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Introduction: Anorectal physiology tests are indicated for patients who have refractory symptoms of constipation, but the best sequence of investigation remains controversial. Objective: To evaluate the influence of colonic transit time and anorectal manometry in the diagnosis of chronic constipation in adults. Method: This was a study of adult patients with constipation at a private clinic in a city in southern Brazil, from January 1, 2009 to December 31, 2018. Those who showed warning signs were referred for colonoscopy and those with any anatomical alterations were excluded. The patients received 10 g of psyllium and those who remained symptomatic after three weeks were referred for functional assessment with colonic transit time (CTT). Those who presented outlet obstruction in the colonic transit time were referred to anorectal manometry. Results: Of the 889 adult patients surveyed, 227 were included. Of the 216 who completed the study, 167 responded to primary treatment. Forty-nine underwent CTT. In these, 16 had normal colonic transit time and 33 were altered. In those with altered colonic transit time, eight had a pattern of colonic inertia and 25 had an obstruction pattern. The 25 patients with an outlet obstruction pattern underwent anorectal manometry. Eighteen had signs of paradoxical contracture of the puborectal muscle (PPRC) and seven did not. Conclusion: This study concluded that anorectal physiology exams contribute to the diagnosis of constipation, often changing the behavior. These exams should be performed whenever the patient does not respond to hygienic changes and fiber replacement. Resumo Introdução: Os exames de fisiologia anorretal estão indicados nos pacientes que mantém sintomas refratários de constipação, porém uma sequência desejada de investigação permanece contraditória. Objetivo: Avaliar a influência do tempo de trânsito colônico e da manometria anorretal no diagnóstico da constipação crônica de adultos. Método: Estudamos os pacientes adultos de uma clínica privada em uma cidade do sul do Brasil, no período de 01 de Janeiro de 2009 a 31 de Dezembro de 2018 apresentando constipação. Aqueles que apresentassem sinais de alerta, eram encaminhados a colonoscopia e com qualquer alteração anatômica eram excluídos. Foram prescritos 10 g de Psyllium e aqueles que permaneceram sintomáticos após três semanas foram encaminhados à avaliação funcional com tempo de trânsito colônico (TTC). Os que apresentavam obstrução de saída ao tempo de trânsito colônico foram encaminhados a manometria anorretal. Resultados: Dos 889 pacientes adultos levantados, 227 foram incluídos. Dos 216 que concluíram o estudo, 167 responderam ao tratamento primário. Quarenta e nove realizaram TTC. Nestes, 16 tiveram tempo de trânsito colônico normal e 33 alterado. Naqueles com tempo de trânsito colônico alterado: oito tinham padrão de inércia colônica e 25, padrão de obstrução de saída. Os 25 pacientes com padrão de obstrução de saída foram submetidos à manometria anorretal. Dezoito tinham sinais de Contratura Paradoxal do músculo Puborretal (CPPR) e sete não. Conclusão: Concluímos que os exames de fisiologia anorretal contribuem para o diagnóstico da constipação, muitas vezes alterando a conduta. Estes exames devem ser realizados sempre que o paciente não responder as alterações higienodietéticas e a reposição de fibras.

Background and Aim: There have been no large-scale epidemiological study of functional constipation of pediatric gastroenterology services. This survey was undertaken to investigate the prevalence of functional constipation and magnitude of related problems in hospital settings of various countries as well as the practice of pediatric gastroenterologists in management of these conditions. Methods: The survey was conducted by sending questionnaires to members of Societies for Pediatric Gastroenterology Hepatology and Nutrition of various continents. Results: A total of 274 pediatric gastroenterologists from 41 countries participated in this study. Functional constipation accounted for overall 30% of patients attending pediatric gastroenterology outpatient clinics. In comparison with non-western countries, respondents from western countries reported significantly higher median annual numbers of new patients with intractable functional constipation (10 [4,25] vs 5 [2,10], P < 0.001), dyssynergic defecation (3 [0,15] vs 1 [0,4], P < 0.001), and colonic inertia (2 [0,5] vs 0 [0,1], P < 0.001). The use of high dose polyethylene glycol for fecal disimpaction was significantly more commonly among respondents from western countries, whereas rectal enema was significantly more favored in non-western countries. Respondents from different continents reported significant discrepancies in choices of investigations and management of patients with dyssynergic defecation and colonic inertia. Conclusions: Functional constipation is a major problem for pediatric gastroenterology outpatient services worldwide. There were significant variations in the investigations of choice and therapeutic management of functional constipation, intractable functional constipation, and related problems among pediatric gastroenterologists of different geographic regions.

Aim Subtotal colectomy is the treatment of last resort in patients with severe colonic inertia (SCI) refractory to laxatives. Some studies have reported hypoplasia of the interstitial cells of Cajal (ICC) using a semi-quantitative analysis. The aims of this study were first to investigate if semi-quantitative or morphometry is better at the quantification of colonic ICC and secondly to determine whether there is a relationship between the number of ICC and the severity of constipation. Method Clinical and pathological data from patients with subtotal colectomy for SCI were collected. Quantification of ICC using CD117 immunohistochemistry and morphometric methods was performed at three different colonic sites in patients and controls. Results Twenty patients had a colectomy for SCI. All were considered to have failed maximal medical treatment and 45 % were hospitalized at least once for colonic obstruction due to faecaloma. Using a semi-quantitative methodology, 30 % of patients displayed ICC hypoplasia (< 7 per high power field (HPF)) and all controls had normal ICC. Using morphometry, the percentage of colonic ICC was significantly less in patients compared with controls with no significant differences between the ascending, transverse and descending colonic segments. Overall 60 % of patients had ICC hypoplasia (< 1% vs. 20 % of controls [p = 0.009]). The severity of constipation was not related to the quantity of ICC. Conclusion In patients with SCI, morphometric analysis is more sensitive than semi-quantitative analysis in the detection of ICC hypoplasia. The severity of constipation was not related to the quantity of ICC. This article is protected by copyright. All rights reserved.

To investigate the effect of constipation on the development of inguinal herniation and type of herniation using the Constipation severity scale. A total of 100 patients who underwent surgical inguinal hernia repair (study group) and 100 healthy volunteers without inguinal herniation (control group) were included in this study. The constipation severity scale was administered to all patients. The type of the herniation was classified using Nyhus scale during surgery and the side of the herniation was recorded on completed questionnaires. The obstructive defecation sub-scale score, colonic inertia sub-scale score, pain sub-scale score, and the total score were recorded for each patient and the association between constipation and the development of inguinal herniation was investigated. The mean age of patients in Group 1 and 2 was 40.92 ± 17.80 and 33.71 ± 9.13, respectively. There was a significant difference between the two groups in terms of obstructive defecation and colonic inertia sub-scale scores (p

We present two cases of natural orifice specimen extraction (NOSE) after laparoscopic total colectomy and ileorectal anastomosis (TC-IRA), and we also review all of the previously reported cases. Our aim was to focus on patient selection for NOSE after TC-IRA. The PubMed and Google Scholar databases were scanned. Demographic features, surgical indications, and techniques were analyzed. Basic calculations were used for statistical analysis. A total of 13 cases were detected in addition to our 2 cases. All of the specimens were removed through the natural orifices successfully. No case required a diverting ileostomy. No patients were converted to open surgery or to conventional laparoscopy. Complications were reported in three patients. Transanal extractions were performed in 12 cases (10 colonic inertia, 2 polyposis), and transvaginal extractions were performed in 3 cases (2 malignancy, 1 colonic inertia). Both transanal and transvaginal specimen extractions after laparoscopic TC-IRA can be preferred. However, transanal extraction seems to be feasible in cases of TC for benign disease with a limited mesenteric-omental resection. If the indication is a malignancy requiring a mesenteric-omental resection, a transvaginal route should be preferred for a voluminous specimen.

Total abdominal colectomy (TAC) with or without restoration of bowel continuity is commonly performed for inflammatory bowel disease, synchronous colon neoplasia, and inherited or familial polyposis syndromes with increased risk for colon adenocarcinoma. Additional indications include transverse colon malignancies, repeat or reoperative colectomy, large bowel obstruction with toxic megacolon, and functional disorders of the colon such as colonic inertia. This operation can be performed open or laparoscopically, with the operative approach typically influenced by surgeon experience and patient-related factors such as hemodynamic instability, obesity, presence of megacolon, and previous abdominal operations. This chapter reviews the indications and operative steps for laparoscopic total abdominal colectomy.

