Audit of constipation in a gastroenterology referral center

Usefulness of ultrasonographic evaluation of stool and/or gas distribution for the treatment strategy of chronic constipation

BACKGROUND AND AIM

This study aimed to evaluate the capability of ultrasonography to predict favorable outcomes of various medical therapies in patients with chronic constipation.

METHODS

We enrolled 223 patients with chronic constipation (75 men, 148 women; mean age 62.9 ± 3.4 years). Transverse diameters of four segments of the colon (ascending [A], transverse [T], descending [D], sigmoid [S]), and the rectum [R]) were measured. The patients' stool and/or gas distribution was evaluated using the constipation index (CI) ([A + T + D + S + R]/5) and the left/right distribution ratio ([D + S]/[A + T]) according to our previous study. Patients were first treated with fiber- or osmosis-based laxatives for 2 weeks. When constipation was not alleviated, stimulant-based laxatives were added, and the patients were followed for another 2 weeks.

RESULTS

Based on their clinical courses, patients were divided into four groups: nonresponders (group A) or responders (group B) to fiber- or osmosis-based laxatives; nonresponders to any medical therapy (group C); and responders to stimulant-based laxatives (group D). The CI was significantly higher in group A than group B (P < 0.05), with the receiver operating characteristic (ROC) curve analysis showing a CI cut-off of 21.2 for predicting favorable outcomes of either fiber- or osmosis-based laxatives (P < 0.05). Left/right distribution ratio was significantly lower in group C than group D (P < 0.05), and the ROC curve analysis showed a left/right cut-off of 0.5 for predicting responders to stimulant-based laxatives (P < 0.05).

CONCLUSION

These findings could help physicians predict favorable outcomes with laxatives without side effects for this patient population.

Is There a Link Between H. Pylori and the Epidemiology of Crohn's Disease?

INTRODUCTION

Case control studies suggest an inverse association between Helicobacter pylori (H. pylori) and Crohn's disease (CD). It is possible this could be accounted for by confounders such as antibiotic therapy. Analyzing the geographic distribution of H. pylori and the links with the incidence and prevalence of CD would be an alternative approach to circumvent these confounders.

METHODS

The literature was searched for studies published between 1990 and 2016 that reported incidence or prevalence data for CD in random population samples in developed countries (GDP per capita >20,000 USD/year). Corresponding prevalence studies for H. pylori in these same regions were then sought matched to the same time period (±6 years). The association between the incidence and prevalence of CD and H. pylori prevalence rates were assessed before and after adjusting for GDP and life expectancy.

RESULTS

A total of 19 CD prevalence and 22 CD incidence studies from 10 European countries, Japan, USA, and Australia with date-matched H. pylori prevalence data were identified. The mean H. pylori prevalence rate was 43.4% (range 15.5-85%), and the mean rates for incidence and prevalence for CD were 6.9 and 91.0/100,000 respectively. The incidence (r = -0.469, p < 0.03) and prevalence (r = -0.527, p = 0.02) of CD was inversely and significantly associated with prevalence of H. pylori infection.

CONCLUSIONS

Our data demonstrate a significant inverse association between geographic distribution of H. pylori and CD. Thus, it is highly unlikely that the findings of previous case control studies were simply due to confounding factors such as concomitant antibiotic use in CD patients.

Rectal Gas Volume Measured by Computerized Tomography Identifies Evacuation Disorders in Patients With Constipation

BACKGROUND & AIMS

Approximately one third of patients who present to gastroenterology care with constipation have rectal evacuation disorders. We aimed to compare rectal gas volume, measured by computerized tomography (CT), in constipated patients with and without rectal evacuation disorders.

METHODS

In a retrospective study, we collected data from 1553 patients with constipation, evaluated over 20 years. We analyzed data from 141 patients evaluated by anorectal manometry, balloon expulsion tests, and colon transit tests, collecting records of abdominal and pelvic CT examinations. Patients were classified into 3 subgroups: those with rectal evacuation disorders, slow-transit constipation, or normal-transit constipation. Two observers used standard CT software to identify variable regions of interest on each cross-sectional CT image that contained rectum and measured areas of gas in each slice; they then summated entire volumes of rectal gas. For the 3 groups, we compared rectal gas volume, maximal rectal gas transaxial area (measured by CT), and area of rectal gas (vertical) on the 2-dimensional abdominal film (scout) using the Kruskal-Wallis test.

