Digestive Diseases and Sciences

, Volume 39, Issue 7, pp 1558–1564 | Cite as

Anorectal manometric abnormalities and colonic propulsive impairment in patients with severe chronic idiopathic constipation

  • Gabrio Bassotti
  • Giuseppe Chiarioni
  • Italo Vantini
  • Cesare Betti
  • Carla Fusaro
  • Maria Antonietta Pelli
  • Antonio Morelli
Original Articles

Abstract

Idiopathic chronic constipation is a frequent and disabling symptom, but its pathophysiological grounds are still poorly understood. In particular, there is little knowledge about the relationships between distal (anorectal area) and proximal (colonic area) motor abnormalities in this condition, especially concerning high-amplitude propagated colonic activity. For this purpose, we studied 25 patients complaining of severe idiopathic constipation and categorized them as normal- or slow-transit constipation according to colonic transit time. Twenty-five age-matched controls were also studied. Investigations included standard anorectal motility testing and prolonged (24-hr) colonic motility studies. Analysis of results showed that both groups of constipated patients displayed significantly different (P<0.05) minimum relaxation volumes of the internal anal sphincter, defecatory sensation thresholds, and maximum rectal tolerable volumes with respect to controls. Patients with normal-transit constipation also showed lower internal anal sphincter pressure with respect to slow-transit constipation and controls (P<0.001 andP<0.02, respectively). The daily number of high-amplitude propagated contractions (mass movements) as well as their amplitude and duration, was significantly reduced in both subgroups of constipated patients (P<0.02 vs controls). We conclude that (1) in normal-transit constipation, motor abnormalities are not limited to the anorectal area; (2) patients with slow-transit constipation probably have a severe neuropathic rectal defect; (3) prolonged colonic motility studies may highlight further the functional abnormalities in constipated subjects; and (4) an approach taking into account proximal and distal colon motor abnormalities might be useful to understand pathophysiological grounds of chronic constipation and lead to better therapeutic approaches.