Aim: The aim of this study is to evaluate the short- and long-term efficacy of sacral nerve stimulation (SNS) for treating slow-transit constipation (STC). Method: This is a retrospective cohort analysis of the efficacy of SNS in treating patients affected by STC, who previously failed to respond to conservative therapies. Only patients free of concomitant diseases were enrolled in our study. A temporary stimulation lead was initially implanted; patients with a > 50% symptom reduction were eventually deemed eligible for a permanent implant. Results: This study enrolled 25 patients who underwent a SNS test stimulation; 21 patients (13 women; median age 32years) eventually got a permanent implant. The median preoperative Cleveland Clinic Constipation Score (CCCS) was 21 (16–25). Preoperative colorectal transit time recorded a median of 10 markers (7–19) retained in the colorectal tract. At 6-month postoperative follow-up, the total number of markers retained in the colorectal tract decreased to 3 (0–4). The CCCS score improved during the first postoperative year (P < 0.001), but progressively worsened over the longer term. The SF-36 questionnaire showed an improvement in all 8 scales measuring physical and psycho-emotional states; all parameters recorded into the bowel diary also improved. Overall, at 60-month follow up, the overall neuromodulator removal rate was 48%. Conclusions: The SNS is a minimally invasive surgical procedure that we tested for treating STC. The short-term outcome was promisingly after 6months; however, there was a declining trend beyond this interval. Thus, the long-term efficacy of SNS needs to be further assessed.

AIM. To evaluate the effectiveness of radiological control of original radiopaque markerspassage through the gastrointestinal tract in the diagnosis of chronic constipation. MATERIALS AND METHODS. In examination of 28 patients with chronic constipation syndrome method of passage the original radiopaque markers through gastrointestinal tract has been used. The markers were non-adhesive and insoluble compounds based on barium sulfate. RESULTS. The specifics of radiopaque markers passage in different severity of chronic constipation, as well as in abnormal architectonics and disposition of the colon in the abdominal cavity has been studied. We noted the peculiarities of radiopaque markers passage in two main patterns of motility disorders: colonic inertia and outlet obstruction. The speed of markers movement, their distribution in the gut, and the timing of the evacuation objectively reflects impaired evacuation function, moreover the method is easy to perform and interpret. CONCLUSION. This method expands the resources of diagnostic methods in chronic constipation and can be considered as an effective tool of functional diagnostics, allowing to make the differentiated approach to selection of the kind of the treatment, and in the case of surgical approach - to choose a range of resection.

Purpose The Oral-anal Transit Test (OTT) is a simple method of obtaining information about colonic transit. We aim to assess the correlation of OTT with the neuromuscular integrity of the colon determined by colonic manometry (CM). Methods All patients who had OTT followed by CM were evaluated. Less than 6 of 24 markers remaining on OTT was considered normal. CM was performed per previously published guidelines. A normal CM was defined as at least one High Amplitude Propagating Contraction progressing from the most proximal sensor through the sigmoid colon. Results A total of 34 patients underwent both OTT and CM (44% male, age 4-18 years, mean 11.5 years, 97% functional constipation +/- soiling, Hirschsprung's Disease). Of normal and abnormal OTT patients, 85.7% (6/7) and 18.5% (5/27) respectively had normal CM. When all markers progressed to at least the sigmoid colon, this was 100% predictive against colonic inertia. Greater than 50% of patients with manometric isolated sigmoid dysfunction had markers proximal to the recto-sigmoid. Conclusion OTT and CM are both valuable studies that assess different aspects of colonic function. OTT can be used as a screening test to rule out colonic inertia. However, the most proximal extent of remaining markers does not predict the anatomical extent of the manometric abnormality, particularly in isolated sigmoid dysfunction.

The aim of this study was to evaluate the published professional association guidelines regarding the current diagnosis and treatment of functional intestinal constipation in adults and to compare those guidelines with the authors’ experience to standardize actions that aid clinical reasoning and decision-making for medical professionals. A literature search was conducted in the Medline/PubMed, Scielo, EMBASE and Cochrane online databases using the following terms: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Conclusively, chronic intestinal constipation is a common condition in adults and occurs most frequently in the elderly and in women. Establishing a precise diagnosis of the physiopathology of functional chronic constipation is complex and requires many functional tests in refractory cases. An understanding of intestinal motility and the defecatory process is critical for the appropriate management of chronic functional intestinal constipation, with surgery reserved for cases in which pharmacologic intervention has failed. The information contained in this review article is subject to the critical evaluation of the medical specialist responsible for determining the action plan to be followed within the context of the conditions and clinical status of each individual patient. Resumo: O objetivo deste trabalho foi avaliar os consensos de sociedade de especialistas e guidelines publicados sobre o diagnóstico e tratamento da constipação intestinal crônica em adultos, e confrontar com a experiência dos autores, a fim de padronizar condutas que auxiliem o raciocínio e a tomada de conduta do médico. Foi realizada busca na literatura científica, mais precisamente nas bases de dados eletrônicos Medline/Pubmed, Scielo, EMBASE and Cochrane, tendo sido utilizado os seguintes descritores: chronic constipation, diagnosis, management of chronic constipation, Roma IV and surgical treatment. Pode-se concluir que constipação crônica é condição comum em adultos, ocorrendo com maior frequência em idosos e mulheres. Identificar com precisão a fisiopatologia presente na constipação crônica funcional é complexo, requerendo a realização de testes funcionais nos casos refratários. O entendimento da motilidade intestinal e do mecanismo defecatório é importante para o manejo da constipação intestinal crônica funcional, sendo o tratamento cirúrgico indicado para casos selecionados, onde à abordagem medicamentosa não surtiu efeito. As informações contidas neste artigo de revisão devem ser submetidas à avaliação e à crítica do médico especialista responsável pela conduta a ser tomada, frente à sua realidade e ao estado clínico de cada paciente. Keywords: Chronic constipation, Outlet obstruction, Colonic inertia, Laxatives, Surgical treatment, Palavras-chave: Constipação crônica, Disfunção do assoalho pélvico, Inércia cólica, Laxativos, Tratamento cirúrgico

Introduction Total colectomy and ileorectal anastomosis can result in significant defecatory frequency and poor bowel function. The aim of this study was to assess whether a laparoscopic approach is associated with any improvement in this regard. Methods A single institution retrospective review was undertaken of patients undergoing elective total colectomy and ileorectal anastomosis between 2000 and 2011. Those undergoing emergency surgery and paediatric surgery were excluded. The primary outcome measure was satisfactory defecatory function after surgery. Results Forty-nine patients (24 male, 25 female) were included in the study. The median age was 48 years (range: 20–83 years). Laparoscopic total colectomy (LTC) was performed in 20 patients and open total colectomy (OTC) in 29 patients. Indications for surgery were slow colonic transit (n=17), colorectal cancer (CRC) (n=17), CRC with hereditary colorectal cancer syndrome (n=8), inflammatory bowel disease (n=4) and diverticular disease (n=3). In the LTC group, 85% had a satisfactory defecatory frequency of 1–6 motions per day compared with 45% in the OTC cohort (p=0.006). There was no statistically significant difference in bowel frequency related to primary pathology (benign vs cancer surgery, p=1.0). Postoperative complications for both groups included relaparotomy (n=3), anastomotic leak (n=2), small bowel obstruction (n=2), postoperative bleeding (n=1) and pneumonia (n=1). Conclusions This study indicates that long-term defecatory function is better following LTC than following OTC and ileorectal anastomosis. The mechanism for this improvement is unclear but it may relate to the underlying reason for surgery or possibly to reduced small bowel handling leading to fewer adhesions after laparoscopic surgery.

Context.— Colonic inertia is a debilitating form of primary chronic constipation with unknown etiology and diagnostic criteria, often requiring pancolectomy. We have occasionally observed massively enlarged submucosal ganglia containing at least 20 perikarya, in addition to previously described giant ganglia with greater than 8 perikarya, in cases of colonic inertia. These massively enlarged ganglia have yet to be formally recognized. Objective.— To determine whether such “massive submucosal ganglia,” defined as ganglia harboring at least 20 perikarya, characterize colonic inertia. Design.— We retrospectively reviewed specimens from colectomies of patients with colonic inertia and compared the prevalence of massive submucosal ganglia occurring in this setting to the prevalence of massive submucosal ganglia occurring in a set of control specimens from patients lacking chronic constipation. Results.— Seven of 8 specimens affected by colonic inertia harbored 1 to 4 massive ganglia, for a total of 11 massive ganglia. One specimen lacked massive ganglia but had limited sampling and nearly massive ganglia. Massive ganglia occupied both superficial and deep submucosal plexus. The patient with 4 massive ganglia also had 1 mitotically active giant ganglion. Only 1 massive ganglion occupied the entire set of 10 specimens from patients lacking chronic constipation. Conclusions.— We performed the first, albeit distinctly small, study of massive submucosal ganglia and showed that massive ganglia may be linked to colonic inertia. Further, larger studies are necessary to determine whether massive ganglia are pathogenetic or secondary phenomena, and whether massive ganglia or mitotically active ganglia distinguish colonic inertia from other types of chronic constipation.

