Indian J Gastroenterol (November–December 2014) 33(6):530–536 DOI 10.1007/s12664-014-0505-8
ORIGINAL ARTICLE
Clinical and investigative assessment of constipation: A study from a referral center in western India Nimish Shah & Rajiv Baijal & Praveen Kumar & Deepak Gupta & Sandeep Kulkarni & Soham Doshi & Deepak Amarapurkar
Received: 7 April 2014 / Accepted: 14 September 2014 / Published online: 15 October 2014 # Indian Society of Gastroenterology 2014
Abstract Introduction Constipation may be primary or secondary. Pathophysiologic subtypes of primary constipation are dyssynergic defecation (DD), slow (STC), and normal transit constipation (NTC). Clinical subtypes are functional constipation (FC) and constipation predominant IBS (C-IBS). Aims The objectives of this paper are to study the clinical profile, categorize and compare various subtypes of primary constipation, and to assess the success of biofeedback therapy (BFT) in a non-randomized, uncontrolled open-label study among patients with DD. Material and Methods Consecutive constipation patients (April 2011 to December 2012) were evaluated. Patients 35 years) than among those with younger age (≤35 years) [3]. Among outpatient clinic visits, constipation is one of the five most common physician diagnoses for gastrointestinal disorders [4]. Constipation also consumes substantial health care resources because of high prevalence. In majority of cases, chronic constipation is an aggravating, but not lifethreatening or debilitating, thus leading to the use of selfadministered over-the-counter laxatives and complementary and alternative medications (CAM) like ayurvedic preparations [5]. It is estimated that only 30 % of patients with constipation seek medical advice and 30 % are habitual consumers of laxatives, which, although it improves stool frequency but do not improve the general well being and abdominal and extraabdominal symptoms, cause significant
Indian J Gastroenterol (November–December 2014) 33(6):530–536
decline in quality of life and occasionally induce serious adverse events [6]. Constipation may be primary (idiopathic) or secondary to other factors. Several subtypes of primary constipation are recognized [7]. According to gut transit time, constipation may be categorized into slow transit (prolonged delay in passage of stool through the colon) or normal transit. With slow and normal transit times, there may be functional obstruction in the form of dysfunction of pelvic floor and anal sphincter muscles (anismus), leading to difficulty in expelling stools from the anorectum, or there can be no identifiable pathology with normal transit constipation (NTC). In patients not responding to laxatives, identifying the subtype of primary constipation helps in selecting further treatment strategy [8]. Primary constipation may also be categorized as functional constipation (FC) or as irritable bowel syndrome with constipation predominance with the help of Rome III criteria with the presence of abdominal pain or discomfort in IBS-C being the differentiating feature [9]. With recent advances in treatment, patients with slow transit constipation are managed with newer drugs like serotonin 5-HT4 receptor agonists which increase gut transit [10] and intestinal secretagogues which increase intestinal chloride secretion by activating channels on the apical (luminal) enterocyte surface and accelerate small intestinal and colonic transit [11]. Patient with defecatory disorders are effectively managed with biofeedback-aided pelvic floor retraining using anorectal manometry (ARM) [12]. Indian Society of Gastroenterology (ISG) Task Force on irritable bowel syndrome (IBS) performed a nationwide study which found constipation (53 %) to be more prevalent than diarrhea (47 %) with an estimated prevalence of IBS around 4.2 % in India [13]. Another community-based study from northern Indian showed an IBS prevalence of 4 % and IBS with constipation prevalence of 0.3 % in a rural community setting [2]. In this common disorder, identifying the pathophysiologic subtypes is important as emphasized earlier. We therefore conducted a prospective study to evaluate the clinical profile, categorize FC according to the pathophysiology of constipation using colon transit study and ARM study, and compare these subtypes. We also assessed the success of biofeedback therapy (BFT) in patients with defecatory disorder in a non-randomized, uncontrolled open-label study.
Material and Methods We conducted a prospective evaluation of (indoor and outdoor) patients presenting with constipation to the Department of Gastroenterology at Jagjivan Ram Railway Hospital, Mumbai.
