Normal Defecation Research Articles

Hirschsprung’s Disease in Patients of Advanced Age

Hirschsprung’s disease is a congenital motility disorder that is easily overlooked as a cause of chronic refractory constipation in adults. We present a case of Hirschsprung’s disease in a patient 70 years of age with a history of long-standing constipation, chronic use of laxatives, and recurrent episodes of colonic obstruction. Presumptive preoperative diagnosis was chronic ischemic sigmoid stenosis or intermittent sigmoid volvulus before Hirschsprung’s disease was suspected based on intraoperative colonoscopy and surgical findings. The diagnosis was confirmed by the absence of intrinsic ganglion cells on histopathologic examination of the surgical specimen and the absence of the rectoanal inhibitory reflex on postoperative manometry. A conservative surgical approach that limited the resection to the grossly diseased rectum successfully restored normal defecation despite the anastomosis being performed on the distal aganglionic rectum. This approach, which avoids extensive rectal dissection, may be suitable for older or frail patients. Heightened awareness of Hirschsprung’s disease is necessary to ensure its prompt recognition in the elderly.

The Physiology of Human Defecation

Human defecation involves integrated and coordinated sensorimotor functions, orchestrated by central, spinal, peripheral (somatic and visceral), and enteric neural activities, acting on a morphologically intact gastrointestinal tract (including the final common path, the pelvic floor, and anal sphincters). The multiple factors that ultimately result in defecation are best appreciated by describing four temporally and physiologically fairly distinct phases. This article details our current understanding of normal defecation, including recent advances, but importantly identifies those areas where knowledge or consensus is still lacking. Appreciation of normal physiology is central to directed treatment of constipation and also of fecal incontinence, which are prevalent in the general population and cause significant morbidity.

Topographic and manometric characterization of the recto-anal inhibitory reflex.

Recto-anal inhibitory reflex (RAIR) is an integral part of normal defecation. The physiologic characteristics of RAIR along anal length and anterior-posterior axis are unknown. The aim of this study was to perform topographic and vector-graphic evaluation of RAIR along anal canal using high definition manometry (HDM), and examine the role of various muscle components. Anorectal topography was assessed in 10 healthy volunteers using HDM probe with 256 sensors. Recto-anal inhibitory reflex data were analyzed every mm along the length of anal canal for topographic, baseline, residual, and plateau pressures during five mean volumes of balloon inflation (15 cc, 40 cc, 71 cc, 101 cc, 177 cc), and in 3D by dividing anal canal into 4 × 2.1 mm grids. Relaxation pressure progressively increases along anal canal with increasing balloon volume up to 71 cc and thereafter plateaus. In 3D, RAIR is maximally seen at the middle and upper portions of anal canal (levels 1.2-3.2 cm) and posteriorly. Peak residual pressure was seen at proximal anal canal. Recto-anal inhibitory reflex is characterized by differential anal relaxation along anterior-posterior axis, longitudinally along the length of anal canal, and it depends on the rectal distention volume. It is maximally seen at internal anal sphincter pressure zone. Multidimensional analyses indicate that external anal sphincter provides bulk of anal residual pressure. Our findings emphasize importance of sensor location and orientation; as anterior and more distal location may miss RAIR.

Comparison of laxative and antioxidant activities of raw, processed and fermented Polygoni Multiflori Radix

Aim To observe the anti-oxidative activity and adverse laxative effect of raw, traditional processed and fermented products of Polygoni Multiflori Radix (PMR), and furthermore, to evaluate the fermentation method used in the processing procedure of PMR. Methods In vitro ferric reducing antioxidant power (FRAP) assay was carried out to evaluate the anti-oxidative activity. Modulation of normal defecation and effect on gastrointestinal motility in mice were carried out to investigate their adverse laxative effect. Results Fermented PMR induced less severe laxative adverse effect than Polygoni Multiflori Radix Praeparata (PMRP). PMR fermented with Rhizopus sp. (FB) could modulate the defecation significantly. The gastrointestinal motility was inhibited by PMRP and PMR fermented with Rhizopus oryzae (FA). FA and FB showed better antioxidant activity than PMRP in 50% and 95% ethanol group. Contents of 2, 3, 5, 4′-tetrahydroxy-stilbene-2- O-β-D-glucoside (TSG) were reduced significantly after traditional processing but maintained after fermentation. Emodin and physcion were increased after traditional processing and fermented with Rhizopus oryzae. Conclusion All processing procedure, including fermentation, might reduce its anti-oxidative activity. However, most of the processed products could lessen the adverse effect on gastrointestinal tract compared to PMR. Fermentation with Rhizopus oryzae was considered as a promising processing method of PMR.

