Constipation

Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
J Pediatr Gastroenterol Nutr. 2006 Sep;43(3):e1-13.

Constipation, defined as a delay or difficulty in defecation, present for 2 or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers. The Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) has formulated a clinical practice guideline for the management of pediatric constipation. The Constipation Guideline Committee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. Consensus was achieved through Nominal Group Technique, a structured quantitative method. The Committee developed two algorithms to assist with medical management, one for older infants and children and the second for infants less than 1 year of age. The guideline provides recommendations for management by the primary care provider, including evaluation, initial treatment, follow-up management, and indications for consultation by a specialist. The Constipation Guideline Committee also provided recommendations for management by the pediatric gastroenterologist. Pediatric Gastroenterology, Hepatology and Nutrition

Fifty Years Ago in The Journal of Pediatrics Soiling in children due to chronic fecal impaction.
Lamphear JG, Focht DR
J Pediatr. 2006 Sep;149(3):377.

Neostigmine for refractory constipation in advanced cancer patients.
Rubiales AS, Hernansanz S, Gutierrez C, Del Valle ML, Flores LA
J Pain Symptom Manage. 2006 Sep;32(3):204-5.

Surgical Treatment of Chagasic Megacolon by Abdominal Rectosigmoidectomy With Immediate Posterior End-to-Side Stapling (Habr-Gama Technique).
Nahas SC, Habr-Gama A, Nahas CS, Araujo SE, Marques CF, Sobrado CW, Bocchini SF, Kiss DR
Dis Colon Rectum. 2006 Aug 4;.

PURPOSE: Various techniques have been used in the surgical treatment of Chagasic megacolon, including sympathectomy, sphincterotomy, anterior abdominal resection with high or low anastomosis, pull-through procedures, and Duhamel technique. However, results have not been consistently satisfactory, with reportedly high morbidity and mortality rates. The purpose of this study was to assess the technique and results of anterior rectosigmoidectomy with immediate posterior colorectal end-to-side stapled anastomosis for the treatment of Chagasic megacolon. METHODS: A prospective, noncontrolled study between 1989 and 2000 analyzed 49 patients with Chagasic megacolon. Preoperative barium enema confirmed Chagasic megacolon in all patients and preoperative anorectal manometry in 33 patients (67 percent). Rectal stump closure was undertaken by surgical stapling in 41 patients (84 percent); mechanical colorectal anastomosis was accomplished with a circular stapler in all patients. RESULTS: Symptoms of intestinal constipation ranged from 6 months to 40 years, Chagas' serology was positive in 98 percent of patients, 41 percent used bowel enemas for evacuation, and 71 percent had a history of fecaloma. The overall postoperative complication rate was 20 percent. Surgical complications occurred in 18 percent, 2 percent had nonsurgical complications, and there was no mortality. Postoperative barium enema was performed in 82 percent of cases, confirming the absence of disease. Postoperative anorectal manometry demonstrated normal resting pressure and rectal capacity; the inhibitory reflex remained absent and rectal sensitivity was increased. Ninety-three percent of patients were followed for more than 48 months, and all patients reported daily stool elimination without recurrence of constipation. CONCLUSIONS: The current study indicates that our technique is effective for surgical treatment of patients with Chagasic megacolon.

July

Hand-assisted laparoscopic vs. open total colectomy in treating slow transit constipation.
Zhang LY
Tech Coloproctol. 2006 Jul;10(2):152-3.

Is pseudomelanosis coli a marker of colonic neuropathy in severely constipated patients?
Villanacci V, Bassotti G, Cathomas G, Maurer CA, Di Fabio F, Fisogni S, Cadei M, Mazzocchi A, Salerni B
Histopathology. 2006 Aug;49(2):132-7.

To study relationships between the number of pseudomelanosis coli cells and that of colonic enteric neurons and interstitial cells of Cajal, which are significantly reduced compared with controls in severely constipated patients. Pseudomelanosis coli is frequent in patients using anthraquinone laxatives. It is not known whether the prolonged use of these compounds damages the enteric nervous system in constipated patients. The relationship between the number of pseudomelanosis coli cells and that of colonic enteric neurons (as well as that of apoptotic enteric neurons) and of interstitial cells of Cajal was assessed by histological and immunohistochemical methods in 16 patients with chronic use of anthraquinone laxatives undergoing surgery for severe constipation unresponsive to medical treatment. No relationship was found between the number of pseudomelanosis coli cells and that of enteric neurons (and that of the apoptotic ones), nor of interstitial cells of Cajal, in either the submucosal or the myenteric plexus. The use of anthraquinone laxatives, leading to the appearance of pseudomelanosis coli, is probably not related to the abnormalities of the enteric nervous system found in severely constipated patients.

Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia.
Van Outryve M, Pelckmans P
Gastroenterology. 2006 Jul;131(1):333-4; author reply 334.

Clinical case: chronic constipation.
Kamm MA
Gastroenterology. 2006 Jul;131(1):233-9.

Rho kinase as a novel molecular therapeutic target for hypertensive internal anal sphincter.
Rattan S, De Godoy MA, Patel CA
Gastroenterology. 2006 Jul;131(1):108-16.

BACKGROUND & AIMS: An increase in Rho kinase (ROK) activity has been associated with agonist-induced sustained contraction of the smooth muscle, but its role in the pathophysiology of spontaneously tonic smooth muscle is not known. METHODS: Present studies examined the effects of ROK inhibitor Y-27632 in the tonic smooth muscle of the rat internal anal sphincter (IAS) versus in the flanking phasic smooth muscle of the rectum. In addition, studies were performed to determine the relationship between the decreases in the basal IAS tone and the ROK activity. Confocal microscopic studies determined the cellular distribution of the smooth muscle-predominant isoform of ROK (ROCK-II) in the smooth muscle cells (SMCs). RESULTS: In in vitro studies using neurohumoral inhibitors and tetrodotoxin and the use of SMCs demonstrate direct relaxation of the IAS SMCs by Y-27632. The ROK inhibitor was more potent in the IAS than in the rectal smooth muscle. The IAS relaxation by Y-27632 correlated specifically with the decrease in ROK activity. Confocal microscopy revealed high levels of ROCK-II toward the periphery of the IAS SMCs. In in vivo studies, the lower doses of Y-27632 caused a potent and selective decrease in the IAS pressures without any adverse cardiovascular systemic effects. The ROK inhibitor also caused potent relaxation of the hypertensive IAS. CONCLUSIONS: RhoA/ROK play a crucial role in the maintenance of the basal tone in the IAS, and ROK inhibitors have a therapeutic potential in the IAS dysfunction characterized by the hypertensive IAS.