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Inclusion criteria Adult patients (age >18 years) with chronic constipation defined by Rome III criteria for FC and constipation predominant irritable bowel syndrome (C-IBS) seen in indoor or outdoor facility at our hospital were included in the study. Exclusion criteria Patients with chronic constipation who had secondary causes like mechanical obstruction and anatomical disorders of anorectum and pelvic floor, medications and toxins, diabetes, thyroid and hypercalcemia, and neurological dysfunction. Study protocol After obtaining the written informed consent, patients who fulfilled the inclusion criteria of FC or C-IBS were enrolled in the study. Complete history and physical examination of all patients including Bristol stool form scale were noted. All patients underwent complete blood count, fasting blood sugar, 2-h postprandial blood sugar, serum calcium, thyroid function test, serum creatinine, stool examination, colonoscopy (age >55 years—all patients, age 20 %) relaxation of the resting anal sphincter pressure or inadequate propulsive forces (a rise in intrarectal pressure >40 mmHg) were considered to have dyssynergic defecation (DD). Dyssynergic defecation was further divided into four types—in type I dyssynergia, the subject could generate an adequate (>40 %) propulsive force along with paradoxical increase in anal sphincter pressure. In type II dyssynergia, the subject was unable to generate an adequate propulsive force; additionally, there was paradoxical anal contraction. In type III dyssynergia, the subject could generate an adequate propulsive force but there was either an absent relaxation or incomplete (≤20 %) relaxation of the anal sphincter. In type IV dyssynergia, the subject was unable to generate an adequate propulsive force together with an absent or incomplete relaxation of anal sphincter [16]. Colon transit study This was done using radio-opaque markers manufactured locally. Subjects were asked to ingest four capsules at a time (five markers in each capsule) at 0, 12, and 24 h. Subsequently, an abdominal X-ray was obtained in the erect posture at 36 and 60 h. The subjects were on a normal diet and did normal activities during the study period. No patient took any drug that could alter gastrointestinal motility within 7 days before and during the study period. Laxatives and enemas were also avoided during the study period. The transit was said to be slow if more than 30 and/or 14 radio-opaque markers were seen after 36 and 60 h, respectively [17]. Table 1 Showing normal values during anorectal manometry (as provided by the high-resolution manometry developer) Normal values
Women
Men
Length of anal canal (cm) Resting anal canal pressure (mmHg) Maximal squeeze pressure (mmHg) Balloon distention-first sensation (cc) Balloon distention-desire to defecate (cc) Balloon distention-discomfort to distention (cc) Rectoanal inhibitory reflex
4±1 50±13 100–134 16–24 85–127 156–200 Present
4±1 63±12 126–200 11–29 78–140 139–231 Present
Biofeedback therapy Patients with DD were advised BFT. The purpose of this training was to produce a coordinated defecatory movement that consists of an adequate abdominal push effort as reflected by a rise in intrarectal pressure on the manometric tracing that is synchronized with relaxation of the pelvic floor and anal canal as depicted by a decrease in anal sphincter pressure [15]. During the feedback session, the subject was asked to take a good diaphragmatic breath and to push and bear down as if to defecate. The subject was encouraged to watch the monitor while performing this maneuver. The subject’s posture and breathing techniques were continuously monitored and corrected. The visual display of the pressure changes in the rectum and anal canal on the monitor provided instant feedback. Biofeedback was done in the left lateral position at a frequency of 2 weeks. The subject was instructed to do similar exercise 3–4 times a day in the intervening days. A minimum of four sessions of biofeedback were considered to be adequate before assessing response. Response was assessed as improvement in passing complete spontaneous bowel movements [18].
Results Out of 128 patients with constipation presenting at our department from June 2011 to December 2012, 74 (58 %) patients had functional constipation, 25 (19 %) had IBS-C, and 29 (23 %) had secondary constipation. The main reasons for exclusion were patients with secondary constipation due to diabetes mellitus (25), hypothyroidism (2), structural lesion (2), neurological (3), and drugs (3). Six patients had more than one cause for secondary constipation. Thus, 99 (77 %) patients with primary constipation were included in the study. The mean age of presentation was 53.5 years (range 21– 86 years), 22 (22 %) were females and 77 (77 %) were males. Fifty (50 %) patients presented with a duration of illness of 6 months to 1 year, 18 (18 %) had a duration of illness of 1 to 2 years, and 31 (31 %) had constipation for more than 2 years. Six patients had constipation for more than 10 years. Since all patients in our study had constipation, Bristol stool scale was less than 4 in most of the patients (90 %). Six patients were evaluated after indoor admission, with four being admitted for other medical/surgical conditions and were referred to our department for constipation. Subtypes of primary constipation Among those with primary constipation (99), colon transit study showed a slow transit in 15 (15 %). Dyssynergic defecation was seen in 40 (40 %) patients with 29 (72 %) having
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type 1 dyssynergia, 5 (13 %) having type 2 dyssynergia, 5 (13 %) having type 3 dyssynergia, and 1 (2 %) had type 4. While 46 (46 %) had normal colon transit and normal defecatory pattern, 2 had both slow transit and DD. Functional constipation was diagnosed in 74 (75 %) and C-IBS in 25 (25 %) patients using Rome III module.
patients with DD and NTC compared to patients with slow transit constipation (p-values 0.004 and 0.005, respectively). Other manometric parameters like squeeze pressure and rectal sensations were not significantly different among the various pathophysiologic subtypes of constipation.
Comparison of functional constipation and IBS-related constipation
Clinical presentation as a guide to underlying pathophysiologic process
Comparing of means of age, stools per week, duration of symptoms, Bristol stool scale, and manometry findings did not reveal significant difference between the two groups of FC and IBS-C (Table 2). There was no statistical difference between FC and IBS-C with respect to the occurrence of DD and slow colon transit in both the groups.
