Chronic Intractable Constipation Research Articles

S187 Percutaneous Endoscopic Colostomy: A Systematic Review of More Than Two Decades Experience

Introduction: Percutaneous endoscopic colostomy (PEC) is a minimally invasive procedure used to treat recurrent colonic pseudo-obstruction, sigmoid volvulus, chronic intracTable constipation, and neurogenic bowel. Traditional management of these conditions involving surgical colostomy or bowel resection in many cases has been replaced by percutaneous approaches under imaging or endoscopic guidance due to high rates of technical success and low morbidity rates. We conducted a systematic literature review to summarize the use, indications, and complications of PEC in adult patients. Methods: A systematic literature review was conducted using PubMed, Medline, Google Scholar, and Embase to identify patients who had undergone PEC for any indication. The search terms used were “percutaneous endoscopic colostomy”, “percutaneous endoscopic cecostomy”, “percutaneous cecostomy”, and “percutaneous colostomy”. Exclusion criteria were colostomy tubes that were not placed endoscopically. Results: A total of 11 observational studies (3 prospective, 8 retrospective), 18 case reports, and 7 case series between 1998 and 2022 were identified. A total of 318 patients who underwent PEC were identified. The mean age was 66.4 ± 23.5 and 64% were male. The most common indication was sigmoid volvulus (n= 131) followed by pseudo-obstruction (n=43), chronic intrac table constipation (n=83), neurogenic bowel (n=45), and others (n=9). The procedure was technically successful in 311 patients (97.7%). The total complication rate was 37.6%, 83.5% (n=66) of which were minor complications such as pain, bleeding, infection, leakage, and 16.4% (n=13) of which were major complications such as peritonitis, pneumoperitoneum, and sepsis. PEC-related mortality was 1.3% (n=4). The most common locations for tube placement were the left colon (59%) followed by right colon (13%), the rest of the cases the location was not reported. The number of tubes removed was 57, 8 due to symptom resolution, 3 for planned colostomy, and 1 for pain. (Figure) Conclusion: PEC is an underutilized procedure that offers a viable treatment alternative for select patients who are deemed high risk for surgical intervention and in whom conservative therapy is unsuccessful. It can lead to durable relief of symptoms with good technical success and low risk of major complications. Further prospective studies are needed to establish the optimal placement technique, long-term efficacy, and safety.Figure 1.: Percutaneous Endoscopic Colostomy tube indications

Median Filter Data Analysis of Bowel Activity using Wireless Intracolonic Sensor

HypothesisThe mechanical and neurological mechanisms contributing to intractable chronic constipation and fecal incontinence are not yet fully understood, in part because of challenges in measuring the slow actions of the bowel. To enable multimodal data collection with a route to endoscopic implantation, we developed the Colonic Monitor of Conscious Activity (ColoMOCA). The ColoMOCA was designed for use with electrophysiology tools and to be affixed to the colon wall. After implant, the ColoMOCA wirelessly transmits colonic pressures and electrical properties of stool over multiple days. In this analysis, we are determining the capability of the ColoMOCA device in qualitatively observing slower bowel activity through the use of a median filter analysis.Study Design and MethodsThe ColoMOCA included battery‐powered pressure‐sensing electronics, stainless‐steel electrodes for measuring salinity of bowel contents. The ColoMOCA measured pressure from two locations 63 mm apart, and electrically measured stool conductivity in 3 overlapping regions (approximately 36, 28, and 20 cm long). The ColoMOCA transmitted data 10 times per second to a pager‐like wearable radio for ambulatory data recording.Colonic pressures and electrode readings were made with animals fully conscious and untethered. Data was received by a wireless radio worn by the animal. The radio recorded data to an onboard memory card, and forwarded data over Bluetooth to a computer that plotted data in real time. During recordings the animal ate food, walked, urinated, and defecated freely.Recorded raw pressure and electrode data were analyzed in MATLAB. The raw pressure data was downsampled to match the sampling rate of the electrode data. Following this, all data were passed through a 13th order median filter in order to observe slower colonic activity (occurring over the span of several seconds) in the animal bowel. Peak locations were then annotated by eye, where the annotator had no prior knowledge of physiological expectations of colonic activity when making annotations. The difference between the peaks was taken as period data for colonic slow waves and placed into histograms containing 10 bins.ResultsAfter applying a downsample and median filter analysis to the data, slower waves of colon activity were visible in both the pressure and electrode data. Within these plots, there exist portions of time where the slow wave activity peaks seem to align relatively well between sensor probes. Once the slow waves were available, manual annotation by eye (Figure 1) showed a median pressure wave period that ranged from roughly 48‐92 sec and a median length of 76 sec and 59 sec for the respective pressure probes: P1 and P2 (Figure 2). Electrode wave activity showed longer activity and ranged from 48‐142 sec, with a median period length of roughly 83 sec, 93 sec, 99 sec for electrode probes: E1, E2, and E3.ConclusionThese results display the viability of qualitatively observing longer trends in the ColoMOCA pressure and electrode data to observe median filter analysis. These results provide a prelude to a more quantitative analysis with regards the ColoMOCA device capability of observing slower wave activity of the bowel.

