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Thorsen AJ. Management of Rectocele with and without Obstructed Defecation. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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2
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PASSOS MDCF, ALVARIZ RC, ANDRÉ EA, BARBUTI RC, FILLMANN HS, MURAD-REGADAS SM, REZENDE FILHO J, PERROTTI M, GUEDES L. DIAGNOSIS AND MANAGEMENT OF CHRONIC IDIOPATHIC CONSTIPATION: A NARRATIVE REVIEW FROM A BRAZILIAN EXPERT TASK FORCE. ARQUIVOS DE GASTROENTEROLOGIA 2022; 59:137-144. [DOI: 10.1590/s0004-2803.202200001-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022]
Abstract
ABSTRACT Background Chronic idiopathic constipation (CIC) is a condition that widely affects the global population, represents relevant healthcare resource utilization and costs, and impacts the individual’s well-being. Objective To review the consensus of expert societies and published guidelines on the diagnosis and treatment of CIC in adults, seeking to assist reasoning and decision-making for medical management of patients with CIC and provide a practical reference material. Methods A Brazilian medical task force searched the scientific literature in the following electronic databases: MEDLINE/PubMed, SciELO, EMBASE and Cochrane, using the following descriptors: chronic constipation, diagnosis, management of chronic constipation. In addition, a review of articles on the mechanism of action, safety, and efficacy of therapeutic options available in Brazil was carried out. Results The diagnostic approach and the understanding of the pathophysiology present in CIC are essential items to indicate the appropriate therapy and to understand the ecosystem of the patient’s needs. Conclusion CIC is a common condition in adults, occurring more frequently in the elderly and in women. Proper management is defined by detailed medical history and physical examination, together with appropriate therapeutics, regardless pharmacological or not, and depending on the best moment of indication. This way, the impact on quality of life is also optimized.
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Matsumoto M, Misawa N, Tsuda M, Manabe N, Kessoku T, Tamai N, Kawamoto A, Sugama J, Tanaka H, Kato M, Haruma K, Sanada H, Nakajima A. Expert Consensus Document: Diagnosis for Chronic Constipation with Faecal Retention in the Rectum Using Ultrasonography. Diagnostics (Basel) 2022; 12:diagnostics12020300. [PMID: 35204390 PMCID: PMC8871156 DOI: 10.3390/diagnostics12020300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/10/2022] [Accepted: 01/15/2022] [Indexed: 12/12/2022] Open
Abstract
Chronic constipation is a common gastrointestinal disorder in older adults, and it is very important to manage chronic constipation. However, evaluating these subjective symptoms is extremely difficult in cases where patients are unable to express their symptoms because of a cognitive or physical impairment. Hence, it is necessary to observe the patient’s colonic faecal retention using objective methods. Ultrasonography observation for colonic faecal retention is useful for diagnosing constipation and evaluating the effectiveness of treatment. Since there was no standard protocol for interpreting rectal ultrasonography findings, we developed an observation protocol through an expert consensus. We convened a group of experts in the diagnosis and evaluation of chronic constipation and ultrasonography to discuss and review the current literature on this matter. Together, they composed a succinct, evidence-based observation protocol for rectal faecal retention using ultrasonography. We created an observation protocol to enhance the quality and accuracy of diagnosis of chronic constipation, especially rectal constipation. This consensus statement is intended to serve as a guide for physicians, laboratory technicians and nurses who do not specialise in ultrasound or the diagnosis of chronic constipation.
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Affiliation(s)
- Masaru Matsumoto
- School of Nursing, Ishikawa Prefectural Nursing University, 1-1 Gakuendai, Kahoku 929-1210, Japan;
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
| | - Noboru Misawa
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; (N.M.); (T.K.)
| | - Momoko Tsuda
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, 18-16 Kawahara-cho, Hakodate 041-8512, Japan; (M.T.); (M.K.)
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama 700-8505, Japan; (N.M.); (K.H.)
| | - Takaomi Kessoku
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; (N.M.); (T.K.)
- Department of Palliative Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Nao Tamai
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Atsuo Kawamoto
- Division of Ultrasound and Department of Diagnostic Imaging, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan;
| | - Junko Sugama
- Research Center for Implementation Nursing Science Initiative, School of Health Sciences, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake 470-1192, Japan;
| | - Hideko Tanaka
- School of Nursing, College of Nursing and Nutrition, Shukutoku University, 673 Nitona-cho, Chuo-ku, Chiba City 260-8703, Japan;
| | - Mototsugu Kato
- Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, 18-16 Kawahara-cho, Hakodate 041-8512, Japan; (M.T.); (M.K.)
| | - Ken Haruma
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama 700-8505, Japan; (N.M.); (K.H.)
| | - Hiromi Sanada
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan;
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan; (N.M.); (T.K.)
- Correspondence: ; Tel.: +81-45-787-2640
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Abstract
Normal defecation is a complex and coordinated physiologic process that involves the rectum, anus, anal sphincter complex, and pelvic floor muscles. Any alteration of this process can be considered defecatory dysfunction, a term that covers a broad range of disorders, including slow-transit constipation, functional constipation, and functional or anatomic outlet obstruction. Evaluation should include history, physical, and consideration of additional testing such as colonoscopy, colonic transit studies, defecography, and/or anorectal manometry. Depending on the etiology, management options can include conservative measures such as dietary or lifestyle modifications, medications, pelvic floor physical therapy, or surgical repair.
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DELSA HANANE, Serraj I, Khalis M, Kabbaj N. Anorectal Manometry on Children: A Moroccan Series and Literature Review. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction and objectives: Anorectal manometry is a test that evaluates the function of the rectum,but also the anus. It is useful for the diagnosis of several conditions like fecal incontinence and constipation.In children these tests are being increasingly used for all ages.The aim of this study was to determine the benefit of anorectal manometry in children and to report our experience.
Material and Methods:Over a period of four years, 273children that underwent anorectal manometry were included in the study,their data and tests results were analyzed.
Results:Out of 273 patients included,68,5% were boys and 31,5% were girls.The mean age was 9 years.154patients(51,6%) had Fecal incontinence(Group1),75children(27,5%) had chronic constipation(Group2),and both of them(Group3) were reported in 37children(13,6%).An awake manometry was performed in 248children(91%) however this test under sedation allowed us the exclusion of Hirschsprung’s disease in 21children(84%).In group1, 25%patients had bad anal contraction.In groupe3, 21,6%children had bad anal contraction.The statistical analysis showed a significant difference in age(p=0.022) and resting pressure(p=0.050) between the three groups.Children with fecal incontinence had a higher rate of dyssynergy,80.2% and 83.8% in groups 1 and 3 respectively compared to 60.4% in patients with chronic constipation(p=0,852)
Conclusion:The gold standard for the exploration of children’s terminal constipation and encopresis is the anorectal manometry.It is an important tool to establish diagnosis.In our study, this test allow the exclusion of Hirschsprung’s disease in infants with constipation, in other hand we found a higher rate of dyssynergy in children with fecal incontinence(80%) which had allow us to propose a biofeedback therapy.