Out of 44 patients having a sensation of anorectal obstruction suggestive of a probable defecatory disorder, ARM was abnormal in 34 (77 %) and normal in 10 (22 %) patients (p-value −0.0001). Out of 57 patients having a sensation of incomplete evacuation suggestive of a probable defecatory disorder, ARM was abnormal in 34 (59 %) and normal in 23 (41 %) patients (p-value −0.0001). Out of 37 patients with an average of 3 stools/week, the colon transit was slow in 10 (27 %) and normal in 27 (73 %) patients (p-value −0.0185). Ten out of 15 patients with slow transit had stool frequency of ≤3 stools/ week. Solitary rectal ulcer syndrome was seen in 7 patients out of 99, all of them had defecatory dysfunction on ARM with 6 having a history of finger evacuation.
Comparison of normal transit constipation, slow transit constipation, and dyssynergic defecation Patients with DD were more likely to have a history of finger evacuation, straining, incomplete evacuation, hard stools, and sensation of anorectal obstruction than normal defecation pattern (Tables 3 and 4). Sixty-nine percent of patients with STC had ≤3 stools/week compared to 37 % with NTC (pvalue 0.018). Comparing of means of age, duration of symptoms, and Bristol stool scale did not reveal significant difference between these groups. However, stools/week were significantly lower in patients with slow transit constipation compared to patients with NTC (p=0.015). Comparing the manometry parameters of basal anal pressure, squeeze, and rectal sensations with gradual balloon distention showed higher basal anal pressure in
Table 2 Showing comparison of functional constipation and irritable bowel syndrome related constipation
Response to biofeedback therapy Thirty out of 40 patients with DD agreed for biofeedback therapy (BFT), 6 patients received only 1 session, 24 patients received more than 1 session, but 20 (45 %) patients completed 4 and more sessions (Fig. 1). Fourteen (70 %) out of 20 patients who completed more than 4 sessions had a significant response to symptoms after therapy in form of passing complete spontaneous bowel movements (CSBM) (from 4.4 CSBM/week to 6.1
Functional constipation (n=74) Age (years) Stools/week (no.) Duration of symptoms (years) Bristol stool scale Basal anal pressure (mmHg) Squeeze (mmHg) Rectal sensation (a) First sensation (mL) (b) Urgency (mL) (c) Maximum discomfort (mL) Dyssynergic defecation, n (%) Slow transit constipation, n (%)
C-IBS (n=25)
p-value
52.9±(15.1) 4.2±(1.3) 2.3±(1.6)
55.1±(10.2) 4.3±(1.3) 3.9±(1.7)
0.499 0.674 0.061
2.5±(0.9) 71.7±(17.3) 171.8±(56.1)
2.4±(0.9) 71.7±(25.1) 162.4±(60.5)
0.644 0.999 0.475
85.7±(34.6) 149.4±(46.7) 214.1±(63.3) 28 (38) 11 (15)
82.0±(23.4) 150.8±(38.3) 219.6±(60.9) 12 (48) 4 (16)
0.620 0.897 0.710
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Indian J Gastroenterol (November–December 2014) 33(6):530–536
Table 3 Showing comparison of symptom profile of dyssynergic defecation, normal transit constipation, and slow transit constipation
Values are n (%)
Dyssynergic defecation (total=38)
Incomplete evacuation Hard stools Straining during defecation Sensation of anorectal obstruction Weight loss Finger evacuation ≤3 stools per week
Without dyssynergic defecation (total=59)
p-value (dyssynergic defecation vs. normal defecation pattern)
Normal transit (total=46)
Slow transit (total=13)
33 (87) 28 (73) 34 (89)
20 (43) 20 (43) 27 (58)
3 (23) 6 (46) 4 (30)
0.0001 0.002 0.002
21 (55)
9 (19)
1 (7)
0.0001
4 (10) 17 (44) 10 (26)
6 (13) 4 (8) 17 (37)
1 (7) 0 (0) 9 (69)
0.003 0.0001 0.281
CSBM/week) (p-value 0.0001). The limitation of our study is that it is a nonrandomized uncontrolled data and response to BFT was evaluated only clinically. Anorectal manometric variables were not assessed after BFT in our study.
