has been demonstrated that the viscus contracts according to a circadian trend, is responsive to physiological stimuli (meals, sleep), and features high amplitude, propulsive contractions that are part of the complex dynamic of the defecatory process. These physiological properties and their alterations in patients with chronic idiopathic constipation are reviewed in this article.

Chronic Disease↗
PubMed2000

Functional bowel disorders in the geriatric patient: constipation, fecal impaction, and fecal incontinence.

Functional bowel disorders, including constipation, fecal impaction, and fecal incontinence, are common gastrointestinal diseases in the elderly and a major source of morbidity. Often the etiology is multifactorial. Evaluation should investigate presenting symptoms and important historical clues. An appropriate workup, including radiological studies, endoscopy, and physiological testing should be individualized. Therapy should be directed against relieving the major complaint and treating the underlying pathophysiological mechanism.

Aged↗
PubMed2000

Psychological disorders in patients with evacuation disorders and constipation in a tertiary practice.

OBJECTIVE: We aimed to evaluate the prevalence of psychological impairment in patients with rectal evacuation disorders and the influence of psychological disorder on the early outcome of behavioral treatment. METHODS: We retrospectively reviewed the medical records of patients with rectal evacuation disorders referred for biofeedback retraining at a tertiary referral center. The psychological disorder was classified using the DSM IV criteria. Outcome of biofeedback treatment of evacuation at 2 wk was based on symptoms or on the ability to spontaneously expel a balloon placed in the rectum. Improvements in the groups without versus with a psychological disorder or an eating disorder were compared by Fisher's exact test. RESULTS: In the 60 patients (55 women; 5 men; mean age, 38 yr), psychological disorders were identified in 39 (65%); also noted were eating disorder (n = 5), rumination syndrome (n = 3), pain disorder (n = 6), anxiety-depression (n = 10), a combination of depression and pain disorder (n = 3), and a combination of eating disorder with anxiety-depression and pain disorder (n = 12). There was an association between psychological status and outcome at 2 wk of behavioral treatment for evacuation disorder (p = 0.03). The coexistence of eating disorder and psychological disorder resulted in an unfavorable outcome (p = 0.02), compared with those without psychological disorder. CONCLUSION: Psychological impairment was identified in 65% of the patients with evacuation disorder and constipation in a tertiary care practice, and has a significant negative impact on the outcome of behavioral treatment. These data reinforce the importance of a multidisciplinary approach in the management of these patients.

Adolescent↗
PubMed2003

Automated quantitative analysis of nocturnal jejunal motor activity identifies abnormalities in individuals and subgroups of patients with slow transit constipation.

OBJECTIVE: Small bowel dysmotility has previously been demonstrated in some patients with slow transit constipation (STC), suggesting a generalized intestinal disorder. However, no study has addressed whether the incidence of small intestinal dysfunction differs between subgroups of patients in this heterogeneous population. Using appropriate methodology, we aimed to determine prospectively the proportion of individuals with abnormal small bowel motility, and to assess whether heterogeneity in terms of pattern of colonic transit delay (based on (111)In diethylene-triamine-pentaacetic acid (DTPA) isotope scintigraphy), or mode of onset (based on clinical history) is of importance. METHODS: Thirty-seven patients with STC underwent 24-h ambulatory jejunal manometry; data were compared with those obtained in 38 healthy controls. Automated quantitative analysis of seven variables of the nocturnal migrating motor complex was performed, to assess whether differences existed between groups, and whether individual patients had evidence of small intestinal dysmotility, defined as two or more measures of migrating motor complex variables outside the normal range. Four variables differed significantly between STC patients and controls: in phase III, propagation was slower, duration was longer, and contraction amplitude was higher; in phase II, contraction frequency was increased. Seven of 24 patients with a generalized pattern of colonic transit delay had abnormal small bowel motility compared with none of 13 with a left-sided delay (p < 0.04). These included four patients with chronic idiopathic symptoms and three with acquired symptoms. Approximately one third of patients with a generalized delay in colonic transit had evidence of jejunal enteric neuromuscular dysfunction. Individual patients with a left-sided colonic delay did not satisfy the criteria for nocturnal small bowel dysmotility, but as a group, some differences were noted from controls. In contrast to previous reports, evidence of generalized enteric dysmotility may be present irrespective of the mode of onset.