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Matsumoto M, Tsutaoka T, Nakagami G, Tanaka S, Yoshida M, Miura Y, Sugama J, Okada S, Ohta H, Sanada H. Deep learning-based classification of rectal fecal retention and analysis of fecal properties using ultrasound images in older adult patients. Jpn J Nurs Sci 2020; 17:e12340. [PMID: 32394621 DOI: 10.1111/jjns.12340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/02/2020] [Accepted: 03/13/2020] [Indexed: 11/30/2022]
Abstract
AIM The present study aimed to analyze the use of machine learning in ultrasound (US)-based fecal retention assessment. METHODS The accuracy of deep learning techniques and conventional US methods for the evaluation of fecal properties was compared. The presence or absence of rectal feces was analyzed in 42 patients. Eleven patients without rectal fecal retention on US images were excluded from the analysis; thus, fecal properties were analyzed in 31 patients. Deep learning was used to classify the transverse US images into three types: absence of feces, hyperechoic area, and strong hyperechoic area in the rectum. RESULTS Of the 42 patients, 31 tested positive for the presence of rectal feces, zero were false positive, zero were false negative, and 11 were negative, indicating a sensitivity of 100% and a specificity of 100% for the detection of rectal feces in the rectum. Of the 31 positive patients, 14 had hard stools and 17 had other types. Hard stool was detected by US findings in 100% of the patients (14/14), whereas deep learning-based classification detected hard stool in 85.7% of the patients (12/14). Other stool types were detected by US findings in 88.2% of the patients (15/17), while deep learning-based classification also detected other stool types in 88.2% of the patients (15/17). CONCLUSIONS The results showed that US findings and deep learning-based classification can detect rectal fecal retention in older adult patients and distinguish between the types of fecal retention.
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Affiliation(s)
- Masaru Matsumoto
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuya Tsutaoka
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Gojiro Nakagami
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gerontological Nursing / Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shiho Tanaka
- Department of Gerontological Nursing / Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mikako Yoshida
- Department of Women's Health Nursing & Midwifery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuka Miura
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junko Sugama
- Institute for Frontier Science Initiative, Kanazawa University, Ishikawa, Japan
| | - Shingo Okada
- Department of Surgery, Kitamihara Clinic, Hokkaido, Japan
| | - Hideki Ohta
- Medical Corporation Activities Supporting Medicine: Systematic Services (A.S.M.ss), Tochigi, Japan
| | - Hiromi Sanada
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Gerontological Nursing / Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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7
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Yabunaka K, Matsumoto M, Yoshida M, Tanaka S, Miura Y, Tsutaoka T, Handa M, Nakagami G, Sugama J, Okada S, Sanada H. Assessment of rectal feces storage condition by a point-of-care pocket-size ultrasound device for healthy adult subjects: A preliminary study. Drug Discov Ther 2019; 12:42-46. [PMID: 29553082 DOI: 10.5582/ddt.2018.01001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to assess rectal feces storage condition by a pocket-size ultrasonography (PUS) in healthy adults so as to define normal rectal defecation desire. Participants were first assessed rectum by PUS imaging immediately after defecation desire (pre-defecation). Nurses checked the amount and quality of the participants' feces using King's Stool Chart and Bristol stool scale. Finally, PUS was performed for defecation with no defecation desire (post-defecation). Pre-defecation PUS detected high echo area in all patients. All of the post-defecation PUS did not detect high echo area (perfectly no recognizable high echo area in 54.5%, high echo line in 36.4%, and low echo of entire circumference in 9.1% of the patients). Average diameter of rectal crescent was 4.22 ± 0.8 cm. Bristol Stool Scale 1 or 2 (indicating hard stool) of pre-defecation PUS indicated high echo area and acoustic shadow in 100% of the patients. This study showed that healthy adult with defecation desire had high average rectal echo area of 4.0 cm in diameter. PUS may be able to define the rectum diameter for defecation desire of elderly people. PUS is capable of assessing fecal retention of the rectum for point-of-care examinations in home care.
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Affiliation(s)
- Koichi Yabunaka
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo.,Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo
| | - Masaru Matsumoto
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo.,Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo
| | - Mikako Yoshida
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo.,Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo
| | - Shiho Tanaka
- Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo
| | - Yuka Miura
- nstitute for Frontier Science Initiative, Kanazawa University
| | - Takuya Tsutaoka
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo.,Imaging Technology Center, Research & Development Management Headquarters, Fujifilm Corporation
| | - Mayumi Handa
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo.,Marketing Planning Group, Ultrasound Promotion Department, Fujifilm Medical Corporation
| | - Gojiro Nakagami
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo.,Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo
| | - Junko Sugama
- nstitute for Frontier Science Initiative, Kanazawa University
| | | | - Hiromi Sanada
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo.,Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo
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8
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Parkinson's Disease and Current Treatments for Its Gastrointestinal Neurogastromotility Effects. ACTA ACUST UNITED AC 2018; 16:489-510. [PMID: 30361854 DOI: 10.1007/s11938-018-0201-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Gastrointestinal disturbances are seen in nearly all patients with Parkinson's disease and lead to impaired quality of life, affect drug pharmacodynamics, and potentially worsen patient's existing motor fluctuations, leading to further disability. Recent evidence links abnormal accumulations of α-synuclein aggregates in the periphery (gut) as seen in the cortex which causes dysfunctions impacting every level of the gastrointestinal tract from the esophagus, to the stomach, small bowel, colon, and rectum and can even predate the onset of the central neurologic disorder itself. Many treatments exist for the clinical phenotypes that result from the autonomic dysfunction and neuropathy involved in this neurodegenerative disorder. The treatments for the gut dysfunction seen in Parkinson's disease (PD) depend on the specific area of the gastrointestinal tract affected. For dysphagia, behavioral therapies with speech pathology, neuromuscular electrical stimulation, or botulinum toxin injection may be helpful. For gastroparesis, domperidone may serve as an antiemetic while also blunting the hypotensive potential of Levodopa while new treatments such as ghrelin agonists may prove beneficial to help appetite, satiety, gastric emptying in those with constipation, and even improve constipation. Antibiotics such as rifaximin with poor systemic absorption may be used to treat small bacterial overgrowth also found in those with PD while the benefits of probiotics is yet to be determined. Finally, constipation in PD can be a reflection of pelvic floor dyssynergia, slow transit constipation, or both, thus treatments targeting the specific anorectal dysfunction is necessary for better outcomes.
