Mucosal neuroendocrine cell abnormalities in patients with chronic constipation

Indian consensus on chronic constipation in adults: A joint position statement of the Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology

The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for management of chronic constipation. A modified Delphi process was used to develop this consensus containing 29 statements, which were generated by electronic voting iteration as well as face to face meeting and review of the supporting literature primarily from India. These statements include 9 on epidemiology, clinical presentation, and diagnostic criteria; 8 on pathophysiology; and the remaining 12 on investigations and treatment. When the proportion of those who voted either to accept completely or with minor reservation was 80% or higher, the statement was regarded as accepted. The members of the consensus team believe that this would be useful for teaching, clinical practice, and research on chronic constipation in India and in other countries with similar spectrum of the disorders.

A case of single incision laparoscopic total colectomy for intestinal neuronal dysplasia type B

•

In patients with refractory constipation, it is necessary to care in mind that some patients require surgery.

•

Single incision laparoscopic surgery (SILS) is regarded as the major advance in minimally invasive surgery.

•

Total colectomy by SILS is very useful for the patients with intestinal neuronal dysplasia-type B.

Introduction

Intestinal neuronal dysplasia type B (IND-B) is an infrequent disease of the submucosal plexus of intestine manifesting chronic intestinal obstruction or severe chronic constipation. IND is rarely reported in adult patients.

Presentation of a case

The present study reports on the case of a 36 year-old woman suffering from longstanding chronic constipation and who was diagnosed with severe constipation in more than 20 years. Although she began to take a large amount of stimulant laxatives, such as “senna” and “bisacodyl”, constipation symptoms did not improve, she was admitted to our hospital. It was diagnosed with refractory constipation of the medication treatment-resistance, total colectomy with ileorectal anastomosis by single incision laparoscopic surgery (SILS) was performed. The final pathological diagnosis was IND-B.

Discussion

Refractory constipation after medical treatment is often seen in young generation. SILS has benefits of better cosmesis, reduced morbidity, reduced postoperative pain, and reduced length of hospital stay.

Conclusion

For the patients with refractory constipation associated with neuropathy such as IND, total colectomy by SILS was very effective.

Alterations in the small intestinal wall and motor function after repeated cisplatin in rat

BACKGROUND

Gastrointestinal adverse effects occurring during cancer chemotherapy are well known and feared; those persisting once treatment has finished are relatively unknown. We characterized the alterations occurring in the rat small intestine, after repeated treatment with cisplatin.

METHODS

Male Wistar rats received saline or cisplatin (2 mg kg^-1  week^-1 , for 5 weeks, ip). Gastric motor function was studied non-invasively throughout treatment (W1-W5) and 1 week after treatment finalization (W6). During W6, upper gastrointestinal motility was also invasively studied and small intestinal samples were collected for histopathological and molecular studies. Structural alterations in the small intestinal wall, mucosa, submucosa, muscle layers, and lymphocytic nodules were histologically studied. Periodic acid-Schiff staining and immunohistochemistry for Ki-67, chromogranin A, and neuronal-specific enolase were used to detect secretory, proliferating, endocrine and neural cells, respectively. The expression of different markers in the tunica muscularis was analyzed by RT/qPCR.

KEY RESULTS

Repeated cisplatin induced motility alterations during and after treatment. After treatment (W6), the small intestinal wall showed histopathological alterations in most parameters measured, including a reduction in the thickness of circular and longitudinal muscle layers. Expression of c-KIT (for interstitial cells of Cajal), nNOS (for inhibitory motor neurons), pChAT, and cChAT (for excitatory motor neurons) increased significantly (although both ChATs to a lesser extent).

CONCLUSIONS & INFERENCES

Repeated cisplatin induces relatively long-lasting gut dysmotility in rat associated with important histopathological and molecular alterations in the small intestinal wall. In cancer survivors, the possible chemotherapy-induced histopathological, molecular, and functional intestinal sequelae should be evaluated.

Intestinal neuronal dysplasia type B in adults: a controversial entity

Intestinal neuronal dysplasia (IND) is a well-defined entity which raises controversy among authors, described as a congenital malformation of gastrointestinal innervation and caused by dysplastic embryonal development of the enteric nervous system. It is potentially associated with mild and chronic gastrointestinal motility disturbances. IND is rarely reported in adults and especially elderly patients. The present study reports on the case of a 71-year-old man suffering from longstanding idiopathic constipation and who was misdiagnosed for more than 60 years, despite several hospital admissions and a sigmoidectomy in the meantime. On the last admission, the patient presented with megacolon, abdominal pain and X-ray finding of bowel obstruction. Due to massive large bowel dilatation, an exploratory laparotomy failed to reveal any obvious mechanical cause, and a subtotal colectomy and Hartmann's procedure was performed. Bowel continuity was performed 3 months later. Analysis of full-thickness biopsies revealed enlarged myenteric and submucosal neurons as well as an increased number of giant cells and increased acetylcholinesterase activity in the mucosa. The diagnosis of IND was established. The main diagnostic criteria, the underlining pathophysiology and the recommended therapeutic approach of this rare entity are extensively reviewed.

