Anal Sphincters Evaluation by Endoanal Ultrasound in Obstructed Defecation.

OBJECTIVES: To evaluate anal sphincter abnormalities detected by endoanal ultrasound in obstructed defecation due to rectocele and rectal intussusception. METHODS: The retrospective analysis includes 45 patients with obstructed defecation syndrome due to rectocele and/or rectal intussusception with or without fecal incontinence, and submitted to endoanal ultrasound. RESULTS: Ninety-three percent (n = 42) were women (mean age of 63 ± 12 years), and 47% (n = 21) of the patients had fecal incontinence. In total, 29% (n = 13) had a previous anorectal surgery, and 93% (n = 39) of the women had a previous vaginal delivery. An isolated rectal intussusception was diagnosed in 20% (n = 9) of the patients, an isolated rectocele in 24% (n = 11), and rectal intussusception and rectocele in 56% (n = 25). Thirty-six percent of patients had anal sphincter lacerations (n = 16): 12% (n = 2) had only internal laceration, 69% (n = 11) had only external laceration, and 19% (n = 3) had both. Two patients had a thinner internal anal sphincter with 0.9 and 1.2 mm, respectively. In total, 25% of the patients without fecal incontinence had an occult anal sphincter laceration, and all were women with an external sphincter laceration in the anterior quadrant and a previous vaginal delivery. In patients with obstructed defecation and fecal incontinence, 48% had sphincter lacerations. Previous anorectal surgery was a predictor of anal sphincter laceration (odds ratio [OR] 4.8; 95% confidence interval [CI] = 1.214-18.971; P = .025), but fecal incontinence (OR 2.7; 95% CI = 0.774-9.613; P = .119) and previous vaginal delivery (OR 1.250; 95% CI = 0.104-15.011; P = .860) were not. CONCLUSIONS: Endoanal ultrasound should be considered in obstructed defecation with or without fecal incontinence, especially if surgical correction is planned.

Prevalence and factors associated with faecal impaction in the Spanish old population.

Background: Faecal impaction (FI) is a common problem in old people living in nursing home. Its prevalence and associated factors remain unknown in the general population. Aim: To evaluate FI prevalence in the Spanish population older than 65 years and to assess the factors associated with it. Methods: A telephone survey was carried out of a Spanish population older than 65 years random sample (N = 1000). FI was assessed using a previously validated questionnaire. Results: A total of 28,128 calls were made; 1,431 subjects were eligible and 1,000 subjects were enrollled, mean aged 74.6 ± 7.3 (65­97); 57.5% were women. At least 53 people reported FI within the past year (5.3% (CI 95%: 3.9­6.7%)). Only 0.03% met criteria for chronic constipation and faecal incontinence. FI-associated factors were constipation, female gender, reduced physical activity, and chronic renal failure (CRF). Conclusion: FI is a prevalent problem in old Spanish population. Constipation and female gender are the main associated factors; low physical activity and CRF appear to play also a significant role. Further studies are required to confirm this association.

Fecal impaction: a systematic review of its medical complications.

BACKGROUND: Fecal impaction (FI) is a common problem in the elderly and other at-risk groups, such as patients with a neuro-psychiatric disease. It has been associated with medical problems and high morbi-mortality. A systematic review of this topic might be useful to improve the knowledge in this area and helpful to make an appropriate and early diagnosis. METHODS: A PubMed systematic search was performed using relevant keywords. Case reports published in English, Spanish or French till June 2014 were included if they had a diagnosis of FI and a medical complication secondary to it. Each case was classified based on its principal complication. The main objective is to create a classification of FI complications based on published clinical cases. RESULTS: 188 articles met inclusion criteria, comprising 280 clinical cases. Out of the total, 43,5% were over 65 years old, 49% suffered from chronic constipation, 29% had an underlying neuropsychiatric disease and 15% were hospitalised or institutionalised. A total of 346 medical complications secondary to FI were collected. They were divided according to gastrointestinal tract involvement and then classified based on their anatomical and pathophysiological mechanism into three groups: Complications secondary to fecaloma effect on the intestinal wall (73.4%), on the intestinal lumen (14%) and on adjacent structures (12.6%). CONCLUSIONS: FI causes complications that might be fatal. The elderly, underlying neuropsychiatric disease and hospitalised or institutionalised patients integrate the high-risk group in which FI must be suspected. The first FI complications classification is presented to improve the knowledge about this entity.