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9
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Larkin PJ, Cherny NI, La Carpia D, Guglielmo M, Ostgathe C, Scotté F, Ripamonti CI. Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv111-iv125. [PMID: 30016389 DOI: 10.1093/annonc/mdy148] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- P J Larkin
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin
- Our Lady's Hospice and Care Services, Dublin, Ireland
| | - N I Cherny
- Cancer Pain and Palliative Medicine Service, Department of Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - D La Carpia
- Centro Medicina Dell'Invecchiamento (Ce.M.I.), Fondazione Policlinico Agostino, Gemelli, Roma
| | - M Guglielmo
- Oncology-Supportive Care Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - C Ostgathe
- Palliative Care Department, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - F Scotté
- Department of Medical Oncology and Supportive Care, Foch Hospital, Suresnes, France
| | - C I Ripamonti
- Oncology-Supportive Care Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
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10
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Yabunaka K, Nakagami G, Tabata K, Sugama J, Matsumoto M, Kido Y, Iuchi T, Sanada H. Constipation in the elderly in a Japanese long-term medical facility: An ultrasonographic investigation. Drug Discov Ther 2018; 12:233-238. [PMID: 30224595 DOI: 10.5582/ddt.2018.01033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study aims to assess the fecal retention in elderly patients using colonic ultrasonography (US) in Japanese long-term care facility and determine the correlation between nutrition management methods and the fecal retention by US. This cross-sectional, single-center study was conducted in a long-term care facility in Japan. Patients with chronic constipation fulfilled the Rome III criteria for the diagnosis of functional constipation. US was performed on constipation patients with 4-day fecal retention before starting the standard management of constipation. After patients had defecated, nurses checked the outside of feces using King's Stool Chart and Bristol Stool Chart. All of 32 patients underwent the management of suppository laxative, the daily life independence level in grade C. In all cases, the King's Stool Chart did not detect > 200 g of fecal matter; the Bristol Stool Chart revealed type 5-7 in 56.2% of patients. The total parenteral nutrition and tube feeding did not completely detect type 1-2 in 0%. While the fecal retention groups comprised 15.6%, the non-fecal retention groups comprised 84.4%. The total parenteral nutrition did not completely detect the fecal retention in 0%. In the non-fecal retention groups, the King's Stool Chart indicated < 100 g in 81.8%, and the Bristol Stool Chart indicated type 5-7 in 100%. In conclusion, fecal properties of elderly constipation patients with the long-term parenteral nutrition should be assessed in follow-up examination by US, which is possible for personalized medical care by US, to avoid the administered regular management of constipation.
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Affiliation(s)
- Koichi Yabunaka
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo.,Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo
| | - Gojiro Nakagami
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo.,Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo
| | | | - Junko Sugama
- Institute for Frontier Science Initiative, Kanazawa University
| | - Masaru Matsumoto
- Department of Imaging Nursing Science, Graduate School of Medicine, The University of Tokyo.,Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo
| | | | - Terumi Iuchi
- Wellness Promotion Science Center, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University
| | - Hiromi Sanada
- Global Nursing Research Center, Graduate School of Medicine, The University of Tokyo.,Department of Gerontological Nursing/Wound Care Management, Graduate School of Medicine, The University of Tokyo
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11
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Rangan V, Zakari M, Hirsch W, Ballou S, Singh P, Sommers T, Iturrino J, Nee J, Staller K, Lembo A. Clinical and manometric characteristics of women with paradoxical puborectalis syndrome. United European Gastroenterol J 2018; 6:1578-1585. [PMID: 30574329 DOI: 10.1177/2050640618798227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
Abstract
Background A subset of patients with functional defecation disorders have predominance of the puborectalis muscle (PRM) on three-dimensional high definition anorectal manometry (HDARM), known as paradoxical puborectalis syndrome (PPS). The aim of this study was to assess clinical and manometric differences between patients with and without PPS. Methods A total of 227 women with functional defecation disorders undergoing HDARM between December 2012 and October 2016 at a single center were included in this study. All completed the Rome III constipation module and Pelvic Floor Distress Inventory 20 (PFDI-20). Results Eighty-seven out of 227 women had a 3D pressure topographic profile consistent with PPS. They had higher mean PDFI-20 scores for straining and incomplete evacuation symptoms than those without PPS. In addition, they demonstrated higher mean resting anal pressure, a more negative mean anorectal pressure differential, and a greater proportion with prolonged balloon expulsion test. These findings were more pronounced in a subgroup of 58 PPS patients with a distinct pattern of both posterior and posterolateral wall indentation. Conclusion Among female patients with functional defecation disorders, those with PPS demonstrated clinical and manometric differences compared to those without PPS. These differences may be driven by predominant posterolateral wall indentation in a subgroup of PPS patients.
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Affiliation(s)
- Vikram Rangan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Mohammed Zakari
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - William Hirsch
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Sarah Ballou
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Prashant Singh
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Thomas Sommers
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Johanna Iturrino
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Judy Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
| | - Kyle Staller
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Anthony Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
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12
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Patcharatrakul T, Rao SS. Update on the Pathophysiology and Management of Anorectal Disorders. Gut Liver 2018; 12:375-384. [PMID: 29050194 PMCID: PMC6027829 DOI: 10.5009/gnl17172] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/05/2017] [Accepted: 06/10/2017] [Indexed: 12/11/2022] Open
Abstract
Anorectal disorders are common and present with overlapping symptoms. They include several disorders with both structural and functional dysfunction(s). Because symptoms alone are poor predictors of the underlying pathophysiology, a diagnosis should only be made after evaluating symptoms and physiologic and structural abnormalities. A detailed history, a thorough physical and digital rectal examination and a systematic evaluation with high resolution and/or high definition three-dimensional (3D) anorectal manometry, 3D anal ultrasonography, magnetic resonance defecography and neurophysiology tests are essential to correctly identify these conditions. These physiological and imaging tests play a key role in facilitating a precise diagnosis and in providing a better understanding of the pathophysiology and functional anatomy. In turn, this leads to better and more comprehensive management using medical, behavioral and surgical approaches. For example, patients presenting with difficult defecation may demonstrate dyssynergic defecation and will benefit from biofeedback therapy before considering surgical treatment of coexisting anomalies such as rectoceles or intussusception. Similarly, patients with significant rectal prolapse and pelvic floor dysfunction or patients with complex enteroceles and pelvic organ prolapse may benefit from combined behavioral and surgical approaches, including an open, laparoscopic, transabdominal or transanal, and/or robotic-assisted surgery. Here, we provide an update on the pathophysiology, diagnosis, and management of selected common anorectal disorders.