RESULTS

The intraclass correlation coefficient between 2 observers' measurements of rectal gas volume was 0.99 (P < .001). There were overall group differences in rectal gas volume and the maximal rectal gas transaxial area (both P < .001). The median rectal gas volume was higher in patients with rectal evacuation disorders (13.84 cm³) than in patients with slow-transit (2.51 cm³) or normal-transit constipation (1.33 cm³, both P < .05). Similarly, the area of rectal gas, which correlated with the maximal rectal gas transaxial area (Spearman correlation coefficient, 0.7; P < .001), showed overall 3-group differences (P = .033), with greater areas of rectal gas on the abdominal scout film in patients with rectal evacuation disorders than in those with normal-transit constipation.

CONCLUSIONS

In an analysis of patients with constipation, we found rectal gas volume, determined by abdominal CT imaging, to be greater in patients with than without rectal evacuation disorders.

The incidence rate and characteristics of clinically diagnosed defecatory disorders in the community

BACKGROUND

Defecatory disorders (DD) are defined by clinical and objective features of impaired rectal evacuation. The epidemiology of DD in the population is unknown, partly because many constipated patients do not undergo anorectal tests. Our objectives were to estimate the incidence rate and clinical features of DD in the community.

METHODS

We reviewed the medical records of all patients older than 16 years in Olmsted County, MN, who had constipation and underwent anorectal manometry from 1999 through 2008. Criteria for diagnosing DD were constipation for 6 months or longer and one of the following: (i) abnormal rectal balloon expulsion test; (ii) reduced or increased perineal descent; or (iii) two or more abnormal features with defecography or surface electromyography.

KEY RESULTS

Of 11 112 constipated patients, 516 had undergone anorectal tests; 245 of these (209 women, 36 men) had a DD. The mean (±SD) age at diagnosis was 44 years (±18) among women and 49 years (±19) among men. The overall age- and sex-adjusted incidence rate per 100 000 person-years was 19.3 (95% CI: 16.8-21.8). The age-adjusted incidence per 100 000 person-years was greater (p < 0.0001) in women (31.8, 95% CI: 27.4-36.1) than in men (6.6, 95% CI: 4.4-8.9). Prior to the diagnosis of DD, nearly 30% of patients had irritable bowel syndrome (IBS), 48% had a psychiatric diagnosis, 18% had a history of abuse, and 21% reported urinary and/or fecal incontinence.

CONCLUSIONS & INFERENCES

Among constipated patients, DD are fourfold more common in women than men and often associated with IBS and psychiatric diagnoses.

Long-term efficacy of biofeedback therapy in patients with dyssynergic defecation: results of a median 44 months follow-up

BACKGROUND

The beneficial effect of biofeedback therapy (BFT) over a period of more than 2 years has not been studied in a large group of patients. The aim of this study was to evaluate the long-term efficacy of BFT for dyssynergic defecation (DD).

METHODS

We evaluated the results for 347 consecutive constipated patients with DD who underwent BFT for a median of five sessions between 2004 and 2009. Initial responses were assessed immediately after the completion of BFT. A responder was defined as a subject with at least a three-point improvement from before to after BFT on an 11-point global bowel satisfaction (GBS) scale, or a two-point improvement if the baseline GBS was more than six points. The probability of remaining a responder was estimated by non-parametric maximum likelihood estimation.

KEY RESULTS

The initial response rate to BFT was 72.3% (n = 251), Parkinson's disease and higher baseline GBS scores were associated with initial non-response. The long-term efficacy of BFT was analyzed in 103 patients who were followed up for more than 6 months; the initial effects of BFT were maintained in 85 of the patients (82.5%) during a median of 44 months of follow-up (IQR = 12-68). The probability of remaining a responder was 60% at 2 years, and 58% at 5 years.

CONCLUSIONS & INFERENCES

The efficacy of BFT is maintained for more than 2 years after BFT in a considerable proportion of constipated patients with DD. BFT is effective and durable treatment for managing DD.

Cellular and molecular basis of chronic constipation: Taking the functional/idiopathic label out

In recent years, the improvement of technology and the increase in knowledge have shifted several strongly held paradigms. This is particularly true in gastroenterology, and specifically in the field of the so-called “functional” or “idiopathic” disease, where conditions thought for decades to be based mainly on alterations of visceral perception or aberrant psychosomatic mechanisms have, in fact, be reconducted to an organic basis (or, at the very least, have shown one or more demonstrable abnormalities). This is particularly true, for instance, for irritable bowel syndrome, the prototype entity of “functional” gastrointestinal disorders, where low-grade inflammation of both mucosa and myenteric plexus has been repeatedly demonstrated. Thus, researchers have also investigated other functional/idiopathic gastrointestinal disorders, and found that some organic ground is present, such as abnormal neurotransmission and myenteric plexitis in esophageal achalasia and mucosal immune activation and mild eosinophilia in functional dyspepsia. Here we show evidence, based on our own and other authors’ work, that chronic constipation has several abnormalities reconductable to alterations in the enteric nervous system, abnormalities mainly characterized by a constant decrease of enteric glial cells and interstitial cells of Cajal (and, sometimes, of enteric neurons). Thus, we feel that (at least some forms of) chronic constipation should no more be considered as a functional/idiopathic gastrointestinal disorder, but instead as a true enteric neuropathic abnormality.

