Constipation : symptoms and findings in relation to structural and functional abnormalities

Abstract: The aim of this study was to increase the knowledge about functional constipation with special reference to symptoms analysis, laboratory investigations and histopathology findings. 155 consecutive patients with intractable constipation underwent anorectal manometry, electromyography (EMG), balloon expulsion test, colonic transit time, and defecography. All investigations were completed by 134 patients. Whole-gut transit time was delayed in 55 patients (41%) and pelvic floor dysfunction (PFD) was diagnosed in 59 patients (44%) but in 35% of the patients both transit time and pelvic floor function were normal. It was concluded that about two thirds of patients with constipation have objective evidence of either colonic or pelvic floor dysfunction. Symptoms were good predictors of transit time but less good predictors of pelvic floor function in patients with constipation. Self-administered questionnaires were used to assess quality of life (Psychological General Well-Being Index, PGWB) and severity of gastrointestinal symptoms (Gastrointestinal Symptom Rating Scale, GSRS) in 84 patients with constipation. The overall mean score and confidence interval (CI) for quality of life in our patient material was 85.5 (CI: 80.9-89.9), which indicates that the well-being of patients with constipation is impaired compared to the normal population which exhibits an average index score of 102.9 (CI: 102.1-103.8). Patients with normal whole-gut transit time scored lower values in the total PGWB (median 82, interquartile range 69.5-96.5) than did patients with slow transit (median 94, interquartile range 77.8-105.8). The overall PGWB index was strongly corTelated with the total GSRS and with each of its three dimensions, dyspeptic syndrome, indigestion syndrome and bowel dysfunction syndrome. Symptom severity was negatively correlated with the perceived quality of life. Twenty consecutive patients with slow transit constipation underwent antroduodenal manometry. Twelve patients [60%] had one or more abnormal patterns of motor activity indicating motor abnormalities. This study concluded that a significant proportion of patients with slow transit constipation have manometric findings which indicate a generalised motor disorder of the gut. Bowel specimens were obtained from 16 patients with slow transit constipation. 13 colonic and 14 small bowel tissue were available for inummohistochernical study. All patients studied had abnormalities of intestinal neuromuscular structures. The majority of our patients had neuropathic changes both in the colon and in the small bowel but some had findings indicating a primary visceral myopathy. It was concluded that intrinsic neuromuscular abnormalities and defects in the interstitial cells of CaJal may underlie the colonic hypornotility that can be seen in patients with STC and hence contribute to their constipation. Twenty-six patients with paradoxical puborectalis contraction PPC were retrained by either of two feedback modes: anal pressure using a manometry probe, or anal sphincter electromyography (EMG) using surface electrodes. In the global assessment, 14 out of 20 patients who completed the therapy (6 in the manometry group, 8 in the EMG group) considered that their symptoms had improved after biofeedback therapy. The overall efficacy was maintained at follow-up 6 months later. It was concluded that alteration of an abnormal EMG pattern by biofeedback therapy could lead to long-standing improvement of symptoms and bowel function. We found no difference in the efficacy of biofeedback between the use of manometry or EMG for feedback.