Practical symptom-based evaluation of chronic constipation.
Bleser SD
J Fam Pract. 2006 Jul;55(7):580-4.

A symptom-based approach is the best means for diagnosing chronic constipation. Extensive diagnostic testing is seldom necessary unless alarm features are present. Encourage routine colon cancer screening tests for all patients aged 50 years or older.

June

Nutritional care of the patient with constipation.
Fernandez-Banares F
Best Pract Res Clin Gastroenterol. 2006 Jun;20(3):575-87.

Chronic constipation is defined as a symptom-based disorder based on the presence for at least 3 months in the last year of unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both. On the other hand, the presence of clinically important abdominal discomfort or pain associated with constipation defines irritable bowel syndrome (IBS) with constipation. Intake of dietary fibre and bulking agents (psyllium) may be effective in alleviating chronic constipation in patients without slow colonic transit or disordered constipation. On the other hand, fibre may improve stool consistency in patients with IBS with constipation, but it is considered to be not effective in improving abdominal pain, distension or bloating. Probiotics may be effective in relieving constipation; however, the effect of lactic acid bacteria ingestion may be dependent on the bacterial strain used and the population being studied. Lactulose, which is a substrate for lactic acid bacteria (prebiotic), is effective to treat patients with chronic constipation.

Fiber intake, constipation, and overweight among adolescents living in Sao Paulo city.
de Carvalho EB, Vitolo MR, Gama CM, Lopez FA, Taddei JA, de Morais MB
Nutrition. 2006 Jul-Aug;22(7-8):744-9.

OBJECTIVE: This study evaluated the dietary fiber intake of adolescents in the metropolitan area of Sao Paulo city and any association between low dietary fiber intake with constipation and overweight. METHODS: In total, 716 adolescents were included within the study, of whom 314 attended private school and 402 attended public school. Evaluation of fiber intake was based on a 24-h daily intake record and a frequency questionnaire. Data concerning bowel movements and height and weight measurements were also taken. RESULTS: Fiber consumption, below that recommended ("age + 5"), was found in 61.8% and 41.4% (P = 0.000) of girls attending private and public schools, respectively, and in 44.1% and 25.6% of boys (P = 0.001). Adolescents who did not eat beans on more than 4 d/wk presented a higher risk of fiber intake below that recommended (age + 5; P < 0.05), with odds ratios ranging from 10.4 to 14.2 according gender and private or public schooling. Dietary fiber intake below that recommended was associated with a greater risk (P < 0.05) toward overweight in students attending public schooling (odds ratios 2.84 and 2.95 for males and females, respectively). Low dietary fiber intake was not associated with constipation. CONCLUSION: Intake of beans more than four times per week is associated with the appropriate level of fiber intake. Dietary fiber intake below the recommendation was not associated with constipation but was associated with being overweight among those students attending public schooling.

Relationship between physical activity and body mass index in adolescents.
Sulemana H, Smolensky MH, Lai D
Med Sci Sports Exerc. 2006 Jun;38(6):1182-6.

PURPOSE: To examine the associations between physical activity and body mass index (BMI) among females aged 14 to 17 yr. METHODS: A convenience sample of 65 Mexican American, 58 African American, and 49 non-Hispanic white girls in an urban high school in Texas participated in this study. Physical activity was assessed by ankle actigraphy. Average activity per period (before, during and after school) of the day and total activity were derived by a software program as movements per minute. The Center for Disease Control and Prevention 2000 BMI charts were used to calculate overweight status. Pearson correlation coefficient and analysis of variance were used to determine the strength of association and to compare activity levels by BMI status. RESULTS: There was a statistically significant inverse association between total diurnal physical activity level and BMI (r=-0.37; P<0.05); and a statistically significant association between after-school activity and BMI (r= -0.28; P<0.05). After adjusting for the effects of age, race, and sexual maturity, total diurnal activity level was 10% less (P=0.03) for overweight females; for females at risk of overweight, diurnal activity level was 6% less (P=0.04) than for normal-weight females. Ethnic differences showed an 8% lower activity level among African American than for non-Hispanic white and 6% lower than for Mexican American females. CONCLUSION: The study indicated that adolescent females in schools are at risk for inactivity at certain times of the day. Schools in partnership with their communities should assume a major role to promote participation in physical activity among adolescents through innovative activity programs in schools.

Novel mutations of RET gene in Korean patients with sporadic Hirschsprung's disease.
Kim JH, Yoon KO, Kim JK, Kim JW, Lee SK, Kong SY, Seo JM
J Pediatr Surg. 2006 Jul;41(7):1250-4.

BACKGROUND/PURPOSE: Hirschsprung's disease (HSCR) is a congenital abnormality that can cause an intestinal obstruction. Although HSCR demonstrates a sex-modified polygenic inheritance with contributions from multiple genes, mutations in the RET gene are believed to be the major sign of susceptibility in the development of disease. The allele frequency of polymorphisms was mostly tested in the American and European population, but the data of an ethnically diverse nonwhite population are unclear. METHODS: All 21 exons and intron/exon boundaries of the RET gene in 18 Korean patients with sporadic HSCR and 84 normal individuals were screened using polymerase chain reaction amplification and direct sequencing. RESULTS: A total of 11 different nucleotide substitutions were identified. Of these, 2 were new missense mutations (C558Y, cysteine-rich domain; R844W, tyrosine kinase domain) and 9 previously described variants. This study also analyzed the haplotypes for the association between the variants identified with HSCR, but the estimated RET haplotypes did not show any disease risk. CONCLUSIONS: This study identified additional mutations of RET gene, which represents the first comprehensive genetic dissection of sporadic HSCR disease in Koreans.

