Clin Colon Rectal Surg 2005; 18(2): 65-75
DOI: 10.1055/s-2005-870886
Copyright © 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

The Evaluation of Constipation

Matthew D. Vrees1 , Eric G. Weiss1
  • 1Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
24. Mai 2005 (online)

ABSTRACT

Constipation is a major medical problem in the United States, affecting 2% to 28% of the population. Individual patients may have different conceptions of what constipation is, and the findings overlap with those in other functional gastrointestinal disorders. In 1999, an international panel of experts laid out specific criteria for the diagnosis of constipation known as the Rome II criteria. When patients present with complaints of constipation, a complete history and physical examination can elicit the cause of constipation. It is imperative to rule out a malignancy or other organic causes of the patient's symptoms prior to making the diagnosis of functional constipation. Many patients' symptoms can be relieved with lifestyle and dietary modification, both of which should be implemented before other potentially unnecessary tests are performed.

Functional constipation is divided into two subtypes: slow transit constipation and obstructive defecation. Because many different terms are used interchangeably to describe these subtypes of constipation, physicians need to be comfortable with the language.

Slow transit constipation is due to abnormal colonic motility. The diagnosis is made with the use of a colonic transit study. We continue to use a single-capsule technique as first described in the literature, but modifications of the capsule technique as well as scintigraphic techniques are validated and can be substituted in place of the capsule.

Obstructive defecation is a much more complex problem, with etiologies ranging from rare diseases such as Hirschsprung's to physiologic abnormalities such as paradoxical puborectalis contraction. To fully evaluate the patient with obstructive defecation, anorectal manometry, defecography, and electromyography should be utilized. The different techniques available for each test are fully covered in this article.

When evaluating each patient with constipation, it is important to keep in mind that the disease may be specific to one subtype or a combination of both subtypes. Because it is difficult to differentiate the subtypes from the patient's history, we feel it is imperative to evaluate patients fully for both slow transit and obstructive defecation prior to any surgical intervention. Furthermore, we have described many tests that need to be applied to one's population of patients on the basis of the capabilities and expertise the institution offers.