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Affiliation(s)
- Tanisa Patcharatrakul
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA,
USA
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok,
Thailand
| | - Satish S.C. Rao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, GA,
USA
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13
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Cooke CM, Moloo H, Suen MWH, Singh SS. When it’s not deep endometriosis—bowel dysmotility in a patient with endometriosis: A case report and review. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2018. [DOI: 10.1177/2284026518773227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: Patients who present to a gynecologist often describe concurrent bowel symptoms, which may or may not be related to their gynecologic diagnosis. Despite the common association of these symptoms with gynecologic diseases, such as deep endometriosis, these symptoms may also be caused by non-gynecologic conditions, including primary chronic constipation. Objective: To outline the principle of diagnostic bias and educate gynecologists on the topic of primary chronic constipation. Methods/results: We present the case of a 38-year-old woman with chronic pelvic pain and constipation. She was diagnosed with primary chronic constipation in the setting of deep endometriosis affecting the bowel, and managed surgically, leading to great improvement in her quality of life. Conclusion: Gynecologists should consider alternative non-gynecologic conditions when formulating their differential diagnosis of patients presenting with bowel symptoms.
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Affiliation(s)
- Carly M Cooke
- Department of Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Husein Moloo
- Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Michael WH Suen
- Department of Obstetrics and Gynecology, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Sukhbir Sony Singh
- Department of Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Obstetrics and Gynecology, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
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The Mexican consensus on chronic constipation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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The Mexican consensus on chronic constipation. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:168-189. [PMID: 29555103 DOI: 10.1016/j.rgmx.2017.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/08/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Significant advances have been made in the knowledge and understanding of the epidemiology, pathophysiology, diagnosis, and treatment of chronic constipation, since the publication of the 2011 guidelines on chronic constipation diagnosis and treatment in Mexico from the Asociación Mexicana de Gastroenterología. AIMS To present a consensus review of the current state of knowledge about chronic constipation, providing updated information and integrating the new scientific evidence. METHODS Three general coordinators reviewed the literature published within the time frame of January 2011 and January 2017. From that information, 62 initial statements were formulated and then sent to 12 national experts for their revision. The statements were voted upon, using the Delphi system in 3 voting rounds (2 electronic and one face-to-face). The statements were classified through the GRADE system and those that reached agreement >75% were included in the consensus. RESULTS AND CONCLUSIONS The present consensus is made up of 42 final statements that provide updated knowledge, supplementing the information that had not been included in the previous guidelines. The strength of recommendation and quality (level) of evidence were established for each statement. The current definitions of chronic constipation, functional constipation, and opioid-induced constipation are given, and diagnostic strategies based on the available diagnostic methods are described. The consensus treatment recommendations were established from evidence on the roles of diet and exercise, fiber, laxatives, new drugs (such as prucalopride, lubiprostone, linaclotide, plecanatide), biofeedback therapy, and surgery.
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Lee J, Hong KS, Kim JS, Jung HC. Balloon Expulsion Test Does Not Seem to Be Useful for Screening or Exclusion of Dyssynergic Defecation as a Single Test. J Neurogastroenterol Motil 2017; 23:446-452. [PMID: 28578564 PMCID: PMC5503295 DOI: 10.5056/jnm16158] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 04/02/2017] [Accepted: 04/16/2017] [Indexed: 01/24/2023] Open
Abstract
Background/Aims Balloon expulsion test (BET) is regarded as a screening tool of dyssynergic defecation (DD). However, some patients with normal BET results may be treated effectively by biofeedback training. This study aims to validate BET as a single screening test. Methods Two hundred and thirty-two patients who were diagnosed with functional constipation or irritable bowel syndrome with constipation who underwent anorectal manometry (ARM) and BET at Seoul National University Hospital were enrolled. We evaluated the validity of BET based on ARM and electromyography (EMG) during biofeedback training. Results If BET ≤ 1 minute was defined as normal, sensitivity and negative predictive value (NPV) of BET in predicting paradoxical contraction based on ARM findings were 71.4% and 13.9%. If BET ≤ 3 minutes was defined as normal, sensitivity and NPV were 35.2% and 6.6%. Specificity and positive predictive value (PPV) of BET ≤ 3 minutes criteria were 84.8% and 93.3%. Same analysis was conducted in 107 patients who underwent EMG during biofeedback training. With 1-minute criteria, sensitivity and NPV of BET were 70.3% and 14.3%. With 3 minutes criteria, sensitivity and NPV of BET was 38.6% and 8.8%. Specificity and positive predictive values were both 100.0%. Conclusions Based on either ARM or EMG during biofeedback training, sensitivity was at most 71.4% and NPV was less than 15.0% irrespective of whether BET was within 1minute or within 3 minutes. BET seems to have a limitation as both a screening test for dyssynergic defecation and a simple assessment to rule out the necessity of biofeedback training.
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Affiliation(s)
- Jooyoung Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Sup Hong
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Gastrointestinal transit scintigraphy in chronic constipation evaluation in paediatric age; an infrequent test. Rev Esp Med Nucl Imagen Mol 2017. [DOI: 10.1016/j.remnie.2017.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Zakari M, Nee J, Hirsch W, Kuo B, Lembo A, Staller K. Gender differences in chronic constipation on anorectal motility. Neurogastroenterol Motil 2017; 29. [PMID: 27891696 DOI: 10.1111/nmo.12980] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 09/21/2016] [Accepted: 09/23/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The epidemiology of chronic constipation (CC) skews toward female predominance, yet men make up an important component of those suffering from CC. We sought to determine whether there are sex-specific differences in symptoms and physiologic parameters on anorectal manometry (ARM). METHODS We performed a case-control analysis of sequential men and age-matched women (2:1 ratio) presenting for ARM as part of the evaluation of CC. We collected physiologic parameters derived from 3D high-resolution ARM in addition to the ROME III constipation module and the Pelvic Floor Distress Inventory 20 (PFDI-20) questionnaires. We analyzed univariate, sex-specific differences in ARM physiologic parameters and PFDI-20 parameters and adjusted for putative confounders using multivariate logistic regression. KEY RESULTS Our study enrolled 80 men and 165 age-matched women. Men had a higher median sphincter resting pressure (81.2 vs 75.2 mm Hg, P=.01) and mean squeeze pressure (257.0 vs 170.5 mm Hg, P<.0001) than women. Although men reported significantly less severe straining and incomplete evacuation, they had greater mean rectoanal pressure differential (-106.7 vs -71.1 mm Hg, P<.0001), smaller mean defecation index (0.17 vs 0.27, P=.03) and higher volume threshold for urgency (115.2 v. 103.4 mL, P=.03). However, women were more likely to have abnormal balloon expulsion time (BET) than men (52.7% vs 35.0%, P=.01). After multivariate analysis, male gender was the only independent predictor of a normal BET (OR: 0.48, 95% CI: 0.27-0.86, P=.01). CONCLUSIONS & INFERENCES Men and women with CC differ with regard to symptom severity and physiologic parameters derived from ARM suggesting differences in their pathophysiology.