Effectiveness and safety of kamikihito, a traditional Japanese medicine, in managing anxiety among female patients with intractable chronic constipation

Background and purposeThe prevalence of anxiety in patients with chronic constipation is particularly high and these individuals are not necessarily satisfied by normal treatments targeting the gastrointestinal tract. Kamikihito, a traditional Japanese Kampo medicine, has been widely used to date in treating anxiety and neurosis in Japan. We conducted a single-arm, open-label pilot study of female patients with intractable chronic constipation and anxiety who took kamikihito by mouth for 12 weeks. Materials and methodsValidated symptom questionnaires on anxiety and gastrointestinal symptoms [the Profile of Mood States, second edition (POMS2); the State–Trait Anxiety Inventory (STAI); and the Gastrointestinal Symptom Rating Scale (GSRS)] were completed at each study visit. Plasma, salivary, and stool samples were also assessed to evaluate levels of clinical bioactive substances linked to stress and inflammation, oxidative levels, the metabolome profile, and gut microbiota. ResultsTwenty-four patients completed this study. Anxiety was significantly reduced at four and 12 weeks (Tension–Anxiety subscale of the POMS2, p = 0.006 and p = 0.039; Trait anxiety score of the STAI, p < 0.001 and p = 0.034), while the total GSRS score was improved at 12 weeks (p = 0.039). Targeted metabolomics in plasma showed significant alterations in some metabolites associated with psychological symptoms, such as O-phosphoethanolamine. No significant differences were found between pre- and posttreatment levels of clinical bioactive substances related to stress and inflammation, oxidative levels, and the gut microbiota in this cohort. No serious adverse events occurred. ConclusionKamikihito ameliorated psychological and gastrointestinal symptoms in patients with chronic constipation. In parallel with the onset of efficacy, kamikihito modulated some anxiety-related metabolites. Kamikihito was safe and well-tolerated.

Obscure duodenal malformation and other midgut malrotation defects in an elder with acute abdomen due to different prominent complicated pathology

A 70-year old man with severe comorbidities, hemodynamically stable, was emergently admitted for bowel obstruction. His chronic intractable constipation had never been evaluated. The patient had no history of abdominal surgery. Computed tomography indicated a large obstructive rectosigmoid tumour and dolichocolon. Immediate rectoscopy confirmed the presence of the obstructive tumour. Additionally, on emergent laparotomy, a malformed right-sided duodenum with right-sided small bowel and other midgut malrotation defects, along with a small palpable lesion in the proximal descending colon, were also found. We performed a subtotal colectomy, mobilization of the only existing first and second duodenal portions, division of mesenteric root adhesions, and a terminal ileostomy. The patient had a favourable outcome, was discharged on day 8. Histology revealed a pT3N1b rectosigmoid adenocarcinoma and an 1 cm in diameter localized c-kit+ stromal tumour in the proximal descending colon. He received chemotherapy. The patient underwent a postoperative upper gastrointestinal contrast study which showed a well-functioning right-sided deranged duodenum. During a 36-months follow-up no recurrence of malignancy or of midgut malrotation defects has been recognized.