REFERENCES

  • 1 Drossman D A, Li Z, Toner B B et al.. Functional bowel disorders. A multicenter comparison of health status and development of illness severity index.  Dig Dis Sci. 1995;  40 986-995
  • 2 Drossman D A, Li Z, Andruzzi E et al.. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact.  Dig Dis Sci. 1993;  38 1569-1580
  • 3 Higgins P D, Johanson J F. Epidemiology of constipation in North America: a systematic review.  Am J Gastroenterol. 2004;  99 750-759
  • 4 Everhart J E, Go V L, Johannes R S, Fitzsimmons S C, Roth H P, White L R. A longitudinal survey of self-reported bowel habits in the United States.  Dig Dis Sci. 1989;  34 1153-1162
  • 5 Talley N J, Fleming K C, Evans J M et al.. Constipation in an elderly community: a study of prevalence and potential risk factors.  Am J Gastroenterol. 1996;  91 19-25
  • 6 Johanson J F, Sonnenberg A, Koch T R. Clinical epidemiology of chronic constipation.  J Clin Gastroenterol. 1989;  11 525-536
  • 7 Connell A M, Hilton C, Irvine G, Lennard-Jones J E, Misiewicz J J. Variation of bowel habit in two population samples.  Br Med J. 1965;  5470 1095-1099
  • 8 Agachan F, Chen T, Pfeifer J, Reissman P, Wexner S D. A constipation scoring system to simplify evaluation and management of constipated patients.  Dis Colon Rectum. 1996;  39 681-685
  • 9 Arce D A, Ermocilla C A, Costa H. Evaluation of constipation.  Am Fam Physician. 2002;  65 2283-2290
  • 10 D'Hoore A, Penninckx F. Obstructed defecation.  Colorectal Dis. 2003;  5 280-287
  • 11 Pfeifer J, Agachan F, Wexner S D. Surgery for constipation: a review.  Dis Colon Rectum. 1996;  39 444-460
  • 12 Rao S S. Constipation: evaluation and treatment.  Gastroenterol Clin North Am. 2003;  32 659-683
  • 13 Sonnenberg A, Koch T R. Epidemiology of constipation in the United States.  Dis Colon Rectum. 1989;  32 1-8
  • 14 Stewart W F, Liberman J N, Sandler R S et al.. Epidemiology of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic features.  Am J Gastroenterol. 1999;  94 3530-3540
  • 15 Thompson W G, Longstreth G F, Drossman D A, Heaton K W, Irvine E J, Muller-Lissner S A. Functional bowel disorders and functional abdominal pain.  Gut. 1999;  45(suppl 2) II43-II47
  • 16 Thompson W G. The road to Rome.  Gut. 1999;  45(suppl 2) II80
  • 17 Bennett E J, Evans P, Scott A M et al.. Psychological and sex features of delayed gut transit in functional gastrointestinal disorders.  Gut. 2000;  46 83-87
  • 18 El-Salhy M. Chronic idiopathic slow transit constipation: pathophysiology and management.  Colorectal Dis. 2003;  5 288-296
  • 19 Leroi A M, Bernier C, Watier A et al.. Prevalence of sexual abuse among patients with functional disorders of the lower gastrointestinal tract.  Int J Colorectal Dis. 1995;  10 200-206
  • 20 Talley N J, Jones M, Nuyts G, Dubois D. Risk factors for chronic constipation based on a general practice sample.  Am J Gastroenterol. 2003;  98 1107-1111
  • 21 Wald A, Hinds J P, Caruana B J. Psychological and physiological characteristics of patients with severe idiopathic constipation.  Gastroenterology. 1989;  97 932-937
  • 22 Pepin C, Ladabaum U. The yield of lower endoscopy in patients with constipation: survey of a university hospital, a public county hospital, and a Veterans Administration medical center.  Gastrointest Endosc. 2002;  56 325-332
  • 23 Bassotti G, Roberto G D, Sediari L, Morelli A. Toward a definition of colonic inertia.  World J Gastroenterol. 2004;  10 2465-2467
  • 24 Prather C M. Subtypes of constipation: sorting out the confusion.  Rev Gastroenterol Disord. 2004;  4(suppl 2) S11-S16
  • 25 Shafik A, Shafik A A, El-Sibai O, Mostafa R M. Electric activity of the colon in subjects with constipation due to total colonic inertia: an electrophysiologic study.  Arch Surg. 2003;  138 1007-1011 , discussion 1011
  • 26 Xing J H, Soffer E E. Adverse effects of laxatives.  Dis Colon Rectum. 2001;  44 1201-1209
  • 27 Talley N J. Definitions, epidemiology, and impact of chronic constipation.  Rev Gastroenterol Disord. 2004;  4(suppl 2) S3-S10
  • 28 Stewart R B, Moore M T, Marks R G, Hale W E. Correlates of constipation in an ambulatory elderly population.  Am J Gastroenterol. 1992;  87 859-864
