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Mechanisms and Management of Chronic Constipation

  • James C. Reynolds
Part of the Topics in Gastroenterology book series (TGEN)

Abstract

The mechanisms of chronic constipation are complex and vary in severity from a dietary deficiency of fiber to a diffuse systemic neuropathy. Most patients with milder degrees of constipation will respond promptly to an increase in dietary fiber.1–3 In fact, epidemiologic studies indicate that many colonic disorders that are endemic to Western nations, including the irritable bowel syndrome (IBS), constipation, and colon cancer, occur rarely in societies that injest higher quantities of dietary fiber.4,5 In contrast, there are increasing reports about the medical and surgical treatment of more intractable forms of constipation.6–12 Figure 1 shows the abdominal x-rays of a patient with severe constipation due to anal sphincter dysfunction. The diagnosis went unrecognized for over a decade, and thus led to years of discomfort that could have been avoided by earlier treatment. Data from several centers suggest that in a subset of patients, constipation may be the presenting symptom of a diffuse disorder of enteric and autonomic nerves.7,10 An increased understanding of the mechanisms of constipation will lead to a more rational approach to the diagnosis and treatment of patients suffering from this condition.

Keywords

Irritable Bowel Syndrome Dietary Fiber Anal Sphincter Internal Anal Sphincter Chronic Constipation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Manning AP, Thompson WG, Heaton KW, et al: Towards positive diagnosis of the irritable bowel. Br Med J suppl 2: 653–654, 1978Google Scholar
  2. 2.
    Whitehead WE, Engel BT, Schuster MM: Irritable bowel syndrome. Dig Dis Sci 25: 404, 1980PubMedCrossRefGoogle Scholar
  3. 3.
    Drossman DA, Powell DW, Sessions JT: The irritable bowel syndrome. Gastroenterology 73: 811, 1977PubMedGoogle Scholar
  4. 4.
    Burkitt DP, Walker ARP, Painter NS: Effect of dietary fibre on stools and transit-times, and its role in the causation of disease. Lancet 2: 1408, 1972PubMedCrossRefGoogle Scholar
  5. 5.
    Burkitt D: Fiber as protective against gastrointestinal diseases. Gastroenterology 79: 249, 1984Google Scholar
  6. 6.
    Reynolds JC, Ouyang A, Lee CA, et al: Chronic severe constipation: Prospective motility studies in twenty-five consecutive patients. Gastroenterology 92: 414–420, 1987PubMedGoogle Scholar
  7. 7.
    Martelli H, Devroede G, Arhan P, et al: Mechanisms of idiopathic constipation: Outlet obstruction. Gastroenterology 75: 623, 1978PubMedGoogle Scholar
  8. 8.
    Muenier P, Rochas A, Lambert R: Motor activity of the sigmoid colon in chronic constipation: Comparative study with normal subjects. Gut 20: 1095, 1979CrossRefGoogle Scholar
  9. 9.
    Corazziari E, Bausano G, Torsoli A, et al: Italian cooperative study on chronic constipation, in Wienbeck M (ed): Motility of the Digestive Tract. New York, Raven Press, 1982, p 523Google Scholar
  10. 10.
    Watier A, Devroede G, Duranceau A, et al: Constipation with colonic inertia: A manifestation of systemic disease? Dig Dis Sci 28: 1025. 1983PubMedCrossRefGoogle Scholar
  11. 11.
    Preston DM, Lennard-Jones JE: Pelvic motility and response to intraluminal bisacodyl in slow-transit constipation. Dig Dis Sci 30: 289, 1985PubMedCrossRefGoogle Scholar
  12. 12.