Imperforate anus, malrotation, and Hirschsprung's disease: a rare and important association.
Arbell D, Gross E, Orkin B, Koplewitz BZ, Udassin R
J Pediatr Surg. 2006 Jul;41(7):1335-7.

Imperforate anus and malrotation rarely occur together. The conjoint occurrence of these with Hirschsprung's disease is exceedingly rare, but failure to recognize its existence may lead to catastrophic results. We present a case in which awareness to this possibility caused early detection and avoidance of possible complications.

Rectal suction biopsy in the diagnosis of intestinal dysganglionoses: 5-year experience with Solo-RBT in 389 patients.
Pini-Prato A, Martucciello G, Jasonni V
J Pediatr Surg. 2006 Jun;41(6):1043-8.

INTRODUCTION: Since Noblett (J Pediatr Surg 1969;4:406-409) described her innovative tool, rectal suction biopsy (RSB) has become the gold standard in the diagnosis of Hirschsprung's disease and other intestinal dysganglionoses. Many different instruments have been developed during the last 30 years, but none of them proved to be free of disadvantages. In 2000, at Gaslini Research Institute, we developed an improved tool to perform RSBs called Solo-RBT (SAMO Biomedica, Bologna, Italy), which has some advantages: (1) the procedure is easily performed by one operator alone; (2) the instrument can be adjusted for each patient according to age and weight; and (3) the instrument can be completely disassembled for decontamination and heat sterilization. This study describes our experience with Solo-RBT in the diagnosis of intestinal dysganglionoses. MATERIALS AND METHODS: Between February 2000 and January 2005, we performed RSBs on 389 patients. Detailed information regarding patients, technique, histochemical staining, diagnostic criteria, complications, and diagnoses are provided. Moreover, patients were divided in 3 age-related groups to compare results. RESULTS: One thousand twelve biopsies were performed on 389 patients. Age range at biopsy was 4 days to 66 years. Median age was 2.4 years. Each patient underwent a mean of 2.6 biopsies. Fifty-nine patients experienced complications, including 2 persistent rectal bleedings (0.5%) in patients younger than 1 year and 57 inadequate biopsies (14.5%). Neither perforation nor pelvic sepsis occurred. Sixty-five cases of Hirschsprung's disease and 58 of intestinal neuronal dysplasia have been diagnosed with Solo-RBT. CONCLUSIONS: The very low incidence of major complications proved that Solo-RBT is safe and effective. The wide age range at biopsy confirms the great versatility of this tool. Our study demonstrated that age does not represent a risk factor for inadequacy of the specimen; however, it showed that patients younger than 1 year have a higher risk of major complications. Therefore, although Solo-RBT increases safety and reliability of RSBs, great attention should be paid when this procedure is performed in newborns and infants.

Segmental dilatation of the intestine.
Ben Brahim M, Belghith M, Mekki M, Jouini R, Sahnoun L, Maazoun K, Krichene I, Golli M, Monastiri K, Nouri A
J Pediatr Surg. 2006 Jun;41(6):1130-3.

PURPOSE: The aim of this work is to discuss the pathogenesis of the segmental dilatation of the intestine (SDI) and to review its clinical presentation and the ways to confirm the diagnosis. METHODS: Eight cases of pathologically proven SDI from 1987 to 2003 were reviewed and discussed. There were 7 newborns and a 1-year-old boy. RESULTS: Our patients are 5 boys and 3 girls. In all cases, the diagnosis was not suspected before surgery. Two patients presented with a low neonatal bowel obstruction. Six patients were operated for omphalocele, which was the most frequent associated malformation. The SDI involved the ileum in all patients. The treatment consisted on a resection of the dilated segment with an end-to-end anastomosis. Histological examination demonstrated the presence of ganglion cells in all cases. The muscular layer was hypertrophied in two cases and very thin in one case. A heterotopic gastric mucosa was observed in one case. No anomalies were observed in 5 cases. The postoperative course was uneventful in 6 cases with a mean follow-up of 5 years. CONCLUSIONS: Segmental intestinal dilatation is an exceptional pathology with an unknown etiology and a misleading clinical presentation. Several theories were proposed to explain this malformation; however, most authors are rather inclined to an embryological theory incriminating an extrinsic intrauterine intestinal compression. Most cases are neonatal discoveries. The clinical polymorphism and the lack of specificity of radiological investigations explain the difficulties to have a preoperative diagnosis. However, this difficulty is compensated by the favorable evolution after the resection of the dilated segment.

HLA and enteric antineuronal antibodies in patients with achalasia.
Latiano A, De Giorgio R, Volta U, Palmieri O, Zagaria C, Stanghellini V, Barbara G, Mangia A, Andriulli A, Corinaldesi R, Annese V
Neurogastroenterol Motil. 2006 Jul;18(7):520-5.

The aetiopathogenesis of primary achalasia is largely unknown, although an immunogenetic predisposition is suspected. To establish whether a correlation exists among possible aetiological factors, including class II human leucocyte antigen (HLA) alleles and autoantibodies to enteric neurones, and clinical features of patients with achalasia, a total of 60 patients and 200 healthy subjects were typed by high-resolution HLA-DQ and HLA-DR alleles. Circulating antineuronal antibodies were investigated by using indirect immunofluorescence on enteric neurones of rat ileum and colon and immunoblotting assay in a subset of achalasic patients and in all controls. The DQB1*0502 and DQB1*0601 alleles were significantly increased in patients with achalasia compared with controls (P < 0.03, P < 0.001, respectively). Moreover a negative correlation with the DQB1*0201 allele was found (P = 0.016). As a whole, 14 of 60 (23.3%) achalasia patients were carriers of HLA risk alleles, and 10 of 41 (24.4%) presented antineuronal antibodies. No significant correlation among HLA risk alleles, antineuronal antibodies and clinical features was found. In achalasia, no correlation exists among HLA alleles, antineuronal antibodies and clinical features. However, given the association between achalasia and HLA-DQ1, further research is needed to clarify the role of HLA antigens and antineuronal antibodies in this disease.

