Cause Of Chronic Constipation Research Articles

The Diagnostic Yield of Laboratory Tests in Chronic Constipation in Adults.

Chronic constipation is a common gastrointestinal complaint characterized by infrequent or difficult bowel movements, significantly affecting patients' quality of life. Laboratory markers offer potential diagnostic value in identifying physiological changes associated with chronic constipation, yet their effectiveness remains underexplored. The objective of this study was to evaluate the diagnostic value of various laboratory tests in identifying the underlying causes of chronic constipation among adults. A cross-sectional study was conducted at Kurdistan Private Hospital and Jeen Clinics in Duhok, Kurdistan, Iraq, from December 2022 to May 2024. A total of 132 patients meeting the Rome IV criteria for chronic constipation were included. Data collection involved demographic information, lifestyle factors, and laboratory tests, including complete blood count (CBC), thyroid stimulating hormone (TSH), serum calcium, serum potassium, serum glucose, serum creatinine, parathyroid hormone (PTH), and vitamin D levels. The study population consisted of 56 males (42.4%) and 76 females (57.6%) with a mean age of 46.5 years (SD=17 years) and a range of 18-81 years. Regular exercise was performed by only 56 (42.4%) patients, 85 (64.4%) patients were drinking less than 2 liters of water per day, and 108 (81.8%) were overweight or obese. Of the study population, hypothyroidism was detected in 27 (20.4%), hyperparathyroidism in 27 (20.4%), anemia in 58 (44%), leukocytosis in 24 (18.2%), renal impairment in 48 (36.4%), hypokalemia in four (3%), hyperkalemia in 12 (9.1%), hypocalcemia in 10 (7.6%), hypercalcemia in 12 (9.1%), impaired fasting glucose in 46 (34.8%), hyperglycemia in 21 (15.9%), and vitamin D deficiency in 80 (60.6%). Of the study population, 40 (30%) patients had normal laboratory investigations panel. In chronic constipation, laboratory tests have high diagnostic yield in adults and are essential for ruling out secondary causes of chronic constipation. Unhealthy lifestyles are prevalent in patients with chronic constipation.

Defecatory disorders are a common cause of chronic constipation in Parkinson disease.

Up to 50% of patients with Parkinson disease have constipation (PD-C), but the prevalence of defecatory disorders caused by rectoanal dyscoordination in PD-C is unknown. We aimed to compare anorectal function of patients with PD-C versus idiopathic chronic constipation (CC). Anorectal pressures, rectal sensation, and rectal balloon expulsion time (BET) were measured with high-resolution anorectal manometry (HR-ARM) in patients with PD-C and control patients with CC, matched for age and sex. We identified 97 patients with PD-C and 173 control patients. Eighty-six patients with PD-C (89%) had early PD, and 39 (40%) had a defecatory disorder, manifest by a prolonged rectal balloon expulsion time (37 patients) or a lower rectoanal pressure difference during evacuation (2 patients). PD-C patients with a prolonged BET had a greater anal resting pressure (p = 0.02), a lower rectal pressure increment (p = 0.005), greater anal pressure (p = 0.047), and a lower rectoanal pressure difference during evacuation (p < 0.001). Rectal sensory thresholds were greater in patients with abnormal BET. In the multivariate model comparing CC and PD-C (AUROC = 0.76), PD-C was associated with a lower anal squeeze increment (odds ratio [OR] for PD-C, 0.93 [95% CI, 0.91-0.95]), longer squeeze duration (OR, 1.05 [95% CI, 1.03-1.08]), lower rectal pressure increment (OR per 10 mm Hg, 0.72 [95% CI, 0.66-0.79]), and negative rectoanal gradient during evacuation (OR per 10 mm Hg, 1.16 [95% CI, 1.08-1.26]). Compared with CC, PD-C was characterized by impaired squeeze pressure, longer squeeze duration, lower increase in rectal pressure, and a more negative rectoanal gradient during evacuation.