Discussion Constipation is a syndrome that is defined by bowel symptoms (difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation) that may occur either in isolation or secondary to another underlying disorder (e.g. Parkinson’s disease) [19]. Constipation is a condition beleaguered by subjectivity. Although many physicians regard constipation as synonymous with reduced stool frequency, others also consider straining to
defecate, hard stools, and the inability to defecate at will as constipation. Hence, the Rome III symptom criteria for constipation incorporate several bowel symptoms for defining constipation. Majority of our patients are in their sixth decade and older, with a male to female ratio of (3.5:1). This is in contrast to various studies which have shown a higher prevalence of constipation in females. Since India is a male-dominant society, health-seeking behavior of males is probably the best explanation for this difference. ISG Task Force on IBS also found more males (68 %) than females in their study [13]. In a study carried out among 1,149 patients with constipation to determine commonness of various presentations, only 36 % patients had fewer than 3 stools which is similar to the findings in our study [20]. The predominant symptom in both their and our study was straining during defecation reaching
Table 4 Showing comparison of clinical and manometric findings of dyssynergic defecation, normal transit constipation, and slow transit constipation
Age (years) Stools/week (no.) Duration of symptoms (years) Bristol stool scale Anal canal length (cm) Basal pressure (mmHg) Squeeze pressure (mmHg) Rectal sensation (a) First sensation (cc) (b) Urgency (cc) (c) Maximum discomfort (cc)
Dyssynergic defecation (total=38)
Normal transit (total=48)
Slow transit (total=13)
p-value (dyssynergic defecation vs. normal transit)
p-value (dyssynergic defecation vs. slow transit)
p-value (normal transit vs. slow transit)
52.8±(12.5) 4.5±(1.3) 2.7±(3.1) 2.4±(1.0) 4.1±(0.4) 75.6±(20.6) 178.1±(53.5)
53.3±(14.9) 4.2±(1.3) 3.0±(4.1) 2.4±(0.9) 3.9±(0.5) 72.1±(17.4) 170.3±(51.2)
57.0 (16.1) 3.3 (0.7) 3.2 (4.1) 2.6 (0.7) 3.8 (0.5) 56.3 (17.1) 142.5 (81.8)
0..858 0.360 0.707 0.953 0.103 0.407 0.497
0.334 0.002 0.636 0.586 0.099 0.004 0.078
0.444 0.015 0.866 0.526 0.716 0.005 0.140
90.5±(34.3) 158.6±(48.3) 226.8 (71.6)
81.3±(31.9) 145.2±(42.0) 206.5±(56.5)
76.9 (26.2) 132.3 (30.0) 204.6 (41.1)
0.210 0.176 0.150
0.199 0.072 0.296
0.648 0.307 0.910
On multivariate analysis, none of the manometric parameter was significantly different among those with dyssynergic defecation compared to normal transit and slow transit constipation
Indian J Gastroenterol (November–December 2014) 33(6):530–536 Fig. 1 Showing response to biofeedback therapy
40/99 patients had dyssynergic defecation
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30/40 went for biofeedback therapy
up to 81 % in their study and 67 % in our study, thus emphasizing that other symptoms of constipation are more common than mere decrease in stool frequency to 4) of therapy for patients with DD, with each session lasting for at least 30 min. Seventy percent of those who received adequate BFT had a significant response in the form of complete spontaneous bowel movements (CSBM) which is comparable with other similar studies. However, defecography was also used along with manometry in other studies to confirm a diagnosis of defecation disorder which was not feasible in our study [31–36]. These findings suggest the importance of identifying DD in patients with constipation, thereby avoiding unnecessary laxative abuse. BFT is devoid of any complications but is underused in clinical practice.
536 Conflict of interest NS, RB, PK, DG, SK, that they have no conflict of interest.
Indian J Gastroenterol (November–December 2014) 33(6):530–536 SD, and DA all declare
Ethics statement The study was performed in a manner to conform with the Helsinki Declaration of 1975, as revised in 2000 and 2008 concerning human and animal rights, and that the authors followed the policy concerning informed consent as shown on Springer.com.
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18. Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol. 2007;5:331–8. 19. Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013;144:218–38. 20. Irvine EJ, Ferrazzi S, Pare P, Thompson WG, Rance L. Health-related quality of life in functional GI disorders: focus on constipation and resource utilization. Am J Gastroenterol. 2002;97:1986–93. 21. Zhao YF, Ma XQ, Wang R, et al. Epidemiology of functional constipation and comparison with constipation-predominant irritable bowel syndrome: the Systematic Investigation of Gastrointestinal Diseases in China (SILC). Aliment Pharmacol Ther. 2011;34:1020–9. 22. Park JM, Choi MG, Cho YK, et al. Functional gastrointestinal disorders diagnosed by Rome III questionnaire in Korea. J Neurogastroenterol Motil. 2011;17:279–86. 23. Dinning PG, Jones M, Hunt L, et al. Factor analysis identifies subgroups of constipation. World J Gastroenterol. 2011;17:1468–74. 24. Wong RK, Palsson OS, Turner MJ, et al. Inability of the Rome III criteria to distinguish functional constipation from constipationsubtype irritable bowel syndrome. Am J Gastroenterol. 2010;105: 2228–34. 25. Nyam DC, Pemberton JH, Ilstrup DM, Rath DM. Long-term results of surgery for chronic constipation. Dis Colon Rectum. 1997;40: 273–9. 26. Minguez M, Herreros B, Sanchiz V, et al. Predictive value of the balloon expulsion test for excluding the diagnosis of pelvic floor dyssynergia in constipation. Gastroenterology. 2004;126:57–62. 27. Reiner CS, Tutuian R, Solopova AE, Pohl D, Marincek B, Weishaupt D. MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value. Br J Radiol. 2011;84: 136–44. 