Endogenous ethanol production in a patient with chronic intestinal pseudo-obstruction and small intestinal bacterial overgrowth.
Spinucci G, Guidetti M, Lanzoni E, Pironi L
Eur J Gastroenterol Hepatol. 2006 Jul;18(7):799-802.

The case of the gastrointestinal production of ethanol from Candida albicans and Saccharomyces cerevisiae in a Caucasian man with chronic intestinal pseudo-obstruction is reported. The patient, who declared to have always abstained from alcohol, was hospitalized for abdominal pain, belching and mental confusion. The laboratory findings showed the presence of ethanol in the blood. Gastric juice and faecal microbiological cultures were positive for C. albicans and S. cerevisiae. At home, he was on oral antibiotic therapy with amoxicillin plus clavulanic acid for a small bowel bacterial overgrowth, associated with a simple sugar-rich diet. Twenty-four hours after stopping both the antibiotic therapy and the simple sugar-rich diet, the blood ethanol disappeared. A provocative test, performed by giving amoxicillin plus clavulanic acid associated with the simple sugar-rich diet was followed by the reappearance of ethanol in the blood. A review of the literature is reported.

Intestinal neuronal dysplasia.
Skaba R, Frantlova M, Horak J
Eur J Gastroenterol Hepatol. 2006 Jul;18(7):699-701.

Intestinal neuronal dysplasia type B (IND B) is currently defined as a disease of the submucous plexus of the intestine. The aetiology of IND B remains largely obscure. The congenital origin of IND B is supposed; nevertheless, the findings of IND B associated with chronic intestinal obstruction support the notion that this disease could be caused by a reaction of the enteral nervous system to intestinal obstruction or inflammatory disease either in the fetal or the postnatal period. The treatment of IND type B has no unified concept of treatment. The ultimate clinical diagnosis of IND B should be based on a definitive histological diagnosis relating to clinical symptoms, the course of treatment and long-term follow-up of patients with this dysfunction of intestinal motility, despite the fact that no correlations of the clinical picture, radiological investigation and anorectal manometric studies with IND B have been found so far.

Prospective randomized crossover trial comparing fibre with lactulose in the treatment of idiopathic chronic constipation.
Quah HM, Ooi BS, Seow-Choen F, Sng KK, Ho KS
Tech Coloproctol. 2006 Jun;10(2):111-4. Epub 2006 Jun 19.

BACKGROUND: Fibre is often recommended as the first-choice treatment but its effects can be uneven. The aim of the study was to compare the clinical efficacy and tolerability of fibre versus lactulose in outpatients with chronic constipation.METHODS: In a prospective randomized crossover trial, patients were randomized to receive fibre or lactulose for four weeks. Between treatments, patients had at least one week free of laxatives.RESULTS: 50 patients, of median age 50 years (range, 18-85) were recruited and 39 patients completed the trial. Compared to fibre, lactulose resulted in significantly higher mean bowel frequency (7.3, 95% CI 5.7 to 8.9 vs. 5.5, 95% CI 4.4 to 6.5; p=0.001) and stool consistency score (3.4, 95% CI 3.1 to 3.7 vs. 2.9, 95% CI 2.5 to 3.3; p=0.018). Scores for ease of evacuation were similar. The frequencies of adverse effects were not significantly different, but greater in the lactulose group. Mean patients' recorded improvement score was significantly higher after taking lactulose than fibre (6.2, 95% CI 5.5 to 7.0 vs. 4.8, 95% CI 4.0 to 5.9; p=0.017). Of the 39 patients who completed the trial, 24 (61.5%) preferred lactulose and 14 (35.9%) preferred fibre.CONCLUSIONS: Lactulose had better efficacy than fibre for chronic constipation in ambulant patients, although both treatments were equally well tolerated in terms of adverse effects.

May

Massive fecal impaction presenting with megarectum and perforation of a stercoral ulcer at the rectosigmoid junction.
Lundy JB, Gadacz TR
South Med J. 2006 May;99(5):525-7.

A 25-year-old male with lifelong constipation presented to the emergency department with an acute abdomen. Initial resuscitation was performed, and the patient underwent urgent laparotomy. He was found to have feculent peritonitis with megabowel involving the rectum and sigmoid colon and a stercoral ulcer with full thickness erosion, and perforation was also identified on the anti-mesocolic surface at the rectosigmoid junction. Abdominal irrigation and subtotal colectomy with proximal fecal diversion was performed. This case illustrates that recognition of severe, chronic constipation should lead to interventions including disimpaction and aggressive medical management. When indicated, megabowel can be managed surgically in an elective setting based on anatomic findings and physiologic studies. Peritonitis is an ominous late finding in patients with severe constipation.

Fecal impaction and systemic inflammatory response syndrome in a young male with cerebral palsy.
ElHajj II, El-Zahabi LM, Abdul-Baki H, Barada KA
South Med J. 2006 May;99(5):521-4.

Symptoms of fecal impaction extend from constipation, anorexia, nausea, vomiting and abdominal pain, to full blown sepsis. We present the case of a patient with cerebral palsy and mental retardation, who presented to the Emergency Department with a 3-day history of diffuse abdominal pain and fecal incontinence. Evaluation revealed severe fecal impaction. The patient developed systemic inflammatory response syndrome (SIRS), with negative workup for underlying etiology. He responded well to digital disimpaction and antibiotics. Our case illustrates the serious sequelae of fecal impaction, which should be considered in patients with neurologic disorders and SIRS.