Key words

anorectal colon constipation manometry 

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References

  1. 1.
    Hinton JM, Lennard-Jones JE: Constipation: Definition and classification. Postgrad Med J 44:720–723, 1968Google Scholar
  2. 2.
    Martelli H, Devroede G, Arhan P, Duguay C: Mechanisms of idiopathic constipation: outlet obstruction. Gastroenterology 75:623Google Scholar
  3. 3.
    Wald A: Colonic transit time and anorectal manometry in chronic idiopathic constipation. Arch Intern Med 14:1713–1716, 1986Google Scholar
  4. 4.
    Reynolds JC, Ouyang A, Lee CA, Baker L, Sunshine AG, Cohen S: Chronic severe constipation. Prospective motility studies in 25 consecutive patients. Gastroenterology 92:414–420, 1987Google Scholar
  5. 5.
    Devroede G: Constipation.In Gastrointestinal Disease, 4th ed. MH Sleisenger, JS Fordtran, (eds). Philadelphia, WB Saunders, 1989, pp 331–368Google Scholar
  6. 6.
    Dolk A, Brodén G, Holmström B, Johansson C, Schultzberg M: Slow transit chronic constipation (Arbuthnot Lane's disease). An immunohistochemical study of neuropeptide-containing nerves in resected specimens from the large bowel. Int J Colorect Dis 5:181–187, 1990Google Scholar
  7. 7.
    Chaussade S, Atienza P, Beretta O: Méthodes d'explorations fonctionnelles dans la constipation idiopathique chronique de l'adulte. Gastroenterol Clin Biol 14:163–170, 1990Google Scholar
  8. 8.
    Kamm MA: Pathophysiology of constipation.In The Large Intestine: Physiology, Pathophysiology, and Disease. SF Phillips, JH Pemberton, RG Shorter (eds). New York, Raven Press, 1991, pp 709–726Google Scholar
  9. 9.
    Bartolo DCC: Diagnostic procedures for incontinence, constipation.In The Large Intestine: Physiology, Pathophysiology, and Disease. SF Phillips, JH Pemberton, RG Shorter (eds). New York, Raven Press, 1991, pp 727–745Google Scholar
  10. 10.
    Hinton HM, Lennard-Jones JE, Young C: A new method for studying gut transit times using radiopaque markers. Gut 10:842–847, 1969Google Scholar
  11. 11.
    Martelli H, Devroede G, Arhan P, Duguay C, Dornic C, Faverdin C: Some parameters of large bowel motility in man. Gastroenterology 75:612–618, 1978Google Scholar
  12. 12.
    Arhan P, Devroede G, Jehanninn B, Lanza M, Faverdin C, Dornic C, Persoz B, Tetrault L, Perey B, Pellerin D: Segmental colonic transit time. Dis Colon Rectum 24:625–629, 1981Google Scholar
  13. 13.
    Chaussade S, Roche H, Khyari A, Couturier D, Guerre J: Mesure du temps de transit colique global et segmentaire: Description et validation d'une nouvelle technique. Gastroenterol Clin Biol 10:385–389, 1986Google Scholar
  14. 14.
    Metcalf AM, Phillips SF, Zinsmeister AR, McCarty RL, Beart BW, Wolff BG: Simplified assessment of segmental colonic transit time. Gastroenterology 92:40–47, 1987Google Scholar
  15. 15.
    Chaussade S, Khyari A, Roche H, Garret M, Gaudric M, Couturier D, Guerre J: Determination of total and segmental colonic transit time in constipated patients: Results in 91 patients with a new simplified method. Dig Dis Sci 34:1168–1172, 1989Google Scholar
  16. 16.
    Baldi F, Ferrarini F, Corinaldesi R, Balestra R, Cassan M, Fenati GP, Barbara L: Function of the internal anal sphincter and rectal sensitivity in idiopathic constipation. Digestion 24:14–22, 1982Google Scholar
  17. 17.
    Read NW, Timms JM, Barfield LJ, Donnecy TC, Bannister JJ: Impairment of defecation in young women with severe constipation. Gastroenterology 90:53–60, 1986Google Scholar
  18. 18.
    Whitehead WE, Schuster MM: Anorectal physiology and pathophysiology. Am J Gastroenterol 82:487–497, 1987Google Scholar
  19. 19.
    Fotherby KJ, Hunter JO: Idiopathic slow transit constipation: whole gut transit time, measured by a new simplified method, are not shortened by opioid antagonist. Aliment Pharmacol Ther 1:263–272, 1987Google Scholar
  20. 20.
    Heppel J, Kelly KA, Phillips SF, Beart RW, Telander RL, Perrault J: Physiologic aspects of continence after colectomy, mucosal proctectomy, and endorectal ileo-anal anastomosis. Ann Surg 195:435–443, 1982Google Scholar
  21. 21.
    Preston DM, Lennard-Jones JE: Pelvic motility and response to intraluminal bisacodyl in slow-transit constipation. Dig Dis Sci 30:289–294, 1985Google Scholar
  22. 22.
    Meunier P: Physiologic study of the terminal digestive tract in chronic painful constipation. Gut 27:1018–1024, 1986Google Scholar
  23. 23.
    Waldron D, Bowes KL, Kingma YJ, Cote KB: Colonic and anorectal motility in young women with severe idiopathic constipation. Gastroenterology 95:1388–1394, 1988Google Scholar