Portal vein thrombosis (PVT) has been recently documented after a variety of laparoscopic surgeries. Although it is well established in splenectomies, its prevalence in other laparoscopic procedures is rare. PVT in colectomies has been associated with inflammatory processes, such as ulcerative colitis and diverticulitis. We report a case of postoperative PVT following a total abdominal colectomy for colonic inertia. A 27-year-old female underwent an uneventful elective laparoscopic total colectomy with ileorectal anastomosis for colonic inertia, and presented on postoperative day (POD) 3 with obstipation, abdominal distention and emesis. Her abdominal pain increased on POD 4 and computed tomography revealed PVT. PVT following laparoscopic surgery is rare in cases not involving the spleen. Although previously seen in colectomies for inflammatory conditions, it can present after colonic inertia. A high index of suspicion should be maintained to diagnosis this rare complication.

Although chronically constipated patients usually respond to medical treatment, there is a subgroup with scarce/no response, generally labeled as refractory or intractable. However, whether this lack of response is real or due to ancillary causes (suboptimal dosage, lack of compliance etc.) is unknown. To see whether a pharmacologic test (bisacodyl colonic intraluminal infusion during manometric assessment) may predict the therapeutic outcome. Data of patients undergoing 24/h colonic manometry for severe intractable constipation in whom the bisacodyl test (10 ml of drug dissolved into saline and injected through the more proximal recording port) had been carried out were retrieved and analysed, and correlations with the therapeutic outcome made. Overall, charts from 38 patients (5 men) were available; of these, only 21% displayed naive high-amplitude propagated contractions (average, less than 2/24 h), mostly meal-induced, during the recordings. A bisacodyl response was present in 31.6% patients, with a mean number of events of 1.8 per patient. After bisacodyl testing, 47.3% patients underwent intensive medical treatment, 44.7% surgery (medical failures), and 8% transanal irrigation, a procedure employed to treat refractory patients. The presence of naive propulsive contractions significantly correlated with the response to bisacodyl infusion (p

Objective: Revision of the state of the art of the knowledge regarding pathophysiology, diagnosis and treatment of Colonic Inertia, which predominantly affects young women and has a significant socio-economic impact. Methods: A search was made in “colonic inertia”, “colon inertia” and “slow transit constipation” in PubMed database for articles of the last 5 years, in Portuguese or English with available abstract and full text. 59 articles and 2013 guidelines of the American Gastroenterological Association on constipation were included. Results: The pathophysiology is not completely elucidated and the reduction of the interstitial cells of Cajal is the most consistent histological finding. Diagnosis requires the exclusion of secondary causes of constipation and obstructed defecation syndrome, to which contribute several complementary diagnostic tests. Given the frequency of failure of the medical treatment, surgery is often the only possible option. Sacral nerve stimulation seems to be a promising therapeutical alternative. Conclusion: A deeper investigation of the pathophysiological mechanisms is fundamental to acquire a more global and integrated vision. Rigorous patient selection for each treatment and the discovery of new therapeutical targets may avoid the use of surgical therapies. Resumo: Objetivo: Revisão do estado da arte do conhecimento da patofisiologia, diagnóstico e tratamento da Inércia Cólica, que afeta predominantemente mulheres jovens e tem um impacto socioeconómico significativo. Métodos: Pesquisou-se na base de dados PubMed por “colonic inertia”, “colon inertia” e “slow transit constipation” por artigos apenas dos últimos 5 anos, em português ou em inglês com resumo e texto completo disponíveis. Incluíram-se 59 artigos e as recomendações de 2013 da Associação Americana de Gastroenterologia para a obstipação. Resultados: A patofisiologia ainda não está completamente esclarecida, sendo que a redução das células intersticiais de Cajal constitui o achado histológico mais consistente. O diagnóstico requer a exclusão de causas secundárias de obstipação e de síndrome de obstrução defecatória, para o qual contribuem vários exames complementares de diagnóstico. Dada a frequência do insucesso do tratamento médico, a cirurgia é, muitas vezes, a única opção possível. A estimulação nervosa sagrada parece ser uma alternativa terapêutica promissora. Conclusão: É fundamental uma investigação mais profunda dos mecanismos patofisiológicos envolvidos para adquirir uma visão mais global e integrada. A seleção rigorosa de pacientes para cada tratamento e a descoberta de novos alvos terapêuticos poderão evitar a utilização de terapêuticas cirúrgicas. Keywords: Constipation, Gastrointestinal motility, Gastrointestinal transit, Palavras-chave: Obstipação, Motilidade gastrointestinal, Trânsito gastrointestinal

Background: Constipation is a common disorder in pediatrics, although the underlying pathogenesis is not fully understood. The current study aimed at evaluating the efficacy of different colonic transit time (CTT) indices for differentiating normal from nonnormal sensation in children with chronic functional constipation identified by anorectal manometry (ARM). Materials and Methods: In this cross-sectional study, 47 children with chronic idiopathic constipation, aged 5–15 years, were studied. The total and segmental CTTs were estimated by administering multiple radiopaque markers for 6 days and performing a single abdominal radiograph on day 7. Anorectal function was evaluated using manometry with an Arhan probe. The predictive value of CTT indices was evaluated by receiver operating characteristic curve analysis. Area under the curve (AUC) along with 95% confidence interval (CI) as well as sensitivity and specificity was calculated. Results: The mean age of the participants was 8.30 ± 2.99 years, with a mean constipation duration of 2.90 ± 0.46; 28 children were identified with nonnormal sensation. The mean values of CTT indices were statistically significantly longer in the nonnormal sensation patients than that in the normal group (P < 0.001). In addition, the mean values of manometry parameters were statistically significantly higher in nonnormal sensation patients than that in normal group (P < 0.01). Among CTT indices, rectosigmoid CTT (AUC [95% CI] =0.999 [0.99–1]; P < 0.001) with sensitivity = 100% and specificity = 94.7% and total CTT (AUC [95% CI] =0.972 [0.93–1] P < 0.001) with sensitivity = 82.3% and specificity = 100% had the highest predictive values for differentiating nonnormal from normal sensation patients. Conclusion: CTT is a simple and noninvasive technique for classifying patients with constipation. It can be used for identifying children suffering from chronic constipation with nonnormal sensation reliably, instead of ARM. Colonic inertia may be a manifestation of global motility dysfunction. Children with delayed distal colonic transits are more likely to have abnormal defecation dynamics.

Objective In adults, colonic manometry and colonic scintigraphy are both valuable studies in discriminating normal and abnormal colonic motility. The objective of this study was to compare the diagnostic yield and tolerability of colonic manometry and colonic scintigraphy in children with severe constipation. Methods Twenty-six children (mean age 11.4 years, 77% boys) who had received colonic manometry and colonic scintigraphy as part of a colonic motility evaluation were included. Manometry was performed as per department protocol. After swallowing a methacrylate-coated capsule containing indium-111, images were taken at 4, 24, and 48 hours, and geometric centers were calculated. Results of both tests were categorized in 3 groups: normal, abnormal function in the distal part of the colon, and colonic inertia. Cohen κ was used for the level of agreement. Patients and parents completed a questionnaire regarding their experience. Results Colonic scintigraphy showed normal transit time in 20%, delay in the distal colon in 48%, and colonic inertia in 32% of patients. Colonic manometry was normal in 40%, abnormal in the distal colon in 40%, and colonic inertia was diagnosed in 20%. The κ score was 0.34. All 5 patients with colonic inertia during manometry had a similar result by scintigraphy. Eighty-eight percent of patients preferred scintigraphy over manometry and 28% of parents preferred colonic manometry over scintigraphy. Conclusions Colonic manometry and colonic scintigraphy have a fair agreement regarding the categorization of constipation. Scintigraphy is well tolerated in pediatric patients and may be a useful tool in the evaluation of children with severe constipation.

This study was performed to evaluate the efficiency of the education programme for prevention of constipation in women. This study was performed as a pre-test-posttest design. Thirty-five women were included who have constipation problem. Data were collected by questionnaire: Constipation Severity Instrument (CSI), Constipation Visual Analogue Scale (CVAS) and Bristol Stool Chart (BSC). Eight home visits were made for each of the women and they were followed up for 3 months. Participants received an individual education programme that included advice on dietary consumption such as pulpy-fibrous nutrient consumption, fluid intake, an exercise regime and counselling about optimal position to defecate. The subscales of 'Colonic Inertia' and 'Pain', and CSI total mean scores and CVAS mean scores were decreased significantly after education programme (P < 0.05). According to the BSC, 71.5% of the women stated their stool form to be 'sausage-shaped, but lumpy' before the education programme, but after the said programme the percentage had dropped to 17.1%. Education programme given to women who had constipation were determined to have been effective in alleviating constipation. Nurses should develop appropriate and effective strategies to help women prevent constipation.