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Affiliation(s)
- M Zakari
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - J Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - W Hirsch
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - B Kuo
- Center for Neurointestinal Health and Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - A Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - K Staller
- Center for Neurointestinal Health and Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
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Yabunaka K, Nakagami G, Komagata K, Sanada H. Ultrasonographic follow-up of functional chronic constipation in adults: A report of two cases. SAGE Open Med Case Rep 2017; 5:2050313X17694234. [PMID: 28250918 PMCID: PMC5317036 DOI: 10.1177/2050313x17694234] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/23/2017] [Indexed: 12/14/2022] Open
Abstract
Chronic constipation is a disorder frequently encountered in clinical practice. Here, we describe the use of ultrasonography as a new approach to the follow-up of adult patients with functional chronic constipation. Specifically, we report two cases of functional chronic constipation: fecal retention in the rectum and not fecal retention in the rectum. In the not fecal retention in the rectum patient, ultrasonography showed no evidence of fecal retention in the rectum, including no rectal fecaloma, whereas in the fecal retention in the rectum patient, fecal retention in the rectum was clearly recognized. Moreover, ultrasonography can guide the choice of laxative, enema, or appropriate manual maneuver to treat chronic constipation. As a simple and noninvasive method for assessing functional chronic constipation in adults, ultrasonography not only provides important clinical information but can also aid in determining the location of fecal retention.
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Affiliation(s)
- Koichi Yabunaka
- Department of Gerontological Nursing and Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Gojiro Nakagami
- Department of Gerontological Nursing and Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunori Komagata
- Department of Nursing Administration and Advanced Clinical Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiromi Sanada
- Department of Gerontological Nursing and Wound Care Management, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Sharma A, Rao S. Constipation: Pathophysiology and Current Therapeutic Approaches. Handb Exp Pharmacol 2017; 239:59-74. [PMID: 28185025 DOI: 10.1007/164_2016_111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Chronic constipation is a common, persistent condition affecting many patients worldwide, presenting significant economic burden and resulting in substantial healthcare utilization. In addition to infrequent bowel movements, the definition of constipation includes excessive straining, a sense of incomplete evacuation, failed or lengthy attempts to defecate, use of digital manoeuvres for evacuation of stool, abdominal bloating, and hard consistency of stools. After excluding secondary causes of constipation, chronic idiopathic or primary constipation can be classified as functional defecation disorder, slow-transit constipation (STC), and constipation-predominant irritable bowel syndrome (IBS-C). These classifications are not mutually exclusive and significant overlap exists. Initial therapeutic approach to primary constipation, regardless of aetiology, consists of diet and lifestyle changes such as encouraging adequate fluid and fibre intake, regular exercise, and dietary modification. Laxatives are the mainstay of pharmacologic treatment for potential long-term therapy in patients who do not respond to lifestyle or dietary modification. After a failed empiric trial of laxatives, diagnostic testing is necessary to understand underlying anorectal and/or colonic pathophysiology. No single test provides a comprehensive assessment for primary constipation; therefore, multiple tests are used to provide complementary information to one another. Dyssynergic defecation, a functional defecation disorder, is an acquired behavioural disorder of defecation present in two-thirds of adult patients, where an inability to coordinate the abdominal, recto-anal, and pelvic floor muscles during attempted defecation exists. Biofeedback therapy is the mainstay treatment for dyssynergic defecation aimed at improving coordination of abdominal and anorectal muscles. A large percentage of patients with dyssynergic defecation also exhibit rectal hyposensitivity and may benefit from the addition of sensory retraining. Our understanding of the pathophysiology of STC is evolving. The advent of high-resolution colonic manometry allows for the improved identification of colonic motor patterns and may provide further insight into pathophysiological mechanisms. In a minority of cases of STC, identification of colonic neuropathy suggests a medically refractory condition, warranting consideration of colectomy. The pathophysiology of IBS-C is poorly understood with multiple etiological factors implicated. Pharmacological advances in the treatment of primary constipation have added therapeutic options to the armamentarium of this disorder. Drug development in the secretagogue, serotonergic prokinetic, and ileal bile acid transporter inhibition pathways has yielded current and future medical treatment options for primary chronic constipation.
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Affiliation(s)
- Amol Sharma
- Division of Gastroenterology and Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA.
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Gastrointestinal transit scintigraphy in chronic constipation evaluation in pediatric age; an infrequent test. Rev Esp Med Nucl Imagen Mol 2016; 36:146-151. [PMID: 27956094 DOI: 10.1016/j.remn.2016.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/19/2016] [Accepted: 10/25/2016] [Indexed: 11/21/2022]
Abstract
AIM Chronic constipation is a common pathology in children. The aim of this paper was to show the usefulness of gastrointestinal transit scintigraphy in pediatric patients with chronic constipation, and the advantages with respect to other imaging techniques, despite our limited experience. MATERIAL AND METHODS We evaluated 5 patients sent to our service with a diagnosis of chronic constipation refractory to treatment. We performed a complete study protocol, including liquid gastric emptying scintigraphy and small and large bowel transit times, using a single dose of 111In-DTPA. Following international guidelines regions of interest were defined in stomach, terminal ileum and in 6 regions of the large intestine. RESULTS All patients showed altered scintigraphy study, showing 4 of them normal radiological tests. Radioisotopic study changed diagnosis in 2 patients and in other 2 patients contributed to clarify it, since discordance between normal radiological tests and abnormal rectal biopsy. One of the patients showed concordance between each imaging modality. The results of the test changed the therapeutic management in 2 cases. CONCLUSIONS Our limited experience coincides with published data in which scintigraphy study turns out to be a reproducible and accurate method. It provides physiological, quantitative and useful information in the study of constipation, being the unique exploration that allows both global and regional gastrointestinal transit time determination.
