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Tese de doutoramento em Medicina, Objectivos: Pretende-se com este trabalho, através de uma descrição epidemiológica da obstipação crónica, identificar factores e comportamentos potencialmente modificáveis na nossa população. Pretende-se também avaliar o papel de técnicas de baixo custo no rastreio de distúrbios evacuatórios nos doentes obstipados. Métodos: Foi realizado um inquérito epidemiológico transversal na população de Braga que incluiu os hábitos intestinais e possíveis aspectos relacionados. Os doentes obstipados do nosso hospital terciário foram avaliados prospectivamente com técnicas de baixo custo (score clínico, score de toque rectal e teste de expulsão de balão), além de submetidos à avaliação fisiológica anorectal convencional. Resultados: O inquérito epidemiológico analisou 1335 indivíduos. A prevalência da obstipação crónica foi 17,8%. Os doentes obstipados eram mais jovens (OR 1.01; 95% CI, 1.007-1.031), sós (OR 2.48; 95% CI, 1.7-3.47) e com baixo rendimento (OR 2.40; 95% CI, 1.77-3.47). Além disso, os doentes obstipados descreveram uma evacuação prolongada (p=0.001) e comportamentos específicos na casa-de-banho como ausência de padrão matinal (p=0.008), recurso a factores desencadeantes (p=0.001) e a material de leitura/tecnológico (p=0.006) para facilitar a evacuação. O estudo prospectivo avaliou 98 doentes obstipados (38,9% com distúrbios evacuatórios). O teste de balão sequencial com volume variável (associado a vontade constante de evacuar), seguido pelo teste de expulsão de balão convencional (com volume fixo), melhorou a performance desta técnica no rastreio dos distúrbios defecatórios, com uma sensibilidade de 86%, especificidade de 67% e valor preditivo negativo de 87%. Discussão e Conclusão: A obstipação crónica afecta 1 em cada 5 Portugueses que desenvolvem um perfil específico de hábitos evacuatórios. Embora o score clínico e o toque rectal não tenham revelado poder discriminatório suficiente, ao mudar a técnica de expulsão de balão, adicionamos a avaliação sensorial ao teste e melhorámos a sua performance no rastreio de distúrbios defecatórios., Aims: We intend to analyse factors and behaviours related to chronic constipation in the local community. We also plan to evaluate the performance of low-cost tools for screening for defecation disorders in constipated patients. Methods: A cross-sectional epidemiological survey regarding bowel habits in the general community of Braga was conducted. Besides, constipated patients of our tertiary hospital were prospectively assessed by low-cost tools (clinical score, digital rectal examination score and balloon expulsion test), besides the gold standard anorectal physiological evaluation. Results: Regarding the survey, 1335 questionnaires were analysed. The prevalence of chronic constipation was 17,8%. This condition was more likely in younger (OR 1.01; 95% CI, 1.007-1.031), solo (OR 2.48; 95% CI, 1.7-3.47) and low-income (OR 2.40; 95% CI, 1.77-3.47) individuals. Constipated individuals spent more time at defecation (p=0.001) and have specific toilet behaviours as the absence of morning pattern (p=0.008), the use of triggers (p=0.001) and reading/technological material (p=0.006) to facilitate the evacuation. The prospective study evaluated 98 constipated patients (38,9% with a defecation disorder). A sequential balloon expulsion test with a variable volume (associated with a constant desire to evacuate) followed by the standard fixed volume balloon expulsion test improved the performance of the technique, with a sensitivity of 86%, specificity of 67% and a negative predictive value of 87%. The sequential balloon expulsion test had an OR 8.942, p> 0.001, CI 3.18-25.14, revealing to be the most significant predictor for defecation disorders screening. Discussion and Conclusions: Chronic constipation affects 1 in each 5 Portuguese. Constipated patients are younger, solo and with low-income. They develop a clear toilet behaviour profile. By changing the technique of the balloon expulsion test, we allowed the evaluation of rectal sensory and improved the performance of this low-cost tool making it a more effective screening tool for defecation disorders., Financial support was provided by the project NORTE-01-0145-FEDER- 000039, supported by Norte Portugal Regional Operational Programme (NORTE 2020), under the PORTUGAL 2020 Partnership Agreement, through the European Regional Development Fund (ERDF).and by National funds, through the Foundation for Science and Technology (FCT) - project UIDB/50026/2020 and UIDP/50026/2020.