To assess the functional outcomes and quality of life in patients with laparoscopic total colectomy for slow-transit constipation (STC). All patients undergoing laparoscopic colectomy with ileorectal anastomosis for colonic inertia at two referral centers were analyzed. Their preoperative, intraoperative and postoperative details were recorded with a one-year follow-up. Their quality of life was assessed using the SF-36 questionnaire. Between 2004 and 2007, 710 patients were evaluated. Eight female patients (1.1 %) fulfilled the criteria for STC without obstructive defecation syndrome. Their mean age was 38 years ± 15 (range from 22 to 62). The conversion rate was 12.5 %. The morbidity rate was 37.5 %, and mortality was nil. The preoperative abdominal pain was 6.6 ± 0.3 and had decreased to 3.6 ± 2.3 postoperatively (P = 0.008). At 1 year, the defecation frequency per week had increased from 0.84 ± 0.24 to 6.75 ± 3.4 (P = 0.001). Three patients developed nocturnal leakage (37.5 %). Eighty-eight percent of the patients recommend the procedure. All parameters of the SF-36 questionnaire had improved at the one-year follow-up examination. Laparoscopic colectomy for slow-transit constipation is safe and increased the number of evacuations per week. Although nocturnal leakage may occur, these patients experience improvements in their quality of life.

Aim Whether bowel related dysfunction adversely affects postoperative recovery after total colectomy with ileorectal anastomosis (C + IRA) for colonic inertia (CI) has not been previously well evaluated. This study compared the early postoperative outcome of C + IRA for CI and for other noninflammatory indications. Method Patients undergoing elective C + IRA from 1999 to 2010 were identified from a prospectively maintained database. Since inflammation in the rectum or small bowel may influence the outcome, patients with inflammatory bowel disease were excluded. Patients undergoing surgery for CI (group A) were compared with patients having the operation for other benign noninflammatory diseases (group B). Demographics, American Society of Anesthesiologists (ASA) score, body mass index (BMI), surgical procedure and 30-day complications were assessed. Results The study population consisted of 333 patients undergoing elective C + IRA (99 men, mean age 39 ± 16 years). The procedure was laparoscopic in 163 (49%) patients. Groups A (n = 131) and B (n = 202) had similar age and ASA score (39 ± 11 vs 39 ± 19 years, P = 0.4; 2.2 ± 0.5 vs 2.4 ± 0.7). Group A patients had lower BMI (25 ± 5 vs 28 ± 8 kg/m2, P = 0.002), more women (99 vs 51%, P

While most colonic motor activity is segmental and non-propulsive, colonic high amplitude propagated contractions (HAPC) can transfer colonic contents over long distances and often precede defecation. High amplitude propagated contractions occur spontaneously, in response to pharmacological agents or colonic distention. A subset of patients with slow transit constipation have fewer HAPC. In this issue of Neurogastroenterology and Motility, Rodriguez et al. report that anal relaxation during spontaneous and bisacodyl-induced HAPC exceeds anal relaxation during rectal distention in constipated children undergoing colonic manometry. Moreover, and consistent with a neural mechanism, anal relaxation often precedes arrival of HAPC in the left colon. High amplitude propagated contractions are also used to evaluate the motor response to a meal and pharmacological stimuli (e.g., bisacodyl, neostigmine) and to identify colonic inertia during colonic motility testing in chronic constipation. This editorial comprehensively reviews the characteristics, physiology and pharmacology of HAPC, their assessment by manometry, and relevance to constipation and diarrhea.

Aim Chronic constipation is classified as outlet obstruction, colonic inertia or both. We aimed to determine the incidence of isolated colonic inertia in chronic constipation and to study symptom pattern in those with prolonged colonic transit time. Methods Chronic constipation patients were classified radiologically by surgeon-reported defaecating proctography and transit study into four groups: isolated outlet obstruction, isolated colonic inertia, outlet obstruction plus colonic inertia, or normal. Symptom patterns were defined as stool infrequency (twice weekly or less) or frequent unsuccessful evacuations (more than twice weekly). Results Of 541 patients with chronic constipation, 289 (53%) were classified as isolated outlet obstruction, 26 (5%) as isolated colonic inertia, 159 (29%) as outlet obstruction plus colonic inertia and 67 (12%) as normal. Of 448 patients (83%) with outlet obstruction, 35% had additional colonic inertia. Only 14% of those with prolonged colonic transit time had isolated colonic inertia. Frequent unsuccessful evacuations rather than stool infrequency was the commonest symptom pattern in all three disease groups (isolated outlet obstruction 86%, isolated colonic inertia 54% and outlet obstruction plus colonic inertia 63%). Conclusion Isolated colonic inertia is an unusual cause of chronic constipation. Most patients with colonic inertia have associated outlet obstruction. These data question the clinical significance of isolated colonic inertia.

Aim Chronic constipation is classified as outlet obstruction, colonic inertia or both. We aimed to determine the incidence of isolated colonic inertia in chronic constipation and to study symptom pattern in those with prolonged colonic transit time. Methods Chronic constipation patients were classified radiologically by surgeon-reported defaecating proctography and transit study into four groups: isolated outlet obstruction, isolated colonic inertia, outlet obstruction plus colonic inertia, or normal. Symptom patterns were defined as stool infrequency (twice weekly or less) or frequent unsuccessful evacuations (more than twice weekly). Results Of 541 patients with chronic constipation, 289 (53%) were classified as isolated outlet obstruction, 26 (5%) as isolated colonic inertia, 159 (29%) as outlet obstruction plus colonic inertia and 67 (12%) as normal. Of 448 patients (83%) with outlet obstruction, 35% had additional colonic inertia. Only 14% of those with prolonged colonic transit time had isolated colonic inertia. Frequent unsuccessful evacuations rather than stool infrequency was the commonest symptom pattern in all three disease groups (isolated outlet obstruction 86%, isolated colonic inertia 54% and outlet obstruction plus colonic inertia 63%). Conclusion Isolated colonic inertia is an unusual cause of chronic constipation. Most patients with colonic inertia have associated outlet obstruction. These data question the clinical significance of isolated colonic inertia.

Purpose The aim of this study was to evaluate outcomes of a total colectomy with ileorectal anastomosis in patients with slow transit constipation. Methods A retrospective review of 37 consecutive patients with slow transit constipation who underwent a total colectomy between 1994 and 2008 was undertaken. Preoperative and postoperative Wexner's constipation scores were collected and used to evaluate the outcomes after surgical treatment. Also patients' postoperative satisfaction scores were collected using a 4-point scale. Results The 37 patients consisted of 31 women and 6 men, with a median age of 41 years (range, 17 to 71 years). Pre- and post-operative Wexner's scores were collected from 33 patients (89.1%), and the mean preoperative Wexner's score was 19.3 (range, 11 to 24), which decreased to an average post-operative score of 2.3 (range, 0 to 8). Neither intraoperative complications nor postoperative mortalities were noted. Five patients (13.5%) had early postoperative complications, and the most common complication was postoperative ileus (10.8%). Seven patients (18.9%) had late postoperative complications, and postoperative ileus (10.8%) was also the most common. Twenty seven of 33 patients were satisfied with their surgical outcome (81.8%). Conclusion A total colectomy with ileorectal anastomosis might be an effective surgical procedure with acceptable morbidity to treat medically intractable slow transit constipation.

The Colonic manometry is an important technique to evaluate human colonic motor functions, which are critical for doctors to understand the pathology of intestinal diseases like slow transit constipation (STC) and colonic inertia (CI). However, in the obtained pressure signals, several patterns of colonic motor activities as well as noises mixed together, which made it difficult to observe the information people really needed. In this article, a new method was proposed to extract patterns of colonic motility from the mixed signals, so that researchers could study them thoroughly. Colonic pressure recordings from 26 volunteers were obtained by the water-perfused manometry catheters. Then independent component analysis (ICA) was introduced, which successfully separated colonic motility patterns and noises into four independent components. And according to the rhythm of contractions examined by ICA, subjects' colonic motility could be divided into three types: regular rhythm (12 subjects), slow rhythm (8 subjects) and disordered (6 subjects), which exactly accorded with their original diagnosis.