  • 29 Prather C M. Pregnancy-related constipation.  Curr Gastroenterol Rep. 2004;  6 402-404
  • 30 Kim H J, Camilleri M, Carlson P J et al.. Association of distinct alpha(2) adrenoceptor and serotonin transporter polymorphisms with constipation and somatic symptoms in functional gastrointestinal disorders.  Gut. 2004;  53 829-837
  • 31 Chen C Y, Chuang T Y, Tsai Y A et al.. Loss of sympathetic coordination appears to delay gastrointestinal transit in patients with spinal cord injury.  Dig Dis Sci. 2004;  49 738-743
  • 32 Cao W, Pricolo V, Zhang L, Behar J, Bianciani P, Kirber M. Gq-linked NK(2) receptors mediate neurally induced contraction of human sigmoid circular smooth muscle.  Gastroenterology. 2000;  119 51-61
  • 33 Rosen R, Buonomo C, Andrade R, Nurko S. Incidence of spinal cord lesions in patients with intractable constipation.  J Pediatr. 2004;  145 409-411
  • 34 Welch A C. Constipation & diabetes. Constipation can affect up to 60 percent of people with diabetes. Some treatments may work better than others. Which ones are right for you?.  Diabetes Forecast. 2003;  56 65-66
  • 35 el-Salhy M, Norrgard O. Colonic neuroendocrine peptide levels in patients with chronic idiopathic slow transit constipation.  Ups J Med Sci. 1998;  103 223-230
  • 36 El-Salhy M, Norrgard O, Spinnell S. Abnormal colonic endocrine cells in patients with chronic idiopathic slow-transit constipation.  Scand J Gastroenterol. 1999;  34 1007-1011
  • 37 He C L, Burgart L, Wang L et al.. Decreased interstitial cell of cajal volume in patients with slow-transit constipation.  Gastroenterology. 2000;  118 14-21
  • 38 Lyford G L, He C L, Soffer E et al.. Pan-colonic decrease in interstitial cells of Cajal in patients with slow transit constipation.  Gut. 2002;  51 496-501
  • 39 Tong W D, Liu B H, Zhang L Y, Zhang S B. Study on distribution of interstitial cells of Cajal in the sigmoid colon of patients with slow transit constipation.  Zhonghua Wai Ke Za Zhi. 2004;  42 853-856
  • 40 Tong W D, Liu B H, Zhang L Y, Zhang S B, Lei Y. Decreased interstitial cells of Cajal in the sigmoid colon of patients with slow transit constipation.  Int J Colorectal Dis. 2004;  19 467-473
  • 41 Zhao R, Baig M K, Wexner S D et al.. Enterochromaffin and serotonin cells are abnormal for patients with colonic inertia.  Dis Colon Rectum. 2000;  43 858-863
  • 42 Kinnunen O, Salokannel J. Comparison of the effects of magnesium hydroxide and a bulk laxative on lipids, carbohydrates, vitamins A and E, and minerals in geriatric hospital patients in the treatment of constipation.  J Int Med Res. 1989;  17 442-454
  • 43 Scott S M, Knowles C H, Newell M, Garvie N, Williams N S, Lunniss P J. Scintigraphic assessment of colonic transit in women with slow-transit constipation arising de novo and following pelvic surgery or childbirth.  Br J Surg. 2001;  88 405-411
  • 44 Nam Y S, Pikarsky A J, Wexner S D et al.. Reproducibility of colonic transit study in patients with chronic constipation.  Dis Colon Rectum. 2001;  44 86-92
  • 45 Hinton J M, Lennard-Jones J E, Young A C. A ne method for studying gut transit times using radioopaque markers.  Gut. 1969;  10 842-847
  • 46 Gutierrez C, Marco A, Nogales A, Tebar R. Total and segmental colonic transit time and anorectal manometry in children with chronic idiopathic constipation.  J Pediatr Gastroenterol Nutr. 2002;  35 31-38
  • 47 Chaussade S, Khyari A, Roche H et al.. Determination of total and segmental colonic transit time in constipated patients. Results in 91 patients with a new simplified method.  Dig Dis Sci. 1989;  34 1168-1172
  • 48 Chaussade S, Roche H, Khyari A, Couturier D, Guerre J. Measurement of colonic transit time: description and validation of a new method.  Gastroenterol Clin Biol. 1986;  10 385-389
  • 49 Bouchoucha M, Devroede G, Arhan P et al.. What is the meaning of colorectal transit time measurement?.  Dis Colon Rectum. 1992;  35 773-782
  • 50 Arhan P, Devroede G, Jehannin B et al.. Segmental colonic transit time.  Dis Colon Rectum. 1981;  24 625-629