Usefulness of the Monti\u2013Malone procedure as a reconstruction of the antegrade continence enema procedure: a case report

BackgroundThe antegrade continence enema (ACE) procedure is effective for severe constipation in patients with spina bifida and can improve quality of life (QOL). The Monti–Malone procedure (MM), which is a method of creating an enema tract from the colon, has been reported as an alternative to the ACE procedure when the appendix cannot be used. We report the usefulness of MM as a reconstruction of the antegrade continence enema procedure.Case presentationOur patient was a 22-year-old man with congenital spina bifida and hydrocephalus. Ventriculoperitoneal (VP) shunt surgery was performed immediately after birth, and preventative appendectomy was carried out during VP shunt repair when 4 months old. At 5 years of age, the ACE procedure using a balloon-button gastrostomy tube was performed for intractable chronic constipation. Simple management was expected, but after 17 years of age, he experienced increased stool leakage around the gastrostomy tube and his QOL declined due to difficulty in managing the ACE. Therefore, reconstruction of the ACE procedure by MM was performed. After reconstruction, the ACE performed well without any complications. The patient is currently satisfied because management of the ACE is easier than before, and his QOL has markedly improved without stool leakage and dermatitis.ConclusionsMM is less likely to cause complications and is useful as a reconstruction of the ACE procedure.

Promotion of basic research in efficacy enhancement of chronic constipation

The incidence of chronic constipation increases year by year, but it is underestimated in affecting the health of patients. Clinical diagnosis and treatment of chronic intractable constipation is difficult, owing to the diversity of clinical manifestations and the unclear pathogenesis. The basic research is expected to identify the pathophysiological mechanism of chronic intractable constipation in the future, which can find out a ultimate solution approach and improve clinical efficacy. At present there are several basic research ways attracting our attention, including enteric nervous system (such as nerve cells, intestinal neurotransmitters, intestinal sensory nerve regulation mechanism), intestinal smooth muscle cells, Cajal interstitial cells and sacral neuromodulation and intestinal microecology. Although current basic researches are still very preliminary, but they have laid foundations of clinical drug development and application of new technology.

Characterizing colonic motility in children with chronic intractable constipation: a look beyond high-amplitude propagating sequences.

Children with chronic intractable constipation experience severe and long-lasting symptoms, which respond poorly to conventional therapeutic strategies. Detailed characterization of colonic motor patterns in such children has not yet been obtained. In 18 children with chronic intractable constipation, a high-resolution water-perfused manometry catheter (36 sensors at 1.5-cm intervals) was colonoscopically placed with the tip at the distal transverse colon. Colonic motor patterns were recorded for 2 h prior to and after a meal and then after colonic infusion of bisacodyl. These data were compared with previously published colonic manometry data from 12 healthy adult controls and 14 adults with slow-transit constipation. The postprandial number of the retrograde cyclic propagating motor pattern was significantly reduced in these children compared with healthy adults (children, 3.1 ± 4.7/h vs healthy adults, 34.7 ± 45.8/h; p < 0.0001) but not constipated adults (4.5 ± 5.6/h; p = 0.9). The number of preprandial long-single motor patterns was significantly higher (p = 0.003) in children (8.0 ± 13.2/h) than in healthy adults (0.4 ± 0.9/h) and in constipated adults (0.4 ± 0.7/h). Postprandial high-amplitude propagating sequences (HAPSs) were rarely observed in children (2/18), but HAPS could be induced by bisacodyl in 16 of 18 children. Children with chronic intractable constipation show a similar impaired postprandial colonic response to that seen in adults with slow-transit constipation. Children may have attenuated extrinsic parasympathetic inputs to the colon associated with an increased incidence of spontaneous long-single motor patterns.