28. Ribas Y, Saldaña E, Martí-Ragué J, Clavé P. Prevalence and pathophysiology of functional constipation among women in Catalonia, Spain. Dis Colon Rectum. 2011;54:1560–9. 29. Ghoshal UC, Ghoshal U, Ayyagari A, et al. Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time. J Gastroenterol Hepatol. 2003;18:540–7. 30. Nabar AA, Bhatia SJ, Abraham P, Ravi P, Mistry FP. Total and segmental colonic transit time in non-ulcer dyspepsia. Indian J Gastroenterol. 1995;14:131–3. 31. Bleijenberg G, Kuijpers HC. Treatment of the spastic pelvic floor syndrome with biofeedback. Dis Colon Rectum. 1987;30:108–11. 32. Kawimbe BM, Papachrysostomou M, Binnie NR, Clare N, Smith AN. Outlet obstruction constipation (anismus) managed by biofeedback. Gut. 1991;32:1175–9. 33. Dahl J, Lindquist BL, Tysk C, Leissner P, Philipson L, Järnerot G. Behavioral medicine treatment in chronic constipation with paradoxical anal sphincter contraction. Dis Colon Rectum. 1991;34:769–76. 34. Wexner SD, Cheape JD, Jorge JM, Heymen S, Jagelman DG. Prospective assessment of biofeedback for the treatment of paradoxical puborectalis contraction. Dis Colon Rectum. 1992;35:145–50. 35. Fleshman JW, Dreznik Z, Meyer K, Fry RD, Carney R, Kodner IJ. Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction. Dis Colon Rectum. 1992;35:1–7. 36. Koutsomanis D, Lennard-Jones JE, Kamm MA. Prospective study of biofeedback treatment for patients with slow and normal transit constipation. Eur J Gastroenterol Hepatol. 1994;6:131–8.
ORIGINAL ARTICLE
Clinical and investigative assessment of constipation: A study from a referral center in western India Nimish Shah & Rajiv Baijal & Praveen Kumar & Deepak Gupta & Sandeep Kulkarni & Soham Doshi & Deepak Amarapurkar
Received: 7 April 2014 / Accepted: 14 September 2014 / Published online: 15 October 2014 # Indian Society of Gastroenterology 2014
Abstract Introduction Constipation may be primary or secondary. Pathophysiologic subtypes of primary constipation are dyssynergic defecation (DD), slow (STC), and normal transit constipation (NTC). Clinical subtypes are functional constipation (FC) and constipation predominant IBS (C-IBS). Aims The objectives of this paper are to study the clinical profile, categorize and compare various subtypes of primary constipation, and to assess the success of biofeedback therapy (BFT) in a non-randomized, uncontrolled open-label study among patients with DD. Material and Methods Consecutive constipation patients (April 2011 to December 2012) were evaluated. Patients 35 years) than among those with younger age (≤35 years) [3]. Among outpatient clinic visits, constipation is one of the five most common physician diagnoses for gastrointestinal disorders [4]. Constipation also consumes substantial health care resources because of high prevalence. In majority of cases, chronic constipation is an aggravating, but not lifethreatening or debilitating, thus leading to the use of selfadministered over-the-counter laxatives and complementary and alternative medications (CAM) like ayurvedic preparations [5]. It is estimated that only 30 % of patients with constipation seek medical advice and 30 % are habitual consumers of laxatives, which, although it improves stool frequency but do not improve the general well being and abdominal and extraabdominal symptoms, cause significant
Indian J Gastroenterol (November–December 2014) 33(6):530–536
decline in quality of life and occasionally induce serious adverse events [6]. Constipation may be primary (idiopathic) or secondary to other factors. Several subtypes of primary constipation are recognized [7]. According to gut transit time, constipation may be categorized into slow transit (prolonged delay in passage of stool through the colon) or normal transit. With slow and normal transit times, there may be functional obstruction in the form of dysfunction of pelvic floor and anal sphincter muscles (anismus), leading to difficulty in expelling stools from the anorectum, or there can be no identifiable pathology with normal transit constipation (NTC). In patients not responding to laxatives, identifying the subtype of primary constipation helps in selecting further treatment strategy [8]. Primary constipation may also be categorized as functional constipation (FC) or as irritable bowel syndrome with constipation predominance with the help of Rome III criteria with the presence of abdominal pain or discomfort in IBS-C being the differentiating feature [9]. With recent advances in treatment, patients with slow transit constipation are managed with newer drugs like serotonin 5-HT4 receptor agonists which increase gut transit [10] and intestinal secretagogues which increase intestinal chloride secretion by activating channels on the apical (luminal) enterocyte surface and accelerate small intestinal and colonic transit [11]. Patient with defecatory disorders are effectively managed with biofeedback-aided pelvic floor retraining using anorectal manometry (ARM) [12]. Indian Society of Gastroenterology (ISG) Task Force on irritable bowel syndrome (IBS) performed a nationwide study which found constipation (53 %) to be more prevalent than diarrhea (47 %) with an estimated prevalence of IBS around 4.2 % in India [13]. Another community-based study from northern Indian showed an IBS prevalence of 4 % and IBS with constipation prevalence of 0.3 % in a rural community setting [2]. In this common disorder, identifying the pathophysiologic subtypes is important as emphasized earlier. We therefore conducted a prospective study to evaluate the clinical profile, categorize FC according to the pathophysiology of constipation using colon transit study and ARM study, and compare these subtypes. We also assessed the success of biofeedback therapy (BFT) in patients with defecatory disorder in a non-randomized, uncontrolled open-label study.
