Constipation - Causes, Diagnosis and Treatment

186 Pages·2012·6.607 MB·English

by  A. Catto-Smith

CONSTIPATION –
CAUSES, DIAGNOSIS
AND TREATMENT

Edited by Anthony G. Catto-Smith
Constipation – Causes, Diagnosis and Treatment
Edited by Anthony G. Catto-Smith

Published by InTech
Janeza Trdine 9, 51000 Rijeka, Croatia

Copyright © 2012 InTech
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First published March, 2012
Printed in Croatia

A free online edition of this book is available at www.intechopen.com
Additional hard copies can be obtained from [email protected]

Constipation – Causes, Diagnosis and Treatment, Edited by Anthony G. Catto-Smith
p. cm.
ISBN 978-953-51-0237-3

Contents

Preface IX
Chapter 1 Diagnostic Approach to Constipation in Children 1
Kathleen H. McGrath and Patrina Caldwell
Chapter 2 The Role of Diagnostic Tests in Constipation in Children 19
Anthony G. Catto-Smith and Kathleen H. McGrath
Chapter 3 The Role of Interstitial Cells of Cajal (ICC)
in Gastrointestinal Motility Disorders –
What the Gastroenterologist Has to Know 33
Christian Breuer
Chapter 4 Skipping Breakfast is Associated
with Constipation in Post-Adolescent
Female College Students in Japan 47
Tomoko Fujiwara
Chapter 5 Irritable Bowel Syndrome and Constipation 55
Brian C. Dobson
Chapter 6 Opioid Induced Constipation 81
Caterina Aurilio, Maria Caterina Pace,
Vincenzo Pota and Pasquale Sansone
Chapter 7 Drugs in Development
for Opioid-Induced Constipation 89
Kelly S. Sprawls, Egilius L.H. Spierings and Dustin Tran
Chapter 8 Constipation Treatment in Neurological Disorders 99
Gallelli Luca, Pirritano Domenico,
Palleria Caterina and De Sarro Giovambattista
Chapter 9 Bowel Dysfunction in Persons
with Multiple Sclerosis 117
Elsie E. Gulick and Marie Namey
VI Contents

Chapter 10 Multimodal Treatment of Constipation:
Surgery, Rehabilitation or Both? 139
Luigi Brusciano, Crescenzo Di Stazio, Paolo Limongelli,
Gian Mattia Del Genio, Salvatore Tolone, Saverio Sansone,
Francesco Lucido, Ignazio Verde, Antonio D’Alessandro,
Roberto Ruggiero, Simona Gili, Assia Topatino, Vincenzo Amoroso,
Pina Casalino, Giovanni Docimo and Ludovico Docimo
Chapter 11 Core Aspects of Clinical Development
and Trials in Chronic Idiopathic Constipation 147
M. Scott Harris and Oranee T. Daniels

Preface

Constipation is common in both adults and children. Estimates would suggest a
median prevalence of around 12-16% in the general population.1 While regarded as a
minor nuisance in some cases, its consequences can be severe, with a substantial
impact on quality of life.2 Secondary faecal soiling has a profound psychological effect
at all ages.
This book provides specific contributions which clarify the pathogenesis, diagnosis, and
therapy of constipation for the general population and also for certain high risk groups.
Surprisingly, consensus definitions of constipation have been hard to achieve, but that
achieved by the PACCT group3 for children included having at least 2 of the following
features within the last 8 weeks:
 Fewer than 3 bowel movements per week
 More than one episode of fecal incontinence per week
 Large stools in the rectum or palpable on abdominal examination
 Passing of stools so large that they obstruct the toilet
 Retentive posturing and withholding behavior
 Painful defecation.
Importantly, it may not be recognised, only coming to attention because of abdominal
pain, soiling or behavioural disturbances. The chapter by Kathleen McGrath critically
examines the impact defaecation disorders have in children and the diagnostic criteria
used to identify them.
Defaecation disorders are also much more prevalent in certain groups. The very young
and the elderly4, 5 are at particular risk. They also pose a particular difficulty for both
children and adults with developmental disabilities6, neurological dysfunction and
spinal cord injury.7 Medical and surgical therapy may also lead to constipation
through the use of potent analgesics such as opiods. The chapters by Caterina Aurilio
and Kelly Sprawls provide insights into the aetiology of opiod-induced constipation
and pharmaceutical approaches to avoiding it and its therapy. Occasionally,
constipation may be the presenting feature of another condition such as thyroid
disease or colorectal malignancy.8 The relationship between colorectal tumors and
colonoscopy is addressed in the chapter by Brusciano. The chapters by Luca Galleli
X Preface

and Elsie Gulick provide insights into the impact of the broad spectrum of
neurological disorders and multiple sclerosis respectively on colorectal dysfunction.
In most situations, constipation occurs in otherwise well individuals. The pathogenesis
in these cases is usually proposed to be inadequate dietary fibre, a sedentary lifestyle,
or poor toileting techniques. The chapter by Tomoko Fujiwara provides an insightful
and unique window into the impact of the all too common habit of skipping breakfast
on bowel function.
Diagnosis is usually straightforward, but it often helpful to make reference to
diagnostic criteria such as that achieved by the PACCT group. Further diagnostic
testing is not usually required, but can be invaluable in specific instances. The chapter
on diagnostic tests (Catto-Smith et al.) provides a review of the available testing
techniques. While abdominal radiography is often employed, it is rarely adds much.
Studies of colorectal motility9, 10 provide an immense amount of information but are
either expensive, invasive, or difficult to interpret11. However, they have enabled a
better understanding of the motility dysfunction responsible for constipation.12
Sensory dysfunction is clearly important as many patients are unaware of the extent of
rectal filling.13 These type of studies have however meant that entities such as slow
transit constipation, anorectal incoordination, sphincteric dysfunction and the basis for
constipation in irritable bowel syndrome are now much better understood14. The
chapter by Brian Dobson provides a novel hypothesis into the pathogenesis of
defaecation disorders in irritable bowel syndrome.
In many situations, otherwise uncomplicated constipation will respond to simple
interventions such as attention to diet15 and toileting, but in other patients it can be
extraordinarily difficult to achieve therapeutic success. Medications generally function
through either assisting colorectal contractility or softening the stool.16 Unfortunately,
drugs only offer temporary relief if the primary cause is unable to be improved. Recent
interest has centred on possibly dysbiotic colonic flora in the hope that probiotics17
may be helpful. There are a variety of traditional and complementary medications that
are used widely in the community.18
Behavioural therapies are often very effective in children,19, 20 and biofeedback
modalities have attracted a great deal of interest, particularly in adults. 21
Better understanding of the pathophysiology of defaecation disorders has opened the
doors to novel treatments. Abnormalities in the excitatory cells primarily responsible
controlling gastrointestinal motility have been postulated to have a major role in
certain types of constipation such as slow transit22 and even that associated with
diabetes.23 The chapter by Christian Breuer provides a good understanding of the
Interstitial Cell of Cajal – a central player in gastrointestinal dysmotility and slow
transit constipation. Sacral stimulation is certainly effective, but is invasive. A very
exciting new area is that of transabdominal electrical stimulation, 24 which appears to
offer the unenviable combination of low cost, ease of use, durability of effect to an
otherwise treatment-resistant population.25, 26