The Role of Laparoscopic Total Colectomy in Treatment of Slow- Transit Constipation: A Prospective Study

Background: Patients with intractable chronic constipation should be evaluated with physiologic tests after structural disorders, and extracolonic causes have been excluded. Conservative treatment options should be tried excessively. If surgery is indicated, subtotal or total colectomy with ileorectal anastomosis is the treatment method of choice. Patients and methods: In this prospective study, 7 patients were reviewed including patient demography, clinical manifestations, preoperative investigations, operative procedure, intraoperative and postoperative complications, and postoperative follow up. All patients enrolled in the study underwent laparoscopic total colectomy (LTC), with ileorectal anastomosis (IRA). Average age of the patients was (35±15.8 years), average operative time was (80±30 min), average blood loss was (75±30 ml), average hospital stay was (6±2.5 days). Results: 7 patients in our study were diagnosed to have slow-transit constipation via history, clinical examination, colonoscopy and barium enema to rule out structural disorders, colonic motility study, anorectal manometry, colonic transit time, and defecography. All patients underwent LTC with IRA after failure of conservative treatment. 3 patients(42.8%) had postoperative diarrhea which resolved spontaneously after 2 weeks, 1 patient (14.2%) had wound infection, 1patient(14.2%) had minor anastomotic leak which subsided on conservative treatment.2 patients had abdominal pain and bloating which improved gradually,1 patient had recurrent constipation which was improved on laxatives, median number of motions/day was 3, with median satisfaction and success rate of about 82%. Conclusion: Laparoscopic treatment of slow-transit constipation seems to be safe, feasible, and effective procedure with satisfactory results, with minimal postoperative complications, short hospital stay, with a faster return to social activity, along with a better cosmetic results and good functional results.

Le syndrome de Currarino : forme syndromique de malformation anorectale. Aspects cliniques, génétiques et thérapeutiques

More than 30 years ago, G. Curranino described a rare congenital malformations association, as three main clinical features, all sharing a common embryological origin: typical scimitar sacral malformation, hindgut anomaly, and presacral tumor. To date, more than 300 Currarino syndrome cases have been reported in literature. They clearly show that Currarino syndrome often displays a broad inter- and intra-familial phenotypic variability, leading to diagnosis divergences or late discoveries, when severe complications have already occurred. In 1998, heterozygous mutations of the HLXB9 gene–which is now the MNX1 gene since 2008 - located at the 7q36 locus, were identified as disease-causing in half of cases, with an autosomal dominant mode of inheritance. The MNX1 gene encodes the HB9 homeobox transcription factor. Considering the reported series and the phenotypic analysis, Currarino syndrome appears actually as a wide clinical spectrum due to a malformative sequence, which has started early in embryological development. It has a wide variability of expressivity, and could be revealed by four major clinical signs with terminal spinal cord anomalies in 70% of cases. Therefore, the syndrome should always be considered even when only a partial phenotype is present. The major complication is infection of the pre sacral mass, linked to the chronic intractable constipation, with a risk of diffusion to cerebro-spinal fluid. A second complication is the malignant degenerescence of the pre sacral teratoma, which is rare, but not exceptionnal.

Management of chronic intractable constipation in children.

Chronic intractable constipation (CIC) is a debilitating disease that is challenging to manage. Treatment options in children include medications, enemas, and surgical management in selected cases. We reviewed medical records of pediatric patients diagnosed as having CIC at Tufts Medical Center from 2005 to 2012. Demographic variables, diagnostic procedures, and medical and surgical outcomes were collected. Clinical outcome was defined using the Rome III criteria. A total of 14 patients were included in the study (10 boys). The age range was 10 to 21 years. All of the patients had the diagnosis of CIC. Eleven patients had cecostomy placement. During the follow-up period, 10 patients underwent total abdominal colectomy with ileorectal anastomosis, 1 had total colectomy with ileostomy, and 1 had partial colectomy with colorectal anastomosis. Successful clinical outcome was reported in 7 patients with 3 patients reporting persistent fecal incontinence. Colonic motility studies were performed on 12 patients (colonic neuropathy in 11 patients and normal study in 1 patient). Defecography was consistent with isolated pelvic floor dysfunction in 1 patient, abnormal motility and anatomy in 1 patient, pelvic floor dysfunction and abnormal motility in 2 patients, and found abnormal motility only in 5. Defecography study was normal in 5 patients. All of the patients with abnormal colonic manometry underwent a surgical procedure. Anorectal manometry, colonic manometry, and defecography help in understanding the pathophysiology of defecation disorders in children. The majority of patients with abnormal colonic manometry underwent TAC-IRA. There was no statistical correlation between individual investigations (anorectal manometry, colonic manometry, and defecography) with surgical intervention (P > 0.35). TAC-IRA may be safe and useful intervention in a subset of patients when other treatment options have failed.