Differences in Symptom Severity and Quality of Life in Patients With Obstructive Defecation and Colonic Inertia.

BACKGROUND: Little is known about how obstructive defecation and colonic inertia symptoms contribute to constipation-related quality of life. OBJECTIVE: We sought to characterize the differences in quality of life in patients with severe obstructive defecation and colonic inertia symptoms. DESIGN: This study was a cross-sectional analysis of a prospective database. SETTING: Patients were enrolled at a single tertiary referral center. PATIENTS: We included consecutive adults with severe symptoms of obstructive defecation (n = 115) or colonic inertia (n = 90) as measured by the Constipation Severity Instrument. MAIN OUTCOME MEASURES: 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. RESULTS: 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 p < 0.001). 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). LIMITATIONS: The use of patient self-report instruments resulted in a proportion of patients with incomplete data. CONCLUSION: 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.

A case of giant fecaloma in a 24-year-old woman.

Chronic constipation is a very common complaint at outpatient clinics. It can progress to fecal impaction, and rarely to fecalomas if not managed promptly. Fecaloma is characterized by a hardened large mass of feces frequently localized in sigmoid colon and rectum and is difficult to discharge. Fecaliths, stagnating and hardening by time, may cause intestinal obstruction,ulcer development and colonic wall perforation. We present the case of a 24-year-old woman who admitted to our hospital with complaints of severe constipation with 1 bowel movement every third-fifth day with passage of hard stools only with using laxatives and meteorism. This is a rare case of fecalomas and megacolon, when conservative measures were absolutely ineffective and surgical treatment was needed. Therefore, diagnosis of fecaloma must be considered in patients presenting with chronic constipation and abdominal mass.Further investigations are mandatory to delineate guidelines for clinical management of megacolon especially in women of childbearing age.

[Colon transit time in children and young adults with open spinal dysraphism]. / Temps du transit colique chez l'enfant atteint de dysraphisme ouvert.

INTRODUCTION: Patients with open spinal dysraphism (OSD) frequently present constipation and incontinence requiring treatment. AIM: Evaluation of colon transit time (CTT) in patients with OSD, in relation to neural lesion, mobility, bowel habits, and continence status. METHODS: OSD patients aged between 6 and 20 years, who did not use antegrade enemas, were invited to participate in the study. Data from the medical file and information retrieved by questionnaires for constipation and incontinence were collected. The control group consisted of 13 healthy age-matched children. CTT was measured using the 6-day pellet method with an abdominal X-ray on day 7. Laxatives were continued and retrograde colon enemas were stopped 48h prior the X-ray. RESULTS: Thirty of the 33 patients who met the inclusion criteria agreed to participate. Twelve (40%) patients were constipated (Rome III criteria) despite treatment. Fifteen (50%) were continent, with or without treatment. Total CTT was significantly longer in OSD patients (median CTT: 86.4h vs. 43.2h controls). Constipated OSD patients had a significantly prolonged CTT compared to non-constipated patients (CTT: 125.4h vs. 51.6h). Spontaneous continent OSD patients had a normal CTT (CTT: 33.6h). An abnormal CTT predicted the necessity of treatment to achieve continence (P<0.006). CONCLUSION: CTT in OSD patients is significantly prolonged, indicating a neurogenic involvement of the bowel and a slow transit constipation. An abnormal CTT predicts the necessity of therapy to achieve fecal continence.

Long-term follow-up of the Jinling procedure for combined slow-transit constipation and obstructive defecation.