Surgical treatment of patients with chronic slow-transit constipation leads to unsatisfactory results in almost a third of cases. It appears relevant to the search for the causes of unsatisfactory results of surgical interventions in such patients and the need to develop a rational diagnostic algorithm; its implementation will allow us to determine the indications for surgical treatment and justify the volume of colon resection. For this purpose, the results of the examination and treatment of 53 patients with constipation were analyzed. The median disease duration was 15 years, and the median duration of constipation was 6.2 1.6 days. Patients were divided into a group with a positive effect of conservative treatment and a group without the expected effect. The symptoms, results of laboratory tests of blood and feces, and instrumental studies of the colon were analyzed. A balloon expulsion test was used to exclude proctogenic constipation. The evacuation function of the colon was studied by X-ray examination, while the transit time of barium sulfate or X-ray contrast markers through the gastrointestinal tract was estimated. Twenty-four patients underwent surgery for chronic slow-transit constipation, while the sigmoid colon was removed in one patient, including 7-left-sided hemicolectomy and 16-subtotal resection of the colon. Long-term results were examined in the period from 3 to 6 months after surgery. In the total examination of the semiotics of chronic slow-transit constipation, the results did not show significant differences between the groups of patients and did not allow us to justify the stratification into severe and non-severe disease course by its specific symptoms. The use of X-ray contrast markers for the assessment of the state of the evacuation function of the colon makes it possible to quantify the severity of various motor disorders and justify the choice of the volume of its resection. The analysis of the long-term results of the treatment of patients with chronic slow-transit constipation allows us to conclude that segmental resections of the colon (left-sided hemicolectomy, resection of the sigmoid colon) have a good therapeutic effect if the preoperative examination revealed a segmental type of failure of the evacuation function of the colon, and subtotal resection of the colon is appropriate for the common type. The absence of negative results of surgical treatment of patients with chronic slow-transit constipation, in which the formation of a colonic anastomosis was performed with a short stump of the sigmoid colon, indicates the possibility of using this option to complete the surgical intervention.

Zusammenfassung. Die anorektale Funktionsdiagnostik ermöglicht die Messung des Analsphinkterdrucks, die Evaluierung der Rektumsensibilität sowie die Überprüfung der rektoanalen Reflexe, die wesentliche Elemente der Beurteilung der Darmentleerung darstellen. Sie wird mit einem Ballonexpulsionstest kombiniert, um sicherzustellen, dass die manometrischen Befunde mit der anorektalen Funktion übereinstimmen. Diese Tests finden in der diagnostischen Abklärung der chronischen Stuhlentleerungsstörung, der Obstipation und der fäkalen Inkontinenz ihre Anwendung, können aber auch im prä- und postoperativen Setting, bei funktionellen anorektalen Schmerzen und anderen Störungen der Beckenbodenfunktion Klärung bringen. Bei den meisten Patienten, die zur Untersuchung dieser Symptome überwiesen werden, ist eine umfassende Beurteilung der anorektalen Struktur und Funktion erforderlich. Aufgrund der hohen Variabilität der Normalwerte und Komplexität der anorektalen Funktion liefert keine einzelne Untersuchung alle Informationen, die für eine symptomerklärende, schlüssige Diagnose erforderlich sind und die Therapieentscheidung beeinflussen. Die anorektale Manometrie ist nützlich, um das Ausmass der Beeinträchtigung der anorektalen Funktion zu beurteilen und zwischen organischen und funktionellen Erkrankungen (inklusive Beckenbodendyssynergie) zu unterscheiden. Eine vorangehende ausführliche Anamnese sowie endoskopische (Prokto- / Rektoskopie) und bildgebende Verfahren (anorektale Endosonographie, dynamische MR-Defäkographie) vervollständigen die Diagnostik.