Outcome of laparoscopic modified Duhamel procedure with Z-shaped anastomosis for Hirschsprung’s disease

Several laparoscopic Duhamel-type procedures for Hirschsprung's disease (HD) have been reported, but laparoscopic, Z-shaped, colorectal, side-to-side anastomosis has not been described. Z-shaped anastomosis has been used as the treatment of choice for HD at our clinic for a long time. A laparoscopic approach was adopted to perform this Z-shaped anastomosis in 2001. We describe herein our experiences with laparoscopic Z-shaped anastomosis and evaluate the clinical outcomes. Between 2001 and 2010, 26 children with rectosigmoid HD underwent a laparoscopic modified Duhamel procedure comprising Z-shaped anastomosis. Mean age at operation was 17.2 months. Mean weight was 8.7 kg. No children had a colostomy. Seven children had trisomy 21 and one had Klinefelter syndrome. Laparoscopic modified Duhamel procedure was performed using three 5-mm trocars. Intra- and postoperative complications and functional outcomes were evaluated. Patients with trisomy 21 were excluded from the functional evaluation. The operation was completed laparoscopically for 25 of the 26 patients, with only one patient requiring conversion to an open procedure because of injury to the ureter. Mean operating time was 296 min. In one case, a minor leak was observed. No infections or related complications were observed. Mean follow-up period was 50.4 months. Sudden death secondary to rotaviral enterocolitis occurred 8 months postoperatively in one case. Twenty-one of the 25 patients (84%) showed episodes of constipation during the early follow-up period, and one child required late myectomy due to sphincter achalasia. As the child grew older, the need for medication was diminished. Of the 14 patients over 4 years old, excluding those patients with trisomy 21, all achieved normal defecation without incontinence. Our series revealed that all patients over 4 years old who underwent laparoscopic Z-shaped colorectal anastomosis achieved normal defecation without fecal incontinence. Laparoscopic Z-shaped colorectal anastomosis for HD appears feasible and safe to perform with good results.

Normal defecation pattern, frequency of constipation and factors related to constipation in Turkish children 0-6 years old

The aim of this study is to figure out defecation features, constipation frequency, reasons and factors effecting on functional constipation in 0-6 years old children. This descriptive study had been carried out in Gazi University School of Medicine Pediatric polyclinics between February-June 2007 and 1018 children aged 0-6 years were included. The study comprises data about defecation pattern and prevalence of constipation. Children were divided into five groups according to the age. Their parents were asked to complete a structured questionnaire. Physical examinations, stool frequency according to the age, feeding patterns, age and gender distributions, major complaints and associated factors were all investigated. Among 1018 children there were 526 (51.7%) boys and 492 (48.3%) girls. One hundred ninety five (88.2%) infants were exclusively breastfed, 42 children (17.8%) were getting additional feeding in 0-6 months age group. Forty-eight of 1018 children (4.7%) were diagnosed as constipated. Twenty-eight (58.3%) were male and 20 (41.7%) were female. Parents of the constipated children defined the major complaints with defecation as discomfort (33%), pain (25%), seldom defecation (21%), hard stools (17%) and rectal bleeding (4%). Eighteen parents (37.5%) thought that constipation is related to dietary type. Refraining from school toilet was defined by seven parents (14.6%). Constipation may predict serious organic problems in newborns; however organic problems are not encountered in 95% of bigger children. These cases are described as functional constipation. Dietary factors and refraining from school toilets have to be considered during treatment.