Material and Methods We conducted a prospective evaluation of (indoor and outdoor) patients presenting with constipation to the Department of Gastroenterology at Jagjivan Ram Railway Hospital, Mumbai.
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Inclusion criteria Adult patients (age >18 years) with chronic constipation defined by Rome III criteria for FC and constipation predominant irritable bowel syndrome (C-IBS) seen in indoor or outdoor facility at our hospital were included in the study. Exclusion criteria Patients with chronic constipation who had secondary causes like mechanical obstruction and anatomical disorders of anorectum and pelvic floor, medications and toxins, diabetes, thyroid and hypercalcemia, and neurological dysfunction. Study protocol After obtaining the written informed consent, patients who fulfilled the inclusion criteria of FC or C-IBS were enrolled in the study. Complete history and physical examination of all patients including Bristol stool form scale were noted. All patients underwent complete blood count, fasting blood sugar, 2-h postprandial blood sugar, serum calcium, thyroid function test, serum creatinine, stool examination, colonoscopy (age >55 years—all patients, age 20 %) relaxation of the resting anal sphincter pressure or inadequate propulsive forces (a rise in intrarectal pressure >40 mmHg) were considered to have dyssynergic defecation (DD). Dyssynergic defecation was further divided into four types—in type I dyssynergia, the subject could generate an adequate (>40 %) propulsive force along with paradoxical increase in anal sphincter pressure. In type II dyssynergia, the subject was unable to generate an adequate propulsive force; additionally, there was paradoxical anal contraction. In type III dyssynergia, the subject could generate an adequate propulsive force but there was either an absent relaxation or incomplete (≤20 %) relaxation of the anal sphincter. In type IV dyssynergia, the subject was unable to generate an adequate propulsive force together with an absent or incomplete relaxation of anal sphincter [16]. Colon transit study This was done using radio-opaque markers manufactured locally. Subjects were asked to ingest four capsules at a time (five markers in each capsule) at 0, 12, and 24 h. Subsequently, an abdominal X-ray was obtained in the erect posture at 36 and 60 h. The subjects were on a normal diet and did normal activities during the study period. No patient took any drug that could alter gastrointestinal motility within 7 days before and during the study period. Laxatives and enemas were also avoided during the study period. The transit was said to be slow if more than 30 and/or 14 radio-opaque markers were seen after 36 and 60 h, respectively [17]. Table 1 Showing normal values during anorectal manometry (as provided by the high-resolution manometry developer) Normal values
Women
Men
Length of anal canal (cm) Resting anal canal pressure (mmHg) Maximal squeeze pressure (mmHg) Balloon distention-first sensation (cc) Balloon distention-desire to defecate (cc) Balloon distention-discomfort to distention (cc) Rectoanal inhibitory reflex
4±1 50±13 100–134 16–24 85–127 156–200 Present
4±1 63±12 126–200 11–29 78–140 139–231 Present
Biofeedback therapy Patients with DD were advised BFT. The purpose of this training was to produce a coordinated defecatory movement that consists of an adequate abdominal push effort as reflected by a rise in intrarectal pressure on the manometric tracing that is synchronized with relaxation of the pelvic floor and anal canal as depicted by a decrease in anal sphincter pressure [15]. During the feedback session, the subject was asked to take a good diaphragmatic breath and to push and bear down as if to defecate. The subject was encouraged to watch the monitor while performing this maneuver. The subject’s posture and breathing techniques were continuously monitored and corrected. The visual display of the pressure changes in the rectum and anal canal on the monitor provided instant feedback. Biofeedback was done in the left lateral position at a frequency of 2 weeks. The subject was instructed to do similar exercise 3–4 times a day in the intervening days. A minimum of four sessions of biofeedback were considered to be adequate before assessing response. Response was assessed as improvement in passing complete spontaneous bowel movements [18].