BACKGROUND: Surgery is indicated for chronic constipation refractory to conservative therapy. The treatment of combined slow-transit constipation and obstructive defecation is controversial. OBJECTIVE: The aim of the study is to describe the Jinling procedure and examine safety, effectiveness, and quality of life over 4 years of follow-up. DESIGN: The study is a retrospective review of prospectively gathered data in a patient registry database. SETTINGS: This investigation was conducted at a tertiary-care gastroenterology surgical center in China. PATIENTS: The study included 117 consecutive patients with slow-transit constipation combined with obstructive defecation treated between January 2005 and December 2007. INTERVENTION: The Jinling procedure modifies the classic procedure of subtotal colectomy with colorectal anastomosis by adding a new side-to-side cecorectal anastomosis to solve the coexistence of obstructive defecation and slow-transit constipation in one operation. MAIN OUTCOME MEASURES: We measured morbidity and mortality rates, Wexner constipation scores, and Gastrointestinal Quality of Life Index at baseline and after 1, 6, 12, 24, 36 and 48 months of follow-up. RESULTS: A total of 117 patients underwent the Jinling procedure, which was laparoscopically assisted in 56 patients (47.9%) and an open procedure in 61 patients (52.1%). Of the total, 72 patients (61.5%) had undergone previous surgical intervention without improvement. A total of 28 complications and adverse events were reported in 117 procedures, giving an overall morbidity rate of 23.9%; 23 patients (19.7%) had 1 or more events. Most complications were managed conservatively. A significant reduction in Wexner constipation score was observed from baseline (mean, 21.9) to 1 month (mean, 9.8), and the reduction was maintained at 48 months (mean 5.1; p < 0.001). Compared with baseline, significant overall improvements were also seen in gastrointestinal quality of life at 12, 24, and 48 months of follow-up (p < 0.01). LIMITATIONS: This study did not include a comparison group. CONCLUSIONS: Our clinical practice demonstrates that Jinling procedure is safe and effective for refractory slow-transit constipation associated with obstructive defecation, with minimal major complications, significant improvement of quality of life, and a high satisfaction rate after 4-year follow up.

Stapled transanal rectal resection with contour transtar for obstructed defecation syndrome: lessons learned after more than 3 years of single-center activity.

BACKGROUND: Obstructed defecation syndrome is a widespread and disabling disease. OBJECTIVE: We aim to evaluate the safety and efficacy of stapled transanal rectal resection performed with a new dedicated curved device in the treatment of obstructed defecation syndrome. DESIGN: A retrospective review of 187 stapled transanal rectal resections performed from June 2007 to February 2011 was conducted. SETTINGS: The entire study was conducted at a university hospital. PATIENTS: : All the patients with symptomatic obstructed defecation syndrome and the presence of a rectocele and/or a rectorectal or rectoanal intussusception, in the absence of sphincter contractile deficiency, were included in the treatment protocol. INTERVENTIONS: All procedures were performed with the use of the Contour Transtar device. We analyzed the functional results of this technique, the incidence and features of the surgical and functional complications, and ways to prevent or treat them. MAIN OUTCOME MEASURES: Constipation was graded by using the Agachan-Wexner constipation score; use of aids to defecate and patient satisfaction were assessed preoperatively and 6 months after surgery. Intraoperative and postoperative complications were also investigated. RESULTS: The constipation intensity was statistically reduced from the preoperative mean value of 15.8 (± 4.9) to 5.2 (± 3.9) at 6 months after surgery (p < 0.0001). Of the 151 (80.3%) patients who took laxatives and the 49 (26.2%) who used enemas before treatment, only 25 (13.2%; p < 0.0001) and 7 (3.7%; p < 0.0001) continued to do so after surgery. None of the 17 (9.1%) patients who had previously helped themselves with digitations needed to continue this practice. Almost all patients showed a good satisfaction rate (3.87/5) after the procedure. LIMITATIONS: Limitations are the short follow-up of 1 year and the design of the study that may introduce potential selection bias. CONCLUSIONS: The results of this study show that stapled transanal rectal resection performed with the use of the Contour Transtar is a safe and effective procedure to treat obstructed defecation syndrome.

Abdominal radiograph in the assessment of fecal impaction in children with functional constipation: comparing three scoring systems.