Effectiveness and safety of botulinum neurotoxin for treating dyssynergic defecation: A systematic review and meta-analysis

Dyssynergic defecation (DD) is a common cause of chronic constipation. Owing to the lack of a comprehensive synthesis of available data on the effectiveness of botulinum neurotoxin (BoNT) for treating DD, we performed a systematic review and meta-analysis. We searched the PubMed, Embase, and Cochrane databases from inception to May 9, 2023. The outcomes comprise short-term and long-term symptom improvement, various anorectal function measurements, complications of fecal incontinence, and symptom improvement after repeated BoNT injections. A meta-analysis comparing BoNT injection with either surgery or biofeedback (BFB) therapy in treating DD was also conducted. Subgroup analysis and meta-regression were performed to identify possible moderator effects. We included five randomized controlled trials, seven prospective studies, and two retrospective observational studies. Short-term potential improvement in symptoms (event rate [ER], 66.4%; 95% CI, 0.513 to 0.783) was identified, but in the long-term (>12 months), this effect was decreased (ER, 38.2%; 95% CI, 0.267 to 0.511). Short-term improvements in objective anorectal physiologic parameters were also observed. Repeated BoNT injection was effective for patients with symptom recurrence. Subgroup analysis revealed enhanced long-term symptom improvement with high-dose BoNT, but this treatment also increased the risk of complications and recurrence compared with low doses. The effectiveness, complications, and recurrence of symptoms associated with BoNT injection and surgery did not differ significantly. BoNT injection significantly provided short-term symptom improvement but also heightened the risk of incontinence compared with BFB therapy. Our systematic review and meta-analysis indicated that BoNT could be beneficial for short-term symptom improvement in patients with DD, but this effect tended to decline 12 months after injection. Standardized BoNT intervention protocols remain warranted. Among the several treatments for DD, we concluded that BoNT injection is not inferior to other options considering its effectiveness in relieving symptoms, the associated complication development, and the risk of symptom recurrence.

Comparative morphometric characteristics of the dolichocolon decompensated stage

Introduction. Chronic constipation is one of the most actual problems in modern coloproctology and found in 14–16% of developed countries population. The causes of chronic constipation vary widely from functional to organic. The latter include dolichocolon, different variants of which occur in 16% cases.Aim: To give a morphological and quantitative characteristic of the decompensated stage of dolichocolon based on the morphogenesis of changes in comparison with the histologically normal colon.Material and Methods. Colon tissue samples from 16 people were used and divided into two groups. The first, control group, included 8 sectional cases of a morphologically normal colon wall. The second, the study group, was represented by surgical material from 8 patients with dolichocolon decompensated stage. Observation groups were comparable by sex and age.Results. In average, in patients with the decompensated dolichocolon stage, in comparison with the control group, statistically significantly (p ˂ 0.05), the thickness of the mucous and muscular membranes decreases by 1.07 and 2.26 times, respectively. The thickness of the submucosa increases by 1.17 times. However, the maximum and minimum values of this parameter change only by 1.35 times, while in the control group – by 7.21 times, as a consequence of the development of insufficiency of the evacuation-motor function of the colon which indicates the maximum smoothness of the colon wall, and is a consequence of its functional insufficiency. The specific proportion of neuro plexuses in the muscular membrane is 1.45 times higher than in the control group. However, the number of nerve cells decreases by 2.98 times, as a result of the development of insufficiency in the evacuation-motor function of the colon. The average area of lymphatic follicles decreases by 1.49 times, and secondary follicles disappear altogether, meaning the depletion of the compensatory-adaptive reactions of the lymphoid apparatus.Conclusion. Morphological and morphometric signs of irreversible changes, such as dystrophy, atrophy and sclerosis of all structural elements of the thick wall in the stage of decompensated dolichocolon, suggest surgical treatment, as well as prevention of the development of decompensation of the general condition of patients.