Introduction Digital rectal examination (DRE) and balloon expulsion test (BET) are simple tests to diagnose dyssynergic defecation (DD). Aim To determine differences in symptoms and manometry findings in patients with abnormal BET and normal BET. The secondary objective was to ascertain the sensitivity and specificity of BET and DRE + BET for the diagnosis of DD in an Indian setting using ARM findings as the gold standard. Material and methods Retrospective analysis of patients with chronic constipation referred for anorectal manometry (ARM) between December 2012 and March 2019. DD was diagnosed using ARM. Findings on BET and, in a subset of cases, on DRE + BET were compared with ARM findings. The data were analyzed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Agreement of BET and DRE + BET with ARM was calculated using Cohen’s κ coefficient. A p-value of < 0.05 was considered significant. Results A total of 1006 cases (734 males, 73%) formed the study cohort. Patients with abnormal BET more frequently reported digitation, bleeding per rectum, and straining (p < 0.00001). Moreover, they had a significantly higher median basal pressure compared to those with normal BET (80 vs. 67, p = 0.03). DD was significantly more common in those with abnormal BET. The sensitivity, specificity, PPV, and NPV of BET in detecting DD were 28.29%, 97.15%, 81.13%, and 75.78%, respectively. The percentage of agreement was 76.34%, and there was fair degree of correlation between the two tests. In a smaller subset of cases (166), DRE and BET findings were both available for analysis. We noted that the sensitivity, specificity, PPV, and NPV of combined DRE + BET were 57.63%, 88.79%, 73.91%, and 79.17%, respectively. The Cohen’s κ correlation coefficient was 0.49, suggesting moderate agreement. Conclusions Patients with abnormal BET more frequently report digitation, straining, and bleeding per rectum, and have higher resting anal pressure. BET is a good screening test for DD in an Indian setting.

BACKGROUND Most patients who have undergone low anterior resection suffer from bowel dysfunction postoperatively. This condition is referred to as low anterior resection syndrome (LARS). The aim was to study defecatory patterns in LARS patients compared to a primary control group of fecal incontinence (FI) patients and normal subjects (NS) with the Fecobionics device. METHODS Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics probe contained pressure sensors at the front, rear, and inside the bag. The bag was distended until urge sensation in rectum in 11 LARS patients (5F/6M, 63.2 ± 2.9 years), 11 FI subjects (7F/4M, 64.4 ± 2.5 years), and 11 NS (7F/4M, 63.6 ± 3.0 years). Defecation indices were computed from the Fecobionics data. All subjects had high-resolution anorectal manometry (ARM) and balloon expulsion test (BET) done. Symptoms were evaluated with LARS and Wexner scores. KEY RESULTS The LARS score in the LARS patients was 39.0 ± 0.6. The Wexner score in the LARS, FI, and NS groups was 14.2 ± 0.7, 10.1±1.0, and 0.0 ± 0.0 (p

Faecal incontinence and evacuation disorders are common conditions that cause significant morbidity. Patient-reported symptoms are poor predictors of underlying pathophysiology, so anorectal function testing is a key component of the clinical evaluation when initial management strategies fail. A number of investigations are available to assess anorectal structure (endoanal ultrasound, defaecography) and function (anorectal manometry, rectal sensory test, balloon expulsion test, defaecography). This review article outlines the usefulness and relevance of these investigations for the investigation of patients with faecal incontinence and/or evacuatory difficulty.

BACKGROUND: The first option to be considered in the treatment of functional defecation disorder is to correct the dyssynergia. However, limited studies exist to show the effectiveness of biofeedback. OBJECTIVE: We evaluated the effect of biofeedback on the severity of constipation, quality of life, and anorectal manometry in patients with dyssynergic defecation in which the biofeedback method was applied. METHODS: Effectiveness of biofeedback method on the quality of life of 24 dyssynergic defecation patients according to Rome III criteria after clinical and balloon expulsion tests (BETs) and colonic transit time was measured. Data were collected with patient identification form, Bristol Stool Chart, Constipation Quality of Life Scale forms, Visual Analogue Scale, diaphragmatic breathing exercises form, constipation diary, and constipation biofeedback monitoring form. Dyssnergic defecation cases received 6-week biofeedback training. For the same timeframe, the control group had a catheter into the rectum without any intervention. RESULTS: Constipation severity was reduced in both groups before biofeedback to post-biofeedback (P < .05). Anal canal pressure, BET, colonic transit time, and quality of life significantly improved in biofeedback patients compared with controls. CONCLUSIONS: : Biofeedback has a favorable effect on therapy and quality of life in dyssynergic defecation cases.