Ultradian rhythm in the intestine of Caenorhabditis elegans is controlled by the C-terminal region of the FLR-1 ion channel and the hydrophobic domain of the FLR-4 protein kinase

Defecation behavior in Caenorhabditis elegans is driven by an endogenous ultradian clock in the intestine. Its periods are positively regulated by FLR-1, an ion channel of the epithelial sodium channel/degenerin superfamily, and FLR-4, a protein kinase with a hydrophobic domain at the carboxyl terminus. FLR-1 has many putative phosphorylation sites in the C-terminal intracellular region. This structure implies that the periods may be regulated by the phosphorylation of FLR-1 by FLR-4, but it remains to be clarified. Here, we show that a truncated FLR-1 lacking the C-terminal intracellular region resulted in longer periods, suggesting that this region is involved in the negative regulation of defecation cycle periods. Contrary to our expectation, FLR-4 was still necessary for the function of the truncated FLR-1. Furthermore, FLR-4 containing a kinase-dead mutation or lacking the whole kinase domain was sufficient for normal defecation cycle periods. FLR-4 was necessary for the stable expression of FLR-1::GFP, and its hydrophobic domain was sufficient also for this function. FLR-1 and FLR-4 are often colocalized in the plasma membrane. These data showed an unexpected role of FLR-4: its hydrophobic domain stabilizes the FLR-1 ion channel, a key regulator of defecation cycle periods in the intestine.

Antidiarrhoeal activity of bisnordihydrotoxiferine isolated from the root bark of Strychnos trinervis (Vell.) Mart. (Loganiaceae).

Bisnordihydrotoxiferine, a dimeric tertiary indole alkaloid obtained from the root bark of Strychnos trinervis (Vell.) Mart. (Loganiaceae), inhibited normal defaecation and castor oil, arachidonic acid, and magnesium sulphate-induced diarrhoea on intraperitoneal administration in mice. The effect may be related to the ability of the compound to decrease normal and castor oil-stimulated gastric emptying, small intestinal transit and water and electrolyte accumulation, and inhibition of normal colonic transit. As prostaglandins are involved in gastrointestinal functions, inhibition of their synthesis is likely to contribute to the anticathartic activity, which has never been reported before for an indole alkaloid.

Management of faecal incontinence in acutely ill patients

Faecal incontinence is common in acutely ill patients, and has many predisposing factors. It is important that nursing staff understand the process of normal defecation as well as the adverse effects faecal incontinence has on patients, relatives and carers. New techniques are emerging for the management of faecal incontinence and it is important that nurses are aware of these.

Antidiarrhoeal effects of ethanolic leaf extract ofErythrina indicaL. in experimental animals

The ethanolic extract of the leaves of Erythrina indica significantly modified normal defecation frequency as well as inhibited castor oil-induced diarrhoea in Wistar rats. In addition, the extract showed a significant reduction in gastrointestinal motility in charcoal meal test. Phytochemical tests revealed that the main constituents were alkaloids. These findings suggested that the ethanolic extract of leaves of Erythrina indica elicits potent antidiarrhoeal effects and thus substantiated its traditional claim as an antidiarrhoeal agent.

Function and morphology correlates of rectal nerve mechanoreceptors innervating the guinea pig internal anal sphincter

Mechanoreceptors to the internal anal sphincter (IAS) contribute to continence and normal defecation, yet relatively little is known about their function or morphology. We investigated the function and structure of mechanoreceptors to the guinea pig IAS. Extracellular recordings from rectal nerve branches to the IAS in vitro, combined with anterograde labeling of recorded nerve trunks, were used to characterize extrinsic afferent nerve endings activated by circumferential distension. Slowly adapting, stretch-sensitive afferents were recorded in rectal nerves to the IAS. Ten of 11 were silent under basal conditions and responded to circumferential stretch in a saturating linear manner. Rectal nerve afferents responded to compression with von Frey hairs with low thresholds (0.3-0.5 mN) and 3.4 ± 0.5 discrete, elongated mechanosensitive fields of innervation aligned parallel to circular muscle bundles (length = 62 ± 16 mm, n = 10). Anterogradely labeled rectal nerve axons typically passed through sparse irregular myenteric ganglia adjacent to the IAS, before ending in extensive varicose arrays within the circular muscle and, to a lesser extent, the longitudinal muscle overlying the IAS. Few (8%) IAS myenteric ganglia contained intraganglionic laminar endings. In eight preparations, mechanotransduction sites were mapped in combination with successful anterograde fills. Mechanotransduction sites were strongly associated with extensive fine varicose arrays within the circular muscle (P < 0.05), and not with any other neural structures. Mechanotransduction sites for low-threshold, slowly adapting mechanoreceptors innervating the IAS are likely to correspond to extensive fine varicose arrays within the circular muscle.

