These are comments on refractory constipation

1. .
Cairo University
Egypt
Mohamed-Naguib Wifi
Comment on The Case

2. • Colonic transit testing is rarely
necessary among patients with
symptomatic response to first-line
constipation over-the-counter and
prescription treatments.
• But once patients have established
refractory disease, we see great
value in determining transit as a
dichotomous variable: either slow or
not.

3. • The most common form of transit testing
uses the ingestion of radiopaque markers
with an abdominal x-ray performed at set
intervals to determine passage of markers.
• We use the Hinton et al method, where an
abdominal film is obtained 5 days after
ingestion of 24 radiopaque markers in a
gelatin capsule (Sitzmarks capsules, Konsyl
Pharmaceuticals, Easton, MD).
• Retention of 5 or more markers on
imaging is defined as slow colonic transit.

4. The wireless motility capsule (SmartPill):
• Provide information on gastric emptying
• Small bowel transit time
• Good correlation with radiopaque marker
tests and scintigraphy
• Enables calculation of overall and regional
colonic transit times
• But is limited in availability to only a few
centers.

5. The most important result from a colonic transit test is the negative or
normal-transit result:
• Clinicians can focus less on accelerating colonic transit.
• More on treating other issues such as visceral hypersensitivity with IBS
overlap and/or rectal evacuation disorders.
• Moreover, the normal transit study provides a basis for added counseling
and realigning patient expectations.
• The normal transit patient should be instructed to focus less on bowel
movement frequency as the primary problem and more on non-laxative
measures to address their discomfort.

6. What To Do?

7. • We do not avoid TCAs completely in patients with CC, but only use them
in patients with no evidence of slow transit on a colonic transit study.
• In the absence of severe slow transit, we tend to avoid stimulant laxatives
among these patients (especially those recovering from an eating disorder)
for fear of reinforcing unrealistic bowel movement frequency expectations
or creating/exacerbating an addiction to the cathartic feeling stimulants can
induce.
• In more severely affected patients with slow-transit constipation, increasing
doses of stimulant laxatives may be needed to achieve bowel movements
(tolerance), but we see this as a reflection of more severe slow
transit rather than damage to the enteric nervous system.

8. • Some experts would argue that there is less of a role for osmotic
laxatives in slow transit, but most clinicians will still use osmotic
laxatives in combination with other therapies in this patient group.
• In patients with severe symptoms and documented slow transit
who have failed traditional therapies, 5-HT4 agonist prucalopride
was found to be significantly more effective than placebo.
• When everything fails??? What to do???

9. The Massachusetts
General Hospital
algorithm for the
evaluation and
management of
refractory constipation

10. Thank you