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Lubiprostone Accelerates Intestinal Transit and Alleviates Small Intestinal Bacterial Overgrowth in Patients With Chronic Constipation. Am J Med Sci 2016; 352:231-8. [DOI: 10.1016/j.amjms.2016.05.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 03/17/2016] [Accepted: 05/17/2016] [Indexed: 12/12/2022]
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Abstract
Chronic constipation is a common health condition representing a substantial proportion of primary care visits and referrals to specialist providers. Chronic constipation can have a significant negative effect on health-related quality of life and has been associated with psychological distress in severely affected patients. It has the potential to cause patients to curtail work, school, and social activities. While different pathophysiological mechanisms have been implicated in the development of chronic constipation, in some instances, the causes of chronic constipation are not easily determined. Expenditures for the evaluation and management of chronic constipation represent a significant burden on patients and payers, and it is important for clinicians to have a clear understanding of the different pathophysiological mechanisms associated with constipation, understand the different testing modalities and treatments that are available including their appropriateness and limitations, and tailor that knowledge to the management of individual patients.
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Affiliation(s)
- Hani Sbahi
- Division of Gastroenterology, University of South Alabama, 75 University Boulevard S, Suite 6000-B, Mobile, Al, 36688, USA.
| | - Brooks D Cash
- Division of Gastroenterology, University of South Alabama, 75 University Boulevard S, Suite 6000-B, Mobile, Al, 36688, USA.
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Rao SSC, Patcharatrakul T. Diagnosis and Treatment of Dyssynergic Defecation. J Neurogastroenterol Motil 2016; 22:423-35. [PMID: 27270989 PMCID: PMC4930297 DOI: 10.5056/jnm16060] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 04/27/2016] [Indexed: 12/11/2022] Open
Abstract
Dyssynergic defecation is common and affects up to one half of patients with chronic constipation. This acquired behavioral problem is due to the inability to coordinate the abdominal and pelvic floor muscles to evacuate stools. A detailed history, prospective stool diaries, and a careful digital rectal examination will not only identify the nature of bowel dysfunction, but also raise the index of suspicion for this evacuation disorder. Anorectal physiology tests and balloon expulsion test are essential for a diagnosis. Newer techniques such as high-resolution manometry and magnetic resonance defecography can provide mechanistic insights. Recently, randomized controlled trials have shown that biofeedback therapy is more effective than laxatives and other modalities, both in the short term and long term, without side effects. Also, symptom improvements correlated with changes in underlying pathophysiology. Biofeedback therapy has been recommended as the first-line of treatment for dyssynergic defecation. Here, we provide an overview of the burden of illness and pathophysiology of dyssynergic defecation, and how to diagnose and treat this condition with biofeedback therapy.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA
| | - Tanisa Patcharatrakul
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Augusta University, Augusta, Georgia, USA.,Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Rao SSC, Rattanakovit K, Patcharatrakul T. Diagnosis and management of chronic constipation in adults. Nat Rev Gastroenterol Hepatol 2016; 13:295-305. [PMID: 27033126 DOI: 10.1038/nrgastro.2016.53] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Constipation is a heterogeneous, polysymptomatic, multifactorial disease. Acute or transient constipation can be due to changes in diet, travel or stress, and secondary constipation can result from drug treatment, neurological or metabolic conditions or, rarely, colon cancer. A diagnosis of primary chronic constipation is made after exclusion of secondary causes of constipation and encompasses several overlapping subtypes. Slow-transit constipation is characterized by prolonged colonic transit in the absence of pelvic floor dysfunction. This subtype of constipation can be identified using either the radio-opaque marker test or wireless motility capsule test, and is best treated with laxatives such as polyethylene glycol or newer agents such as linaclotide or lubiprostone. If unsuccessful, subspecialist referral should be considered. Dyssynergic defecation results from impaired coordination of rectoanal and pelvic floor muscles, and causes difficulty with defecation. The condition can be identified using anorectal manometry and balloon expulsion tests and is best managed with biofeedback therapy. Opioid-induced constipation is an emerging entity, and several drugs including naloxegol, methylnaltrexone and lubiprostone are approved for its treatment. In this Review, we provide an overview of the burden and pathophysiology of chronic constipation, as well as a detailed discussion of the available diagnostic tools and treatment options.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Augusta University, Medical College of Georgia, 1120 15th Street, AD 2226, Augusta, GA 30912, USA
| | - Kulthep Rattanakovit
- Division of Gastroenterology and Hepatology, Augusta University, Medical College of Georgia, 1120 15th Street, AD 2226, Augusta, GA 30912, USA
| | - Tanisa Patcharatrakul
- Division of Gastroenterology and Hepatology, Augusta University, Medical College of Georgia, 1120 15th Street, AD 2226, Augusta, GA 30912, USA
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Yabunaka K, Matsuo J, Hara A, Takii M, Nakagami G, Gotanda T, Nishimura G, Sanada H. Sonographic Visualization of Fecal Loading in Adults. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2015. [DOI: 10.1177/8756479314566045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The aim of this study was to compare ultrasonographic assessment of fecal loading in adults with that of computed tomography. Ultrasonography (US) was performed on 43 adult patients immediately after abdominal computed tomography images had identified fecal loading in their colons. In 18 of 43 patients (haustrations-visualized cases), fecal loading was detected as crescent-shaped acoustic shadows associated with haustrations behind the strong echoes off the colon wall. In the remaining 25 patients (haustrations-not-visualized cases), fecal loading was detected as attenuating echoes with multiple high echoic spots behind weak high echoes off the colon wall in 17 patients and similar to those seen in the haustrations-visualized cases but without haustrations in 8 patients. US can be used for qualitative assessment of fecal loading in the colon. This new technique is simple and noninvasive and can be used concomitantly with physical examination to assess severity of constipation.
