Evaluation and surgical treatment of severe chronic constipation.

Patients with chronic constipation may have one of several physiologic disorders, not all of which are amenable to operative therapy. The aim of this study was to test colonic and pelvic floor function preoperatively, to identify patients suitable for surgery based on these studies, and to determine operative outcome over time. Between 1987 and January 1991, 277 patients referred for severe symptoms of chronic intractable constipation underwent colon transit studies, measurement of anal canal pressures and reflexes, and measurements of anorectal angle movements and efficiency of evacuation. Balloon expulsion studies, electromyography of the pelvic floor, and defecating proctograms also were done. Based on these studies, patients were categorized as having: slow transit constipation (STC), 29 patients; pelvic floor dysfunction (PFD), 37 patients; STC + PFD, combined slow transit and pelvic floor dysfunction, 14 patients; and irritable bowel syndrome (IBS), 197 patients. Slow transit constipation patients underwent abdominal colectomy and reanastomosis. Pelvic floor dysfunction patients underwent pelvic floor retraining only. Patients with STC + PFD underwent pelvic floor retraining followed by abdominal colectomy. Irritable bowel syndrome patients were treated symptomatically. Among the 38 patients operated on (STC and STC + PFD), there was no operative mortality. Prolonged ileus developed in 13%, and small bowel obstruction occurred in 11% of patients. On follow-up, a mean of 20 months after ileorectostomy, no patient was constipated, none required a laxative, and none was incontinent. The mean number of stools per day was four. The authors concluded that a prospective evaluation of colonic and pelvic floor function reliably delineated constipated patients with slow transit, suitable for operative management, from those with pure pelvic floor dysfunction or irritable bowel syndrome, who were not. Abdominal colectomy and ileorectostomy in the slow transit patients was safe and effective, resulting in prompt and prolonged relief of constipation.

Audit of constipation in a tertiary referral gastroenterology practice.

OBJECTIVE: Our objective was to assess how often "outlet obstruction" was the cause of constipation in a tertiary referral population. METHODS: We retrospectively audited the case records of 70 consecutive patients referred to a single gastroenterologist in a tertiary referral motility clinic. Patients were classified by physiological tests of colonic transit, as well as tests of anorectal and pelvic floor function. A subset of 28 patients also underwent a battery of tests to assess the autonomic nervous system supply. RESULTS: Thirty-six patients had symptoms suggestive of a rectal outlet obstruction syndrome. Thirty seven percent of patients had pelvic floor dysfunction, 27% had slow transit constipation, and 8% had anismus. Fully 55% of those with pelvic floor dysfunction had slow transit in addition. The remaining patients (23%) had at least two of Manning's criteria suggestive of the irritable bowel syndrome. Only four patients had documented abnormalities of autonomic function. CONCLUSIONS: Pelvic floor dysfunction is the most common cause of severe constipation in a tertiary referral motility clinic; slow transit constipation and irritable bowel syndrome occur equally. An algorithmic approach to evaluating patients using clinical features, anorectal functions tests, and assessment of colonic transit facilitates selection of management strategies. Autonomic dysfunction occurs rarely.

Anorectal dysfunction and rectal prolapse in progressive systemic sclerosis.

Our aim was to characterize the clinical spectrum of anorectal dysfunction among eight patients with progressive systemic sclerosis (PSS) who presented with altered bowel movements with or without fecal incontinence. The anorectum was assessed by physical examination, proctosigmoidoscopy, and anorectal manometry. There was concomitant involvement of the other regions of the digestive tract in all patients as determined by barium studies, endoscopy, or manometry: eight esophageal, three gastric, four small bowel, and two colonic. Seven patients had fecal incontinence, and four also had second-degree complete rectal prolapse. Abnormal anorectal function, particularly abnormal anal sphincter resting pressures, were detected in all patients; anal sphincter pressures were lower in those with rectal prolapse. Rectal capacity and wall compliance were impaired in seven of seven patients. Successful surgical correction of prolapse in three patients resulted in restoration of incontinence for six months and seven years in two of the three patients. We conclude that rectal dysfunction and weakness of the anal sphincters are important factors contributing, respectively, to altered bowel movements and fecal incontinence in patients with gastrointestinal involvement by PSS. Rectal prolapse worsens anal sphincter dysfunction and should be sought routinely as it is a treatable factor aggravating fecal incontinence in patients with PSS.

Long-term results of surgery for chronic constipation.

BACKGROUND: Developments in anorectal physiologic testing have facilitated better understanding of the process of defecation and factors that might cause chronic constipation. AIM: Patients with severe idiopathic chronic constipation were evaluated using colonic transit and pelvic floor function in an attempt to identify those patients suitable for aggressive surgical intervention. MATERIALS AND RESULTS: Among 1,009 patients studied using either a marker or scintigraphic transit technique and tests of pelvic floor function, 52 with slow-transit constipation (STC) were identified and underwent abdominal colectomy and ileorectostomy (IRA). Twenty-two patients had pelvic floor dysfunction and STC; these patients underwent initial pelvic floor retraining followed by IRA. A total of 249 patients had pelvic floor dysfunction without evidence of slow-transit and were offered pelvic floor retraining alone. The remaining 597 patients had no quantifiable abnormality of colon or pelvic floor dysfunction; these patients had normal transit constipation/irritable bowel syndrome and were treated medically. There were, thus, 74 patients operated on, 68 women, with a mean age of 53 years and a mean follow-up of 56 months. There was no operative mortality, seven patients (9 percent) had small-bowel obstruction, and nine patients (12 percent) had prolonged ileus. All patients were able to pass a stool spontaneously, 97 percent of patients were satisfied with the results of surgery, and 90 percent have a good or improved quality of life. There was no difference in the outcome of surgery in patients with STC alone compared with STC and pelvic floor dysfunction. CONCLUSION: Physiologic evaluation reliably identified patients with severe chronic constipation who might benefit from surgery. IRA is safe and effective, resulting in prompt and prolonged relief of constipation.

Discriminant value of psychological distress, symptom profiles, and segmental colonic dysfunction in outpatients with severe idiopathic constipation.

Severe idiopathic constipation can be categorised based on physiological testing into subgroups including slow transit constipation and pelvic floor dysfunction. This study aimed to determine if colonic and psychological symptoms, or rectosigmoid transit times, could discriminate among these subgroups. Patients, categorised according to total colonic transit times and pelvic floor function testing, completed a self report questionnaire that recorded symptoms and psychological distress. Patients with normal transit constipation (n = 60) had significantly increased depression scores compared with those who had slow transit constipation (n = 70) or pelvic floor dysfunction (n = 30). The general severity index (GSI, a measure of overall psychological distress) negatively but weakly correlated with total colonic transit (r = -0.26, p < 0.01). A feeling of anal blockage was the only symptom that was associated with pelvic floor dysfunction (v normal transit constipation). Only a more regular defecation pattern, utilisation of different postures to defecate, and a feeling of incomplete evacuation were associated with slow v normal transit constipation. Psychological or colonic symptoms were not, however, significant discriminators in a multivariate analysis. Rectosigmoid transit times at 80% sensitivity had very poor specificity for discriminating pelvic floor dysfunction from other subgroups. It is concluded that clinical symptoms, psychological distress, and rectosigmoid transit times cannot be used to identify subgroups of patients with intractable constipation.