Rectal hyposensitivity.
Gladman MA, Lunniss PJ, Scott SM, Swash M
Am J Gastroenterol. 2006 May;101(5):1140-51.

Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension that is diagnosed during anorectal physiologic investigation. There have been few direct studies of this physiologic abnormality, and its contribution to the development of functional bowel disorders has been relatively neglected. However, it appears to be common in patients with such disorders, being most prevalent in patients with functional constipation with or without fecal incontinence. Indeed, it may be important in the etiology of symptoms in certain patients, given that it is the only "apparent" identifiable abnormality on physiologic testing. Currently, it is usually diagnosed on the basis of elevated sensory threshold volumes during balloon distension in clinical practice, although such a diagnosis may be susceptible to misinterpretation in the presence of altered rectal wall properties, and thus it is uncertain whether a diagnosis of RH reflects true impairment of afferent nerve function. Furthermore, the etiology of RH is unclear, although there is limited evidence to support the role of pelvic nerve injury and abnormal toilet behavior. The optimum treatment of patients with RH is yet to be established. The majority are managed symptomatically, although "sensory-retraining biofeedback" appears to be the most effective treatment, at least in the short term, and is associated with objective improvement in the rectal sensory function. Currently, fundamental questions relating to the contribution of this physiologic abnormality to the development of functional bowel disorders remain unanswered. Acknowledgment of the potential importance of RH is thus required by clinicians and researchers to determine its relevance.

Gastroparesis: clinical update.
Park MI, Camilleri M
Am J Gastroenterol. 2006 May;101(5):1129-39.

Gastroparesis refers to chronically abnormal gastric motility characterized by symptoms suggestive of mechanical obstruction and delayed gastric emptying in the absence of mechanical obstruction. It may be idiopathic or attributable to neuropathic or myopathic abnormalities, such as diabetes mellitus, postvagotomy, postviral infection, and scleroderma. Dietary and behavioral modification, prokinetic drugs, and surgical interventions have been used in managing patients with gastroparesis. Although mild gastroparesis is usually well managed with these treatment options, severe gastroparesis may be very difficult to control and may require referral to a specialist center if symptoms are intractable despite pharmacological therapy and dietetic support. New advances in drug therapy, botulinum toxin injection, and gastric electrical stimulation techniques have been introduced and might provide new hope to patients with refractory gastroparesis. This article critically reviews the advances in the field from the perspective of the clinician.

Alosetron: ischemic colitis and serious complications of constipation.
Gallo-Torres H, Brinker A, Avigan M
Am J Gastroenterol. 2006 May;101(5):1080-3.

Drugs such as alosetron that modulate serotonin effects by stimulating or blocking its receptors may play an important role in the treatment of some patients with irritable bowel system. In the case of alosetron, a 5HT-3 antagonist, an analysis of data from randomized clinical trials and postmarketing experiences have demonstrated a causal relationship between this drug and ischemic colitis and serious complications of constipation. Because the mechanism(s) of drug-induced ischemic colitis and possibly other forms of intestinal ischemia associated with alosetron have not been elucidated, there is need to further assess risk with regard to patient susceptibility and other factors.

Measuring successful treatment of irritable bowel syndrome: is "satisfactory relief " enough?
Schoenfeld P, Talley NJ
Am J Gastroenterol. 2006 May;101(5):1066-8.

The treatment options for the irritable bowel syndrome (IBS) are expanding as new therapies, including probiotics and serotonin receptor agents, become available. Before any new agents gain widespread use, they must be studied in appropriately designed clinical trials. Symptom improvement remains the key clinically but the best technique to measure symptom improvement is unclear. Many IBS therapy studies have used a binary endpoint such as "Have you had satisfactory relief of your IBS symptoms in the past week? Yes/No?" The study by Whitehead and colleagues in this issue suggests that "satisfactory relief" is affected by baseline symptom severity and may not always truly reflect the symptom burden. Future research needs to determine whether "satisfactory relief" is truly adequate, or whether alternatives such as the proportion of patients achieving a > or = 50% reduction in symptom severity would represent a superior approach to capture clinically important improvement.

Short-term effects of magnetic sacral dermatome stimulation for idiopathic slow transit constipation: sham-controlled, cross-over pilot study.
Lee KJ, Kim JH, Cho SW
J Gastroenterol Hepatol. 2006 Jan;21(1 Pt 1):47-53.

BACKGROUND AND AIM: An increase in recto-sigmoid colon activity through electrical stimulation of the sacral dermatomes has previously been reported. It has not been evaluated whether or not sacral dermatome stimulation has beneficial effects on constipation symptoms and anorectal function in constipated patients. Our aim was to evaluate short-term effects of magnetic stimulation of the sacral dermatomes on constipation symptoms and anorectal function in patients with idiopathic slow transit constipation. METHOD: Fourteen patients with idiopathic slow transit constipation were enrolled. Constipation symptoms, stool form and anorectal function were assessed before treatment, and at 3 and 6 weeks of treatment. Six-week treatment consisted of either a 3-week period of sham treatment or a 3-week period of magnetic stimulation of the S2-S3 dermatomes, which was performed in a randomized cross-over design. RESULTS: During the stimulation period, the frequency score of spontaneous bowel movements decreased in eight of the 14 patients (2.9 [2-3]vs 1.4 [0-2]), whose threshold volumes for urge to defecate and maximum tolerable volumes were significantly greater than those of the non-responders, and significantly decreased at the end of treatment. The degree of straining on defecation also significantly decreased in the responders. Responders had shorter right colonic transit time and longer left colonic transit time compared to the non-responders. Sham treatment did not affect constipation symptoms, stool form and rectal sensation. CONCLUSION: Sacral dermatome stimulation may offer potential for therapeutic benefit for a subset of patients with idiopathic slow transit constipation, particularly constipated patients with rectal hyposensation or hindgut dysfunction.