Comparative morphometric characteristics of the dolichocolon decompensated stage

Introduction. Chronic constipation is one of the most actual problems in modern coloproctology and found in 14-16% of developed countries population. The causes of chronic constipation vary widely from functional to organic. The latter include dolichocolon, different variants of which occur in 16% cases.Aim. To give a morphological and quantitative characteristic of the decompensated stage of dolichocolon based on the morphogenesis of changes in comparison with the histologically normal colon.Material and Methods. Colon tissue samples from 16 people were used and divided into two groups. The first, control group, included 8 sectional cases of a morphologically normal colon wall. The second, the study group, was represented by surgical material from 8 patients with dolichocolon decompensated stage. Observation groups were comparable by sex and age.Results. In average, in patients with the decompensated dolichocolon stage, in comparison with the control group, statistically significantly (p ˂ 0.05), the thickness of the mucous and muscular membranes decreases by 1.07 and 2.26 times, respectively. The thickness of the submucosa increases by 1.17 times. However, the maximum and minimum values of this parameter change only by 1.35 times, while in the control group – by 7.21 times, as a consequence of the development of insufficiency of the evacuation-motor function of the colon which indicates the maximum smoothness of the colon wall, and is a consequence of its functional insufficiency. The specific proportion of neuro plexuses in the muscular membrane is 1.45 times higher than in the control group. However, the number of nerve cells decreases by 2.98 times, as a result of the development of insufficiency in the evacuation-motor function of the colon. The average area of lymphatic follicles decreases by 1.49 times, and secondary follicles disappear altogether, meaning the depletion of the compensatory-adaptive reactions of the lymphoid apparatus.Conclusion. Morphological and morphometric signs of irreversible changes, such as dystrophy, atrophy and sclerosis of all structural elements of the thick wall in the stage of decompensated dolichocolon, suggest surgical treatment, as well as prevention of the development of decompensation of the general condition of patients.

Dyssynergic Defecation in Chronically Constipated Children in Korea.

Dyssynergic defecation (DSD) is one of the important causes of chronic constipation in children. We aimed to analyze the clinical features, diagnostic test results, and treatments for DSD in children. Children diagnosed with DSD using fluoroscopic defecography were enrolled in this study. Clinical data, including the results of colon transit time (CTT) test and biofeedback (BF) therapy, were collected from medical records retrospectively. Nineteen children were enrolled. The median age was 9 years (6-18 years), the median frequency of bowel movement was 1/7 days (1-10 days), the median duration of constipation was 7.0 years (2-18 years), the median age of onset of constipation was 2.5 years (1-11 years). In the CTT test, outlet obstruction type was noted in 10/18 (55.6%), slow transit type in 5/18 (27.8%), and normal transit in 1/18 (5.6%). The median CTT was 52 hours (40-142 hours). Initial medical therapy was performed with the polyethylene glycol 4000, and the response was good in 9/19 (47.4%), fair in 9/19 (47.4%), and poor in 1/19 (5.0%). BF was performed in 8/19, with good results in 6/8 (75.0%) children and failure in 2/8 (25.0%) children. After long-term medical therapy (11/19), 3/5 showed good response with medication alone, 6/8 showed good response with BF and medication combined. DSD should be considered as a cause of chronic constipation in children, especially in those with abnormal CTT test results. BF combined with medical therapy is effective even with age-limited cooperation.

PSAT303 Fecal Impaction as a Gastrointestinal Prodrome of Myxedema Coma in an Elderly Woman with Multiple Co-morbidities