    Read NE, Timms JM, Barfield LJ, et al: Impairment of defecation in young women with severe constipation. Gastroenterology 90: 53, 1986PubMedGoogle Scholar
  13. 13.
    Lennar-Jones JE: Functional gastrointestinal disorders. N Engl J Med 308: 431–435, 1983CrossRefGoogle Scholar
  14. 14.
    Plum GE, Weber HM, Sauer WG: Prolonged cathartic abuse resulting in roentgen evidence suggestive of enterocolitis. Roentgenology 83: 919, 1960Google Scholar
  15. 15.
    Fingl E: Laxatives and cathartics, in Gillman AG. Goodman LS. Gilman A (eds): The Pharmacological Basis of Therapeutics, ed 6. New York, Macmillan Co, 1980, p 1002Google Scholar
  16. 16.
    Mahboubl S, Schnaufer L: The barium-enema examination and rectal manometry in Hirschsprung’s disease. Radiology 130: 643. 1979Google Scholar
  17. 17.
    Patriquin H, Martelli H, Devroede G: Barium enema in chronic constipation: Is it meaningful? Gastroenterology 75: 619, 1978PubMedGoogle Scholar
  18. 18.
    Loening-Baucke VA, Younoszai MK: Effect of treatment on rectal and sigmoid motility in chronically constipated children. Pediatrics 73: 199, 1984PubMedGoogle Scholar
  19. 19.
    Liebman WM: Disorders of defecation in children. Postgrad Med 66: 105, 1979PubMedGoogle Scholar
  20. 20.
    Schuster MM: Motions without emotion. Gastroenterology 75: 744, 1978PubMedGoogle Scholar
  21. 21.
    Kirwan WO, Smith AN: Colonic propulsion in diverticular disease, idiopathic constipation and the irritable colon syndrome. Scand J Gastroenterol 12: 331, 1977PubMedCrossRefGoogle Scholar
  22. 22.
    Martelli H, Devroede G. Arhan P, et al: Some parameters of large bowel motility in normal man. Gastroenterology 75: 612, 1978PubMedGoogle Scholar
  23. 23.
    Drossman DA, Sandler RS, McKee DC, et al: Bowel patterns among subjects not seeking health care: Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology 83: 529, 1982PubMedGoogle Scholar
  24. 24.
    Connell AM, Hilton C, Irvine G, et al: Variation of bowel habit in 2 population samples. Br Med J 2: 1095, 1965PubMedCrossRefGoogle Scholar
  25. 25.
    Wyman JB, Heaton KW, Manning AP, et al: Variability of colonic function in healthy subjects. Gut 19: 146, 1978PubMedCrossRefGoogle Scholar
  26. 26.
    Hinton JM, Lennard-Jones, JE, Young AC: A new method for studying gut transit times using radio-opaque markers. Gut 10: 842, 1969PubMedCrossRefGoogle Scholar
  27. 27.
    Melkersson M, Andersson H, Bosaeus I, et al: Intestinal transit time in constipated and nonconstipated geriatric patients. Scand J Gastroenterol 18: 593, 1983PubMedCrossRefGoogle Scholar
  28. 28.
    Metcalfe AM, Phillips SF, Zinmeister, et al: Simplified assessment of segmental colonic transit. Gastroenterology 92: 40–47, 1987Google Scholar
  29. 29.
    Frieri G, Parisi F, Corazziari, et al: Colonic electromyography in chronic constipation. Gastroenterology 84: 737, 1983PubMedGoogle Scholar
  30. 30.
    Tucker DM, Sandstead HH, Logan GM Jr, et al: Dietary fiber and personality factors as determinants of stool output. Gastroenterology 81: 879, 1981PubMedGoogle Scholar
  31. 31.
    Bueno L, Praddaude F, Fioramonte J, et al: Effect of dietary fiber on gastrointestinal and jejunal transit time in dogs. Gastroenterology 80: 701. 1981PubMedGoogle Scholar
  32. 32.
    Spiller GA: Can fecal weight be used to establish a recommendation intake of dietary fiber? Am J Clin Nutr 30: 659, 1977PubMedGoogle Scholar
  33. 33.