April

Multiple food hypersensitivity as a cause of refractory chronic constipation in adults.
Carroccio A, Di Prima L, Iacono G, Florena AM, D'Arpa F, Sciume C, Cefalu AB, Noto D, Averna MR
Scand J Gastroenterol. 2006 Apr;41(4):498-504.

Chronic constipation that is unresponsive to laxative treatment is a severe illness, but children unresponsive to laxatives have been successfully treated with an elimination diet. We report the first cases of refractory chronic constipation caused by food hypersensitivity in adults. Four patients with refractory constipation who were unresponsive to high doses of laxatives were put on an oligo-antigenic diet and underwent successive double-blind, placebo-controlled, food challenges (DBPFC). Routine laboratory tests, immunological assays, colonoscopy, esophago-gastroduodenoscopy and rectal and duodenal histology were performed. While on an elimination diet, bowel habits normalized in all patients and a DBPFC challenge triggered the reappearance of constipation. In comparison with another 13 patients with refractory constipation unresponsive to the elimination diet, observed over the same period, the patients with food-hypersensitivity-related constipation had the following characteristics: longer duration of illness (p < 0.03), lower body mass index (p < 0.03), higher frequency of self-reported food intolerance (p < 0.01), higher frequency of nocturnal abdominal pain and anal itching (p < 0.01). In patients with food hypersensitivity, hemoglobin concentrations and peripheral leukocytes were lower than those in controls (p < 0.03). The duodenal and rectal mucosa histology showed lymphocyte and eosinophil infiltration, and the duodenal villi were flattened in two cases. In adult patients, refractory chronic constipation may be caused by food hypersensitivity and an elimination diet is effective in these subjects.

Acute on chronic intestinal pseudo-obstruction as a cause of death in a previously healthy twenty-year-old male.
Evans JT, Delegge MH, Lawrence C, Lewin D
Dig Dis Sci. 2006 Apr;51(4):647-51.

Long-term continence in patients with Hirschsprung's disease and Down syndrome.
Catto-Smith AG, Trajanovska M, Taylor RG
J Gastroenterol Hepatol. 2006 Apr;21(4):748-53.

Background and Aim: Hirschsprung's disease is more common in children with Down syndrome, but the outcome for continence in this group is unclear. The aim of the present study was to determine the natural history of bowel function in children with Down syndrome and Hirschsprung's disease. Methods: We undertook a retrospective study of all patients with both Down syndrome and Hirschsprung's disease diagnosed at the Royal Children's Hospital, Melbourne, between 1974 and 2001 using a structured questionnaire. Results: Ten of the 20 eligible patients were interviewed. Fecal incontinence was common (87%), as were episodes of diarrhea and perianal excoriation (40%). Persistent constipation was relatively unusual (20%). Adverse reactions to food, especially vegetables and fruit, were very common (90%). There was evidence that bowel dysfunction improved with age, particularly sensation of impending stool (P < 0.05), ability to discriminate stool consistency (P = 0.05), constipation (P < 0.05), episodes of diarrhea (P = 0.08) and excoriation (P < 0.05). Conclusion: Persistent bowel dysfunction is common in children with Down syndrome and Hirschsprung's disease, but there is evidence of improvement with age. There was an unexpectedly high prevalence of food-related adverse reactions.

Constipation of anorectal outlet obstruction: Pathophysiology, evaluation and management.
Andromanakos N, Skandalakis P, Troupis T, Filippou D
J Gastroenterol Hepatol. 2006 Apr;21(4):638-646.

Constipation is a subjective symptom of various pathological conditions. Incidence of constipation fluctuates from 2 to 30% in the general population. Approximately 50% of constipated patients referred to tertiary care centers have obstructed defecation constipation. Constipation of obstructed defecation may be due to mechanical causes or functional disorders of the anorectal region. Mechanical causes are related to morphological abnormalities of the anorectum (megarectum, rectal prolapse, rectocele, enterocele, neoplasms, stenosis). Functional disorders are associated with neurological disorders and dysfunction of the pelvic floor muscles or anorectal muscles (anismus, descending perineum syndrome, Hirschsprung's disease). However, this type of constipation should be differentiated by colonic slow transit constipation which, if coexists, should be managed to a second time. Assessment of patients with severe constipation includes a good history, physical examination and specialized investigations (colonic transit time, anorectal manometry, rectal balloon expulsion test, defecography, electromyography), which contribute to the diagnosis and the differential diagnosis of the cause of the obstructed defecation. Thereby, constipated patients can be given appropriate treatment for their problem, which may be conservative (bulk agents, high-fiber diet or laxatives), biofeedback training or surgery.

March

Incidence of Ischemic Colitis and Serious Complications of Constipation Among Patients Using Alosetron: Systematic Review of Clinical Trials and Post-Marketing Surveillance Data.
Chang L, Chey WD, Harris L, Olden K, Surawicz C, Schoenfeld P
Am J Gastroenterol. 2006 Apr 6;.

BACKGROUND: Ischemic colitis and serious complications of constipation have been reported in association with the use of alosetron, which is approved for women with severe diarrhea-predominant IBS who have failed conventional therapies. This systematic review calculated the incidence of these adverse events in alosetron-using patients in clinical trials and post-marketing surveillance. METHODS: A panel of experts in epidemiology and functional bowel disorders reviewed clinical trial report forms and FDA MedWatch forms of each reported case of ischemic colitis or serious complications of constipation. Experts were blinded about whether patients used alosetron or placebo. Using pre-specified criteria, experts rated the likelihood of an accurate diagnosis and an association between medication use and adverse events. Cases that were not consistent with the reported diagnosis or not possibly associated with medication use were eliminated from calculation of incidence rates of adverse events. RESULTS: Pooled data from clinical trials indicate an increased rate of ischemic colitis among alosetron-using patients compared to placebo-using patients (0.15%vs 0.0%, respectively, p= 0.03), but there was no significant difference in the rate of serious complications of constipation. All (19/19) alosetron-using patients with ischemic colitis had reversible colitis without long-term sequelae. Based on post-marketing surveillance data, the post-adjudication rate of ischemic colitis is 1.1 per 1,000 patient-years of alosetron use and the rate of serious complications of constipation is 0.66 per 1,000 patient-years of alosetron use. CONCLUSION: The incidence of ischemic colitis and serious complications of constipation is very low and is rarely associated with long-term sequelae or serious morbidity.