Abstract Introduction Fecal impaction is a common occurrence in the elderly, with the most common risk factor being chronic constipation. A common cause of chronic constipation that can be overlooked in the elderly is hypothyroidism. If left untreated, hypothyroidism can have life-threatening manifestations including myxedema coma. In this case report, we describe a rare case of myxedema coma with prodromal fecal impaction. Case description An 87-year-old female with a past medical history of colon cancer status post partial colectomy, stroke, and end stage renal failure (ESRD) requiring hemodialysis, presented to the emergency department with extreme rectal pain. She was found to have fecal impaction on abdominal x-ray and was manually disimpacted and discharged home. Five days later, she presented with altered mental status in the setting of a new active herpes zoster infection and possible pneumonia. She was hypothermic (95F) and hypoxic, needing supplemental oxygen (2 L nasal cannula). Her labs showed hyponatremia (133 mg/dL), hypoglycemia (43 mg/dL), an elevated TSH level (100.0 mIU/ml) and decreased free T4 level (0.9 ng/L). Her EKG showed first-degree AV block with low voltage QRS complexes and her chest x-ray demonstrated bilateral pleural effusions. A CT scan of her head did not show hemorrhage or stroke. Given her classic clinical presentation and lab work findings, myxedema coma was diagnosed and the patient was treated with levothyroxine and hydrocortisone, though she was later transitioned to hospice as per her wishes. Discussion Chronic constipation is a known etiology of fecal impaction and can be caused by many chronic conditions in the elderly including ESRD, immobility, and hypothyroidism. Fecal impaction is easily identified but the investigation for the etiology is often overlooked. In this case, we argue that patients with an initial presentation of fecal impaction or with severe and unexplained constipation may warrant screening for hypothyroidism as a manageable risk factor for fecal impaction. By doing so, early recognition and treatment of hypothyroidism may prevent potentially fatal patient outcomes such as myxedema coma. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Morphological and morphometric characteristics of the subcompensated dolichocolon

Chronic constipation is one of the most urgent problems in modern coloproctology and is observed in 14–16% of the population of developed countries. The causes of chronic constipation vary widely from functional to organic. The latter include various variants of dolichocolon, which occur in 16% of cases.The aim of the study was is to give a morphological and quantitative characteristic of subcompensated dolichocolon based on the morphogenesis of changes, compared with histologically normal colon.Material and methods. Colon tissue samples from 15 people were used, which were divided into two groups. The first, control group consisted of 5 sectional cases of a morphologically normal colon wall. The second group was represented by the surgical material of 10 patients with subcompensated dolichocolon. Observation groups were representative by sex and age.Results. In patients with subcompensated dolichocolon, compared with the control group, the thickness of the mucosa in the colon wall is statistically significantly (p=0.034) reduced by 1.06 times, which indicates atrophy; the thickness of the submucosal layer increases by 1.55 times due to edema with foci of sclerosis (p=0.0001); the thickness of the muscle layer increases by 1.16 times (p=0,0003), because of working hypertrophy and compensatory hyperplasia of smooth muscle cells; at the same time, the number of nerve cells in Auerbach's plexuses decreases by 1.59 times (p=0,0001), which will lead to atrophy of the muscle layer and decrease its evacuator-motor function; the average area of lymphoid follicles increases by 1.35 times (p=0,003) and the percentage of secondary follicles decreases 8 times (p=0,0001), which is a consequence of congestion of intestinal contents and activation of the intestinal lymphoid apparatus.Conclusion. Morphological signs of atrophy and sclerosis changes of the cellular elements of the colon neuromuscular apparatus begin to form at the subcompensated stage of dolichocolon, which requires new objective clinical and morphological indications for surgical treatment of patients in order to prevent the development of decompensation of the patients’ general condition and severe complications.

IDF21-0446 Diabetes mellitus with micturition and defecation syncope: Etiology or chance association?

Background: Syncope is a transient and abrupt loss of consciousness with complete return to pre-existing normal neurologic function. Defecation and micturition syncope are types of the situational syncope, which occur immediately after precipitating situations, such as defecation and urination respectively. Situational syncope are considered forms of neurally mediated syncope with reflex-mediated vasodilation and bradycardia, but possibly other mechanisms can also be involved. Micturition syncope is commoner than defecation syncope which is rarely described. Aim: We describe a case who presented with episodes of both micturition as well as defecation syncope. To the best of our knowledge, this is the first description of both types of syncope occurring in a single patient. Method: A 42 year old male, known case of diabetes mellitus since 10 years and on irregular blood sugar control presented to neurology department with complaints of episodic unconsciousness since last 5-6 years. History revealed total 5 episodes of syncope out of which 2 occurred while micturition and 3 while defecation. There were no associated signs suggesting seizure. There was no history of any drug intake except metformin and no history of chronic constipation. He denied history of angina, dyspnoea, palpitations and symptoms suggesting transient ischemic attacks. Results: Examination showed well-built individual with pulse 74 per minute (no arrhythmia), BP 134/76 mm Hg with no significant postural drop or tachycardia. ECG and ECHO were normal. 24 hour holter monitoring did not show any abnormality. Pelvic ultrasound was also normal. Discussion: Micturition syncope and defecation syncope are rare types of situational syncope. While all micturition syncope should be evaluated for bladder mass, defecation syncope should undergo testing for causes of chronic constipation if present. Autoimmune conditions like diabetes mellitus and hypothyroidism are also seen to be associated with these presentations. The exact mechanism of causation of these types of syncope in diabetes is yet unknown but future studies are needed to ascertain whether diabetes is an etiological factor in the causation of situational syncope.