Background A defecation disorder (DD) is a difficulty in evacuation documented by physiological exams. However, this physiological evaluation can be cumbersome, inaccessible and costly. Three “low-cost” tools to evaluate DD—a clinical DD score, the balloon expulsion test (BET) and a digital rectal examination (DRE) score were evaluated as separate or combined tests for DD screening. Methods This prospective study occurred between January 2015 and March 2019 in the Gastroenterology Department of a tertiary hospital. Besides the gold standard physiological tests, constipated patients answered the clinical DD score and were evaluated by DRE and BET [standard and variable volume (VV)]. Results From 98 constipated patients, 35 (38.9%) were diagnosed with DD according to Rome IV criteria, mainly female (n = 30, 86%) with a median age of 60 years old. The clinical DD score revealed an AUC of 0.417 (SE = 0.07, p = 0.191). The DRE score displayed an AUC of 0.56 (SE = 0.063, p = 0.301). The standard BET displayed a sensitivity of 86%, specificity of 58%, positive predictive value (PPV) of 57% and negative predictive value (NPV) of 86%. The sequential VVBET followed by standard BET improved the BET performance regarding the evaluation of DD, with a sensitivity of 86%, specificity of 67%, PPV of 63% and NPV of 87%. The sequential BET had an OR 8.942, p > 0.001, CI 3.18–25.14, revealing to be the most significant predictor for DD screening. Conclusion The sequential BET is a low cost, well-performing DD screening tool, appropriate to the Primary Care Setting.

Background: Perianal Crohn’s disease is a disabling condition, with little known about anorectal function in healed/inactive perianal Crohn’s disease; Aim: To evaluate anorectal function in a cohort of patients with treated/healed perianal Crohn’s disease; Methods: Prospective cohort study, including high-resolution anorectal manometry, balloon expulsion test, and 3D-endoanal ultrasound in all patients; Results: Of the 16 patients studied (mean age ± SD, 42 ± 13 years), 12 (75%) were men. A laceration of the internal anal sphincter and/or anal scarring was seen in nine (56%) patients; there was no laceration of the external anal sphincter. Five (56%) of these nine patients had never experienced faecal incontinence. All had normal anal resting and squeeze pressures. Manometry suggested dyssynergia in 11 (69%) patients, with only one (6%) fulfilling the criteria for obstructed defecation. Hyposensitivity for at least one sensory parameter was seen in 11 (69%) patients and hypersensitivity in five (31%) patients; Conclusions: This study detected sphincter abnormalities in more than half of patients, many of whom were asymptomatic. Alterations in rectal sensation were frequently seen, more commonly with rectal hyposensitivity. Trial registration: ClinicalTrials.gov (NCT03819257).

Background This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high‐resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. Methods Twenty‐nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face‐to‐face and three remote meetings to derive consensus between 2014 and 2018. Key recommendations The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia. Conclusions and Inferences This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much‐needed standardization to these techniques., This document summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance of anorectal function testing and introduces a consensus classification for disorders of anorectal function based on objective, physiological measurement.

Background Diagnosis of rectal evacuation disorders (RED) is currently based on anorectal manometry (ARM) and evacuation tests in specialized laboratories; we recently showed higher rectal gas volume (RGV) and maximum rectal gas transaxial area (MRGTA) measured on abdominal and pelvic computed tomography (CT) in patients with documented RED.The aim of this study was to obtain cut-off values of RGV, MRGTA, and rectal area on scout film (RASF) to differentiate constipated patients with RED from those without RED, based on ARM, balloon expulsion test (BET), and colon transit test. Methods We identified 118 constipated patients (65 with RED) with prior record of CT. Using standard CT software, we used a variable region of interest (ROI) program to measure RGV, MRTGA, and RASF, as previously described. We constructed receiver operating characteristics curves based on different values, and we estimated AUC, specificity, and positive predictive value (PPV) to detect RED in patients with constipation. Key results Receiver operating characteristics of the models to predict RED showed AUC 0.751 for RGV and 0.737 for MRGTA (both P Conclusions & inferences Rectal gas measurements on abdominal imaging may indicate RED in patients with constipation. At ~90% specificity for RED, RGV of 20 or 30 mL or MRGTA of 10 cm2 on CT has PPV ~75%, and RASF of >9 cm2 has PPV of ~69%.