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Affiliation(s)
- Koichi Yabunaka
- Department of Ultrasound, Katsuragi Hospital, Japan
- Department of Gerontological Nursing/Wound Care Management, the University of Tokyo, Tokyo, Japan
| | - Jyunko Matsuo
- Faculty of Nursing, Osaka Medical College, Osaka, Japan
| | - Akiko Hara
- Faculty of Nursing, Osaka Medical College, Osaka, Japan
| | | | - Gojiro Nakagami
- Department of Gerontological Nursing/Wound Care Management, the University of Tokyo, Tokyo, Japan
| | - Tatsuhiro Gotanda
- Department of Radiological Science, Junshin Gakuen University, Fukuoka, Japan
| | - Genichi Nishimura
- Department of Surgery, Japanese Red Cross Kanazawa Hospital, Ishikawa, Japan
| | - Hiromi Sanada
- Faculty of Nursing, Osaka Medical College, Osaka, Japan
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Cosentino M, Beati C, Fornari S, Capalbo E, Peli M, Lovisatti M, Cariati M, Cornalba G. Defaecography and colonic transit time for the evaluation of female patients with obstructed defaecation. Radiol Med 2014; 119:813-9. [PMID: 24846080 DOI: 10.1007/s11547-014-0405-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 02/10/2014] [Indexed: 01/07/2023]
Abstract
PURPOSE Colonic transit time and defaecography are well known, commonly used studies for evaluating patients with chronic constipation. The aim of this study was to compare colonic transit time with radiopaque markers and defaecography in female patients with obstructed defaecation. MATERIALS AND METHODS In a prospective observational study, between January 2010 and December 2012, a total of 30 female patients, mean age 60 years, with symptoms of obstructed defaecation were subjected to colonic transit time and defaecography, and divided into two groups: normal or abnormal colon transit time. The results were statistically compared using the Chi-square test. RESULTS The comparison of data between colonic transit time and defaecography showed the following groups: group 1 (6/30 = 20 %) with normal colonic transit time but abnormal defaecography, and group 2 (24/30 = 80 %) with abnormal colonic transit time; the latter was further divided into two subgroups: group 2a (4/24 = 17 %), patients with inertia coli; group 2b (20/24 = 83 %), patients with impaired defaecation demonstrated at defaecography. There was a significant statistical difference between the radiological findings in these groups. CONCLUSIONS This study confirmed the value of both defaecography and colonic transit time in assessing clinically obstructed women. Obstructed defaecation might not always be associated with abnormal colonic transit time. Likewise, not all constipated patients had signs of obstructed defaecation. The differential diagnosis between colonic slow transit constipation and constipation due to pelvic floor disorders is essential for an adequate strategy of care.
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Affiliation(s)
- Maria Cosentino
- Dipartimento di Scienze Diagnostiche, Unità Operativa Complessa di Radiologia, Ospedale San Carlo Borromeo, Via Pio II, 3, 20153, Milan, Italy,
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Abstract
BACKGROUND Constipation is common and distressing in palliative care. Despite this, approaches to assessment and subsequent treatment are most remarkable for the numbers who fail adequate palliation. AIM The primary aim of this paper is to summarise the current approaches to assessing constipation in palliative care, contrasting these approaches with those recommended by gastroenterologists in the assessment of resistant constipation in non-palliative care. The secondary aim is to suggest ways that the approaches used by gastroenterologist could be modified to be tolerable to palliative care. DESIGN A non-systematic review of the literature was undertaken. DATA SOURCES The electronic databases (MEDLINE, CINHAL) were searched for English language articles that explored assessment of constipation in palliative care and evidence-based gastroenterology guidelines that summarised assessment and management of constipation. RESULTS Currently, the assessment of constipation in palliative care is predominantly based on people's reports, physical examination and if further imaging is deemed necessary, a plain abdominal radiograph. However, data in non-palliative care patients refutes the usefulness of self-reported symptoms to localise whether problems are due to colon dysfunction or structures of defaecation. Plain radiographs are most useful to exclude a bowel obstruction only. In cases of resistant constipation, gastroenterology guidelines recommend an assessment approach that includes measuring colon transit time and an assessment of the structures that facilitate defaecation. CONCLUSIONS Current approaches to assessing constipation in palliative care are very different to those recommended by gastroenterology guidelines. However, modified approaches may be tolerable to palliative care patients and offer the chance of developing targeted palliation.
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Affiliation(s)
- Katherine Clark
- Department of Palliative Care, Calvary Mater Hospital and The University of Newcastle, New South Wales, Australia.
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Abstract
Constipation is one of the most frequent gastrointestinal disorders encountered in clinical practice in Western societies. Its prevalence increases with age and is more frequently reported in female patients. Chronic constipation has been associated with considerable impairment in quality of life, can result in large individual healthcare costs, and represents a burden to healthcare delivery systems. This review will focus on the definition, epidemiology, diagnostic approach, and non-pharmacologic as well as pharmacologic management of chronic constipation in the elderly, including an overview of new medications currently under clinical investigation.
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Feyen BJ, Rao SSC. Functional disorders of defecation: evaluation and treatment. ACTA ACUST UNITED AC 2011; 10:221-30. [PMID: 17547860 DOI: 10.1007/s11938-007-0015-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Functional disorders of defecation are common and often overlap with slow-transit constipation. They are comprised of functional obstructive conditions such as dyssynergic defecation, as well as structural obstructive conditions such as rectal prolapse, excessive perineal descent, and rectocele. Evaluation includes detailed history and rectal and pelvic exam together with physiologic tests such as anorectal manometry, balloon expulsion test, defecography, and MRI. Treatment involves several medical, behavioral, and surgical approaches. Recently, randomized controlled trials have shown that biofeedback therapy is an effective treatment for dyssynergic defecation. Stapled transanal rectal resection appears to be a promising technique for treating defecation disorders associated with rectocele, excessive perineal descent, and mucosal intussusception, but controlled trials are lacking.
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Affiliation(s)
- Bryan J Feyen
- Satish S.C. Rao, MD, PhD, FRCP The University of Iowa Hospital and Clinics, Internal Medicine, GI Division, 200 Hawkins Drive, 4612 JCP, Iowa City, IA 52242, USA.
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Clark K, Currow DC. Plain abdominal radiographs to diagnose constipation patients with advanced progressive illness? J Pain Symptom Manage 2011; 41:e2-3. [PMID: 21481734 DOI: 10.1016/j.jpainsymman.2010.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 11/27/2010] [Indexed: 01/26/2023]
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Rao SSC, Meduri K. What is necessary to diagnose constipation? Best Pract Res Clin Gastroenterol 2011; 25:127-40. [PMID: 21382584 PMCID: PMC3063397 DOI: 10.1016/j.bpg.2010.11.001] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 11/17/2010] [Accepted: 11/19/2010] [Indexed: 01/31/2023]
Abstract
Constipation is a common ailment with multiple symptoms and diverse etiology. Understanding the pathophysiology is important to guide optimal management. During the past few years, there have been remarkable developments in the diagnosis of constipation and defecation disorders. Several innovative manometric, neurophysiologic, and radiologic techniques have been discovered, which have improved the accuracy of identifying the neuromuscular mechanisms of chronic constipation. These include use of digital rectal examination, Bristol stool scale, colonic scintigraphy, wireless motility capsule for assessment of colonic and whole gut transit, high resolution anorectal manometry, and colonic manometry. These tests provide a better definition of the underlying mechanism(s), which in turn can lead to improved management of this condition. In this review, we summarize the recent advances in diagnostic testing with a particular emphasis on when and why to test, and discuss the utility of diagnostic tests for chronic constipation.