  • 50a Metcalf A M, Phillips S F, Zinmeister A R, MacCarthy R L, Beart R W, Wolff B G. Simplified assessment of segmental colonic transit.  Gastroenterology. 1987;  92 40-47
  • 51 Krevsky B, Malmud L S, D'Ercole F, Maurer A H, Fisher R S. Colonic transit scintigraphy. A physiologic approach to the quantitative measurement of colonic transit in humans.  Gastroenterology. 1986;  91 1102-1112
  • 52 Stivland T, Camilleri M, Vassallo M et al.. Scintigraphic measurement of regional gut transit in idiopathic constipation.  Gastroenterology. 1991;  101 107-115
  • 53 Bonapace E S, Maurer A H, Davidoff S, Krevsky B, Fisher R S, Parkman H P. Whole gut transit scintigraphy in the clinical evaluation of patients with upper and lower gastrointestinal symptoms.  Am J Gastroenterol. 2000;  95 2838-2847
  • 54 Roberts J P, Newell M S, Deeks J J, Waldron D W, Garvie N W, Williams N S. Oral [111In]DTPA scintigraphic assessment of colonic transit in constipated subjects.  Dig Dis Sci. 1993;  38 1032-1039
  • 55 McLean R, Smart R, Barbagallo S, King D, Stein P, Talley N. Colon transit scintigraphy using oral indium-111-labeled DTPA. Can scan pattern predict final diagnosis?.  Dig Dis Sci. 1995;  40 2660-2668
  • 56 McLean R G, Smart R C, Lubowski D Z, King D W, Barbagallo S, Talley N A. Oral colon transit scintigraphy using indium-111 DTPA: variability in healthy subjects.  Int J Colorectal Dis. 1992;  7 173-176
  • 57 McLean R G, Smart R C, Gaston-Parry D et al.. Colon transit scintigraphy in health and constipation using oral iodine-131-cellulose.  J Nucl Med. 1990;  31 985-989
  • 58 Hutchinson R, Mostafa A B, Grant E A et al.. Scintigraphic defecography: quantitative and dynamic assessment of anorectal function.  Dis Colon Rectum. 1993;  36 1132-1138
  • 59 Rotholtz N A, Efron J E, Weiss E G, Nogueras J J, Wexner S D. Anal manometric predictors of significant rectocele in constipated patients.  Tech Coloproctol. 2002;  6 73-76 , discussion 76-77
  • 60 Sun W M, Rao S S. Manometric assessment of anorectal function.  Gastroenterol Clin North Am. 2001;  30 15-32
  • 61 Iwai N, Yanagihara J, Tokiwa K, Deguchi E, Perdzynski W, Takahashi T. Reliability of anorectal manometry in the diagnosis of Hirschsprung's disease.  Z Kinderchir. 1988;  43 405-407
  • 62 Moore B G, Singaram C, Eckhoff D E, Gaumnitz E A, Starling J R. Immunohistochemical evaluations of ultrashort-segment Hirschsprung's disease. Report of three cases.  Dis Colon Rectum. 1996;  39 817-822
  • 63 Sullivan P B. Hirschsprung's disease.  Arch Dis Child. 1996;  74 5-7
  • 64 Barnes P R, Lennard-Jones J E, Hawley P R, Todd I P. Hirschsprung's disease and idiopathic megacolon in adults and adolescents.  Gut. 1986;  27 534-541
  • 65 Todd I P. Adult Hirschsprung's disease.  Br J Surg. 1977;  64 311-312
  • 66 Hamel-Roy J, Devroede G, Arhan P, Tetreault J P, Lemieux B, Scott H. Functional abnormalities of the anal sphincters in patients with myotonic dystrophy.  Gastroenterology. 1984;  86 1469-1474
  • 67 Konig P, Ambrose N S, Scott N. Hereditary internal anal sphincter myopathy causing proctalgia fugax and constipation: further clinical and histological characterization in a patient.  Eur J Gastroenterol Hepatol. 2000;  12 127-128
  • 68 Karlbom U, Edebol Eeg-Olofsson K, Graf W, Nilsson S, Pahlman L. Paradoxical puborectalis contraction is associated with impaired rectal evacuation.  Int J Colorectal Dis. 1998;  13 141-147
  • 69 Pucciani F, Rottoli M L, Bologna A et al.. Pelvic floor dyssynergia and bimodal rehabilitation: results of combined pelviperineal kinesitherapy and biofeedback training.  Int J Colorectal Dis. 1998;  13 124-130
  • 70 Jorge J M, Yang Y K, Wexner S D. Incidence and clinical significance of sigmoidoceles as determined by a new classification system.  Dis Colon Rectum. 1994;  37 1112-1117
  • 71 Thorson A G. Anorectal physiology.  Surg Clin North Am. 2002;  82 1115-1123
  • 72 Le Blanc I, Michot F, Duparc F et al.. Anorectal manometry and ileo-anal anastomosis: pre- and postoperative manometric comparison.  Ann Chir. 1994;  48 183-187
  • 73 Preston D M, Lennard-Jones J E, Thomas B M. The balloon proctogram.  Br J Surg. 1984;  71 29-32