Outcome of behavioural treatment for idiopathic chronic constipation.

Behavioural therapy is effective in patients with chronic intractable constipation despite standard treatment, but long-term results in unselected patients are unclear. This study investigates the effects of behavioural therapy on symptoms, subjective well-being, and the physical and mental quality of life. Patients who had failed standard care for idiopathic chronic constipation underwent behavioural therapy in a specialist clinic. Symptom severity and quality of life were assessed before and after therapy using the 'Constipation Scoring System' and the Short-Form 36 questionnaire. The primary outcome was subjective perception of improvement. Secondary outcomes were symptoms of constipation and quality of life scores. Of 233 consecutive patients with self-reported constipation (median symptom duration 5-10 years, median age 44 years, females 86%), 180 (77%) completed treatment in a median of three (range 1-7) sessions. One hundred and sixty-five patients (71% of all referrals or 92% of those completing treatment) reported subjective improvement. Median bowel frequency improved from once every 2-7 days to 1-3 per day (P = 0.05). Pain and bloating improved in more than 80% of patients. The Short-Form 36 physical (P < 0.05) and mental (P < 0.05) composite scores improved significantly. Patients with a longer duration of symptoms were less likely to complete treatment. Digital evacuation prior to treatment was a predictor of poor outcome. Behavioural therapy is associated with significant improvement in symptoms of chronic constipation and quality of life. Non-drug therapies that successfully treat patients with functional gut disorders resistant to standard treatment are needed in the mainstream provision of care.

Transcutaneous Electrical Stimulation and Intractable Chronic Constipation

Intractable chronic constipation, in the form of slow-transit constipation (STC), is often resistant to medical treatment. Some children require appendicostomy to allow antegrade enemas to improve symptoms. Transcutaneous electrical stimulation (TES) has been used by physiotherapists to effectively overcome STC in children. This study aimed to examine the effectiveness of home-based TES when STC children were trained by a naïve clinician. We hypothesized that TES would improve symptoms and reduce laxative use. This was a prospective study (2009–2011) during which a surgeon was trained to deliver TES to children with STC and provide education on the method to patients and their parents, who then self-administered TES at home (1 hr/day for 6 months) using a battery-powered interferential stimulator. Patients filled out a daily continence diary (including laxative use) before and throughout TES; PedsQL4.0 questionnaires and gastrointestinal nuclear transit scintigraphy (NTS) were completed before and after TES. Appendicostomy for antegrade enemas was offered if TES failed to improve symptoms. Statistical analysis was performed with paired t-test & chi-square test; P < .05 was considered significant. Sixty-two subjects (34 females; aged 2–16 years; mean age, 7 years) completed a home-based TES program. Symptoms improved significantly in 56/62 (90%) subjects, with an improvement in gastrointestinal transit index after TES (Table 1). Two subjects who stopped laxative prior to TES had symptom improvement without further laxative use. Only six subjects (10%) required appendicostomy for antegrade enemas. Home-based TES is a promising treatment for children with STC, resulting in avoidance of surgery, reduced laxative use, and symptom improvement in most children. Treatment success requires clinician training and close patient contact.Table 1ParametersPre-TESPost-TESP valueSoiling (days/wk)4.6±2.40.7±1.1<.0001 (paired t-test)Defecation (bowel action/wk)1.6±1.63.5±1.9Abdominal pain (days/wk)1.7±1.90.2±0.5Laxative useNo laxative – 2On laxative – 60Stopped laxative – 15Reduced laxative – 30Same laxative – 15Remained with no laxative - 2<.01 (Pearson chi-square)Gastrointestinal transit index10.8±1.611.6±1.6<.002 (paired t-test) Open table in a new tab

Successful Treatment of Chronic Constipation With Functional Electrical Stimulation of the Abdominal Muscles: A Case Report