Favorable surgical treatment outcomes for chronic constipation with features of colonic pseudo-obstruction

AIM: To determine long-term outcomes of surgical treatments for patients with constipation and features of colonic pseudo-obstruction.

METHODS: Consecutive 42 patients who underwent surgery for chronic constipation within the last 13 years were prospectively collected. We identified a subgroup with colonic pseudo-obstruction (CPO) features, with dilatation of the colon proximal to the narrowed transitional zone, in contrast to typical slow-transit constipation (STC), without any dilated colonic segments. The outcomes of surgical treatments for chronic constipation with features of CPO were analyzed and compared with outcomes for STC.

RESULTS: Of the 42 patients who underwent surgery for constipation, 33 patients had CPO with dilatation of the colon proximal to the narrowed transitional zone. There were 16 males and 17 females with a mean age of 51.2 ± 16.1 years. All had symptoms of chronic intestinal obstruction, including abdominal distension, pain, nausea, or vomiting, and the mean duration of symptoms was 67 mo (range: 6-252 mo). Preoperative defecation frequency was 1.5 ± 0.6 times/wk (range: 1-2 times/wk). Thirty-two patients underwent total colectomy, and one patient underwent diverting transverse colostomy. There was no surgery-related mortality. Postoperative histologic examination showed hypoganglionosis or agangliosis in 23 patients and hypoganglionosis combined with visceral neuropathy or myopathy in 10 patients. In contrast, histology of STC group revealed intestinal neuronal dysplasia type B (n = 6) and visceral myopathy (n = 3). Early postoperative complications developed in six patients with CPO; wound infection (n = 3), paralytic ileus (n = 2), and intraabdominal abscess (n = 1). Defecation frequencies 3 mo after surgery improved to 4.2 ± 3.2 times/d (range: 1-15 times/d). Long-term follow-up (median: 39.7 mo) was available in 32 patients; all patients had improvements in constipation symptoms, but two patients needed intermittent medication for management of diarrhea. All 32 patients had distinct improvements in constipation symptoms (with a mean bowel frequency of 3.3 ± 1.3 times/d), social activities, and body mass index (20.5 kg/m² to 22.1 kg/m²) and were satisfied with the results of their surgical treatment. In comparison with nine patients who underwent colectomy for STC without colon dilatation, those in the CPO group had a lower incidence of small bowel obstructions (0% vs 55.6%, P < 0.01) and less difficulty with long-distance travel (6.7% vs 66.7%, P = 0.007) on long-term follow-up.

CONCLUSION: Chronic constipation patients with features of CPO caused by narrowed transitional zone in the left colon had favorable outcomes after total colectomy.

Colonic Pseudo-Obstruction with Distinct Transitional Zone in Adult Constipation Patients: Pathological Analysis and Results of Surgical Treatment

There are subsets of chronic constipation patients showing features of colonic pseudo-obstruction (CPO) with distinct transitional zone (TZ). We intended to analyze the clinicopathologic characteristics and surgical outcomes of these patients. Twenty-five consecutive patients who underwent surgery for constipation over the 9-year period were analyzed. TZ (+) group was defined as patients showing symptoms or signs of large bowel obstruction with dilated proximal and collapsed distal colon around the TZ at the time of operation, but without any evidence of mechanical causes of obstruction. Nineteen (76%) patients had features of CPO with TZ. All TZs were located in the left colon. Pathologically, segmental hypoganglionosis was identified at the TZ in all TZ (+) patients. On the other hand, pathologic diagnosis was intestinal neuronal dysplasia type B in the remaining six (24%) patients having a uniform colon diameter without demonstrable dilatations (TZ (-) group). Among TZ (+) patients, 17 (90%) underwent total colectomy with ileorectal anastomosis and two (10%) underwent enterostomy. Long-term follow-up (median 56 months) showed no recurrence of constipation in this group of patients. All six TZ (-) patients underwent total colectomy with ileorectal anastomosis and two (33%) of them had persistent symptoms of constipation on long-term follow-up (median 60 months). In a subset of adult constipation patients presenting with features of CPO with TZ, segmental hypoganglionosis was the final pathologic diagnosis. Constipation patients with features of CPO with distinct TZ in the left colon are expected to benefit from surgical intervention.

Intestinal neuronal dysplasia

Intestinal neuronal dysplasia type B (IND B) is currently defined as a disease of the submucous plexus of the intestine. The aetiology of IND B remains largely obscure. The congenital origin of IND B is supposed; nevertheless, the findings of IND B associated with chronic intestinal obstruction support the notion that this disease could be caused by a reaction of the enteral nervous system to intestinal obstruction or inflammatory disease either in the fetal or the postnatal period. The treatment of IND type B has no unified concept of treatment. The ultimate clinical diagnosis of IND B should be based on a definitive histological diagnosis relating to clinical symptoms, the course of treatment and long-term follow-up of patients with this dysfunction of intestinal motility, despite the fact that no correlations of the clinical picture, radiological investigation and anorectal manometric studies with IND B have been found so far.