Is rectal transplantation possible to save lives and improve quality of life?

Experiments have shown rectal transplantation to be technically feasible, although there remain obstacles such as returning physiological function and immunological considerations.Austin O'Bichere and Jacquie Peck argue that further interest in this novel method of restoring normal anal defaecation after excision of the rectum will be driven by the desire to restore quality of life by transplantation of non-essential organs.

Constipation and defecation pattern the first 30 days after thoracic surgery

In clinical practice constipation is often an overlooked aspect of patient care and first gains attention when it has become a severe problem for the patients. Constipation increases the risk for postoperative complications, can prolong hospital stay, increase financial cost, and staff nursing care time. A prospective descriptive design was used. One hundred and thirty nine patients participated in the study from February to June 2006. On admission, day of discharge, and 30 days after surgery patients normal and actual defecation pattern, stool consistency, and if they experienced problems with defecation was assessed by a structured interview. North America Nursing Diagnosis Associations (NANDA's) general definition of constipation was used as a frame of reference for this study. The Bristol Stool Scale was used to measure stool consistency. Prolonged and difficult evacuation and defecation pattern was recorded on a self-composed scale. Fifty per cent of patients developed constipation during the first postoperative period and their normal pattern of defecation was re-established 17 days after discharge. Nearly one third of the patients reported that their daily life was affected by constipation after discharge. The results imply that further studies are needed to prevent constipation and to help patients to cope with this side effect of surgery after discharge. The results of this study also suggest that acute and chronic constipation might be two different disorders.

Is Abnormality in the Conventional Anorectal Manometry Really Abnormal?

A 54-year-old woman, with chronic abdominal discomfort and difficulty in defecation, was admitted to the hospital. There were no abnormal findings on abdominal X-ray and colonic transit time remained within the normal values. The result by colonoscopic examination was normal. Bulk-forming laxatives were prescribed for a month, but symptomatic improvement was not found at all. Then, a defecography and the high resolution anorectal manometry (HR-ARM) of ManoScan TM system (Sierra Scientific Instruments, Los Angeles, CA, USA) were performed to differentiate functional anorectal disorders. Defecogram did not show significant findings. HR-ARM finding in left lateral decubitus position revealed the inappropriate increase of rectal pressure and no decrease in anal sphincter pressure (Fig. 1A). These findings were consistent with pelvic floor dyssynergia. However, when HR-ARM was performed with the patient in the sitting position, the increase of rectal pressure could be found in coordination with relaxation of the anal sphincter pressure (Fig. 1B). These results were consistent with the previous report obtained in the lying position; one-third showed dyssynergia and one-half could not expel artificial stool. However, when sitting with distended rectum, most patients showed a normal defecation pattern and ability to expel stool.1 Figure 1 Colored pressure topography plots of anorectal pressure during simulated defecation in left lateral decubitus position (A) and sitting position (B). High resolution anorectal manometry (HR-ARM) finding in left lateral decubitus position revealed inappropriate ... During the conventional water perfusion manometry, patients are expected to be in their lateral decubitus position, which interferes with an optimal abdominal contraction and anal relaxation during simulated defecation. However, in case of HR-ARM, patients can take sitting position in commode, which is more physiological since patients can feel more comfortable and they can generate enough movement of rectum for defecation and adequate anal relaxation.2 In conclusion, defecation is best evaluated in the sitting position of patient by using HR-ARM.

