Functional disorders of defecation: evaluation and treatment

Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography

Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.

New onset of constipation during long-term physical inactivity: a proof-of-concept study on the immobility-induced bowel changes

BACKGROUND

The pathophysiological mechanisms underlining constipation are incompletely understood, but prolonged bed rest is commonly considered a relevant determinant.

AIMS

Our primary aim was to study the effect of long-term physical inactivity on determining a new onset of constipation. Secondary aim were the evaluation of changes in stool frequency, bowel function and symptoms induced by this prolonged physical inactivity.

METHODS

Ten healthy men underwent a 7-day run-in followed by 35-day study of experimentally-controlled bed rest. The study was sponsored by the Italian Space Agency. The onset of constipation was evaluated according to Rome III criteria for functional constipation. Abdominal bloating, flatulence, pain and urgency were assessed by a 100mm Visual Analog Scales and bowel function by adjectival scales (Bristol Stool Form Scale, ease of passage of stool and sense of incomplete evacuation). Daily measurements of bowel movements was summarized on a weekly score. Pre and post bed rest Quality of Life (SF-36), general health (Goldberg's General Health) and depression mood (Zung scale) questionnaires were administered.

RESULTS

New onset of functional constipation fulfilling Rome III criteria was found in 60% (6/10) of participants (p=0.03). The score of flatulence significantly increased whilst the stool frequency significantly decreased during the week-by-week comparisons period (repeated-measures ANOVA, p=0.02 and p=0.001, respectively). Stool consistency and bowel symptoms were not influenced by prolonged physical inactivity. In addition, no significant changes were observed in general health, in mood state and in quality of life at the end of bed rest.

CONCLUSIONS

Our results provide evidence that prolonged physical inactivity is relevant etiology in functional constipation in healthy individuals. The common clinical suggestion of early mobilization in bedridden patients is supported as well.

A modified Delorme's operation for the treatment of rectal mucosal prolapse

AIMS

Many procedures have been described for the treatment of rectal internal mucosal prolapse (RMP), but the therapeutic effect is questionable. This work is to evaluate clinical and functional outcome of a modified Delorme's operation-trans-anal purse-string sutures for rectal mucosa and submucosa (TAS) for the treatment of RMP.

METHODS

The clinical data of 58 patients with rectal mucosal prolapse treated with rectal mucosa and submucosal tissue (TAS) between June 2004 and June 2008 were analyzed retrospectively.

RESULTS

No patient died. Satisfaction with surgery was high in 48 cases (82.8%), moderate in seven (12.1%), and low in three (5.17%). Prolapse relapse rate was 5.17%. Anal tenesmus and urge to defecate resolved in 52 (89.7%) patients. Constipation improved in 25 of 28 (89.3%) previously constipated patients. No surgery-associated constipation occurred. The mean operative time was 31 (range 22-46) min. Mean hospital stay was 3 days (range 2-6). Mean patient follow-up was 32 months (range 12-60).

CONCLUSIONS

From our data, TAS for the treatment of RMP showed encouraging results with little complications and an acceptable relapse rate. This economical procedure induces only mild trauma and is easy to perform, making it worthy of further practice and investigation.

Practical performance of defecography for the evaluation of constipation and incontinence

By opacifying the sigmoid, rectum, and vagina with different barium consistencies and using fluoroscopy to evaluate the mechanics of defecation in a physiologic setting, a wide range of pathologies associated with constipation and incontinence can be diagnosed. This review article discusses the primary indications for fluoroscopic defecography, techniques, common diagnoses, and challenges faced in clinical practice.