    Becker U, Elsborg L: A new method for the determination of gastrointestinal transit times. Scand J Gastroenterol 14: 355, 1979PubMedCrossRefGoogle Scholar
  34. 34.
    Krevsky B, Malmud L, D’Ercole F, et al: Colonic transit scintigraphy, a physiologic approach to the quantitative measurement of colonic transit in humans. Gastroenterology 91: 1102–1112, 1986PubMedGoogle Scholar
  35. 35.
    Krevsky B, Malmud L, Somers MB, et al: Patterns of colonic transit in chronic idiopathic constipation. Gastroenterology 90: 1503A, 1986Google Scholar
  36. 36.
    Slavin JL, Levine AS: Dietary fiber and gastrointestinal disease. Part 1. What is fiber and how much should you take? Part 2. How to use fiber to treat disease. Pract Gastroenterol May/June, Vol X, 1986, pp 19–56Google Scholar
  37. 37.
    Wald A: Colonic transit and anorectal manometry in chronic idiopathic constipation. Arch Intern Med 146: 1713–1716, 1986PubMedCrossRefGoogle Scholar
  38. 38.
    Likongo Y, Devroede G, Schang J-C, et al: Hindgut dysgenesis as a cause of constipation with delayed colonic transit. Dig Dis Sci 31: 993–1003, 1986PubMedCrossRefGoogle Scholar
  39. 39.
    Burleigh DE, D’Mello A: Neural and pharmacologic factors affecting motility of the internal anal sphincter. Gastroenterology 84: 409, 1983PubMedGoogle Scholar
  40. 40.
    Huizinga JD, Daniel EE: Control of human colonic motor dysfunction. Dig Dis Sci 31: 865, 1986PubMedCrossRefGoogle Scholar
  41. 41.
    Todd IP: Adult Hirschsprung’s disease. Br J Surg 64: 311, 1977PubMedCrossRefGoogle Scholar
  42. 42.
    Meunier P, Marechal JM, DeBeaujeu J: Rectoanal pressures and rectal sensitivity studies in chronic childhood constipation. Gastroenterology 77: 330, 1979PubMedGoogle Scholar
  43. 43.
    Biancani P, Walsh J, Behar J: Vasoactive intestinal peptide: A neurotransmitter for relaxation of the rabbit internal anal sphincter. Gastroenterology 89: 867–874, 1985PubMedGoogle Scholar
  44. 44.
    Battle WM, Snape WJ Jr, Alavi A, et al: Colonic dysfunction in diabetes mellitus. Gastroenterology 79: 1217, 1980PubMedGoogle Scholar
  45. 45.
    Battle WM, Snape WJ Jr, Wright S, et al: Abnormal colonic motility in progressive systemic sclerosis. Ann Intern Med 94: 749, 1981PubMedGoogle Scholar
  46. 46.
    Glick ME, Meshkinpour H, Haldeman S, et al: Colonic dysfunction in multiple sclerosis. Gastroenterology 83: 1002, 1982PubMedGoogle Scholar
  47. 47.
    Ahmed MN, Carpenter S: Autonomic neuropathy and carcinoma of the lung. CMA J 113: 410, 1975Google Scholar
  48. 48.
    Devroede G, Arhan P, Duguay C, et al: Traumatic constipation. Gastroenterology 77:1258, 1979Google Scholar
  49. 49.
    Faulk DL, Anuras S, Gardner GD, et al: A familial visceral myopathy. Ann Intern Med 89 (pt 1): 600, 1978PubMedGoogle Scholar
  50. 50.
    Anuras S, Mitros FA, Nowak TV, et al: A familial visceral myopathy with external ophthalmoplegia and autosomal recessive transmission. Gastroenterology 84: 346, 1983PubMedGoogle Scholar
  51. 51.
    Schuffler MD, Bird TD, Sumi SM, et al: A familial neuronal disease presenting as intestinal pseudo-obstruction. Gastroenterology 75: 889, 1978PubMedGoogle Scholar
  52. 52.
    Schuffler MD, Baird HW, Fleming CR, et al: Intestinal pseudo-obstruction as the presenting manifestation of small-cell carcinoma of the lung. Ann Intern Med 98: 129, 1983PubMedGoogle Scholar
  53. 53.