  24. 24.
    Bassotti G, Gaburri M, Imbimbo BP, Rossi L, Farroni F, Pelli MA, Morelli A: Colonic mass movements in idiopathic chronic constipation. Gut 29:1173–1179, 1988Google Scholar
  25. 25.
    Narducci F, Bassotti G, Gaburri M, Morelli A: Twenty four hour manometric recording of colonic motor activity in man. Gut 28:17–25, 1987Google Scholar
  26. 26.
    Bassotti G, Gaburri M: Manometric investigation of high-amplitude propagated contractile activity of the human colon. Am J Physiol 255:G660-G664, 1988Google Scholar
  27. 27.
    Preston DM, Lennard-Jones JE, Thomas BM: Toward a radiological definition of idiopathic megacolon. Gastrointest Radiol 10:167–169, 1985Google Scholar
  28. 28.
    Bassotti G, Gaburri M, Clausi GG, Pelli MA, Morelli A: Can idiopathic megacolon cause functional motor abnormalities in the upper gastrointestinal tract? Hepato-Gastroenterol 34:186–189, 1987Google Scholar
  29. 29.
    Bassotti G, Imbimbo BP, Gaburri M, Daniotti S, Pelli MA, Morelli A: Transverse and sigmoid colon motility in healthy humans: effect of eating and of cimetropium bromide. Digestion 37:59–64, 1987Google Scholar
  30. 30.
    Bassotti G, Betti C, Imbimbo BP, Pelli MA, Morelli A: Colonic motor response to eating: a manometric investigation in proximal and distal portions of the viscus in man. Am J Gastroenterol 84:118–122, 1989Google Scholar
  31. 31.
    Read NW, Harford WV, Schmulen AC, Read MG, Santa Ana C, Fordtran JS: A clinical study of patients with fecal incontinence and diarrhea. Gastroenterology 76:747–756, 1979Google Scholar
  32. 32.
    Dickinson VA: Maintenance of anal continence: A review of pelvic floor physiology. Gut 19:1163–1174, 1978Google Scholar
  33. 33.
    Devroede G, Arhan P, Schang JC, Heppel J: Orderly and disorderly fecal continence.In Colon, Rectal and Anal Surgery: Current Techniques and Controversies. ID Kodner, RD Fry, JP Roe (eds). St. Louis, CV Mosby, 1985, pp 40–62Google Scholar
  34. 34.
    Pescatori M, Parks AG: The spincteric and sensory components of preserved continence after ileoanal reservoir. Surg Gynecol Obstet 158:517–521, 1984Google Scholar
  35. 35.
    Meunier P, Louis D, de Beaujeau MJ: Physiologic investigation of primary chronic constipation in children: Comparison with the barium enema study. Gastroenterology 87:1351–1357, 1984Google Scholar
  36. 36.
    Arbuthnot-Lane W: Chronic intestinal stasis. Br Med J 1:1408–1411, 1909Google Scholar
  37. 37.
    Preston D, Lennard-Jones JE: Severe chronic constipation of young women: “Idiopathic slow transit constipation.” Gut 27:41–48, 1986Google Scholar
  38. 38.
    Kamm M: Constipation. Br J Hosp Med 41:244–250, 1989Google Scholar
  39. 39.
    Blackstone MO, Kirsner JB: Clinical application of diagnostic tests in selected colonic disorders.In The Large Intestine: Physiology, Pathophysiology, and Disease. SF Phillips, JH Pemberton, RG Shorter (eds). New York, Raven Press, 1991, pp 253–301Google Scholar
  40. 40.
    Read NW, Timms JM: Defecation and the pathophysiology of constipation. Clin Gastroenterol 15:937–965, 1986Google Scholar
  41. 41.
    Manning AP, Wyman JB, Heaton KW: How trustworthy are bowel histories? Comparison of recalled and recorded information. Br Med J 2:213–214, 1976Google Scholar
  42. 42.
    Bannister JJ, Timms JM, Barfield LJ, Donnelly TC, Read NW: Physiological studies in young women with chronic constipation. Int J Color Dis 1:175–182, 1986Google Scholar
  43. 43.
    Shouler P, Keighley MRB: Changes in colorectal function in severe idiopathic constipation. Gastroenterology 90:414–420, 1986Google Scholar
  44. 44.
    Kamm MA, Lennard-Jones JE: Rectal mucosal electrosensory testing: evidence for a rectal sensory neuropathy in idiopathic constipation. Dis Colon Rectum 33:419–423, 1990Google Scholar
  45. 45.
    De Medici A, Badiali D, Corazziari E, Bausano G, Anzini F: Rectal sensitivity in chronic constipation. Dig Dis Sci 34:747–753, 1989Google Scholar
  46. 46.
    Kamm MA, Lennard-Jones JE: Evidence for rectal sensory neuropathy in severe slow transit constipation. Gastroenterology 94:A214, 1988 (abstract)Google Scholar
  47. 47.
    Devroede G: Functions of the anorectum. Defecation and continence.In The Large Intestine: Physiology, Pathophysiology, and Disease. SF Phillips, JH Pemberton, RG Shorter (eds). New York, Raven Press, 1991, pp 115–140Google Scholar
  48. 48.
    Read NW, Sun WM: Anorectal function in normal human subjects. Effect of gender. Int J Color Dis 4:188–196, 1989Google Scholar
  49. 49.
