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Evaluation of Severe Chronic Constipation. Results. Management

Patient Characteristics

Table 1 details the demographic and symptomatic data on the 277 patients by diagnostic category.

Table 1. Characteristics of 277 Patients Presenting with Intractable Constipation by Diagnostic Category (Mean ± SD)
Group N Age
(yr)
Women
(%)
Spontaneous Stools
(% of patients)
Stools/wk
(N)
Enemas
(% of patients)
Laxatives
(% of patients)
Facilitated Defecation
(% of patients)
I Slow transit constipation 29 40 ± 16 84 3** 0.1 ±0.2*** 44 67 11
II Pelvic floor dysfunction 37 36 ±17 * 89 18 1.2 ±2.0 46 50 41****
III Slow transit constipation + pelvic floor dysfunction 14 33 ± 17 * 89 0** 0.2 ± 0.4 78 67 11
IV Irritable bowel syndrome 197 43 ± 17 82 22 NA 50 60 17

* Groups II and III younger than Group IV (p < 0.04).
**Fewer patients in Groups I and III stooled spontaneously than patients in Group IV (p < 0.02).
*** Stool frequency less than Group II (p < 0.001).
**** More patients in Group II facilitated defecation than patients in Groups I, III, and IV (p < 0.02).

Patients

The largest group of patients was the one with normal parameters of bowel function (IBS). Importantly only 83 of 277 patients (30%) had objective evidence of either colon or pelvic floor dysfunction.

Age and Sex

Patients with either pure pelvic floor dysfunction (PFD) or pelvic floor dysfunction and slow transit constipation (STC + PFD) were significantly younger than the patients with irritable bowel syndrome (IBS) and tended to be younger than those with slow transit constipation alone. Over 80% of patients in each diagnostic category were women.

Symptoms

Spontaneous stools occurred least frequently in patients with slow transit constipation, either alone or combined with PFD. Moreover these same patients had the least number of stools per week, whether spontaneous or facilitated by medication. Patients with slow transit as a component of their constipation therefore appeared to be more profoundly constipated than were patients who complained of constipation but who did not have slow transit.

There was a trend for more patients with a combined disorder (STC + PFD) to facilitate stooling using enemas compared with patients in the other groups. The type and frequency with which medications were used to aid stooling, however, did not appear to distinguish among the patient groups.

Importantly patients with pure pelvic floor dysfunction (PFD) facilitated defecation digitally more often than did patients with slow transit constipation alone or those with STC + PFD. These patients with pelvic floor dysfunction often reported straining endlessly on the toilet before digitally extracting the stool. Interestingly this was not a problem reported by patients with PFD and slow transit, perhaps because there was no stool in the rectum to extract.

Physiologic Results

Table 2. Results of Colonic and Pelvic Floor Function Tests in 277 Patients with Intractable Constipation (Mean ± SD)
Colon Transit Group (hr) Pelvic Floor Descent (cm) Scintigraphic Expulsion (% of instillate) Balloon Expulsion (g needed to defecate)
I Slow transit constipation 117 ±25 * 2.4 ± 1.5 67 ±21 70 ± 144
II Pelvic floor dysfunction 80 ± 38 1.4 ± 1.8 ** 58 ±22 248 ± 182  *****
III Slow transit constipation + pelvic floor dysfunction 118 ± 19 * 0.6 ± 0.6 *** 44 ± 23 **** 322 ± 203 ******
IV Irritable bowel syndrome 68 ± 35 1.9 ± 1.6 66 ±20 156 ± 187

* Transit slower than Groups II and IV (p < 0.05).
** Descent less than Group I (p < 0.05).
*** Descent less than Groups I and IV (p < 0.05).
**** Percent expulsion less than Groups I and IV (p < 0.05).
***** Weight required greater than Group I (p < 0.05).
****** Weight required greater than Groups I and IV (p < 0.05).

Colon Transit

Patients with STC or STC + PFD had significantly slower colon transit times than did patients with pure PFD or IBS (p < 0.05).

Pelvic Floor and Anorectal Manometry

There were no differences among groups in mean resting or squeeze anal pressures or rectal capacity. The rectal-anal sphincter inhibitory response was present in all patients, thus ruling out Hirschsprung’s disease in the entire group.