    Schuffler MD, Rohrmann CA, Chaffee RG, et al: Chronic intestinal pseudo-obstruction: A report of 27 cases and review of the literature. Medicine 60: 173, 1981PubMedCrossRefGoogle Scholar
  54. 54.
    Bleijenberg G, Kuijpers HC: Treatment of the spastic pelvis floor syndrome with biofeedback. Dis Colon Rectum 30: 108–111, 1987PubMedCrossRefGoogle Scholar
  55. 55.
    Preston DM, Lennard-Jones JE: Pelvis motility and response to intraluminal bisacodyl in slow-transit constipation. Dig Dis Sci 30: 289–294, 1985PubMedCrossRefGoogle Scholar
  56. 56.
    Harrison MW, Deitz DM, Campbell JR, et al: Diagnosis and management of Hirschsprung’s disease. Am J Surg 152: 49–56, 1986PubMedCrossRefGoogle Scholar
  57. 57.
    Webster W: Embryogenesis of the enteric ganglia in normal mice and in mice that develop congenital aganglionic megacolon. J Embryol Exp Morphol 30: 573–585, 1973PubMedGoogle Scholar
  58. 58.
    Udassin R, Nissan S, Lernau O, et al: The mild form of Hirschsprung’s disease (short segment). Ann Surg 3: 767, 1981CrossRefGoogle Scholar
  59. 59.
    McCready RA, Beart RW: Adult Hirschsprung’s disease: Results of surgical treatment at Mayo Clinic. Dis Colon Rectum 23: 401, 1980PubMedCrossRefGoogle Scholar
  60. 60.
    Bartolo DC, Read NW, Jarret JA, et al: Differences in anal sphincter function and clinical presentation in patients with pelvic floor descent. Gastroenterology 85: 68–75, 1983PubMedGoogle Scholar
  61. 61.
    Roe AM, Bartolo DCC, Read NW, et al: Diagnosis and surgical management of intractable constipation. Br J Surg 73: 854–861, 1986PubMedCrossRefGoogle Scholar
  62. 62.
    Reboa G, Arnulfo G, Frascio M, et al: Colonic motility and colon-anal reflexes in chronic idiopathic constipation. Effects of a novel enterokinetic agent cisapride. Eur J Clin Pharmacol 26: 745, 1984PubMedCrossRefGoogle Scholar
  63. 63.
    Narducci F, Gassotti G, Gaburri M, et al: Twenty-five hour manometric recording of colonic motor activity in healthy man. Gut 28: 17–25, 1987PubMedCrossRefGoogle Scholar
  64. 64.
    Belliveau P, Goldberg SM, Rothenberger DA, et al: Idiopathic acquired megacolon: The value of subtotal colectomy. Dis Colon Rectum 25: 118, 1982PubMedCrossRefGoogle Scholar
  65. 65.
    Sullivan MA, Cohen S, Snape WJ Jr: Colonic myoelectrical activity in irritable bowel syndrome. N Engl J Med 298: 878, 1978PubMedCrossRefGoogle Scholar
  66. 66.
    Chaudhury NA, Phil D, Truelove S: Human colonic motility: A comparative study of normal subjects, patients with ulcerative colitis and patients with the irritable colon syndrome. Gastroenterology 40: 1, 1960Google Scholar
  67. 67.
    Connell AM: The motility of the pelvic colon. (part II). Paradoxical motility in diarrhoea and constipation. Gut 3: 342, 1962PubMedCrossRefGoogle Scholar
  68. 68.
    Waller SL, Misiewicz JJ, Kiley N: Effect of eating on motility of the pelvic colon in constipation or diarrhoea. Gut 13: 805, 1972PubMedCrossRefGoogle Scholar
  69. 69.
    Sasaki D, Kido A, Yoshida Y: An endoscopie method to study the relationship between bowel habit and motility of the ascending and sigmoid colon. Gastro Endoscopy 32: 185–189, 1986CrossRefGoogle Scholar
  70. 70.
    Sjolung KE, Ekman R, Akre F, et al: Motilin in chronic idiopathic constipation. Scand J Gastroenterol 21: 914–918, 1986CrossRefGoogle Scholar
  71. 71.
    Smith B: Effect of irritant purgatives on the myenteric plexus in man and the mouse. Gut 9: 139, 1968PubMedCrossRefGoogle Scholar