Made available in DSpace on 2019-09-11T20:58:47Z (GMT). No. of bitstreams: 0 Previous issue date: 2008 INTRODUÇÃO: A constipação intestinal é um distúrbio do trato digestório em que a atividade intestinal está reduzida, assim como a freqüência de evacuações; associada a fezes secas e endurecidas, acumuladas devido ao longo tempo de permanência no cólon. OBJETIVO: Avaliar quatro pacientes submetidos à colectomia total para o tratamento da constipação intestinal. MÉTODO: Estudo retrospectivo realizado por meio do levantamento de prontuários de pacientes submetidos à ressecção cirúrgica do cólon no tratamento da constipação intestinal crônica no período de 1998 a 2006. RESULTADOS: Em nossa casuística, que envolve o HUT e uma paciente operada no Hospital São Lucas de Taubaté, quatro pacientes foram submetidos à colectomia total para o tratamento da constipação intestinal crônica. Todos eram do sexo feminino, com mais de 30 anos de idade e apresentavam uma evolução do quadro há mais de 10 anos. Os resultados obtidos foram considerados satisfatórios por três pacientes, apesar de uma delas evacuar seis ou mais vezes ao dia. A quarta paciente referiu permanência do quadro, evacuando uma vez a cada sete dias, em média. CONCLUSÃO: O tratamento cirúrgico é uma alternativa nos casos crônicos incapacitantes, refratários a outras formas de tratamento. Os pacientes com indicação cirúrgica devem antes ser submetidos a uma evolução fisiológica e investigação clínica completa, para confirmação do quadro de inércia colônica. INTRODUCTION: The intestinal constipation is a disturb of the alimentary tract in which its activity is reduced, as well as the frequency of evacuations; associated to dry and hardened excrements witch accumulate because of the long permanence in colon. OBJECTIVE: To evaluate four patients submitted to the total colectomy for the treatment of the intestinal constipation. METHOD: Retrospective study carried through by the analysis of handbooks of patients submitted to the surgical removal of colon in the treatment of the chronic intestinal constipation, in the period of 1998 the 2006. RESULTS: In our casuistry, that involves the HUT and a patient operated at Taubaté's São Lucas Hospital, four patients were submitted to total colectomy for treatment of chronic intestinal constipation. They were all of the feminine sex, with more than 30 years of age and presented more than 10 years of evolution. The results were considered satisfactory by three patients, although one of them evacuate six or more times in a day. The fourth patient related the permanence of the constipation, defecating a time to each seven days, on average. CONCLUSION: The surgical treatment is an alternative in the incapacities chronic cases refractory to other forms of treatment. The patients with surgical indication must be submitted to a physiological evolution and complete clinical inquiry, to confirm of the colonic inertia. [Uemura, Lívia Alkmin] Universidade de Taubaté, Brazil César, Maria Auxiliadora Prolungatti; Passos, Mariah Prata Soldi; Bassi, Deomir Germano; Paula, Pedro Roberto De] Universidade de Taubaté, Brazil

Submitted by Guilherme Lemeszenski (guilherme@nead.unesp.br) on 2013-08-22T18:47:04Z No. of bitstreams: 1 S0004-28032008000100011.pdf: 194978 bytes, checksum: c29f296fcf702fa32c429f3f6a905880 (MD5) Made available in DSpace on 2013-08-22T18:47:04Z (GMT). No. of bitstreams: 1 S0004-28032008000100011.pdf: 194978 bytes, checksum: c29f296fcf702fa32c429f3f6a905880 (MD5) Previous issue date: 2008-03-01 Made available in DSpace on 2013-09-30T19:36:45Z (GMT). No. of bitstreams: 2 S0004-28032008000100011.pdf: 194978 bytes, checksum: c29f296fcf702fa32c429f3f6a905880 (MD5) S0004-28032008000100011.pdf.txt: 36376 bytes, checksum: 583d350add3750c90f391d02de5e8690 (MD5) Previous issue date: 2008-03-01 Submitted by Vitor Silverio Rodrigues (vitorsrodrigues@reitoria.unesp.br) on 2014-05-20T13:32:59Z No. of bitstreams: 2 S0004-28032008000100011.pdf: 194978 bytes, checksum: c29f296fcf702fa32c429f3f6a905880 (MD5) S0004-28032008000100011.pdf.txt: 36376 bytes, checksum: 583d350add3750c90f391d02de5e8690 (MD5) Made available in DSpace on 2014-05-20T13:32:59Z (GMT). No. of bitstreams: 2 S0004-28032008000100011.pdf: 194978 bytes, checksum: c29f296fcf702fa32c429f3f6a905880 (MD5) S0004-28032008000100011.pdf.txt: 36376 bytes, checksum: 583d350add3750c90f391d02de5e8690 (MD5) Previous issue date: 2008-03-01 RACIONAL: Pacientes com constipação funcional que não melhoram com suplementação de fibras dietéticas, representam importante problema clínico. OBJETIVOS: Avaliar as relações entre as quantidades de fibras ingeridas, intensidade da constipação e o tempo de trânsito colônico em pacientes com constipação funcional. MÉTODOS: Foram avaliados 30 pacientes constipados funcionais, sem melhoras após suplementação dietética com fibras e 18 pessoas controle, sadias, sem queixas digestivas, utilizando inquéritos individuais quanto à ingestão de fibras e a intensidade da constipação e, por meio da técnica dos marcadores radiopaco, o tempo de trânsito colônico, total e segmentar. RESULTADOS: Apesar da maior ingestão diária de fibras (26,3 ± 12,9 g, constipados x 9,3 ± 5,2 g, controles), os sintomas da constipação mostraram-se intensos nos constipados (escore médio = 21,3 ± 4,07). O tempo normal para o trânsito colônico foi de 58,8h. O trânsito colônico total, em média, foi mais lento nos constipados (41,0 ± 22,8h, constipados x 21,8 ± 18,5h, controles). Constipados com trânsito lento (>58,8h) apresentaram inércia colônica (oito), obstrução de saída (um) e lentificação no cólon esquerdo (um). Constipados com trânsito normal (58.8h) there were colonic inertia (eight), outlet constipation (one) and slow transit in left colon (one), and among constipated patients with normal colonic transit (

OBJECTIVE. The objective of our study was to evaluate the feasibility and efficacy of a radiologic technique in increasing colon visibility in colonic transit time studies. Three radiologists counted segmental colonic radiopaque markers in two patient groups, based on classic criteria in the first group and also on a colonic barium trace in the second. Agreement between marker counts was assessed using method comparison analysis.CONCLUSION. With the barium trace technique, the anatomic conspicuity of colonic segments is improved, a correct segmental marker count can be obtained, and colonic inertia can be more easily distinguished from distal constipation.

Little is known about how obstructive defecation and colonic inertia symptoms contribute to constipation-related quality of life.We sought to characterize the differences in quality of life in patients with severe obstructive defecation and colonic inertia symptoms.This study was a cross-sectional analysis of a prospective database.Patients were enrolled at a single tertiary referral center.We included consecutive adults with severe symptoms of obstructive defecation (n = 115) or colonic inertia (n = 90) as measured by the Constipation Severity Instrument.The primary outcomes measured were the Pelvic Floor Distress Inventory, Constipation-Related Quality of Life instrument, Pelvic Floor Impact Questionnaire, and 12-item Short Form Health Survey.Although physical examination and anorectal physiology testing were similar between groups, patients with severe obstructive defecation symptoms reported worse pain, distress, and constipation-specific quality of life than patients with severe colonic inertia symptoms (all p0.001). Specifically, patients with severe obstructive defecation symptoms showed greater quality-of-life impairment related to eating, bathroom habits, and social functioning (all p ≤ 0.01). Furthermore, patients with severe obstructive defecation symptoms had inferior global quality of life on the 12-item Short Form Health Survey physical component score (p = 0.03) and mental component score (p = 0.06).The use of patient self-report instruments resulted in a proportion of patients with incomplete data.Quality of life was impaired in both groups of patients; however, patients with severe obstructive defecation symptoms were affected to a significantly greater extent. The fact that there were no differences in objective findings on physical examination or anorectal physiology studies highlights the importance of assessing quality of life during the evaluation and treatment of constipated patients.

Objetivo: presentar una visión general de los tratamientos actuales para el estreñimiento con técnicas basadas en la estimulación eléctrica directa o indirecta del colon. Fuente: la búsqueda se realiza en PubMed, Science Direct e ISI Web of Knowledge usando palabras clave: estimulación eléctrica del colon, estreñimiento. Se consideraron los estudios en humanos y los estudios experimentales cuyo objetivo era intervenir los patrones de motilidad del colon en niños y adultos con estas técnicas. Principales conclusiones: el estreñimiento es parte de los trastornos de la motilidad gastrointestinal. Es una patología de etiología multifactorial, con grave impacto sobre la calidad de vida en los casos resistentes a la terapia convencional. La cirugía, que se utiliza en los casos más graves, no está exenta de complicaciones y los resultados están lejos de curar a los enfermos. Algunos medicamentos han sido eficaces en la enfermedad leve, aunque en los casos graves no se ha demostrado su utilidad. Otras estrategias han sido desarrolladas e incluyen estimulación eléctrica del colon con diferentes metodologías, con el objetivo de aumentar la motilidad del órgano. Se hace una extensa revisión de la literatura disponible como punto de partida para enfocar los esfuerzos por realizar. Conclusión: la estimulación eléctrica en pacientes con estreñimiento severo es una terapia prometedora para lograr, desde el punto de vista fisiológico, el restablecimiento de la función del colon, en busca de la menor invasión posible en este grupo de pacientes. Objective: The objective of this study is to present an overview of current treatments for constipation based on techniques to directly or indirectly stimulate the colon electrically. Sources: This study is based on searches of PubMed, ScienceDirect.com, and ISI Web of Knowledge using the keywords electrical stimulation of the colon and constipation. We considered studies of these techniques in humans and experimental studies aimed at intervening in colon motility patterns in children and adults. Principal Conclusions: Constipation is a disorder of gastrointestinal motility. Its etiology is multifactorial etiology, it has severe impacts on patient quality of life, and it is resistant to conventional therapy in many cases. Surgery, used in the most severe cases, has the risk of complications and the results are far from what is needed to cure the patients. Some drugs have been effective for treating milder cases, but have not been proven useful for more severe cases has. Other strategies have been developed to increase motility including various methods of electrical stimulation of the colon. This extensive review of the available literature is a starting point for focusing additional efforts in this area. Conclusion: Electrical stimulation of patients with severe constipation is a promising therapy to achieve restoration of colon function from the physiological point of view in the least invasive manner possible.