INTRODUCTION: Defecation is a complex process that can be easily disturbed. Defecatory disorders may be diagnosed using specialized investigation, including anorectal manometry (ARM) and the balloon expulsion test (BET). Recently, we developed a simulated stool named Fecobionics that integrates several tests and assesses pressures, orientation, and bending during evacuation. The aim was to evaluate the feasibility and performance of Fecobionics for assessing defecatory physiology in normal subjects. METHODS: Physiological expulsion parameters were assessed in an interventional study design. The 10-cm-long Fecobionics probe contained pressure sensors at the front and rear and inside a bag and 2 motion processor units. The bag was distended in the rectum of 20 presumed normal subjects (15 female/5 male) until urge to defecate. ARM-BET was also performed. Three subjects used +2 minutes to evacuate BET, and 1 subject had a high fecal incontinence score. Therefore, the normal group consisted of 16 subjects (13 female/3 male aged 25–78 years). RESULTS: All subjects reported that Fecobionics evacuation was similar to normal defecation. Fecobionics expulsion pressure signatures demonstrated 5 phases, reflecting rectal pressure, anal relaxation, and anal passage. Preload-afterload loop diagrams demonstrated clockwise contraction cycles. The expulsion duration for BET and Fecobionics was 16 ± 2 and 23 ± 5 seconds (P > 0.2), respectively. The duration of the Fecobionics and BET expulsions was associated (P < 0.001). The change in bending of Fecobionics during defecation was 40 ± 3°. DISCUSSION: Fecobionics obtained reliable data under physiological conditions. Agreement was found for comparable variables between ARM-BET and Fecobionics but not for other variables. The study suggests that Fecobionics is safe and effective in evaluation of key defecatory parameters.

Background Anorectal manometry (ARM) is typically preformed in a lateral position. This non-physiological testing position has produced an unexpected negative rectoanal pressure gradient (RAPG, i.e. difference between rectal and anal pressure) with normal defecation. This study was designed (i) to study differences in ARM parameters between water-perfused and solid-state sensors and between lateral and seated positions and (ii) to investigate the roles of ARM parameters in predicting balloon expulsion. Methods ARM was performed in 18 healthy volunteers (HV) and 60 patients with functional constipation (FC) under three randomized conditions: water-perfused in lateral position, solid-state in lateral position, and solid-state in seated position, followed by a balloon expulsion test in seated position. Key Results i) Under the same lateral position, solid-state sensors produced higher rectal resting pressure and RAPG than water-perfused sensors. ii) Using the solid-state sensors, ARM in the seated position revealed higher resting rectal pressure (34.9 vs 10.9 mmHg in HV, 30.9 vs 10.6 mmHg in FC, both P

Background. Rome III criteria add physiological criteria to symptom-based criteria of chronic constipation (CC) for the diagnosis of defecatory disorders (DD). However, a gold-standard test is still lacking and physiological examination is expensive and timeconsuming. Aim. Evaluate the usefulness of two low-cost tests-digital rectal examination (DRE) and balloon expulsion test (BET)-as screening or excluding tests ofDD. Methods. Weperformeda systematic search inPUBMEDandMEDLINE. We selected studies where constipated patients were evaluated by DRE or BET. Heterogeneity was assessed and random effect models were used to calculate the sensitivity, specificity, and negative predictive value (NPV) of the DRE and the BET. Results. Thirteen studies evaluating BET and four studies evaluating DRE (2329 patients) were selected. High heterogeneity (.. 2 > 80%) among studies was demonstrated. The studies evaluating the BET showed a sensitivity and specificity of 67% and 80%, respectively. Regarding the DRE, a sensitivity of 80% and specificity of 84% were calculated. NPV of 72% for the BET and NPV of 64% for the DRE were estimated. The sensitivity and specificity were similar when we restrict the analysis to studies using Rome criteria to define CC. The BET seems to performbetter when a cut-off time of 2minutes is used and when it is compared with a combination of physiological tests. Considering the DRE, strict criteria seem to improve the sensitivity but not the specificity of the test. Conclusion. Neither of the low-cost tests seems suitable for screening or excluding DD., info:eu-repo/semantics/publishedVersion

Anorectal manometry and rectal balloon expulsion tests are necessary for the diagnosis of functional defecatory disorders. They can provide comprehensive information about anal sphincter function, rectal sensation, rectal compliance, anorectal coordination during evacuation, and anorectal reflexes. Moreover, they provide new information that may not be detected clinically and can influence the outcome of patients with defecation disorders. Selective tests should be performed based on the potential indication to evaluate each condition. High-resolution manometry based on spatiotemporal plot was developed recently, and it can display the anorectal change during testing with a great resolution, replacing the conventional manometry system.