Delayed anastomotic leakage following sphincter-preserving surgery for rectal cancer

The aim of the present study was to investigate the characteristics of patients who developed delayed anastomotic leakage (DAL) following sphincter-preserving surgery for rectal cancer. We evaluated the following factors: (1) the incidence of DAL, (2) the clinical features of patients who developed DAL, (3) the risk factors for DAL, and (4) treatment outcomes. We reviewed the case histories of 1,838 rectal cancer patients who had undergone curative resection with sphincter preservation and without protective stoma formation between January 2000 and December 2006. DAL was defined as the development of a pelvic abscess or fistula around the anastomosis more than 3 weeks post-surgery in patients without tumor recurrence who had resumed a normal diet and defecation. In 1.3% (24/1,838) of the patients, DAL developed on median postoperative day 99 (range 22-2,069). Pelvic abscess (50%) and anastomotic-vaginal fistula (41.7%) were the most common causes of DAL. Independent risk factors for the development of DAL were: (1) female gender (hazard ratio 3.03; 95% CI 1.06-8.8), (2) low-level anastomosis (< or = 4 cm from the anal verge) (hazard ratio 5.76; 95% CI 1.37-22.39), and (3) preoperative chemoradiation therapy (hazard ratio 4.56; 95% CI 1.4-14.92). Stoma formation was performed in all of the 24 patients. The 3-year stoma-retention rate in patients with DAL was significantly higher than in patients with early anastomotic leakage (72.2% vs 17.5%, P < 0.001). DAL following sphincter-preserving surgery for rectal cancer occurred relatively frequently in our sample and was associated with female gender, a low level of anastomosis, and preoperative radiotherapy. DAL patients required long-term or permanent stomas.

A comparison of the effectiveness of the Soave and Martin procedures for the treatment of total colonic aganglionosis

Purpose Total colonic aganglionosis (TCA) is a relatively uncommon and severe condition managed by pediatric surgeons. Several procedures exist for the treatment of TCA. However, there is no current consensus on a superior operative procedure. The objective of this article is to evaluate the comparative effectiveness of the Soave procedure and the Martin procedure in the treatment of TCA with respect to preoperative data and postoperative outcome. Methods In the period from January 2001 to June 2008, we recruited 29 patients with TCA who were treated with the Martin procedure (14) or the Soave procedure (15). Relevant data were collected from the medical charts kept in the hospital library. The follow-up study used a detailed questionnaire that was answered by patients either by telephone or directly in the clinic. In the clinic, data, including age, body weight before operation, intraoperative blood transfusion, anastomotic leakage, postoperative enterocolitis, durations of any postoperative fever, days in hospital, and a range of functional outcomes, were particularly recorded to enable a comparison of the effectiveness of the Soave procedure and the Martin procedure. Results A male predominance has been described for patients with TCA, with a male-to-female ratio of approximately 6.25:1. In the Soave group, time between ileostomy and the definitive procedure, body weight before the definitive procedure, and the operative age were less than those in the Martin group ( P < .05). In patients who underwent the Martin procedure, the average duration of postoperative fever and days in hospital were significantly more than those in the Soave group ( P < .05). In the Soave group, the incidence of intraoperative blood transfusion (46.7%), abdominal wound infection (6.67%), and anastomotic leakage (0) was significantly less ( P < .05) than those in the Martin group (92.8%, 28.5%, and 14.3%, respectively). In the follow-up study, 7 patients in the Martin group had enterocolitis, and 4 of them had severe enterocolitis leading to multiple hospitalizations. In contrast, in the Soave group, only 2 patients had enterocolitis, and 1 was ameliorated after the therapy of anus dilation in the clinic. During the 4 weeks after the operation, all patients had an increased frequency of defecation, with soiling in the perianal area. At 3 months after the operation, there were significantly more patients with normal defecation in the Martin group compared to the Soave group ( P < .05). Six months later, 11 (78.6%) patients in the Martin group and 8 (61.5%) patients in the Soave group had normal defecation and the difference was still significant ( P < .05). Conclusion Patients with TCA managed with the Soave procedure had fewer operative complications compared with those of patients who underwent the Martin procedure. However, the patients managed with the Soave procedure took longer to establish normal defecation. Although each procedure has advantages and disadvantages, the Soave procedure is promising for the treatment of TCA, especially with regard to postoperative complications. A long-term follow-up study is needed.