    Waldron DJ, Kumar D, Hallan RI, Wingate DL, Williams NS: Evidence for motor neuropathy and reduced filling of the rectum in chronic intractable constipation. Gut 31:1284–1288, 1990Google Scholar
  50. 50.
    Williams NS, Womack NR: Surgical therapy of constipation and incontinence.In The Large Intestine: Physiology, Pathophysiology, and Disease. SF Phillips, JH Pemberton, RG Shorter (eds). New York, Raven Press, 1991, pp 757–774Google Scholar
  51. 51.
    Bassotti G, Betti C, Pelli MA, Morelli A: Prolonged (24-hour) manometric recording of rectal contractile activity in patients with slow transit constipation. Digestion 49:72–77, 1991Google Scholar
  52. 52.
    Mahieu P, Pringot J, Bodart P: Defecography: I. Description of a new procedure and results in normal patients. Gastrointest Radiol 9:247–251, 1984Google Scholar
  53. 53.
    Ekberg O, Nylander G, Fork FT: Defecography. Radiology 155:45–48, 1985Google Scholar
  54. 54.
    Turnbull GK, Bartram CI, Lennard-Jones JE: Radiologic studies of rectal evacuation in adults with idiopathic constipation. Dis Colon Rectum 31:190–197, 1988Google Scholar
  55. 55.
    Shorvon PJ, McHugh F, Somers S, Stevenson GW: Defecographic findings in young healthy volunteers. Gut 28:A161-A162, 1987 (abstract)Google Scholar
  56. 56.
    Wald A, Caruana BJ, Freimanis MG, Bauman DH, Hinds JP: Contributions of evacuation proctography and anorectal manometry to evaluation of adults with constipation and defecatory difficulty. Dig Dis Sci 35:481–487, 1990Google Scholar
  57. 57.
    Hardcastle JD, Mann CV: Study of large bowel peristalsis. Gut 9:512–520, 1968Google Scholar
  58. 58.
    Torsoli A, Ramorino ML, Ammaturo MV, Capurso L, Paoluzi P, Anzini F: Mass movements and intracolonic pressures. Am J Dig Dis 16:693–696, 1971Google Scholar
  59. 59.
    Moreno-Osset E, Bazzocchi G, Lo S, Trombley B, Ristow E, Reddy SN, Villanueva-Mayer J, Fain JW, Jing I, Mena I, Snape WJ: Association between postprandial changes in colonic intraluminal pressure and transit. Gastroenterology 96:1265–1273, 1989Google Scholar
  60. 60.
    Crowell MD, Bassotti G, Cheskin LJ, Schuster MM, Whitehead WE: Method for prolonged ambulatory monitoring of high-amplitude propagated contractions from colon. Am J Physiol 261:G263-G268, 1991Google Scholar
  61. 61.
    Garcia D, Hita G, Mompean B, Hernandez A, Pellicer E, Morales G, Parrilla P: Colonic motility: Electric and manometric description of mass movements. Dis Colon Rectum 34:577–584, 1991Google Scholar
  62. 62.
    Crowell MD, Whitehead WE, Cheskin LJ, Schuster MM: Twenty-four hour ambulatory monitoring of peristaltic activity from the colon in normal and constipation-predominant IBS patients. Gastroenterology 96:A103, 1989 (abstract)Google Scholar
  63. 63.
    Bassotti G, Betti C, Pelli MA, Morelli A: Extensive investigation of colonic motility with pharmacologic testing is useful for selecting surgical options in patients with inertia colica. Am J Gastroenterol 87:143–147, 1992Google Scholar
  64. 64.
    Kamm MA, Hawley PR, Lennard-Jones JE: Outcome of colectomy for severe idiopathic constipation. Gut 29:969–973, 1988Google Scholar
  65. 65.
    Kamm MA, Hawley PR, Lennard-Jones JE: Lateral division of the pubo-rectalis muscle in the management of severe constipation. Br J Surg 75:661–663, 1988Google Scholar
  66. 66.
    Vasilevsly CA, Nemer FD, Balcos EG, Christensen CE, Goldberg SM: Is subtotal colectomy a viable option in the management of chronic constipation? Dis Colon Rectum 31:679–681, 1988Google Scholar
  67. 67.
    Pinho M, Yoshioka K, Keighley MRB: Long term results of anorectal myectomy for chronic constipation. Br J Surg 76:1163–1164, 1989Google Scholar

Copyright information

© Plenum Publishing Corporation 1994

Authors and Affiliations

  • Gabrio Bassotti
    • 1
    • 2
    • 3
  • Giuseppe Chiarioni
    • 1
    • 2
    • 3
  • Italo Vantini
    • 1
    • 2
    • 3
  • Cesare Betti
    • 1
    • 2
    • 3
  • Carla Fusaro
    • 1
    • 2
    • 3
  • Maria Antonietta Pelli
    • 1
    • 2
    • 3
  • Antonio Morelli
    • 1
    • 2
    • 3
  1. 1.From the Laboratorio di Motilità Intestinale, Clinica di Gastroenterologia et Endoscopia Digestiva, Dipartimento di Medicina Clinica, Patologia e FarmacologiaUniversità di PerugiaItaly
  2. 2.Divisione di Riabilitazione Gastroenterologica, Ospedale Clinicizzato di Valeggio sul MincioUniversità di VeronaItaly
  3. 3.Center for Study of Functional and Motility Disorders of the Gut, Departments of Psychiatry and MedicineThe Johns Hopkins University School of Medicine and Francis Scott Key Medical CenterBaltimore

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