EMG

During defecation straining, some patients in all groups demonstrated paradoxical puborectal muscle contraction. In patients with pelvic floor dysfunction either alone or combined with STC (STC + PFD), 56% and 50% of patients had paradoxical contraction, respectively. In contrast only 43% of patients with STC alone and 34% of patients with irritable bowel syndrome had paradoxical activity in the puborectal muscle. It therefore appeared that abnormal motor activity of the puborectal muscle was not specific for PFD, although the highest incidence (56%) was in the group of patients with pure pelvic floor dysfunction.

Evaluation of Severe Chronic Constipation. Results. Management

Scintigraphic Balloon Topography

The magnitude of movements of the anorectal angle during defecation were similar across all groups. There was a trend for STC + PFD patients to open the anorectal angle less than all the other groups. The mean difference between rest and defecation angles in patients with STC + PFD was 3°, whereas it was 13° in patients with slow transit constipation alone, 9° in patients with PFD alone, and 10° in IBS patients. None of these differences, however, were statistically significant.

Pelvic floor descent, however, was different among groups. Patients with pelvic floor dysfunction either alone or combined with STC had less descent of the pelvic floor than did patients with pure STC or irritable bowel syndrome (IBS).

Scintigraphic Evacuation

Patients with STC + PFD had significantly less evacuation of radiolabeled artificial stool than did patients with slow transit constipation or IBS.

Balloon Expulsion

Significantly fewer patients with PFD (19%) and patients with STC + PFD (13%) spontaneously evacuated the rectal balloon than did patients with either STC alone (60%) or irritable bowel syndrome (42%) (p < 0.05). Of the patients unable to evacuate spontaneously, patients with pelvic floor dysfunction or STC + PFD required greater weight to pass the intrarectal balloon than did patients with pure slow transit constipation or irritable bowel syndrome (IBS).

Defecating Proctograms

Eight patients, three with STC + PFD and five with slow transit constipation, had symptoms of rectal fullness and tenesmus sufficient to warrant obtaining a defecating proctogram, even though previous studies, often including a defecating proctogram, had shown no diagnostic abnormalities. All three patients with STC + PFD were normal. Of the patients with slow transit constipation alone, three patients were normal and one had a rectocele that did not significantly interfere with defecation. The remaining patient had a rectocele that impaired defecation; this patient underwent rectocele repair first and then abdominal colectomy and ileorectostomy.

Upper Gastrointestinal Manometry

Twenty-seven of two hundred seventy-seven patients had upper gastrointestinal manometry performed. Sixteen were normal and 11 showed evidence of small bowel pseudo-obstruction. Four of these patients underwent abdominal colectomy and ileorectostomy, including three patients from group I (STC) and one from group III (STC + PFD). Despite this diagnosis all four were doing well postoperatively, although one has required intermittent use of cisapride.

Management

Slow Transit Constipation

Having determined that all treatment modalities had been explored and had failed, and if the patient was psychologically fit, abdominal colectomy and re-anastomosis was performed in the slow transit constipation group (n = 29). All patients underwent postoperative follow-up by a nurse and data clerk at 2 months, 6 months, and at yearly intervals thereafter.

Pelvic Floor Dysfunction

Patients with abnormal pelvic floor function (n = 37) underwent an intensive 10-day inpatient pelvic floor retraining program. Patients were admitted to an extended care facility of the hospital. Diet and activity were controlled. Pelvic floor retraining was performed after the manner of Bleijenberg and Kuijpers and Weber et al., using biofeedback techniques. Patients were taught to relax the pelvic floor during straining and to correlate relaxation and pushing to achieve defecation.

Slow Transit Constipation + Pelvic Floor Dysfunction

Of the patients having a combined disorder (STC + PFD; n = 14), nine underwent pelvic floor retraining followed by ileorectostomy. Five patients completed retraining but have not had surgery performed.

Irritable Bowel Syndrome

Patients with normal studies were re-referred to their physicians with a diagnosis of irritable bowel syndrome (n = 197) for further symptomatic care. No further diagnostic or any surgical maneuvers were performed in these patients.

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