OBJECTIVES: To compare three radiological scores in the study of fecal impaction in children with constipation. To investigate whether these radiological scores are useful in the assessment of fecal disimpaction therapy and if they present a relation with total colonic transit time. METHODS: The Barr, Blethyn and Leech scores were measured by three observers, independently, in 123 abdominal radiographs. Interobserver agreement in the diagnosis of fecal impaction was calculated for the three scores. In 30 radiographs, the analysis of the scores was performed before and after fecal disimpaction. Total colonic transit time was calculated in 59 radiographs with the use of radiopaque markers. RESULTS: The agreement between pairs of observers was assessed by the kappa coefficient and was good for the Barr (0.56, 0.59 and 0.69) and Leech scores (0.53, 0.58 and 0.61). The Blethyn score presented lower kappa coefficients (0.26, 0.32 and 0.36). In the comparison of methods, Leech and Barr showed a good correlation. After fecal disimpaction, there was a statistically significant reduction (p < 0.001) of scores, most significantly with the Barr score. There was no relation between radiographic scores and colonic transit time. CONCLUSIONS: There is no relation between fecal impaction assessed by radiography of the abdomen and total colonic transit time. Plain radiographs may be a useful tool for the diagnosis of fecal impaction. The Barr score can be considered a good method of analysis, especially to assess the response to treatment of fecal impaction.

Radiografia simples de abdome no diagnóstico da impactação fecal em crianças com constipação intestinal: comparação entre três escores radiológicos / Abdominal radiograph in the assessment of fecal impaction in children with functional constipation: comparing three scoring systems

OBJETIVOS: Comparar três escores radiológicos na pesquisa de impactação fecal em crianças com constipação intestinal. Verificar, ainda, se estes escores radiológicos são úteis na avaliação da terapia de desimpactação fecal e se apresentam relação com o tempo de trânsito colônico total. MATERIAL E MÉTODOS: Os escores de Barr, Blethyn e Leech foram aferidos por três observadores, de forma independente, em 123 radiografias de abdome. A concordância interobservador no diagnóstico da impactação fecal foi calculada para os três escores. Em 30 radiografias, foi feita a análise dos escores antes e após a desimpactação fecal. O tempo de trânsito colônico total foi calculado em 59 radiografias com o emprego de marcadores radiopacos. RESULTADOS: A concordância entre os pares de observadores, avaliada pelo coeficiente de Kappa, foi boa para os escores de Barr (0,56, 0,59 e 0,69) e Leech (0,53, 0,58 e 0,61). O escore de Blethyn apresentou menores coeficientes de Kappa (0,26, 0,32 e 0,36). Na comparação dos métodos, Leech e Barr mostraram boa correlação. Após a desimpactação fecal, houve redução estatisticamente significante (p < 0,001) dos escores, mais expressiva com o escore de Barr. Não houve relação entre os escores radiológicos e o tempo de trânsito colônico. CONCLUSÕES: Não há relação entre impactação fecal avaliada pela radiografia de abdome e o tempo de trânsito colônico total. A radiografia simples pode ser um instrumento útil ao diagnóstico da impactação fecal. O escore de Barr pode ser considerado um bom método de análise, sobretudo para avaliação da resposta ao tratamento da impactação fecal.

OBJECTIVES: To compare three radiological scores in the study of fecal impaction in children with constipation. To investigate whether these radiological scores are useful in the assessment of fecal disimpaction therapy and if they present a relation with total colonic transit time. METHODS: The Barr, Blethyn and Leech scores were measured by three observers, independently, in 123 abdominal radiographs. Interobserver agreement in the diagnosis of fecal impaction was calculated for the three scores. In 30 radiographs, the analysis of the scores was performed before and after fecal disimpaction. Total colonic transit time was calculated in 59 radiographs with the use of radiopaque markers. RESULTS: The agreement between pairs of observers was assessed by the kappa coefficient and was good for the Barr (0.56, 0.59 and 0.69) and Leech scores (0.53, 0.58 and 0.61). The Blethyn score presented lower kappa coefficients (0.26, 0.32 and 0.36). In the comparison of methods, Leech and Barr showed a good correlation. After fecal disimpaction, there was a statistically significant reduction (p < 0.001) of scores, most significantly with the Barr score. There was no relation between radiographic scores and colonic transit time. CONCLUSIONS: There is no relation between fecal impaction assessed by radiography of the abdomen and total colonic transit time. Plain radiographs may be a useful tool for the diagnosis of fecal impaction. The Barr score can be considered a good method of analysis, especially to assess the response to treatment of fecal impaction.

Up-regulated cystic fibrosis transmembrane conductance regulator after anal stenosis in rats.