  72. 72.
    Koch TR, Carney JA, Go L, et al: Idiopathic chronic constipation is associated with decreased colonic vasoactive intestinal peptide. Gastroenterology 94: 300–310, 1988PubMedGoogle Scholar
  73. 73.
    Fain AM, Susat R, Herring M, et al: Treatment of constipation in geriatric and chronically ill patients: A comparison. South Med J 71: 677, 1978PubMedCrossRefGoogle Scholar
  74. 74.
    Formad HF: A case of giant growth of the colon, causing coprostasis or habitual constipation. University of Pennsylvania Medical Magazine, June 1892, pp 1–9Google Scholar
  75. 75.
    Munnings DB, Gardiner GW, Colapinto ND: Stercoral perforation in a patient with adult Hirschsprung’s disease. Dis Colon Rectum 24: 526, 1981PubMedCrossRefGoogle Scholar
  76. 76.
    Gekas P, Schuster MM: Stercoral perforation of the colon: Case report and review of the literature. Gastroenterology 80: 1054, 1981PubMedGoogle Scholar
  77. 77.
    Ford MJ, Anderson JR, Gilmore HM, et al: Clinical spectrum of “solitary ulcer” of the rectum. Gastroenterology 84: 1533, 1983PubMedGoogle Scholar
  78. 78.
    Graham DY, Mose SE, Estes MK, et al: The effect of bran on bowel function in constipation. Gastroenterology 77: 599, 1982Google Scholar
  79. 79.
    Freeman HJ, Spiller GA, Kim YS: A double blind study on the effect of purified cellulose dietary fiber on 1,1 dimethyl hydrazine-induced rat colonic neoplasia. Cancer Res 38: 2912, 1978PubMedGoogle Scholar
  80. 80.
    Morehouse JL, Specian RD, Stewart JJ, et al: Translocation of indigenous bacteria from the gastrointestinal tract of mice after oral ricinoleic acid treatment. Gastroenterology 91: 673, 1986PubMedGoogle Scholar
  81. 81.
    Balzs M: Melanosis coli: Ultrastructural study of 45 patients. Dis Colon Rectum 29: 839–844, 1986CrossRefGoogle Scholar
  82. 82.
    Harris RT: Bulimarexia and related serious eating disorders with medical complication. Ann Intern Med 99: 800, 1983PubMedGoogle Scholar
  83. 83.
    Chapman RW, Sillery J, Fontana DD, et al: Effect of oral dioctyl sodium sulfosuccinate on intake—output studies of human small and large intestine. Gastroenterology 89: 489, 1985PubMedGoogle Scholar
  84. 84.
    Glick ME, Meshkinpour A, Haldeman S, et al: Colonic dysfunction in patients with thoracic spinal cord injury. Gastroenterology 86: 287–294, 1984PubMedGoogle Scholar
  85. 85.
    Kreek MC, Hahn EF, Schaefer RA, et al: Naloxone: A specific opioid antagonist, reverses chronic idiopathic constipation. Lancet 1: 261, 1983PubMedCrossRefGoogle Scholar
  86. 86.
    Istre GR, Kreiss K, Hopkins RS: An outbreak of amebiasis spread by colonic irrigation at a chiropractic clinic. N Engl J Med 307: 339, 1982PubMedCrossRefGoogle Scholar
  87. 87.
    Orr JD, Anderson JR, Scobie WG: The treatment of Hirschsprung’s disease. J R Coll Surg 26: 153, 1981Google Scholar
  88. 88.
    Smith JL: Arbuthnot Lane, chronic intestinal stasis and autotoxication. Ann Intern Med 96: 365, 1982PubMedGoogle Scholar
  89. 89.
    McCready RA, Beart RJ Jr: The surgical treatment of incapacitating constipation associated with idiopathic megacolon. Mayo Clin Proc 54: 779, 1979PubMedGoogle Scholar

Copyright information

© Plenum Publishing Corporation 1989

Authors and Affiliations

  • James C. Reynolds
    • 1
  1. 1.Department of Medicine and PhysiologyHospital of the University of PennsylvaniaPhiladelphiaUSA

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