Intractable chronic constipation is common in patients with multiple sclerosis and often reduces the quality of life. The drug management of this symptom is usually only partially effective and may cause adverse effects. We report here the successful treatment of severe chronic constipation with functional electrical stimulation in a patient with multiple sclerosis. doi: http://dx.doi.org/10.4021/jmc1381w

Successful Treatment of Chronic Constipation With Functional Electrical Stimulation of the Abdominal Muscles: A Case Report

Intractable chronic constipation is common in patients with multiple sclerosis and often reduces the quality of life. The drug management of this symptom is usually only partially effective and may cause adverse effects. We report here the successful treatment of severe chronic constipation with functional electrical stimulation in a patient with multiple sclerosis. J Med Cases. 2013;4(9):581-583 doi: http://dx.doi.org/10.4021/jmc1381w

686 Nuclear Transit Scintigraphy (Nts) - An Evolving Role from Diagnostic to Monitoring Tool in Children With Chronic Constipation

PurposeNuclear transit scintigraphy (NTS) is a relatively new investigation for children with intractable chronic constipation. Three patterns of colonic transit were identified: normal, slow and rapid colonic transit. We aimed...

678 Gastrointestinal Transit Patterns in Childhood Chronic Constipation

Background and AimsConstipation may be a part of a generalized gastrointestinal (GI) tract disorder. Nuclear transit scintigraphy (NTS) provides transit through the stomach, small bowel, colon and anorectum. This study...

Nuclear transit studies of patients with intractable chronic constipation reveal a subgroup with rapid proximal colonic transit

Aims/Background Nuclear transit studies (NTS) allow us to follow transit through the stomach and the small and large intestines. We identified children with chronic constipation with rapid proximal colonic transit and characterized their clinical features. Methods We reviewed NTS from 1998 to 2009 to identify patients with chronic constipation and rapid proximal colonic transit, defined as greater than 25% of tracer beyond hepatic flexure at 6 hour and/or greater than 25% of tracer beyond end of descending colon at 24 hour. This was correlated with clinical symptoms and outcome from patient records. Results Five hundred twenty children with chronic constipation underwent investigation by NTS, and 64 (12%) were identified with rapid proximal colonic transit. The clinical history, symptoms, and outcome in 55 of 64 available for analysis frequently showed family history of allergy (10.9%) and symptoms associated with food allergy/intolerance: abdominal pain (80%), anal fissure (27.3%), and other allergic symptoms (43.6%). Eighteen children were treated with dietary exclusion, with resolution of symptoms in 9 (50%). Conclusions Some children with intractable chronic constipation have rapid proximal colonic transit, have symptoms consistent with possible food allergy/intolerance, and may respond to dietary exclusion. The NTS can identify these patients with rapid proximal transit that may be secondary to food intolerance.

Gender differences in reduced substance P (SP) in children with slow-transit constipation

Adult slow-transit constipation (STC) occurs predominantly in females and is associated with low numbers of substance P (SP)-containing nerves in colonic circular muscle. To determine if reduced SP nerves is female predominant in paediatric STC. Children with STC were identified from records of more than 600 nuclear transit studies (NTS) and intestinal biopsies done for intractable chronic constipation between November 1998 and March 2009. Colonic seromuscular biopsies collected from hepatic and splenic flexures, and sigmoid colon were processed for immunohistochemistry. Nerve fibre density in circular muscle containing SP was measured qualitatively by a pathologist. Eighty-eight children with chronic constipation had both NTS and intestinal biopsies. Seventy-eight children (52 M; age 2-15.5 years; mean 7.7 years) had STC diagnosed by NTS. SP was reduced in 10/26 girls, but only 11/52 boys. In this sample, STC was more common in boys than girls. However, in girls with STC, SP deficiency occurred in 40%, when compared with 20% of boys. During puberty, the percentage of girls with reduced SP decreased, whilst the percentage of boys increased. These results suggest that STC is heterogeneous and that there are some gender differences, the implication of which requires further investigation.

A 56-Year-Old Woman With Severe Chronic Constipation: What Is the Underlying Pathology?