The balloon expulsion test is a simple and useful method for investigating a defecatory disorder assessing the subject's ability to evacuate a simulated stool. However, there is no standard methodology and varying interpretations have been reported. This review discusses the techniques, interpretation and clinical utility of the balloon expulsion test.

Purpose: I investigated the diagnostic accuracy of balloon expulsion test (BET) with various techniques to find out the most appropriate method, and tried to confirm its clinical utility in diagnosing functional defecation disorders (FDD) in constipated patients. Methods: Eighty-seven patients constituted the study population. FDD was defined when patients had at least two positive findings in defecography, manometry, and electromyography. BET was done 4 times in each patient with 2 different positions and 2 different volumes. The positions were seated position (SP) and left lateral decubitus position (LDP). The volumes were fixed volume (FV) of 60 mL and individualized volume with which patient felt a constant desire to defecate (CDV). The results of BETs with 4 different settings (LDP-FV, LDP-CDV, SP-FV, and SP-CDV) were statistically compared and analyzed. Results: Of 87 patients, 23 patients (26.4%) had at least two positive findings in 3 tests and thus were diagnosed to have FDD. On receiver operating characteristic curve analysis, area under curve was highest in BET with SP-FV. With a cutoff value of 30 seconds, the specificity of BET with SP-FV was 86.0%, sensitivity was 73.9%, negative predictive value was 89.8%, positive predictive value was 65.4%, and accuracy rate was 82.8% for diagnosing FDD. Conclusion: SP-FV is the most appropriate method for BET. In this setting, BET has a diagnostic accuracy sufficient to identify constipated patients who do not have FDD. Patients with negative results in BET with SP-FV may not need other onerous tests to exclude FDD.

Chronic constipation is a common and extremely trou-blesome disorder that significantly reduces the quality of life, and this fact is consistent with the high rate at which health care is sought for this condition. The aim of this project was to develop a consensus for the diagnosis and treatment of chronic constipation and obstructed defecation. The commission presents its results in a “Question-Answer” format, including a set of graded recommendations based on a systematic review of the literature and evidence-based medicine. This section represents the consensus for the diagnosis. The history includes information relating to the onset and duration of symptoms and may reveal secondary causes of constipation. The presence of alarm symptoms and risk factors requires investigation. The physical examination should assess the presence of lesions in the anal and perianal region. The evidence does not support the routine use of blood testing and colonoscopy or barium enema for constipation. Various scoring systems are available to quantify the severity of constipation; the Constipation Severity Instrument for constipation and the obstructed defecation syndrome score for obstructed defecation are the most reliable. The Constipation-Related Quality of Life is an excellent tool for evaluating the patient‘s quality of life. No single test provides a pathophysiological basis for constipation. Colonic transit and anorectal manometry define the pathophysiologic subtypes. Balloon expulsion is a simple screening test for defecatory disorders, but it does not define the mechanisms. Defecography detects structural abnormalities and assesses functional parameters. Magnetic resonance imaging and/or pelvic floor sonography can further complement defecography by providing information on the movement of the pelvic floor and the organs that it supports. All these investigations are indicated to differentiate between slow transit constipation and obstructed defecation because the treatments differ between these conditions.

Chronic constipation is a frequently complained condition in clinical practice and may be primary (idiopathic) or due to secondary causes. The definition of the various forms of constipation is presently made according to the Rome III criteria, which recently incorporated also specific diagnostic algorithms. The diagnosis of constipation relies on the patient’s history, including use of drugs, physical examination, and specific investigations (transit time, anorectal manometry, balloon expulsion test, defecography). These will often be useful to start a targeted therapeutic schedule that may include fibres, laxatives, biofeedback training and, in extreme cases, a surgical approach. This review will analyse the clinical and diagnostic aspects of chronic constipation in adult patients, with emphasis on recent therapeutic approaches.