Factors Associated with the Development of Intestinal Strictures or Obstructions in Patients with Crohn's Disease.
Lichtenstein GR, Olson A, Travers S, Diamond RH, Chen DM, Pritchard ML, Feagan BG, Cohen RD, Salzberg BA, Hanauer SB, Sandborn WJ
Am J Gastroenterol. 2006 Apr 6;.

OBJECTIVE: Theoretical concern exists that rapid luminal healing in Crohn's disease (CD) with therapies like infliximab increases the risk of intestinal stenosis, stricture, or obstruction (SSOs). METHODS: Data were analyzed from the ongoing observational TREAT (the Crohn's Therapy, Resource, Evaluation, and Assessment Tool) Registry and ACCENT I (A Crohn's Disease Clinical Trial Evaluating Infliximab in a New Long-Term Treatment Regimen) study. Investigators reported SSOs as adverse events or serious adverse events. RESULTS: In TREAT, SSOs occurred at a significantly higher rate in patients treated with infliximab compared with patients who received other treatments only (1.95 events/100 patient-years vs 0.99 events/100 patient-years; p < 0.001). Using multivariable analyses, however, infliximab therapy was not associated with SSO development. CD severity at the time of event onset (hazard ratio (HR) = 2.35, 95% confidence internal (CI) 1.35-4.09); CD duration (HR = 1.02, 95% CI 1.00-1.04); ileal disease (HR = 1.56, 95% CI 1.04-2.36); and new corticosteroid use (HR = 2.85, 95% CI 1.23-6.57) were associated with SSOs. In ACCENT I, no increase in SSOs was reported in patients who received infliximab maintenance therapy compared with those who received episodic therapy, despite higher median cumulative infliximab exposure. Additionally, there was no increase in SSO development with rapid mucosal healing (healing at week 10). CONCLUSIONS: Although unadjusted analyses suggested that patients who received infliximab were twice as likely to develop SSOs, multivariable analysis adjusting for other factors demonstrated that only disease duration, disease severity, ileal disease, and new corticosteroid use were significantly associated with SSO development.

Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia.
Chiarioni G, Whitehead WE, Pezza V, Morelli A, Bassotti G
Gastroenterology. 2006 Mar;130(3):657-64.

BACKGROUND & AIMS: Uncontrolled trials suggest biofeedback is an effective treatment for pelvic floor dyssynergia (PFD), a type of constipation defined by paradoxical contraction, or inability to relax, pelvic floor muscles during defecation. The aim was to compare biofeedback to laxatives plus education. METHODS: Patients with chronic, severe PFD were first treated with 20 g/day fiber plus enemas or suppositories up to twice weekly. Nonresponders were randomized to either 5 weekly biofeedback sessions (n = 54) or polyethylene glycol 14.6-29.2 g/day plus 5 weekly counseling sessions in preventing constipation (n = 55). Satisfaction with treatment, symptoms of constipation, and pelvic floor physiology were assessed 6 and 12 months later. The biofeedback group was also assessed at 24 months. Laxative-treated patients were instructed to increase the dose of polyethylene glycol from 14.6 to 29.2 g/day after 6 months. RESULTS: At 6 months, major improvement was reported by 43 of 54 (80%) biofeedback patients vs 12 of 55 (22%) laxative-treated patients (P < .001). Biofeedback's benefits were sustained at 12 and 24 months. Biofeedback also produced greater reductions in straining, sensations of incomplete evacuation and anorectal blockage, use of enemas and suppositories, and abdominal pain (all P < .01). Stool frequency increased in both groups. All biofeedback-treated patients reporting major improvement were able to relax the pelvic floor and defecate a 50-mL balloon at 6 and 12 months. CONCLUSIONS: Five biofeedback sessions are more effective than continuous polyethylene glycol for treating PFD, and benefits last at least 2 years. Biofeedback should become the treatment of choice for this common and easily diagnosed type of constipation.

February

Information from your family doctor. Help for your child's constipation.
Am Fam Physician. 2006 Feb 1;73(3):481-2.

[Stopping smoking and constipation.]
Lagrue G, Cormier S, Mautrait C, Divine C
Presse Med. 2006 Feb;35(2 Pt 1):246-8.

Introduction>Among the symptoms that may occur with smoking withdrawal, constipation is relatively frequent, but little studied. Case>Three women reported that constipation developed when they stopped smoking and improved during transient relapses. DISCUSSION:>This constipation sometimes produces serious functional disorders and can induce relapse. It occurs especially among women and those predisposed to it. Nicotine, by acting on the parasympathomimetic system, increases intestinal peristalsis, and a cigarette can appear to be effective self-medication. Magnesium salts are the first-line treatment for this problem. If they fail, neostigmine, an anticholinesterase with parasympathomimetic activity, appears remarkably effective in correcting this disorder.

Information from your family doctor. Chronic constipation in your child.
Am Fam Physician. 2006 Feb 1;73(3):479-80.

Evaluation and treatment of constipation in infants and children.
Biggs WS, Dery WH
Am Fam Physician. 2006 Feb 1;73(3):469-77.