A Feasibility Study of Probiotics Pretreatment as a Bowel Preparation for Colonoscopy in Constipated Patients

The use of probiotics to treat constipation is based on the premise that supplying the gut with healthy bacteria in the form of probiotics can help normalize intestinal function. The aim of this study was to determine the efficacy of a 2-week probiotics pretreatment with oral sodium phosphate (NaP) for bowel cleansing before colonoscopy in patients with constipation. Patients with constipation were prospectively randomized to receive a 2-week probiotics course comprising a mixture of Bacillus subtilis and Streptococcus faecium (group A, n = 51) or placebo (group B, n = 53) with an oral NaP solution. During the same period, another 107 patients with normal bowel movement were enrolled and received the probiotics treatment (n = 53, group C) or placebo (n = 54, group D). The primary outcome measure was the quality of bowel cleansing. Postendoscopic symptoms were estimated using a visual analogue scale. Patients having normal defecation presented with better bowel preparation than those with constipation (57.9% versus 37.5%; P = 0.003). Probiotics pretreatment (group A) was more effective at bowel cleansing for colonoscopy compared with placebo (group B) in constipated patients (54.9% versus 20.8%; P < 0.001). In contrast, preparation quality did not differ significantly between groups C and D. Preparation-related adverse events and postendoscopic symptoms were more frequent and severe in group B than in group A. Two weeks of probiotics pretreatment as part of bowel preparation significantly improves colonic mucosa visualization during colonoscopy and reduces preparation-related and postendoscopic gastrointestinal symptoms in constipated patients.

Nursing of patients with pelvic floor hernia, internal rectal prolapse combined with slow transit constipation

Objective To study the characteristics of peri-operative nursing of pelvic floor hernia, rectal prolapse combined with slow transit constipation. Methods 20 patients with pelvie floor hernia, internal rectal prolapse combined with slow-transit constipation were selected and given corresponding nursing according to peri-operative characteristics, and its influence on surgical effect of patients was ob-served. Results 18 cases restored to normal defecation, 2 cases still needed assisted defecation cathartic, but the amount decreased significantly. Conclusions Peri-operative nursing can promote the recovery of patients with pelvic floor hernia, rectal prolapse combined with colonic slow transit constipation. Key words: Pelvic floor hemia; Internal rectal prolapse; Slow transit constipation; Surgery; Nursing

Building the evidence base – the Zassi Bowel Management System

Uncontrolled faecal incontinence (FI) secondary to diarrhoea represents a major risk to perianal skin integrity and the healing of perineal wounds or burns. In an era of heightened awareness of the morbidity and the costs associated with hospital-acquired infection, there are obvious concerns about the risks of cross-infection associated with diarrhoea or FI. This article evaluates the Zassi Bowel Management System (ZBMS, Hollister), a product that has been designed to manage diarrhoea, faecal incontinence and defaecation in situations where a patient is either completely dependent, has overwhelming uncontrolled diarrhoea that poses a threat to skin integrity and is a cross-infection risk, or where normal defaecation poses a risk to wound integrity and sterility.

Anorectal transplantation

Anorectal transplantation is a valid procedure for the treatment of anorectal dysfunction; however, the lack of a suitable animal model has hampered the development of this method. We describe a simple technique for anorectal transplantation in the rat and compare this procedure with colostomy. The anorectal segment including the skin surrounding the anus were freed by abdominal and perineal dissection. In a heterotopically transplanted group the segment was exteriorized by the formation of an anus through an abdominal incision. In an orthotopically transplanted group the segment was replaced in its original position and reimplanted by suturing. In another group a distal colostomy was performed. A sham-treated control group (simulated surgical procedure) was also included. Changes in behavior, characteristics of the stool, body weight and survival rate were assessed by daily clinical examination. Moribund animals, those with a weight loss of more than 30%, and those surviving at 1 month were killed by an overdose of anesthetic. The results were analyzed using the Mann Whitney, Student's t and chi-squared tests, and p<0.05 was considered significant. Within 4 days after the operation, animals submitted to orthotopic or heterotopic transplantation had achieved normal defecation, body weight gain and clinical evolution similar to the sham-treated group. The overall mortality in these groups was 4.16%. In contrast, colostomized animals showed a high incidence of diarrhea, intestinal obstruction, stress posture and violent behavior (p</=0.05), and a mortality rate of 58.33%. Autotransplantation in the rat is a simple technique, achieves a high rate of success and better clinical evolution than colostomy. This model may ultimately lead to research into anorectal transplantation.