Adolescent↗
PubMed2003

Overlapping upper and lower gastrointestinal symptoms in irritable bowel syndrome patients with constipation or diarrhea.

OBJECTIVES: Distinguishing between irritable bowel syndrome (IBS) and functional dyspepsia can be challenging because of the variations in symptom patterns, which commonly overlap. However, the overlap is poorly quantified, and it is equally uncertain whether symptom patterns differ in subgroups of IBS arbitrarily defined by primary bowel patterns of constipation (IBS-C) and diarrhea (IBS-D). We aimed to determine and to compare the distribution of GI symptoms, both, upper and lower, among IBS-C and IBS-D patients. METHODS: A total of 121 consecutive patients presenting with a diagnosis of IBS were grouped according to primary bowel symptoms as IBS-C (58 women and 18 men, mean age 47 +/- 17 yr) or IBS-D (26 women and 19 men, mean age 47 +/- 15 yr). The Hopkins Bowel Symptom Questionnaire, which includes a brief Quality of Life assessment, and the Hopkins Symptom Checklist 90-Revised were completed by all patients at intake. RESULTS: IBS-C patients reported significantly more overall GI symptoms when compared to patients with IBS-D (6.67 vs 4.62, respectively, p<0.001). Abdominal pain patterns differed in patients with IBS-C versus IBS-D (lower abdominal pain: 40.8% vs 24.4% p=0.05 and upper abdominal pain: 36.8% vs 24.4%, respectively). Bloating was substantially more common in IBS-C patients (75%) than in IBS-D (40.9%). There were no significant differences in personality subscales by IBS subgroup; however, somatization was positively associated with multiple symptom reports and was negatively correlated with quality of life. CONCLUSIONS: Upper GI symptoms consistent with functional dyspepsia were more frequent in IBS-C. Although there was considerable overlap of upper and lower GI symptoms in patients with IBS-C and IBS-D, the former had more frequent lower abdominal pain and bloating.

Adult↗
PubMed2006

Alosetron: ischemic colitis and serious complications of constipation.

Drugs such as alosetron that modulate serotonin effects by stimulating or blocking its receptors may play an important role in the treatment of some patients with irritable bowel system. In the case of alosetron, a 5HT-3 antagonist, an analysis of data from randomized clinical trials and postmarketing experiences have demonstrated a causal relationship between this drug and ischemic colitis and serious complications of constipation. Because the mechanism(s) of drug-induced ischemic colitis and possibly other forms of intestinal ischemia associated with alosetron have not been elucidated, there is need to further assess risk with regard to patient susceptibility and other factors.

Carbolines↗
PubMed2006

Experience with type A botulinum toxin for treatment of outlet-type constipation.

BACKGROUND: Puborectalis syndrome remains a therapeutic challenge for today's physicians. Traditional approaches include use of fiber, laxatives, enemas, biofeedback training, and surgery. These often were tried sequentially and had conflicting or even disappointing results. We investigated the efficacy of injections of botulinum toxin in improving rectal emptying in patients with defecatory disorders involving spastic pelvic-floor muscles. METHODS: Twenty-four consecutive patients with chronic outlet obstruction constipation resulting from puborectalis syndrome were included in the study. The patients were treated with 60 units of type A botulinum toxin, injected into two sites on either side of the puborectalis muscle under ultrasonographic guidance. RESULTS: At 2 months, evaluation inspection revealed a symptomatic improvement in 19 patients. Anorectal manometry demonstrated decreased tone during straining from 98 +/- 24 to 56 +/- 20 mmHg at a 1-month evaluation (p < 0.01) and 56 +/- 29 mmHg at a 2-month follow-up (p < 0.01). Pressure during straining was lower than resting anal pressure at the same time in all patients. Defecography after the treatment showed improvement in anorectal angle during straining, which increased from 98 +/- 9 degrees to 121 +/- 15 degrees (p < 0.01). CONCLUSIONS: Botulinum toxin injections should be considered as a simple therapeutic approach in patients with obstructed defecation. The treatment is safe and effective, especially with the use of the ultrasonographic guidance that accounts for a more precise injection and consequently better long-term results. Otherwise, given the limited effect of the toxin, repeated injections may be necessary to maintain the clinical improvement.

Botulinum Toxins, Type A↗
PubMed1994

Constipation evoked by 5-HT3-receptor antagonism: evidence for heterogeneous efficacy among different antagonists in guinea-pigs.