Constipation in children usually is functional and the result of stool retention. However, family physicians must be alert for red flags that may indicate the presence of an uncommon but serious organic cause of constipation, such as Hirschsprung's disease (congenital aganglionic megacolon), pseudo-obstruction, spinal cord abnormality, hypothyroidism, diabetes insipidus, cystic fibrosis, gluten enteropathy, or congenital anorectal malformation. Treatment of functional constipation involves disimpaction using oral or rectal medication. Polyethylene glycol is effective and well tolerated, but a number of alternatives are available. After disimpaction, a maintenance program may be required for months to years because relapse of functional constipation is common. Maintenance medications include mineral oil, lactulose, milk of magnesia, polyethylene glycol powder, and sorbitol. Education of the family and, when possible, the child is instrumental in improving functional constipation. Behavioral education improves response to treatment; biofeedback training does not. Because cow's milk may promote constipation in some children, a trial of withholding milk may be considered. Adding fiber to the diet may improve constipation. Despite treatment, only 50 to 70 percent of children with functional constipation demonstrate long-term improvement.

Differences Between Painless and Painful Constipation Among Community Women.
Bharucha AE, Locke GR, Zinsmeister AR, Seide BM, McKeon K, Schleck CD, Melton LJ 3rd
Am J Gastroenterol. 2006 Feb 8;.

BACKGROUND: In the Rome II criteria, patients with both constipation and abdominal pain (AP) (i.e., "painful constipation" (PC)), who do not satisfy criteria for irritable bowel syndrome (IBS) are included in the same functional constipation (FC) category as patients with constipation without AP (i.e., "painless constipation" (PLC)). What differences, if any, exist between FC without (i.e., PLC) and with AP (i.e., PC) are unclear. METHODS: To compare clinical features among PLC, PC, constipation-predominant IBS (C-IBS), and non-C-IBS, a validated questionnaire was mailed (with telephone follow-up of nonresponders) to an age-stratified random sample of 5,200 adult women in Olmsted County, Minnesota. RESULTS: Altogether, 2,800 women (53%) responded. The age-adjusted prevalence of PLC (7.1 per 100; 95% confidence interval (95% CI), 6.2-8.0) was higher compared to PC (0.9 per 100; 95% CI, 0.6-1.2). Compared to PLC, patients with PC reported worse general health (i.e., excellent or very good = 37.5%vs 51.2%), more somatic symptoms (mean score = 1.3 vs 0.9), and urinary urgency (% often = 58%vs 32%), and had a higher prevalence of hysterectomy. Bowel symptoms significantly impacted >/=1 domain of quality of life (QOL) in 18% of PC versus 9% of PLC. In a logistic discriminant model, age, general health, impact of bowel symptoms on QOL, somatic symptoms, and urinary urgency independently discriminated between bowel subtypes. CONCLUSIONS: Patients with PC more closely resemble those with C-IBS than PLC. Consideration should be given to separating PC from PLC in the Rome criteria and in therapeutic trials.

A 54-year-old woman with constipation-predominant irritable bowel syndrome.
Lembo AJ
JAMA. 2006 Feb 22;295(8):925-33.

January

Stapled transanal rectal resection to treat obstructed defecation caused by rectal intussusception and rectocele.
Renzi A, Izzo D, Di Sarno G, Izzo G, Di Martino N
Int J Colorectal Dis. 2006 Jan 13;:1-7.

Colectomy for colonic inertia: successful relief of constipation is not enough.
Ringel Y
Gastroenterology. 2006 Jan;130(1):273-4; discussion 274-5.

Reply.
Wexner SD
Gastroenterology. 2006 Jan;130(1):274-5.

Cecostomy in children with defecation disorders.
Mousa HM, Den Berg MM, Caniano DA, Hogan M, Di Lorenzo C, Hayes J
Dig Dis Sci. 2006 Jan;51(1):154-60.

Administration of antegrade enemas through a cecostomy is a therapeutic option for children with severe defecation disorders. The purpose of this study is to report our 4-year experience with the cecostomy procedure in 31 children with functional constipation (n = 9), Hirschsprung's disease (n = 2), imperforate anus (n = 5), spinal abnormalities (n = 8), and imperforate anus in combination with tethered spinal cord (n = 7). Data regarding complications, antegrade enemas used, symptoms, and quality of life were retrospectively obtained. Placement of cecostomy tubes was successful in 30 of 31 patients. Soiling episodes decreased significantly in children with functional constipation (P = 0.01), imperforate anus (P < 0.01), and spinal abnormalities (P = 0.04). Quality of life improved in patients with functional constipation and imperforate anus. No difference in complications was found between percutaneous and surgical placement. Use of antegrade enemas via cecostomy improved symptoms and quality of life in children with a variety of defecation disorders.

New insight into rectal function in pediatric defecation disorders: disturbed rectal compliance is an essential mechanism in pediatric constipation.
Voskuijl WP, van Ginkel R, Benninga MA, Hart GA, Taminiau JA, Boeckxstaens GE
J Pediatr. 2006 Jan;148(1):62-7.

OBJECTIVE: To evaluate rectal sensitivity in patients with pediatric constipation (PC) and nonretentive fecal soiling (FNRFS) using pressure-controlled distention (barostat). STUDY DESIGN: Thresholds for rectal sensitivity (first sensation, urge to defecate, and pain), and rectal compliance were determined using a barostat. RESULTS: A total of 69 patients with PC (50 males; mean age, 10.9 +/- 2.2 years) and 19 patients with FNRFS (15 males; mean age, 10.0 +/- 1.9 years) were compared with 22 healthy volunteers (HVs) (11 males; mean age, 12.7 +/- 2.6 years). Sensitivity thresholds were not significantly different among the 3 groups. Rectal compliance was increased in 58% of the patients with PC (P < .0001 vs HVs). Rectal compliance did not differ between patients with FNRFS and HVs. Children with PC with abnormal rectal function required significantly larger rectal volumes at urge to defecate. CONCLUSIONS: Increased compliance is the most prominent feature in patients with PC. Because of higher compliance in these children, larger stool volumes are required to reach the intrarectal pressure of the urge to defecate. Children with FNRFS have normal rectal function.

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