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Affiliation(s)
- Satish S C Rao
- Department of Internal Medicine, Division of Gastroenterology & Hepatology, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 4612 JCP, Iowa City, IA-52242, USA.
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Tantiphlachiva K, Rao P, Attaluri A, Rao SSC. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol 2010; 8:955-60. [PMID: 20656061 DOI: 10.1016/j.cgh.2010.06.031] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 06/29/2010] [Accepted: 06/30/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Dyssynergic defecation is a common cause of chronic constipation; its diagnosis requires anorectal physiological tests that are not widely available. It is not known whether digital rectal examination (DRE) can be used to identify dyssynergia. We examined the diagnostic yield of DRE in patients with dyssynergic defecation. METHODS Consecutive patients with chronic constipation (Rome III criteria, n = 209) underwent DREs, anorectal manometry analyses, balloon expulsion tests, and colonic transit studies. In the DRE, dyssynergia was identified by 2 or more of the following features: impaired perineal descent, paradoxic anal contraction, or impaired push effort; diagnostic yields were compared with physiological test results. RESULTS Of the patients included in the study, 187 (87%) had dyssynergic defecation, based on standard criteria; 134 (73%) of these were identified to have features of dyssynergia, based on DREs. The sensitivity and specificity of DRE for identifying dyssynergia in patients with chronic constipation were 75% and 87%, respectively; the positive predictive value was 97%. DRE was able to identify normal resting and normal squeeze pressure in 86% and 82% of dyssynergic patients, respectively. CONCLUSIONS DRE appears to be a reliable tool for identifying dyssynergia in patients with chronic constipation and detecting normal, but not abnormal, sphincter tone. DREs could facilitate the selection of appropriate patients for further physiologic testing and treatment.
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Affiliation(s)
- Kasaya Tantiphlachiva
- Division of Gastroenterology and Hepatology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Clark K, Currow DC, Talley NJ. The Use of Digital Rectal Examinations in Palliative Care Inpatients. J Palliat Med 2010; 13:797. [DOI: 10.1089/jpm.2010.0019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Katherine Clark
- Cunningham Centre for Palliative Care, University of Notre Dame Australia, Sydney, New South Wales
| | - David C. Currow
- Department of Supportive and Palliative Care, Flinders University, Adelaide, South Australia
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Clark K, Urban K, Currow DC. Current Approaches to Diagnosing and Managing Constipation in Advanced Cancer and Palliative Care. J Palliat Med 2010; 13:473-6. [DOI: 10.1089/jpm.2009.0274] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Katherine Clark
- Royal Hospital for Women, Darlinghurst, New South Wales, Australia
- Cunningham Centre for Palliative Care, University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Kat Urban
- Sydney Institute of Palliative Care Sydney, New South Wales, Australia
| | - David C. Currow
- Department of Supportive and Palliative Care, Flinders University, Adelaide, South Australia, Australia
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Kwon HK, Do HJ, Kim HJ, Oh SW, Lym YL, Choi JK, Joh HK, Kweon HJ, Cho DY. The Impact of Functional Constipation on the Quality of Life in the Elderly over 60 Years. Korean J Fam Med 2010. [DOI: 10.4082/kjfm.2010.31.1.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Hyeok-Kyu Kwon
- Department of Family Medicine, Konkuk University School of Medicine, Chungju, Korea
| | - Hyun-Jin Do
- Department of Family Medicine, Konkuk University School of Medicine, Chungju, Korea
| | - Hye-Jung Kim
- Department of Family Medicine, Konkuk University School of Medicine, Chungju, Korea
| | - Seung-Won Oh
- Department of Family Medicine, Konkuk University School of Medicine, Chungju, Korea
| | - Youl-Lee Lym
- Department of Family Medicine, Konkuk University School of Medicine, Chungju, Korea
| | - Jae-Kyung Choi
- Department of Family Medicine, Konkuk University School of Medicine, Chungju, Korea
| | - Hee-Kyung Joh
- Department of Family Medicine, Konkuk University School of Medicine, Chungju, Korea
| | - Hyuk-Jung Kweon
- Department of Family Medicine, Konkuk University School of Medicine, Chungju, Korea
| | - Dong-Yung Cho
- Department of Family Medicine, Konkuk University School of Medicine, Chungju, Korea
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Rao SSC. Constipation: evaluation and treatment of colonic and anorectal motility disorders. Gastrointest Endosc Clin N Am 2009; 19:117-39, vii. [PMID: 19232284 DOI: 10.1016/j.giec.2008.12.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This article focuses on the colonic and anorectal motility disturbances that are associated with chronic constipation and their management. Functional chronic constipation consists of three overlapping subtypes: slow transit constipation, dyssynergic defecation, and irritable bowel syndrome with constipation. The Rome criteria may serve as a useful guide for making a clinical diagnosis of functional constipation. Today, an evidence-based approach can be used to treat patients with chronic constipation. The availability of specific drugs for the treatment of chronic constipation, such as tegaserod and lubiprostone, has enhanced the therapeutic armamentarium for managing these patients. Randomized controlled trials have also established the efficacy of biofeedback therapy in the treatment of dyssynergic defecation.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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Rao SSC. Constipation: evaluation and treatment of colonic and anorectal motility disorders. Gastroenterol Clin North Am 2007; 36:687-711, x. [PMID: 17950444 DOI: 10.1016/j.gtc.2007.07.013] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This article focuses on the colonic and anorectal motility disturbances that are associated with chronic constipation and their management. Functional chronic constipation consists of three overlapping subtypes: slow transit constipation, dyssynergic defecation, and irritable bowel syndrome with constipation. The Rome criteria may serve as a useful guide for making a clinical diagnosis of functional constipation. Today, an evidence-based approach can be used to treat patients with chronic constipation. The availability of specific drugs for the treatment of chronic constipation, such as tegaserod and lubiprostone, has enhanced the therapeutic armamentarium for managing these patients. Randomized controlled trials have also established the efficacy of biofeedback therapy in the treatment of dyssynergic defecation.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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