  • 74 Bartram C I, Turnbull G K, Lennard-Jones J E. Evacuation proctography: an investigation of rectal expulsion in 20 subjects without defecatory disturbance.  Gastrointest Radiol. 1988;  13 72-80
  • 75 Fleshman J W, Dreznik Z, Cohen E, Fry R D, Kodner I J. Balloon expulsion test facilitates diagnosis of pelvic floor outlet obstruction due to nonrelaxing puborectalis muscle.  Dis Colon Rectum. 1992;  35 1019-1025
  • 76 Turnbull G K, Lennard-Jones J E, Bartram C I. Failure of rectal expulsion as a cause of constipation: why fibre and laxatives sometimes fail.  Lancet. 1986;  1 767-769
  • 77 Beck D E. A simplified balloon expulsion test.  Dis Colon Rectum. 1992;  35 597-598
  • 78 Shorvon P J, McHugh S, Diamant N E, Somers S, Stevenson G W. Defecography in normal volunteers: results and implications.  Gut. 1989;  30 1737-1749
  • 79 Jorge J M, Habr-Gama A, Wexner S D. Clinical applications and techniques of cinedefecography.  Am J Surg. 2001;  182 93-101
  • 80 Jorge J M, Ger G C, Gonzalez L, Wexner S D. Patient position during cinedefecography. Influence on perineal descent and other measurements.  Dis Colon Rectum. 1994;  37 927-931
  • 81 Jorge J M, Wexner S D, Ger G C, Salanga V D, Nogueras J J, Jagelman D G. Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome.  Dis Colon Rectum. 1993;  36 668-676
  • 82 Agachan F, Pfeifer J, Wexner S D. Defecography and proctography. Results of 744 patients.  Dis Colon Rectum. 1996;  39 899-905
  • 83 Pfeifer J, Oliveira L, Park U C, Gonzalez A, Agachan F, Wexner S D. Are interpretations of video defecographies reliable and reproducible?.  Int J Colorectal Dis. 1997;  12 67-72
  • 84 Weidner A C, Low V H. Imaging studies of the pelvic floor.  Obstet Gynecol Clin North Am. 1998;  25 825-848vii
  • 85 Jones P N, Lubowski D Z, Swash M, Henry M M. Is paradoxical contraction of puborectalis muscle of functional importance?.  Dis Colon Rectum. 1987;  30 667-670
  • 86 Lau C W, Heymen S, Alabaz O, Iroatulam A J, Wexner S D. Prognostic significance of rectocele, intussusception, and abnormal perineal descent in biofeedback treatment for constipated patients with paradoxical puborectalis contraction.  Dis Colon Rectum. 2000;  43 478-482
  • 87 Chen H H, Iroatulam A, Alabaz O, Weiss E G, Nogueras J J, Wexner S D. Associations of defecography and physiologic findings in male patients with rectocele.  Tech Coloproctol. 2001;  5 157-161
  • 88 Altringer W E, Saclarides T J, Dominguez J M, Brubaker L T, Smith C S. Four-contrast defecography: pelvic “floor-oscopy”.  Dis Colon Rectum. 1995;  38 695-699
  • 89 Saclarides T J, Brubaker L T, Altringer W E, Smith C S, Dominguez J M. Clarifying the technique of four-contrast defecography.  Dis Colon Rectum. 1996;  39 826
  • 90 Fletcher J G, Busse R F, Riederer S J et al.. Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders.  Am J Gastroenterol. 2003;  98 399-411
  • 91 Matsuoka H, Desai M B, Wexner S D et al.. A pilot assessment of whether external coil MRI is useful to assess evacuatory disorders.  Int J Colorectal Dis. 2000;  15 91-95
  • 92 Matsuoka H, Wexner S D, Desai M B et al.. A comparison between dynamic pelvic magnetic resonance imaging and videoproctography in patients with constipation.  Dis Colon Rectum. 2001;  44 571-576
  • 93 Pinho M, Hosie K, Bielecki K, Keighley M R. Assessment of noninvasive intra-anal electromyography to evaluate sphincter function.  Dis Colon Rectum. 1991;  34 69-71
  • 94 Pfeifer J, Teoh T A, Salanga V D, Agachan F, Wexner S D. Comparative study between intra-anal sponge and needle electrode for electromyographic evaluation of constipated patients.  Dis Colon Rectum. 1998;  41 1153-1157
  • 95 Podnar S. Electrodiagnosis of the anorectum: a review of techniques and clinical applications.  Tech Coloproctol. 2003;  7 71-76
  • 96 Yeh C Y, Pikarsky A, Wexner S D et al.. Electromyographic findings of paradoxical puborectalis contraction correlate poorly with cinedefecography.  Tech Coloproctol. 2003;  7 77-81

Eric G WeissM.D. 

Department of Colorectal Surgery, Cleveland Clinic Florida

2950 Cleveland Clinic Blvd., Weston, FL 33326

eMail: weisse@ccf.org

    >