Results Out of 128 patients with constipation presenting at our department from June 2011 to December 2012, 74 (58 %) patients had functional constipation, 25 (19 %) had IBS-C, and 29 (23 %) had secondary constipation. The main reasons for exclusion were patients with secondary constipation due to diabetes mellitus (25), hypothyroidism (2), structural lesion (2), neurological (3), and drugs (3). Six patients had more than one cause for secondary constipation. Thus, 99 (77 %) patients with primary constipation were included in the study. The mean age of presentation was 53.5 years (range 21– 86 years), 22 (22 %) were females and 77 (77 %) were males. Fifty (50 %) patients presented with a duration of illness of 6 months to 1 year, 18 (18 %) had a duration of illness of 1 to 2 years, and 31 (31 %) had constipation for more than 2 years. Six patients had constipation for more than 10 years. Since all patients in our study had constipation, Bristol stool scale was less than 4 in most of the patients (90 %). Six patients were evaluated after indoor admission, with four being admitted for other medical/surgical conditions and were referred to our department for constipation. Subtypes of primary constipation Among those with primary constipation (99), colon transit study showed a slow transit in 15 (15 %). Dyssynergic defecation was seen in 40 (40 %) patients with 29 (72 %) having
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type 1 dyssynergia, 5 (13 %) having type 2 dyssynergia, 5 (13 %) having type 3 dyssynergia, and 1 (2 %) had type 4. While 46 (46 %) had normal colon transit and normal defecatory pattern, 2 had both slow transit and DD. Functional constipation was diagnosed in 74 (75 %) and C-IBS in 25 (25 %) patients using Rome III module.
patients with DD and NTC compared to patients with slow transit constipation (p-values 0.004 and 0.005, respectively). Other manometric parameters like squeeze pressure and rectal sensations were not significantly different among the various pathophysiologic subtypes of constipation.
Comparison of functional constipation and IBS-related constipation
Clinical presentation as a guide to underlying pathophysiologic process
Comparing of means of age, stools per week, duration of symptoms, Bristol stool scale, and manometry findings did not reveal significant difference between the two groups of FC and IBS-C (Table 2). There was no statistical difference between FC and IBS-C with respect to the occurrence of DD and slow colon transit in both the groups.
Out of 44 patients having a sensation of anorectal obstruction suggestive of a probable defecatory disorder, ARM was abnormal in 34 (77 %) and normal in 10 (22 %) patients (p-value −0.0001). Out of 57 patients having a sensation of incomplete evacuation suggestive of a probable defecatory disorder, ARM was abnormal in 34 (59 %) and normal in 23 (41 %) patients (p-value −0.0001). Out of 37 patients with an average of 3 stools/week, the colon transit was slow in 10 (27 %) and normal in 27 (73 %) patients (p-value −0.0185). Ten out of 15 patients with slow transit had stool frequency of ≤3 stools/ week. Solitary rectal ulcer syndrome was seen in 7 patients out of 99, all of them had defecatory dysfunction on ARM with 6 having a history of finger evacuation.
Comparison of normal transit constipation, slow transit constipation, and dyssynergic defecation Patients with DD were more likely to have a history of finger evacuation, straining, incomplete evacuation, hard stools, and sensation of anorectal obstruction than normal defecation pattern (Tables 3 and 4). Sixty-nine percent of patients with STC had ≤3 stools/week compared to 37 % with NTC (pvalue 0.018). Comparing of means of age, duration of symptoms, and Bristol stool scale did not reveal significant difference between these groups. However, stools/week were significantly lower in patients with slow transit constipation compared to patients with NTC (p=0.015). Comparing the manometry parameters of basal anal pressure, squeeze, and rectal sensations with gradual balloon distention showed higher basal anal pressure in
Table 2 Showing comparison of functional constipation and irritable bowel syndrome related constipation
Response to biofeedback therapy Thirty out of 40 patients with DD agreed for biofeedback therapy (BFT), 6 patients received only 1 session, 24 patients received more than 1 session, but 20 (45 %) patients completed 4 and more sessions (Fig. 1). Fourteen (70 %) out of 20 patients who completed more than 4 sessions had a significant response to symptoms after therapy in form of passing complete spontaneous bowel movements (CSBM) (from 4.4 CSBM/week to 6.1
Functional constipation (n=74) Age (years) Stools/week (no.) Duration of symptoms (years) Bristol stool scale Basal anal pressure (mmHg) Squeeze (mmHg) Rectal sensation (a) First sensation (mL) (b) Urgency (mL) (c) Maximum discomfort (mL) Dyssynergic defecation, n (%) Slow transit constipation, n (%)
C-IBS (n=25)
p-value
52.9±(15.1) 4.2±(1.3) 2.3±(1.6)
55.1±(10.2) 4.3±(1.3) 3.9±(1.7)
0.499 0.674 0.061
2.5±(0.9) 71.7±(17.3) 171.8±(56.1)
2.4±(0.9) 71.7±(25.1) 162.4±(60.5)
0.644 0.999 0.475
85.7±(34.6) 149.4±(46.7) 214.1±(63.3) 28 (38) 11 (15)
82.0±(23.4) 150.8±(38.3) 219.6±(60.9) 12 (48) 4 (16)
0.620 0.897 0.710
534
Indian J Gastroenterol (November–December 2014) 33(6):530–536
Table 3 Showing comparison of symptom profile of dyssynergic defecation, normal transit constipation, and slow transit constipation
Values are n (%)
Dyssynergic defecation (total=38)
Incomplete evacuation Hard stools Straining during defecation Sensation of anorectal obstruction Weight loss Finger evacuation ≤3 stools per week
Without dyssynergic defecation (total=59)
p-value (dyssynergic defecation vs. normal defecation pattern)
Normal transit (total=46)
Slow transit (total=13)
33 (87) 28 (73) 34 (89)
20 (43) 20 (43) 27 (58)
3 (23) 6 (46) 4 (30)
0.0001 0.002 0.002
21 (55)
9 (19)
1 (7)
0.0001
4 (10) 17 (44) 10 (26)
6 (13) 4 (8) 17 (37)
1 (7) 0 (0) 9 (69)
0.003 0.0001 0.281
CSBM/week) (p-value 0.0001). The limitation of our study is that it is a nonrandomized uncontrolled data and response to BFT was evaluated only clinically. Anorectal manometric variables were not assessed after BFT in our study.