Clinical utility of colonic manometry in slow transit constipation

BACKGROUND

The clinical significance of colorectal sensorimotor evaluation in patients with slow transit constipation (STC) is unclear. We investigated whether colonic manometric evaluation is useful for characterizing colonic sensorimotor dysfunction and for guiding therapy in STC.

METHODS

24-h ambulatory colonic manometry was performed in 80 patients (70 females) with STC by placing a six sensor solid-state probe, along with assessment of colonic sensation with barostat. Anorectal manometry was also performed. Manometrically, patients were categorized as having colonic neuropathy or myopathy based on gastrocolonic response, waking response and high amplitude propagated contractions (HAPC); and based on colonic sensation, as colonic hyposensitivity or hypersensitivity. Clinical response to pharmacological, biofeedback, and surgical treatment was assessed at 1 year and correlated with manometric findings.

KEY RESULTS

Forty seven (59%) patients who had abnormal colonic manometry, with features suggestive of neuropathy (26%), and myopathy (33%); 41% had normal colonic manometry. Patients who had abnormal colonic sensation were 74% and 61% had overlapping dyssynergic defecation. Patients with neuropathy were more likely to have colonic hyposensitivity. Sixty-four percent of patients with colonic myopathy or normal manometry improved with medical/biofeedback therapy when compared to 15% with colonic neuropathy (P < 0.01). Selected patients with colonic neuropathy had excellent response to surgery, but many developed bacterial overgrowth.

CONCLUSIONS & INFERENCES

Colonic manometry demonstrates significant colonic sensorimotor dysfunction in STC patients and reveals considerable pathophysiological heterogeneity. It can be useful for characterizing the underlying pathophysiology and for guiding clinical management in STC, especially surgery.

Evaluating slow-transit constipation in patients using laxatives: a better approach or do we need improved patient selection?

Slow-transit constipation is a relatively frequent subtype of constipation, often refractory to medical treatment. Clinical information is usually obtained in patients during laxative withdrawal; thus, data on the effect of laxatives on their daily symptoms are lacking. The evaluated article reports on the effects of laxatives on symptoms (stool frequency, stool form, straining at stool, pain and bloating) and on laxative use by means of a daily stool questionnaire. Most patients used laxatives on an intermittent basis, and a minority also used associated enemas. Use of laxatives yielded an almost average normal daily number of evacuations in this group, with only a minority having less than three bowel movements per week. The days in which patients used laxatives yielded significantly more frequent and loose stools compared with those without laxatives. Thus, the use of laxatives seems to influence the clinical aspects of patients with slow-transit constipation, and this should be considered when evaluating these participants.

Chronic idiopathic constipation: more than a simple colonic transit disorder

BACKGROUND

Constipation affects up to 28% of Americans in 4 pathophysiologic patterns: slow transit constipation, dyssynergic defecation, a combination of both, and normal colon transit with normal pelvic floor function. Constipation may be a part of a generalized gastrointestinal (GI) tract transit disorder. The purposes of this study were to determine the percentage of constipated patients with the different pathophysiologic subtypes and and to evaluate what percentage of constipated patients has a diffuse GI tract transit disorder.

METHODS

This was a retrospective analysis of 212 patients who underwent anorectal manometry for intractable constipation. Results of anorectal manometry, electromyography, balloon expulsion testing, defecography, and whole-gut transit scintigraphy were reviewed.

RESULTS

Of 212 patients included in the analysis, 91 (42%) had slow transit constipation, 25 (12%) had dyssynergic defecation, 53 (25%) had both, and 43 (20%) had neither. Of patients (91) with slow transit constipation alone, 31 (34%) had delayed gastric emptying, 9 (10%) had delayed small bowel transit, 7 (8%) had a delay in both, and 41 (48%) had normal upper GI tract transit. A similar distribution of upper GI tract transit disorders was observed for patients with dyssynergic defecation, slow transit constipation and dyssynergic defecation, and normal colon transit with normal pelvic floor function.

CONCLUSIONS

Patients with chronic idiopathic constipation have a range of colonic motor disorders. The majority (80%) had slow transit constipation, dyssynergic defecation, or a combination of slow transit constipation and dyssynergic defecation. In addition, many patients (51%) with chronic idiopathic constipation have a concurrent upper GI tract transit disorder.

