Management of colorectal-anal dysfunction

Guidelines for the Diagnosis and Treatment of Chronic Functional Constipation in Korea, 2015 Revised Edition

The Korean Society of Neurogastroenterology and Motility first published guidelines for chronic constipation in 2005 and was updated in 2011. Although the guidelines were updated using evidence-based process, they lacked multidisciplinary participation and did not include a diagnostic approach for chronic constipation. This article includes guidelines for diagnosis and treatment of chronic constipation to realistically fit the situation in Korea and to be applicable to clinical practice. The guideline development was based upon the adaptation method because research evidence was limited in Korea, and an organized multidisciplinary group carried out systematical literature review and series of evidence-based evaluations. Six guidelines were selected using the Appraisal of Guidelines for Research & Evaluation (AGREE) II process. A total 37 recommendations were adopted, including 4 concerning the definition and risk factors of chronic constipation, 8 regarding diagnoses, and 25 regarding treatments. The guidelines are intended to help primary physicians and general health professionals in clinical practice in Korea, to provide the principles of medical treatment to medical students, residents, and other healthcare professionals, and to help patients for choosing medical services based on the information. These guidelines will be updated and revised periodically to reflect new diagnostic and therapeutic methods.

Review Article: Gynecological Disorders in Geriatric Emergency Medicine

Emergency physicians must be competent in caring for elderly women because they constitute the fastest growing segment of the population in the United States. Familiarity with acute geriatric gynecologic issues is crucial to providing satisfactory health care for these patients with complaints relating to incontinence, pelvic floor dysfunction, and other gynecologic conditions. Vigilant suspicion for malignancy should be maintained in facilities that service patients without primary health care or insurance. This article provides a systematic approach to emergency department management of common geriatric gynecological conditions. Anatomical and physiological changes are discussed, as well as the geriatric pelvic examination, malignancy, urinary tract infection, incontinence, pelvic organ prolapse, and vulvovaginitis.

Is total colectomy the right choice in intractable slow-transit constipation?

BACKGROUND

The aim of the study was to evaluate the functional results of surgical treatment for intractable slow-transit constipation and to establish that the importance of correct diagnosis and type of colon resection (total or segmental) is essential to achieve optimal outcome while minimizing side effects.

METHODS

Between 1995 and 2004, of the 450 patients presenting with chronic constipation, we further investigated 33 patients with a diagnosis of slow-transit constipation that had not improved with medical or rehabilitative treatment. Preoperative evaluation included a daily evacuation diary compiled using Wexner score, psychologic assessment, Medical Outcomes Study 36-item Short Form Health Survey (SF-36), radiologic investigation of colonic transit time, enema radiograph, colpo-cysto-defecography, anal manometry, and, in selected patients, colonoscopy and pudendal nerve terminal motor latency. In 15 cases, the cause of constipation was colonic slow-transit (with a mean Wexner score of 22), which was always associated with dolichocolon. The other 18 patients presented outlet obstruction, and, therefore, these results are not included in the present report. The 15 patients with slow-transit constipation were submitted to total laparoscopic colectomy (2), total open colectomy (6), and left laparoscopic hemicolectomy for left colonic slow-transit (7).

RESULTS

Mean follow-up was 38 months. All patients except 1 presented improvement in symptoms with daily evacuations (P < .01; mean Wexner score, 6). Furthermore, results of the SF-36 test showed an improvement in the perception of physical pain, and the emotional, psychologic, and general health spheres after surgical treatment.

CONCLUSIONS

Meticulous preoperative evaluation of intractable slow-transit constipation may discriminate between the different causes of chronic constipation and thus avoid the well-known "Iceberg syndrome," which is responsible for many treatment failures.

Constipation of anorectal outlet obstruction: pathophysiology, evaluation and management

Constipation is a subjective symptom of various pathological conditions. Incidence of constipation fluctuates from 2 to 30% in the general population. Approximately 50% of constipated patients referred to tertiary care centers have obstructed defecation constipation. Constipation of obstructed defecation may be due to mechanical causes or functional disorders of the anorectal region. Mechanical causes are related to morphological abnormalities of the anorectum (megarectum, rectal prolapse, rectocele, enterocele, neoplasms, stenosis). Functional disorders are associated with neurological disorders and dysfunction of the pelvic floor muscles or anorectal muscles (anismus, descending perineum syndrome, Hirschsprung's disease). However, this type of constipation should be differentiated by colonic slow transit constipation which, if coexists, should be managed to a second time. Assessment of patients with severe constipation includes a good history, physical examination and specialized investigations (colonic transit time, anorectal manometry, rectal balloon expulsion test, defecography, electromyography), which contribute to the diagnosis and the differential diagnosis of the cause of the obstructed defecation. Thereby, constipated patients can be given appropriate treatment for their problem, which may be conservative (bulk agents, high-fiber diet or laxatives), biofeedback training or surgery.

Results after colectomy for colonic inertia: a sixteen-year experience

BACKGROUND

Colonic inertia (CI) is a disturbance of colonic motility characterized by severe constipation and abdominal pain. This study was conducted to assess the results of total abdominal colectomy (TAC) in the management of CI.

METHODS

A retrospective chart review of 55 patients who underwent TAC for CI was conducted.

RESULTS

Forty-eight patients (87%) were female with an average age of 40; severe constipation existed 2 years prior to surgery. Symptoms included severe constipation (100%) and abdominal pain (84%); diagnostic workup included sitz marker study, anal manometry, and Gastrografin enema. In all cases, sitz marker studies were abnormal and anal manometry was normal. Histologically, no patient had absence of neuroenteric plexuses. Complications included prolonged ileus (24%) and small bowel obstruction (8%). Some 49 patients (89%) had "good" or "excellent" results and 6 patients (11%) had "poor" results. Postoperative stool frequency was 5, 4, and 3 per day at 1, 2, and 12 months, respectively.

CONCLUSIONS

TAC results in resolution of constipation in most patients. We conclude that TAC is effective treatment in patients with CI.