The abilities of selective 5-HT3-receptor antagonists to evoke constipation were examined in conscious guinea-pigs and in preparations of guinea-pig isolated colon. Compared with vehicle-treated guinea-pigs, acute doses of granisetron (0.1, 1 and 10 mg kg-1, i.p.) and tropisetron (10 mg kg-1, i.p., but not 1 and 0.1 mg kg-1, i.p.) significantly (P < 0.05) reduced the total number of faecal pellets excreted during a 12-h observation period. By contrast, BRL 46470 (0.1-10 mg kg-1, i.p.) had no significant effect on the incidence of defecation. Mid-to-distal lengths of guinea-pig isolated colon spontaneously expelled faecal pellets. Granisetron (0.1 and 1 microM) and tropisetron (1 microM) reduced or prevented the rate at which they were spontaneously expelled. Morphine (0.1 microM) and clonidine (10 nM) also showed faecal pellet transit time. Naloxone (0.1 microM) had no effects alone, but reversed the actions of granisetron, morphine and clonidine. BRL 46470 (1 microM) had no significant effect on the transit of faecal pellets in guinea-pig isolated colon. In segments of guinea-pig isolated colon which did not contain faecal pellets, granisetron, tropisetron and BRL 46470 antagonized the ability of 5-HT to evoke cholinergically-mediated contractions of the longitudinal muscle. The respective pA2 values and slopes of the Schild plots were 8.5 +/- 0.05, slope 1.06 +/- 0.03; 8.5 +/- 0.1, slope 0.91 +/- 0.04; and 7.9 +/- 0.1, slope 0.93 +/- 0.05. Our experiments suggest that not all 5-HT3-receptor antagonists are the same.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1976

Investigation and management of long-standing chronic constipation in childhood.

The anorectal physiology of 106 children with long-standing chronic constipation, who had failed to response to a trial of medical treatment, was assessed. 10 (9%) were shown to have ultrashort-segment Hischsprung's disease, later confirmed on histology, The remainder showed evidence of hypertrophy of the internal sphicter on anorectal manometry and had a vigorous anal dilatation (to accept 4 fingers) under general anesthesia. After this, 38% were able to be weaned off all medication and most of the remainder improved. Further anal dilatation and internal sphincterotomy allowed a further 10 children to stop laxative, bringing the total to 48%.

Adolescent↗
PubMed1995

Radiological assessment of constipation.

A scoring system for faecal loading was constructed by two experienced observers using the abdominal radiographs of 20 children. Four other observers independently graded the radiographs using this system and there was a high degree of agreement between all six observers (p < 0.001), suggesting that radiological assessment of constipation can be standardised.

Adolescent↗
PubMed1995

Radiological evidence of constipation in urinary tract infection.

Little objective evidence has been published to support the claim that constipation is an important contributory factor in recurrent urinary tract infection (UTI) in childhood. Using a radiological scoring system, two observers assessed faecal loading from abdominal radiographs of children with proved UTIs. There was a significant increase in the degree of faecal loading in children with UTI when compared with controls (r = 0.237). This difference was mainly accounted for by girls with recurrent (greater than five) UTIs. This study confirms an association between recurrent UTI and faecal loading. Further studies are needed to establish if there is a causal relationship and benefits from treatment.

Adolescent↗
PubMed1996

Diagnostic dilemmas and results of treatment for chronic constipation.

Chronic functional constipation (CFC) may be difficult to recognise and information regarding its long term prognosis is scarce. The records of 244 children with CFC, aged 0-18 years, were analysed for symptoms at presentation and results of treatment, and long term outcome was evaluated by means of a telephone interview in 137 patients discharged for more than one year. The patients presented with a great variety of symptoms, only 22% having infrequent defecation of increased consistency, another 22% having an obviously normal defecation pattern. The mean duration of treatment was 13 months. At the time of discharge, 69% of the patients still used laxatives. At a median of four years after discharge, 66% of the children were free of symptoms and without medication, 39% having experienced a recurrence. It is concluded that CFC may be difficult to recognise and can be alleviated by an intensive laxative regimen. Recurrence of symptoms is common, but the long term prognosis is good in most patients.

Adolescent↗
PubMed2000

Managing constipation in children.

Constipation, defined as difficulty, delay or pain on defaecation, is common in children and is often difficult to manage. Here, we review the assessment and treatment of affected children and the support that they, and their families, may need.

Cathartics↗