A 56-year-old woman with chronic constipation visited Chung-Ang University Hospital. She had suffered from chronic constipation, abdominal pain and abdominal distention, and took prokinetics, bulking agents and osmotic laxatives for more than 5 years. Her symptoms became worse and she could defecate only 3 or 4 times per a month. She had no history of any specific medical disease or trauma. The abdomen was distended without palpable mass. The laboratory findings were not remarkable. The plain abdominal radiograph showed ileus with air-fluid levels (Fig. 1A). Abdominopelvic CT revealed a marked colonic distension, whereas the entire colon was well traced without a definite obstructive lesion (Fig. 1B). During the colonoscopy and double-contrast barium enema, there was neither an intra-luminal lesion nor narrowed segment which was suggestive of transitional zone. Colon transit time using radio-opaque markers was severely prolonged. The right, left, rectosigmoid and total colon transit time were 106.8, 21.6, 13.2 and 141.6 hours, respectively. Anorectal manometric findings were within normal range and the rectoanal inhibitory reflex was well preserved (Fig. 2). Figure 1 Abdominal X-ray and CT findings. (A) The plain abdominal radiograph shows ileus with multiple air-fluid levels. (B) Abdominopelvic CT reveals marked colonic distensions with abundant feces and fluid from cecum to sigmoid colon, whereas the entire colon ... Figure 2 Rectoanal inhibitory reflex on anorectal manometry. Rapid rectal distention with balloon (30 mL) induces a transient increase in rectal pressure, followed by a more prolonged reduction in anal pressure due to relaxation of the internal anal sphincter. ... She has taken large doses of laxatives for several months, and her symptoms improved temporally. However, the constipation aggravated again and her quality of life deteriorated progressively. Since escalation of medication had not been effective for her constipation for many years, surgical treatment was chosen under the impression of chronic intestinal pseudo-obstruction. Total colectomy with ileorectal anastomosis was performed. Histologically, markedly decreased number of ganglion cells in the myenteric plexus was observed in the entire colon (Fig. 3) in which the pathologic findings confirmed hypoganglionosis. Figure 3 Myenteric (Auerbach) plexus of the colon of the present case (A, B) and the control (C, D). (A) The number of ganglion cells in the present case is markedly reduced (arrow) compared to that in the control (H&E, ×200). (B) Serial section ... Chronic intestinal pseudo-obstruction is a rare debilitating disorder characterized by obstructive symptoms without any lesion occluding the gut.1,2 Chronic idiopathic intestinal pseudoobstruction (CIIPO) is diagnosed when the underlying cause is not found in spite of the thorough medical examination.3,4 The present case is a neuropathic type of CIIPO, and demonstrates hypoganglionosis to be involved in medically intractable chronic constipation.

Colonic Volvulus in Children With Intestinal Motility Disorders

Chronic intestinal pseudo-obstruction (CIP) is a condition characterized by symptoms of bowel obstruction in the absence of an anatomical cause. Patients with CIP and chronic intractable constipation (CIC) can also develop anatomical obstruction, and the presenting symptoms mimic those of underlying pseudo-obstruction. Our objectives were to evaluate the incidence, clinical presentation, and diagnostic investigations of colonic volvulus in children with intestinal motility disorders and to differentiate these episodes of colonic volvulus from the underlying motility disorder based on clinical presentation and imaging techniques. Patients records of children with colonic volvulus cared for at our institution over the previous 20 years were retrospectively reviewed. We identified 8 patients who were between 2 and 22 years of age at the time of diagnosis with colonic volvulus who also had CIP and CIC. The mean age +/- SD at presentation with colonic volvulus was 13.2 +/- 5.05 years. All patients presented with worsening of abdominal distension and pain. The mean duration of symptoms of colonic volvulus before seeking medical help was 4.2 days (range 1-7 days). Water-soluble contrast enema was the single most useful investigation for confirming the diagnosis. All patients required surgery. There was no mortality associated with colonic volvulus. Clinicians should be vigilant and include volvulus in the differential diagnosis of the acute onset of abdominal distension and pain in patients with CIP and CIC. Delay in diagnosis can result in bowel ischemia and perforation.