Biofeedback, biofeedback plus fiber laxative, and biofeedback plus osmotic laxative regimens to treat constipation in patients with pelvic floor dyssynergia: A randomized controlled trial.

Pelvic floor dyssynergia (PFD) is one of the causes of chronic constipation. Laxative-based therapies are not very effective in treating this type of constipation. The therapeutic effectiveness of three therapeutic strategies, including biofeedback (BOF) alone, BOF+ fiber laxative (psyllium), and BOF +osmotic laxative (polyethylene glycol; [PEG]), was assessed in patients with constipation secondary to PFD. Eighty-eight patients with constipation were included during a periodfrom 2017 to 2018. Thirty-two patients were treated with BOF alone, 25 patients received BOF+ fiber laxative (psyllium), and 31 patients received BOF+ osmotic laxative (PEG) for 2 to 3 months. A checklist was used to compare outcomes before and after the interventions. Satisfaction rates from the treatments were 60.83%, 46.88%, and 41.32% in the BOF, BOF + psyllium, and BOF + PEG groups, respectively. Women had a higher satisfaction rate compared to men. Defecation quality improved, and the frequency of enema usage decreased (p <0.05) in all the groups afterintervention. Difficulty in evacuation, need for digitation, and return to the toilet after defecation significantly improved in the BOFalone group. Using laxatives reduced straining during evacuation and increased the duration of defecation. All the three regimens reduced rectal bleeding (p <0.05). Combinations of laxatives with BOF did not offer significant therapeutic benefit. As laxatives may cause dissatisfaction and incomplete/prolonged defecations in patients with PFD, adding laxatives to the BOF regimen is not recommended for these patients.

A case of laparoscopic rectopexy for chronic organic constipation due to insufficient fixation of the rectum to the sacrum in a 14-year-old boy

Constipation in children can be classified as transient or chronic and as functional or organic. Although most pediatric constipation is functional, organic constipation may be masked by a chronic course. We encountered a case of chronic constipation refractory to treatment with rectal fixation and subsequently diagnosed it as organic constipation. A 14-year-old boy experienced chronic constipation since 8 years of age, and used to attempt defecation for more than 1 h at a time. The symptoms did not improve with conservative treatment such as medications. Rectal contrast revealed that the rectum was flexed ventrally and separated from the sacrum, with dilatation of the intestine on the oral side. He was diagnosed with organic constipation due to insufficient fixation of the rectum to the sacrum, and underwent laparoscopic rectal fixation. Postoperative rectal contrast revealed that the rectum had traveled along the curved surface of the sacrum. Defecation remarkably improved after the surgery. In this case, chronic organic constipation occurred due to insufficient fixation of the rectum to the sacrum, and could be resolved by rectal fixation. We should recognize insufficient fixation of the rectum to the sacrum as one of the causes of chronic constipation, and treat childhood chronic constipation accordingly. ● Chronic organic constipation occurred due to insufficient fixation of the rectum ● Organic constipation improves by correction of anatomical abnormalities ● Insufficient fixation of the rectum can be treated with laparoscopic rectopexy

A questionnaire-based survey on the etiopathogenesis of chronic constipation during a medical check-up in Japan.