A large proportion of patients with constipation presenting in tertiary care practice have refractory constipation in whom the primary treatment such as lifestyle modification, osmotic laxative and fibre has failed. A considerable number of these patients may be suffering from colonic and anorectal motility disorders such as slow colonic transit, faecal evacuation disorder or a combination of these. In a study from a tertiary care centre in Thailand, of 103 patients with chronic constipation, 30, 14, 11 and 48 patients were diagnosed to have anorectal dysfunction, colonic inertia, anorectal dysfunction with colonic inertia, and normal transit constipation, respectively [1]. In a retrospective study from our centre, of 130 patients with chronic constipation referred for anorectal physiological testing, 46 % had abnormal anorectal manometry and 35 % abnormal balloon expulsion test, and 17 % of 48 patients undergoing defaecography had abnormal results suggesting faecal evacuation disorder (unpublished data). In another recent Indian study, of 99 patients with primary chronic constipation, 46, 15 and 40 had normal transit, slow transit constipation, and faecal evacuation disorder, respectively [2]. It is important to understand these pathophysiological mechanisms to treat these patients effectively. Faecal incontinence, another motility abnormality of the anorectum, is not reviewed here.

Total abdominal colectomy (TAC) with ileorectal anastomosis represents the procedure of choice in patients with colonic inertia and relieves constipation in the majority of patients. The aim of this study was to assess postoperative long-term health related quality of life in these patients in relation to their functional outcome.A consecutive series of patients with isolated colonic inertia who underwent TAC between 1993 and 1999 was identified from a clinical database and investigated in a cohort outcome study. Functional variables including the weekly number of bowel movements (BM), abdominal pain, bloating and distension, fecal incontinence, and the use of medications for BM assistance were assessed preoperatively and postoperatively. Main outcome measure was health-related quality of life assessed at follow-up using the SF-36 Health Survey.A total of 17 women with a mean age of 47.8 years (SD=14.3 years) were assessed and were followed postoperatively for 58.3+/-27.3 months. Preoperatively, all patients were constipated with less than one bowel movement per week, used laxatives, and experienced abdominal pain, bloating and distension. Postoperatively, all patients had some relief of constipation symptoms, with 3.7+/-2.8 bowel movements/day; 41% complained of abdominal pain, 65% of bloating, 29% required BM assistance, and 47% had occasional incontinence to gas or liquid stool. The SF-36 scores were significantly lower than those of the general population (p0.005). In univariate regression analysis, postoperative abdominal pain was predictive for lower scores in general health and vitality and the need for BM assistance for lower scores in physical role functioning, social functioning, and emotional role limitations.After TAC, quality of life is significantly reduced in patients with colonic inertia despite successful relief of symptoms of constipation. Postoperative pain and functional impairment are predictive of lower quality of life scores.

Colonic response to food is possibly abnormal in constipation. The colonic response to food was evaluated in 323 patients and 60 healthy subjects by following the movements of radiopaque markers after ingestion of a standard 1,000-cal test meal. Constipated patients were divided into four groups: one with a normal, and three with a delayed colorectal transit time. When the delay was found mainly in the ascending colon, the group was labeled as suffering from “colonic inertia”. In “hindgut dysfunction”, the delay was predominantly found in the descending colon, whereas the term “outlet obstruction” was reserved for constipated patients whose major site of delay was the rectosigmoid area. Colonic response to food was quantified by evaluating the variation of markers in a given abdominal region and the evolution of the geometric center on the entire plain film of the abdomen. Emptying of the caecum-ascending colon and filling of the rectosigmoid area characterize the colonic response to food in healthy subjects. Constipated patients also filled the rectosigmoid, but different patterns were found in the colon. In constipated patients with transit in the normal range, there was a frequent (41%) absence of colonic response to food as compared to controls (13%) and constipated patients with delayed transit (p

症例は21歳,女性. Colonic inertiaの診断にてストーマサイトから無気腹で1孔式腹腔鏡補助下回腸人工肛門造設術を施行した.手術時間は21分,出血量は少量であった.術後経過は良好で,術後1日目経口摂取開始.術後15日目に退院となった.腹部膨満感や腹痛は消失あるいは軽減し,術後3カ月で体重は5kg増加した.ストーマサイト以外の術創はなく患者の満足度も高かった.われわれの施行した術式では特別な処置器具は必要とせず安全に簡単に短時間で施行でき美容的にも優れ,特に若年女性には有用と思われた.またcolonic inertiaに対する症状改善効果と大腸全摘などの術後の機能評価予測のためのminimum invasive surgeryとしても有用と思われた.

We recently defined the sites of four colonic pacemakers that appear to generate the electric waves assumed to be responsible for the colonic motility. We hypothesized that a dysfunction of one or more of these pacemakers might interfere with the generation of electric waves and the colonic motility. This hypothesis was investigated in the current communication. The tests were performed during the repair of huge incisional hernia of 8 subjects (5 F, 3 M; mean age 42.8 +/- 3.3 SD years). Two electrodes were applied to each of the terminal ileum (TI), cecum (C), and ascending (AC), transverse (TC), descending (DC), and sigmoid (SC) colon. The electric activity of the TI and the various colonic segments was recorded using surface silver-silver chloride electrodes applied to the colon. The site of change of the wave variables between the TI and the C and between the different other colonic segments was determined by changing the position of the electrodes placed over the segments to be examined. Presumably, the sites where the wave variables changed represent the potential location of the pacemakers. We anesthetized these sites individually by injection of 2% Xylocaine, and then recorded the electric activity after 20 min in all the subjects and after 2 h in only 5 subjects. Electric waves in the form of pacesetter and action potentials were recorded from the TI and the colon. The sites of potential pacemakers could be defined at the ileocecal and cecocolonic junctions, at the mid third of the TC, and at the colosigmoid junction. Anesthetization of the cecal pole resulted in disappearance of the cecal electric waves, with persistence of the waves from the other colon segments. Anesthetization of the cecocolonic junction eliminated the electric waves of the AC and the right half of the TC, while the waves in the rest of the colon persisted. The remaining two pacemaker sites produced similar results when anesthetized. The electric waves reappeared after the anesthetic effect had waned. Thus, the colon possesses at least four pacemakers that appear to mediate the colonic motor activity. Individual pacemaker block by anesthetization effected disappearance of electric waves in the relative colonic segment, which reappeared after waning of the anesthetic effect. The disappearance of these waves upon pacemaker anesthetization supports a relationship between the pacemakers at the anesthetized site and the electric waves. The electric waves seem to be generated by these pacemakers. We suggest that colonic inertia, segmental or total, results from the dysfunction of one or more pacemakers, and that an artificial pacemaker could be applied for the treatment of such conditions. These suggestions need to be further studied.

PURPOSE: Serotonin regulates colonic motility via receptors expressed on neural fibers and smooth muscle. Colonic inertia is characterized by delayed colonic transit. Abnormalities in serotonin receptor protein, as judged by immunoreactivity levels, could contribute to the origin of colonic inertia. The aim of this study was to investigate the expression of serotonin receptor(s) immunoreactivity in the left colon of patients with colonic inertia compared with controls. METHODS: Sixteen patients who underwent subtotal colectomy for colonic inertia were assessed. Colonic transit time was measured with the radiopaque marker technique and presented as the number of retained markers in the colon on Day 5. The control group consisted of 18 patients who underwent left hemicolectomy for colonic carcinoma; histologically normal tissues from the left colon were used. Immunohistochemical staining for serotonin receptor was performed with a rabbit anti-idiotypic antibody. The average positive area (square pixels) in the mucosa, muscularis mucosa, submucosa, and circular and longitudinal muscles per microscopic field (63×) was calculated based on measurement of the positively stained area in 20 randomly chosen microscopic fields in each related structure. The Scion Image computer analysis system was used. RESULTS: Serotonin receptor(s) immunoreactivity was mainly detected in the muscular mucosa, circular muscles, and longitudinal muscles and rarely in the mucosa and submucosa. In muscularis mucosa and circular muscle, the positive areas were significantly less in the colonic inertia group than in controls (muscularis mucosa: 29.1 ± 10.8 vs. 109.7 ± 28.2, P < 0.05; circular muscle: 25.6 ± 6.2 vs.90.2 ± 19.1, P < 0.01). There were significantly positive correlations in the control group in serotonin receptor(s) immunoreactivity levels between circular muscle and longitudinal muscle (r = 0.54, P < 0.05) and between muscular mucosa and longitudinal muscle (r = 0.57, P < 0.05) but not in colonic inertia patients. In addition, the positive areas in the circular muscle were positively correlated to the colonic transit time (Spearman’s rank correlation, 0.83; P < 0.01). CONCLUSION: In colonic inertia patients, the serotonin receptor(s) immunoreactivity level is lower in muscular mucosa and circular muscle. The absence of a correlation of serotonin receptor(s) immunoreactivity in the muscular mucosa and muscularis propria in the patient group implies that an uncoordinated expression of serotonin receptors may also contribute to colonic inertia. However, the positive correlation between serotonin receptor(s) immunoreactivity levels in the circular muscle and the transit time observed in colonic inertia patients suggests a decrease in stimulatory subtypes and at the same time an increase in inhibitory subtypes of serotonin receptors in this tissue.