Prevalence and pathophysiology of functional constipation among women in Catalonia, Spain

BACKGROUND

Specific treatment of functional bowel disorders requires precise diagnosis. However, prevalence and subtypes of functional constipation among women are not completely understood.

OBJECTIVE

Our aim was to assess the prevalence of functional constipation and investigate the subtypes of dyssynergic defecation and slow transit constipation among Spanish women.

DESIGN

We performed a prospective epidemiological study in healthy young women and retrospective pathophysiological studies in 2 patient cohorts of women with functional constipation according to Rome II criteria.

SETTINGS

Referral centers at Clínica Sagrada Familia, Barcelona, Spain, and Hospital de Mataró, Mataró, Spain.

PATIENTS

The epidemiological study included 600 healthy young women, aged 37.1 (SD, 8.2) years. Patient cohort 1 comprised 172 women with functional constipation without symptoms of pelvic floor dysfunction, ranging in age from 18 to 45 years. Patient cohort 2 comprised 106 women with functional constipation and symptoms of dyssynergic defecation, ranging in age from 45 to 65 years.

MAIN OUTCOME MEASURES

In healthy women, a questionnaire was used to determine rates of functional constipation, dyssynergic defecation, and slow transit constipation. In patients, results of anorectal manometry, EMG, and colonic transit studies were reviewed to assess subtypes of functional constipation; in addition, results of dynamic videoproctography were reviewed in cohort 2 to assess the role of structural pelvic floor disorders.

RESULTS

The prevalence of functional constipation in healthy young women was 28.8%; symptoms of dyssynergic defecation were found in 8.2%, those of isolated slow transit in only 0.17%. In patient cohort 1, a total of 143 patients (83.1%) showed dyssynergic defecation: 117 patients (68.0%) had paradoxical external anal sphincter contraction and 26 (15.1%) had impaired internal anal sphincter relaxation). Slow transit constipation without dyssynergia was observed in 15 (8.7%). Up to 40.2% of patients with dyssynergia also had delayed colonic transit. In the cohort of 106 women with dyssynergic defecation, videoproctography showed impaired puborectal relaxation in 64 patients (60.4%), anterior rectocele in 65 (61.3%), and rectal prolapse in 13 (12.3%).

LIMITATIONS

We could not estimate the prevalence and subtypes of irritable bowel syndrome in the epidemiological study.

CONCLUSIONS

Functional constipation is extremely prevalent among young, healthy, Spanish women, dyssynergic defecation being the most prevalent subtype. Slow transit constipation without dyssynergic defecation is uncommon. Structural pelvic floor disorders are highly prevalent in middle-aged women with dyssynergic defecation.

Isolated colonic inertia is not usually the cause of chronic constipation

AIM

Chronic constipation is classified as outlet obstruction, colonic inertia or both. We aimed to determine the incidence of isolated colonic inertia in chronic constipation and to study symptom pattern in those with prolonged colonic transit time.

METHODS

Chronic constipation patients were classified radiologically by surgeon-reported defaecating proctography and transit study into four groups: isolated outlet obstruction, isolated colonic inertia, outlet obstruction plus colonic inertia, or normal. Symptom patterns were defined as stool infrequency (twice weekly or less) or frequent unsuccessful evacuations (more than twice weekly).

RESULTS

Of 541 patients with chronic constipation, 289 (53%) were classified as isolated outlet obstruction, 26 (5%) as isolated colonic inertia, 159 (29%) as outlet obstruction plus colonic inertia and 67 (12%) as normal. Of 448 patients (83%) with outlet obstruction, 35% had additional colonic inertia. Only 14% of those with prolonged colonic transit time had isolated colonic inertia. Frequent unsuccessful evacuations rather than stool infrequency was the commonest symptom pattern in all three disease groups (isolated outlet obstruction 86%, isolated colonic inertia 54% and outlet obstruction plus colonic inertia 63%).

CONCLUSION

Isolated colonic inertia is an unusual cause of chronic constipation. Most patients with colonic inertia have associated outlet obstruction. These data question the clinical significance of isolated colonic inertia.

Beyond hematoxylin and eosin: the importance of immunohistochemical techniques for evaluating surgically resected constipated patients

Chronic constipation requiring surgical ablation for intractability is often a frustrating condition from the pathologist's point of view. In fact, limiting the histological examination to only hematoxylin-eosin staining usually yields only the information that there are no abnormalities. By employing some simple and widely available immunohistochemical methods, discussed in this review, it is possible to gather data that may help in explaining the pathophysiological basis of constipation in these patients.