The study group of the Japanese Society of Gastroenterology released evidence-based clinical practice guidelines for chronic constipation (CC) in 2017, and irritable bowel syndrome (IBS) was treated as one of the causes of CC. We examined the differences in characteristics between IBS and non-IBS subjects with CC who underwent a medical check-up in Japan. A total of 10,658 subjects participated in this study, and we focused on 467 subjects who fulfilled the diagnostic criteria of CC using a questionnaire survey. The number of IBS subjects was 21, and they had sleep disorders, were more symptomatic (e.g., abdominal pain, abdominal bloating/distension, feeling stressed, annoyance, lack of motivation, fatigue upon waking, and feeling depressed), and had more episodes of sensation of incomplete evacuation and anorectal obstruction/blockage during defecation than non-IBS subjects. Furthermore, stool frequency of IBS subjects was significantly different from non-IBS subjects. Multivariate ordinal logistic regression analysis revealed that the factors associated with a higher stool frequency were IBS [odds ratio (OR), 2.46; 95% confidence interval (CI), 1.00–6.05; p = 0.049], male sex (OR, 1.97; 95% CI, 1.20–3.23; p = 0.007), and regular exercise (OR, 1.80; 95% CI, 1.05–3.07; p = 0.033). These findings suggest that IBS has unique characteristics in subjects with CC.

Chronic Constipation Revealing Geophagia: A Case Report

Geophagia is a frequent cause of chronic constipation. It is often associated with iron-deficiency anemia, which may be the cause. We describe the case of a 4 year-old suffering from a chronic constipation. In which the radiographic examination revealed the presence of sand like stools and thus making an orientation for geophagia. This article come as a reminder of the utility of radiographic examination as a first line abdominal exploration in case of abdominal symptoms.

A RARE CAUSE OF CHRONIC CONSTIPATION IN THE FIELD OF FAMILY MEDICINE PRACTICE: DYSSYNERGIC DEFECATION

Constipation is a disorder that can result in infrequent defecation, pain, stiffness and difficult stool passage and pathogenesis is multifactorial. A 32-year-old female patient was admitted to family medicine clinic with the complaint of constipation that has been present since childhood. Dyssynergic defecation, which is one of the rare causes of chronic constipation, was detected in the patient whose etiological investigation was carried out. Chronic constipation is a condition that should be evaluated with a detailed medical history, taking into account the risk factors and etiological causes.

S541 Dyssynergic Defecation Evaluation in Veterans With Chronic Constipation: Preliminary Results of a Veterans Affairs (VA) Experience

Introduction: Dyssynergic defecation (DD) is a treatable yet underdiagnosed cause of chronic constipation that significantly impacts quality of life. Because symptoms alone are not reliable for predicting DD, the digital rectal exam (DRE) and anorectal manometry (ARM) are vital components of the evaluation of constipation in patients who fail to respond to laxatives. We aim to evaluate the proportion of chronic constipation patients with persistent symptoms despite laxatives who have been evaluated with DRE and/or ARM. ARM is not available at our VA and requires a referral to the community. We also aim to identify the prevalence of DD in those referred for ARM. We hypothesized that DRE and ARM are underutilized at our center. Methods: We conducted a retrospective analysis of patients evaluated at the Dallas VA Gastroenterology clinic. We included adult patients ≥18 years with constipation for > 6 months with persistent symptoms despite laxatives. Patients were identified using ICD-9 and -10 codes and chart review. We performed a descriptive analysis to determine the proportion of patients who were evaluated with DRE and/or ARM. We also evaluated the prevalence of DD in patients who were referred for ARM. Results: In this preliminary analysis, we included 50 Veteran patients. Demographics are summarized in Table 1. Majority of patients reported < 3 bowel movements/week (62%, n=31). The most common symptoms were abdominal pain (21%, n=42), hard or lumpy stools (36%, n=18), and straining (32%, n=16). No patients were evaluated with a DRE, and 18% (n=9) were referred for ARM. Of these patients, 7 completed ARM, and 100% were diagnosed with DD. 3 of these 7 patients underwent pelvic physical therapy and/or biofeedback, and two of these patients had symptomatic improvement with therapy. Finally, 76% (n=38) of patients had a colonoscopy within the past 5 years, and 22% (n=11) of these colonoscopies were performed for evaluation of constipation. No colonoscopy identified a structural etiology of constipation. Conclusion: DD is a treatable and under-recognized cause of chronic constipation. In our study, we identified an underutilization of DRE and ARM to evaluate for DD. These findings suggest that DD is potentially underdiagnosed in our Veteran population. Additionally, colonoscopy was low yield in the evaluation of constipation. Since biofeedback is highly effective for DD, further investigation is needed to identify barriers to DRE and ARM referrals at our center.Table 1.: Title: Table. Reliability Statistics for Categorical Questions Evaluating Bloating and Distension Symptoms Footnotes: ***, near perfect agreement (k ≥ 0.81); **, substantial agreement (0.61 ≤ k < 0.81); *, moderate agreement (0.41 ≤ k < 0.61); k, Cohen's kappa coefficient; CI, confidence interval; Sx, symptom; d, days; hrs, hours