患者は37歳,男性.軽度の精神発達遅延を合併. 30歳時より便秘にて投薬を受けていたが腹部膨満が出現するようになり,近医にて巨大結腸症と診断され,精査加療目的にて当科紹介.直腸肛門内圧検査では異常を認めず,直腸肛門反射も正常であった.血液検査より甲状腺機能低下症,ポルフィリン症も否定され,精神,神経疾患も否定された.排便造影では排便機能障害を認めなかった.消化管運動機能検査にて,大腸のtransit timeが96時間以上と延長しておりcolonic inertiaと診断された.手術は大腸亜全摘,腹膜翻転部直上での回腸直腸吻合術(IRA)を行った.術後3カ月目の現在,排便回数は1日3回,便秘症の再発を認めない.

The purpose of this study was to determine the long-term outcome of patients who had previously undergone subtotal colectomy for severe idiopathic constipation at the University of Florida between 1983 and 1987. In addition, we aimed to determine whether preoperative motility abnormalities of the upper gastrointestinal tract are more common among those patients who have significant postoperative complications after subtotal colectomy. We evaluated 13 patients who underwent subtotal colectomy for refractory constipation between 1983 and 1987 at the University of Florida. Preoperatively, all patients exhibited a pattern consistent with colonic inertia as demonstrated by means of radiopaque markers. Each patient was asked to quantitate the pain intensity and frequency of their bowel movements before and after surgery. In seven patients an ileosigmoid anastomosis was performed, whereas in six patients an ileorectal anastomosis was used. Abdominal pain decreased after subtotal colectomy. Patients with abnormal upper gastrointestinal motility preoperatively experienced greater postoperative pain than those with normal motility regardless of the type of anastomosis. In addition, the number of postoperative surgeries was similar in those patients with abnormal upper motility compared to those with normal motility. Overall, the total number of bowel movements per week increased from 0.5 +/- 0.03 preoperatively to 15 +/- 4.5 (P0.007) postoperatively. The results of our study suggest that patients with isolated colonic inertia have a better long-term outcome from subtotal colectomy than patients with additional upper gastrointestinal motility abnormalities associated with their colonic inertia.

AIM: To evaluate differences in distribution, density and staining intensity of enterochromaffin cells (EC) and serotonin cells (SC) in the colonic mucosa of patients with colonic inertia (CI), idiopathic diarrhoea (ID) and a control group. METHODS: Three groups were studied: 19 patients' colons after subtotal colectomy for CI, and 17 patients' biopsies for diarrhoea (>3 bowel movements/day) with histological findings of normal mucosa (excluding microscopic, eosinophillic and collagenous colitis). The third group included 15 patients who underwent colonoscopy and biopsy for indications other than constipation, inflammatory bowel disease, diarrhoea or neoplasm (control group). Specimen blocks were obtained in each case from the right and left colon. Immunohistochemical staining for EC and SC were done on 4 micro m sections from Hollandes fixed, paraffin embedded tissues with primary rabbit antibody against chromagranin A or serotonin, and biotynylated secondary antibody and enzyme labelled streptavidin. RESULTS: The number of EC in the mucosa of the left colon in patients with CI (16.8 +/- 10.2) and ID (19.9 +/- 9.7) were significantly higher than they were on the right side (CI: 9.4 +/- 6.0, ID: 12.1 +/- 5.3). However, there were no significant differences between the left and right sides in the control group (L: 10.3 +/- 5.3; R: 13.4 +/- 7.6). Although the quantity of EC in the left colon in both patients with CI (P < 0.05) and ID (P < 0.01) were significantly higher than in the controls, there was no significant difference between CI and ID. In both the right and left colon, the percentage of EC with low positive density was significantly higher (P < 0.01) while those cells with moderate or low staining intensity were significantly lower in patients with CI than in either patients with ID or control group. In patients with CI, the quantity of SC in the mucosa of the left colon (12.1 +/- 6.4) was higher than in the right (CI: 7.9 +/- 3.6; control 4.6 +/- 3.3; ID 4.6 +/- 2.9) (P = 0.0057). In contrast there was no significant difference in SC in either the ID or control groups. The quantity of SC in both sides of the colon was significantly higher both in patients with CI as compared to the control group (P < 0.01) and patients with CI vs. patients with ID (L = P < 0.01; R = P < 0.05). There was a significantly positive correlation between the numbers of EC and SC in patients with CI (L: r = 0.5425, P < 0.05; R: r = 0.745, P < 0.01). CONCLUSION: In patients with CI, EC increases possibly due to an increase in SC. Conversely, in patients with ID, the EC increase results from peptides other than SC. Our results suggest that different aetiological factors contribute to ID and CI.

Colonic motility is modulated by the 5-hydroxytryptamine (5-HT)3-dependent gastrocolonic response and 5-HT3-independent peristaltic reflex. We compared descending colon tone responses to antral distension, duodenal lipid perfusion, and colonic distension after double-blind placebo or granisetron in 13 healthy volunteers and nine slow-transit constipated patients. Antral distension (100–300 ml) and duodenal lipids (3 kcal/min) evoked increases in colon tone in volunteers, which were blunted in constipated patients ( P < 0.05). Granisetron (10 μg/kg) reduced responses to antral distension and lipids in volunteers and to lipids in constipated patients ( P < 0.05). The ascending contraction of the peristaltic reflex was blunted in constipated patients ( P < 0.05), whereas descending responses were similar. Granisetron did not modify the peristaltic reflex. Colonic responses to bethanechol were similar in patients and volunteers. In conclusion, antral distension- and duodenal lipid-activated gastrocolonic responses and ascending contractions of the peristaltic reflex are impaired with slow-transit constipation with loss of both 5-HT3-dependent and -independent function. Thus abnormalities of neural reflex modulation of colonic motor function may play pathophysiological roles in slow-transit constipation.

The diagnosis of slow transit functional constipation is based upon diagnostic testing of patients with idiopathic constipation who responded poorly to conservative measures such as fiber supplements, fluids, and stimulant laxatives. These tests include barium enema or colonoscopy, colonic transit of radio-opaque markers, anorectal manometry, and expulsion of a water-filled balloon. Plain abdominal films can identify megacolon, which can be further characterized by barium or gastrografin studies. Colonic transit of radio-opaque markers identifies patients with slow transit with stasis of markers in the proximal colon. However, anorectal function should be characterized to exclude outlet dysfunction, which may coexist with colonic inertia. Because slow colonic transit is defined by studies during which patients consume a high-fiber diet, fiber supplements are generally not effective, nor are osmotic laxatives that consist of unabsorbed sugars. Stimulant laxatives are considered first-line therapy, although studies often show a diminished colonic motor response to such agents. There is no evidence to suggest that chronic use of such laxatives is harmful if they are used two to three times per week. Polyethylene glycol with or without electrolytes may be useful in a minority of patients, often combined with misoprostol. I prefer to start with misoprostol 200 mg every other morning and increase to tolerance or efficacy. I see no advantage in prescribing misoprostol on a TID or QID basis or even daily because it increases cramping unnecessarily. This drug is not acceptable in young women who wish to become pregnant. An alternative may be colchicine, which is reported to be effective when given as 0.6 mg TID. Long-term efficacy has not been studied. Finally, biofeedback is a risk-free approach that has been reported as effective in approximately 60% of patients with slow transit constipation in the absence of outlet dysfunction. Although difficult to understand conceptually, it is worth attempting and certainly so in patients with associated pelvic floor dyssynergia. Subtotal colectomy with ileorectal anastomosis is often effective in those patients with colonic inertia, normal anorectal function, and lack of evidence of generalized intestinal dysmotility. However, morbidity is significant both early and late in the disease process and must be balanced against current disability. Ileostomy is preferred in the presence of anorectal dysfunction or with associated impairment of continence mechanisms. Similar considerations apply to the patient with disabling functional megacolon. An alternative approach is ileostomy with disconnection of the colon, which is more acceptable to some patients who may hope for future reconnection if recovery occurs. An additional alternative approach for patients with colonic inertia or megacolon who are not good surgical risks is tube cecostomy (or in children, use of the appendix as a conduit to the cecum). This permits either decompression (in megacolon) or antegrade enemas (in colonic inertia). Our surgeons are not enthusiastic about this approach, and I have little experience with it. In general, the use of partial resections of the colon should be discouraged, because marker studies do not define pathophysiology in patients with slow transit constipation.