BACKGROUND: The pathophysiology of fecal incontinence from fecal impaction and rectal distension is poorly understood. We hypothesize that fecal impaction elicits up-regulation of cystic fibrosis transmembrane conductance regulator (CFTR), a cAMP-activated mucosal chloride channel. METHODS: The anus was ligated to produce 75% stenosis in rats. Controls received ligation without inducing stenosis. 24 to 48 hours after ligation the colon was removed. Mucosal short-circuit current was measured by Ussing chamber. Western blot analysis was used to detect CFTR expression in the colonic mucosa. Ligated rats failed to defecate, whereas control rats stooled normally. RESULTS: Ligated colons were markedly stool filled and dilated. Water content of feces was significantly increased to 66.5% ± 1.1% (P < .01, n = 12) 24 hours after ligation, vs controls (49.5 ± 5.2%, n = 12). Baseline short-circuit current was significantly increased in the distal (78.8 ± 7.4 µA/cm(2), n = 8, P < .01) and mid colon (24.5 ± 2.5 µA/cm(2), n = 8, P < .05) 24 hours after ligation, compared to control rats (12.5 ± 3.2 µA/cm2, n = 8). CFTR expression was significantly increased 24 hours after ligation in the mid and distal colon. CONCLUSION: We observe that fecal impaction from anal ligation induces early compensatory up-regulation of CFTR, altering function from net absorption to net secretion in the mid and distal colon.

[Surgical treatment of chronic coprostasis].

Surgical treatment of 27 patients with chronic colostasis and dolichocolon was analyzed. Groups of patients with cologenic and proctogenic colostasis were defined, diagnostic criteria were formulated and optimal surgical tactics were described for each group. Short and long-term results were analyzed and proved to be excellent and satisfactory in majority of patients.

Validated tools for evaluating opioid-induced bowel dysfunction.

Adverse effects on the gastrointestinal system are problematic for pain patients receiving opioid treatment. Opioid-induced bowel dysfunction (OIBD) is often misinterpreted as constipation as this is the most frequently reported symptom of OIBD; however, it actually comprises the whole gut with symptoms such as nausea, reflux, bloating, and anorexia being very prevalent as well. Validated methods to evaluate these symptoms are essential before the action of a drug on bowel dysfunction can be evaluated, but only the effect on the most frequently reported symptom, constipation, has been evaluated systematically. Constipation is a personal symptom and there is little correlation between subjective methods for assessment of constipation and objective evaluations, such as transit time and fecal loading. Few questionnaires specific to constipation exist, since most that are regularly used form part of general gastrointestinal investigations, which furthermore are often complicated and time consuming to complete. This article gives an overview of the different evaluation regimes for OIBD with a particular focus on the most frequently reported symptom; constipation.

No role for increased rectal compliance in pediatric functional constipation.

BACKGROUND & AIMS: Increased rectal compliance has been proposed to contribute to pediatric functional constipation (FC). We evaluated the clinical relevance of increased rectal compliance and assessed whether regular use of enemas improves rectal compliance in children with FC. METHODS: A prospective longitudinal study was conducted on children (8-18 years old) with FC. Pressure-controlled rectal distensions were performed at baseline and at 1 year. Rectal compliance was categorized into 3 groups: normal, moderately increased, or severely increased. Patients were randomly assigned to groups given conventional therapy or rectal enemas and conventional therapy. Clinical success was defined as >or=3 spontaneous defecations per week and fecal incontinence <1 per week. RESULTS: Baseline measurements were performed in 101 children (11.0 +/- 2.1 years); rectal compliance was normal in 36%, moderately increased in 40%, and severely increased in 24%. Patients with severely increased rectal compliance had lower defecation frequency (P = .03), more fecal incontinence (P = .04), and more rectal fecal impaction (P < .001). After 1 year, success values were similar between groups: 42% normal, 41% moderately increased, and 40% with severely increased compliance. Barostat studies performed after 1 year in 80 children (37 conventional therapy and 43 rectal enemas in addition to conventional therapy) revealed that rectal compliance had not changed in either group and had not improved in successfully treated patients. CONCLUSIONS: Constipated children with severely increased rectal compliance have severe symptoms. However, increased rectal compliance is not related to treatment failure. Regular use of enemas to avoid rectal fecal impaction does not improve rectal compliance in pediatric FC.