Improving the accuracy of contrast enema in diagnosis of Hirschsprung disease

Abstract Background Hirschsprung’s disease (HD) is one of the most important causes of chronic constipation in children due to its possibly fatal Amir Maurice Eskander complications if left untreated. Contrast enema (CE) is the first investigation done to diagnose Hirschsprung’s disease as it’s the safest, least invasive, most widely available and least expensive as compared to anal manometry and rectal biopsy however it had shown a wide range of sensitivity and specificity in previous studies. Aim of the work to improve the accuracy of contrast enema by studying each possible abnormal finding related to Hirschsprung’s disease and calculating its sensitivity and specificity in comparison with biopsy, as a gold standard method to determine the most reliable signs to use for diagnosis. Patients and Methods This cross sectional study was carried at pediatric radiology unit Ain Shams university hospitals, starting from July 2018 to June 2019. 43 patients met all inclusion and exclusion criteria and were included in the study. Contrast enemas results and findings were compared to the patient’s final diagnosis. PPV, NPV, specificity, and sensitivity was calculated for each finding. Results Absence of rectal gas in the plain film, transitional zone, abnormal recto-sigmoid index, enlarged colonic caliber and delayed evacuation showed significant association with HD. Abnormal recto-sigmoid index was the most reliable sign in our study to diagnose HD having the highest sensitivity and specificity. Conclusion CE is an excellent initial investigation in HD and combining it with detailed history taking and clinical examination can lead to decrease in unnecessary rectal biopsies.

THE MANAGEMENT OF CHRONIC CONSTIPATION IN PEDIATRIC PATIENTS

Introduction. Chronic constipation is a common reason for a pediatric patient to visit a doctor and we think that the number of cases is increasing but only a few patients are diagnosed with Hirschsprung disease. Aim. This study aims to clarify the difference between the two most common causes of chronic constipation in pediatric patients: habitual constipation and Hirschsprung’s disease regarding symptoms, clinical findings, investigations and treatment and to identify what is more important for the patients with chronic constipation: to go further with investigations after the clinical examination or to start the medical treatment as soon as possible in orther to establish a conduit in the management of these patients. Material and method. We present an observational, descriptive and retrospective 4 years study on children diagnosed with chronic constipation. Results. 122 patients were included in this study, in 3 cases Hirschsprung’s disease was diagnosed. As a complication of chronic constipation 58% of the patients had rectorrhagia and at local examination were found 34 patients with fecaloma, 32 with anal fissure and 5 with hemorrhoids, but none of these findings were associated with Hirschsprung disease. Only in 36% of the cases further investigations were needed. The average age at the first examination was 4 years and 3 months and the average age for the patients with rectorrhagia was 5 years and 3 months. Conclusions. The number of children with chronic constipation is increasing. Rectorhhagia, fecalomas, anal fissures and hemorrhoids are associated with habitual constipation but not with Hirschsprung disease. Because of the small number of cases diagnosed with Hirschsprung disease, the fact that the mean age of the children with rectal bleeding is 1 year higher than the one of the group and the small percentage of further investigation needed, we consider that in order to early prevent complications personalized medical treatment is needed and further investigations should not delay the begining of nursing.