Megacolon is a condition that is not uncommon in the cat. Most cases are idiopathic (a cause cannot be determined), and these seem to be a result of colonic inertia. Pelvic fracture malunions are the next most common cause and result in a pelvic outlet obstruction. Total or subtotal colectomy offers good long-term results in cases of idiopathic megacolon and chronic cases of pelvic fracture malunion, and the technique is described in detail.

We have recently demonstrated that the colon possesses at least 4 pacemakers which presumably generate electric waves and that colonic pacing evokes electric activity in colonic inertia. We tested the hypothesis that electric waves produced by artificial colonic pacing in colonic inertia patients may initiate colonic motilitiy and effect evacuation. 17 patients with constipation due to total colonic inertia were divided into 2 groups: 10 (age 45.6 ( 6.3 years, 7 women) in the study group and 7 (age 43.7 ( 5.8 years, 5 women) as controls. 7 healthy volunteers were included in the study. Colonic pacing was tested at 2 sites of pacemakers: mid-transverse colon and colosigmoid junction. A stimulating electrode was hooked to the colonic mucosa at the pacemaker site and 2-3 recording electrodes distally to it. Healthy volunteers showed resting electric waves in the form of pacesetter and action potentials which increased significantly on colonic pacing. Inertia patients exhibited no basal electric activity. Colonic pacing in the study group evoked electric waves and caused expulsion of small volume balloon. Balloon distension at pacemaker site produced mass movement of balloon, while away from pacemaker site step-wise movement. In conclusion, colonic pacing evoked electric waves in colonic inertia patients and effected balloon expulsion. We postulate that the pacemaker generates electric waves which spread along pacemaker branches that are composed of interstitial cells of Cajal and nerve fibers of the enteric nervous plexus and effect colonic mass contraction. Ex-pacemaker stimulation presumably leads to local activation of interstitial cells of Cajal and segmental step-wise contraction.

Colonic inertia, total or segmental, is a known cause of constipation, yet its etiology is poorly understood and its treatment not satisfactory. Although the colonic electric activity has been studied by many investigators, the colonic pacemakers that are assumed to generate the electric waves, are scarcely addressed and their location, to our knowledge, has not been determined. The current communication investigates the possible sites of the colonic pacemakers, aiming at a better understanding of the mechanism of colonic motility and its disorders, notably colonic inertia. The tests were performed during the repair of huge incisional hernia in 12 subjects (mean age 37.7 +/- 10.2 years, 7 women). Monopolar silver-silver chloride electrodes were applied to the terminal ileum (TI) and cecum (C), and to the ascending (AC), transverse (TC), descending (DC) and sigmoid colon (SC); they were fixed by electrode gel to the ileal and colonic serosa. The electric activity of each of the TI, C, AC, TC, DC and SC was recorded. Electric waves in the form of slow waves or pacesetter potentials and action potentials were recorded from the TI and colon. Differences in the frequency, amplitude and conduction velocity of the waves occurred between the TI and the various segments of the colon. The change in the wave variables between the TI and C occurred at the ileocecal junction, between the C and AC at the cecocolonic junction, the AC and TC at the mid third of the TC and the DC and SC at the colosigmoid junction. The colonic electric waves are suggested to be generated by at least 4 pacemakers, which are presumably located at the ileocecal junction, the cecocolonic junction, the mid third of TC and at the colosigmoid junction. The electric waves appear to be responsible for conducting the colonic motor activity. We postulate that disordered colonic pacemakers may produce segmental or total colonic inertia, a proposition that needs further investigation.

“Fast-track” or “enhanced recovery” programs have become paramount in the treatment and care of patients undergoing colorectal surgery. This strategy is divided in three important elements: preoperative, intraoperative, and postoperative care. Of these, the use of laparoscopy has become essential in the reduction of postoperative physiologic stress, morbidity, and reduced hospital length of stay. Surgery remains the only definite treatment in our armamentarium against ulcerative colitis (UC) and laparoscopic restorative proctocolectomy with ileoanal pouch anastomosis (RPC-IPAA) its most attractive alternative. Total colectomy with ileorectal anastomosis also referred to as subtotal colectomy with primary anastomosis may be performed on patients with the attenuated form of familial adenomatous polyposis (FAP) or MUTYH-associated polyposis (MAP) and patients with colon cancer associated with hereditary nonpolyposis colorectal cancer (HNPCC), synchronous colon cancer, or an obstructing mass causing severe dilation of the proximal colon. Other cases include colonic inertia as well as lower gastrointestinal (LGI) bleeding. This chapter will focus on the aforementioned procedures and will review some of the literature supporting their use.

We present a 50-year-old male who suffered from ischemic bowel disease, having undergone massive resection of small intestine and ileocecal valve. He had to cope with 40 cm proximal jejunum and 70 cm distal colon remaining. In the postoperative period parenteral nutrition (PN) was used immediately for nutrition support and electrolyte imbalance correction. We gave him home PN as regular recommendation for the short bowel status after discharge from hospital. This patient has tolerated regular oral intake 2 months later and did not develop significant short bowel syndrome. There were several episodes of venous access infection which troubled this patient and admitted him for treatment during home PN. Therefore, we changed home PN to cyclic tapering pattern. The patient could maintain his nutrition and hydration with oral intake alone after tapering home PN 15 months later. He has survived more than one year without PN support and still maintained 80% ideal body weight with average albumin of 3.5 ± 0.2 mg/dL. Although patient was hospitalized every two months to supplement nutrients, however, this has greatly improved the quality of life.

Colonic inertia and chronic functional megacolon represent two relatively uncommon disorders of colonic motility. In both disorders, there is evidence of disintegration of the neuroenteric system which governs colonic motor function and in the latter, there is (in addition) atrophy of the collagenous connective tissue which permits exaggerated distension of the colon and thinning of the smooth muscle.

PURPOSE: Functional results of total colectomy with ileorectal anastomosis for the treatment of chronic constipation caused by colonic inertia are often considered unsatisfactory because of the frequency of postoperative diarrhea and the high rate of postoperative small-bowel obstruction. Patients affected by severe colonic inertia underwent a subtotal colectomy with a novel antiperistaltic cecorectal anastomosis. The aim of the study was to assess the functional results after preservation of the cecorectal junction. METHODS: Eight females affected by isolated colonic inertia and two females with both paradoxical puborectalis contraction and colonic inertia, of a median age of 40 years, underwent subtotal colectomy with antiperistaltic cecorectal anastomosis. Before antiperistaltic cecorectal anastomosis all ten patients were laxative-dependant, with a mean bowel frequency of ten days; eight of them (80 percent) had distention, seven (70 percent) bloating, and three (30 percent) abdominal pain. RESULTS: There was no mortality or major postoperative morbidity. One month after antiperistaltic cecorectal anastomosis, bowel frequency was a mean of 2.2 (range, 1-4) per day, with a semiliquid stool consistency. After one year, bowel frequency was a mean of 1.3 (range, 0.5-3) per day, with a solid stool consistency; the same results were recorded at last follow-up. Although no patients used antidiarrheal medicine, laxatives continued to be used by both patients with paradoxical puborectalis contraction. All ten (100 percent) of the patients reported a good or improved quality of life. CONCLUSION: This preliminary experience seems to show that antiperistaltic cecorectal anastomosis is safe and effective for patients with colonic inertia. It results in prompt and prolonged relief from constipation for patients with isolated colonic inertia.

Idiopathic slow-transit constipation is a clinical syndrome predominantly affecting women, characterized by intractable constipation and delayed colonic transit. This syndrome is attributed to disordered colonic motor function. The disorder spans a spectrum of variable severity, ranging from patients who have relatively mild delays in transit but are otherwise indistinguishable from irritable bowel syndrome to patients with colonic inertia or chronic megacolon. The diagnosis is made after excluding colonic obstruction, metabolic disorders (hypothyroidism, hypercalcemia), drug-induced constipation, and pelvic floor dysfunction (as discussed by Wald ). Most patients are treated with one or more pharmacologic agents, including dietary fiber supplementation, saline laxatives (milk of magnesia), osmotic agents (lactulose, sorbitol, and polyethylene glycol 3350), and stimulant laxatives (bisacodyl and glycerol). A subtotal colectomy is effective and occasionally is indicated for patients with medically refractory, severe slow-transit constipation, provided pelvic floor dysfunction has been excluded or treated.