Discussion Constipation is a syndrome that is defined by bowel symptoms (difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation) that may occur either in isolation or secondary to another underlying disorder (e.g. Parkinson’s disease) [19]. Constipation is a condition beleaguered by subjectivity. Although many physicians regard constipation as synonymous with reduced stool frequency, others also consider straining to
defecate, hard stools, and the inability to defecate at will as constipation. Hence, the Rome III symptom criteria for constipation incorporate several bowel symptoms for defining constipation. Majority of our patients are in their sixth decade and older, with a male to female ratio of (3.5:1). This is in contrast to various studies which have shown a higher prevalence of constipation in females. Since India is a male-dominant society, health-seeking behavior of males is probably the best explanation for this difference. ISG Task Force on IBS also found more males (68 %) than females in their study [13]. In a study carried out among 1,149 patients with constipation to determine commonness of various presentations, only 36 % patients had fewer than 3 stools which is similar to the findings in our study [20]. The predominant symptom in both their and our study was straining during defecation reaching
Table 4 Showing comparison of clinical and manometric findings of dyssynergic defecation, normal transit constipation, and slow transit constipation
Age (years) Stools/week (no.) Duration of symptoms (years) Bristol stool scale Anal canal length (cm) Basal pressure (mmHg) Squeeze pressure (mmHg) Rectal sensation (a) First sensation (cc) (b) Urgency (cc) (c) Maximum discomfort (cc)
Dyssynergic defecation (total=38)
Normal transit (total=48)
Slow transit (total=13)
p-value (dyssynergic defecation vs. normal transit)
p-value (dyssynergic defecation vs. slow transit)
p-value (normal transit vs. slow transit)
52.8±(12.5) 4.5±(1.3) 2.7±(3.1) 2.4±(1.0) 4.1±(0.4) 75.6±(20.6) 178.1±(53.5)
53.3±(14.9) 4.2±(1.3) 3.0±(4.1) 2.4±(0.9) 3.9±(0.5) 72.1±(17.4) 170.3±(51.2)
57.0 (16.1) 3.3 (0.7) 3.2 (4.1) 2.6 (0.7) 3.8 (0.5) 56.3 (17.1) 142.5 (81.8)
0..858 0.360 0.707 0.953 0.103 0.407 0.497
0.334 0.002 0.636 0.586 0.099 0.004 0.078
0.444 0.015 0.866 0.526 0.716 0.005 0.140
90.5±(34.3) 158.6±(48.3) 226.8 (71.6)
81.3±(31.9) 145.2±(42.0) 206.5±(56.5)
76.9 (26.2) 132.3 (30.0) 204.6 (41.1)
0.210 0.176 0.150
0.199 0.072 0.296
0.648 0.307 0.910
On multivariate analysis, none of the manometric parameter was significantly different among those with dyssynergic defecation compared to normal transit and slow transit constipation
Indian J Gastroenterol (November–December 2014) 33(6):530–536 Fig. 1 Showing response to biofeedback therapy
40/99 patients had dyssynergic defecation
535
30/40 went for biofeedback therapy
up to 81 % in their study and 67 % in our study, thus emphasizing that other symptoms of constipation are more common than mere decrease in stool frequency to 4) of therapy for patients with DD, with each session lasting for at least 30 min. Seventy percent of those who received adequate BFT had a significant response in the form of complete spontaneous bowel movements (CSBM) which is comparable with other similar studies. However, defecography was also used along with manometry in other studies to confirm a diagnosis of defecation disorder which was not feasible in our study [31–36]. These findings suggest the importance of identifying DD in patients with constipation, thereby avoiding unnecessary laxative abuse. BFT is devoid of any complications but is underused in clinical practice.
536 Conflict of interest NS, RB, PK, DG, SK, that they have no conflict of interest.
Indian J Gastroenterol (November–December 2014) 33(6):530–536 SD, and DA all declare
Ethics statement The study was performed in a manner to conform with the Helsinki Declaration of 1975, as revised in 2000 and 2008 concerning human and animal rights, and that the authors followed the policy concerning informed consent as shown on Springer.com.
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