ЛЕЧЕБНО-ДИАГНОСТИЧЕСКИЙ АЛГОРИТМ ПРИ РЕЗИСТЕНТНЫХ ФОРМАХ КОЛОГЕННОГО ЗАПОРА У ВЗРОСЛЫХ

The variety of etiological causes of chronic constipation requires an individual approach to diagnosis and treatment. Outdated views do not consider a detailed examination of patients with long-term constipation. Today, surgical interventions for refractory colonic constipation are used more and more often and have begun to demonstrate positive outcomes. The choice of surgical intervention largely depends on the results of the detected abnormality of the structure and location of the colon, as well as on the functional state of its various parts.

A35 ASSOCIATIONS BETWEEN AUTONOMIC DYSFUNCTION, COLONIC DYSMOTILITY AND ABSENT DEFECATION REFLEXES IN PATIENTS WITH CHRONIC REFRACTORY CONSTIPATION

Abstract Background A defecation reflex involves sensory information from the colon sent to the central nervous system which results in propulsive motor patterns in the colon through programmed neural activity from the autonomic nervous system. Neurological causes of constipation are recognized but specific neurological pathways that contribute to pathophysiology of the disease is underexplored. Diagnosis and treatment usually do not involve the autonomic nervous system. Aims Our objective was to assess autonomic dysfunction and abnormal defecation reflexes as a possible cause of chronic constipation. Methods Defecation reflexes were assessed by high-resolution colonic manometry through balloon distention, meal intake, and rectal bisacodyl. Specific heart rate variability (HRV) parameters were used to assess general orthostatic autonomic reactivity, and autonomic functioning during high resolution colonic manometry, in 14 patients with chronic refractory constipation considered for surgery. Results All patients had a unique combination of motility, reflex ability and HRV profiles. Patients overall did not generate HAPWs or had lower HAPW amplitude and lower propulsive activity compared to healthy individuals. Half of the 14 patients were tested to have high sympathetic tone based on Baevsky’s stress index prior to HRCM, and 11 of the patients had sympathetic hyper-reactivity and/or low parasympathetic reactivity to at least one type of colonic stimulation during HRCM. Abnormal autonomic tone or autonomic reactivity to colonic stimulation was present in all four patients with absence of the vagosacral defecation reflex. Five of the seven patients with absence of the sacral defecation reflex showed high sympathetic tone or high sympathetic reactivity to stimulation. Only two patients had abnormality in coloanal coordination and this was associated with low parasympathetic reactivity to stimulation in both patients. Conclusions The assumption that colonic resection was needed to remove an inert colon was wrong in most patients, but most patients had some form of reflex abnormality. Sympathetic dominance far outweighed parasympathetic dysfunction. Incorporation of assessments of defecation reflexes and autonomic nervous system activity into diagnosis of chronic refractory constipation provides a comprehensive pathophysiological understanding of specific defective neurological pathways contributing to dysmotility. This forms the basis for our individualized treatment efforts through sacral neuromodulation. Funding Agencies CIHR

Functional Constipation: Individualising Assessment and Treatment.

Chronic constipation is one of the five most common symptoms seen by gastroenterologist. In the absence of alarm symptoms, a confident symptom-based diagnosis can often be made using the Rome criteria. Three different subtypes have been identified to date: normal transit constipation, defaecatory disorders and slow transit constipation. Differentiation between these subtypes can be made through functional testing using tests such as anorectal manometry with balloon expulsion and a radio-opaque marker test. In general, patients are initially advised to increase their fluid and fibre intake. When these general lifestyle recommendations do not improve patients' symptoms, a step-wise and add-on treatment approach should be applied. This review summarises the diagnostic criteria to differentiate functional constipation from other causes of chronic constipation. In addition, current drug treatment options, including discussion of new therapeutic targets are discussed. Further, practical treatment approaches (choice and dosing), include discussion of combination/augmentation, treatment failure (adherence/expectations), and relapse prevention are mentioned. Finally, treatment and management of pain and bloating aspects are included.