This document describes a case of a 33-year-old female accountant experiencing worsening constipation. On examination, she was found to have paradoxical anal contractions and increased perineal descent on straining. Anorectal manometry confirmed these findings and showed she was unable to expel a balloon in two minutes, indicating pelvic floor incoordination as the likely cause of her constipation. She was referred for biofeedback training, which has a 70% success rate for resolving constipation.

1. CONSTIPATION
Dr Hafeez Yaqoob
PGR Gastro BMCH Quetta

2. Case
A 33-year-old female accountant consults because of worsening
constipation. She describes on specific questioning passing a bowel
movement every 2 days. She strains excessively to pass the bowel
movement, and the stools feel hard. She has a sensation of
incomplete emptying after she has a bowel movement, and she
finds this troubling. Occasionally, she will press around the anal
area to help hard stool evacuate. She remembers being constipated
as a child and all her life. She has not seen any mucus or blood in
the stools, and she has no history of weight loss, vomiting or any
alarm symptoms. She describes mild abdominal discomfort at
times; this is usually present before she passes stools, but she
denies pain relief with defecation or a change in her stools when
pain begins. She has been regulating her bowels by taking over-the-
counter laxatives, but has found that these have not been very
helpful. She never has diarrhoeal symptoms

3. • She has otherwise been in excellent health. She takes no
other regular medications. There is no family history of
colon cancer, inflammatory bowel disease or other
gastrointestinal diseases.
• Abdominal examination is unremarkable with no evidence
of any organomegaly or distension. Bowel sounds are
normal. Rectal examination is abnormal. While anal
sphincter tone felt normal, on straining there was
paradoxical contraction of the anal musculature felt around
the finger. There was also increased perineal descent seen
on straining. There were no masses palpable and no blood
on the glove. The remainder of the physical examination
was non-contributory

4. investigations
• Because of the history of life-long constipation, further
investigations were ordered. An anorectal manometry
was undertaken to exclude Hirschsprung's disease and
determine whether there is pelvic floor dysfunction.
Anorectal manometry showed the patient had
paradoxical contractions with straining, confirming the
rectal examination findings. Furthermore, she was
unable to expel a 50 mL warm-water-containing
balloon in two minutes, sitting on the commode. There
was a normal rectal inhibitory reflex ruling out
Hirschsprung's disease. In view of the absence of any
alarm features, further evaluation of the colon was not
ordered.

5. Explanation for her constipation ?

6. What you advice?
• The patient was advised that she has pelvic
floor incoordination and this is the most likely
explanation for her constipation. She was
further advised that laxatives are often
unhelpful. She was given the option of trying
suppositories as needed. She was referred for
biofeedback training and advised there was a
70% chance that biofeedback training would
result in long-term resolution of her
constipation.

8. Constipation
Constipation affects a substantial portion of the Western
population and is particularly prevalent in women, children,
and older adults. Many persons with constipation do not
seek medical attention, but because constipation affects
between 3% and 31% of the population, it results in over
$6.9 billion in medical costs annually and is 1 of the most
common reasons for an office visit to a physician.
For most affected persons, constipation is intermittent and
requires no or minimal intervention. For others,
constipation can be challenging to treat and have a
negative impact on quality of life. In these cases, specific
causes of constipation like systemic or structural diseases
must be excluded.

9. DEFINITION AND PRESENTING
SYMPTOMS
• It is important to ask patients what they mean
when they say
• “I am constipated.” Most persons describe
perception of difficulty with bowelmovements or
a discomfort related to bowel movements. The
most common terms used by young.

10. DEFINITION AND PRESENTING
SYMPTOMS
• healthy adults to define constipation are
straining (52%),
• hard stools (44%), and inability to have a
bowel movement (34%).
• Analysis of the National Health Interview
Survey (NHIS) data found that in 10,875
subjects older than age 60, straining and hard
bowel movements were most strongly
associated with self-reported constipation.

11. Definition of constipation
The definition of constipation also varies among health care
providers. The traditional medical definition of constipation,
based on the 95% lower confidence limit for healthy adults in
North America and the United Kingdom, has been 3 or fewer
bowel movements per week. Reports of stool frequency,
however, are often inaccurate and correlate poorly with
complaints of constipation.4 In an attempt to standardize
the definition of constipation, a consensus definition was
initially developed by international experts in 1992 (Rome I
Consensus Committee criteria)5 and was revised in 1999 and
2006 (Rome II and III criteria, respectively

12. Rome criteria
• The Rome criteria incorporate the multiple
symptoms of constipation, of which stool
frequency is only 1, and require that a minimum
of 2 symptoms be present in at least 25% of
bowel movements. Unlike the Rome I criteria, the
Rome II criteria include symptoms suggestive of
pelvic floor dyssynergia or outlet obstruction
(e.g., a sensation of anorectal blockage or
obstruction and use of maneuvers to facilitate
defecation).

13. Rome III Criteria for functional constipation

14. Chronic constipation
• Chronic constipation is defined as the
presence of symptoms for at least 3 months
and should be distinguished from irritable
bowel syndrome (IBS), although the two
entities have overlapping features.

15. EPIDEMIOLOGY
• Prevalence;
The prevalence of constipation ranges from 3% to
31% of the population in Western countries and
varies depending on the demographics of the
population .
highest when constipation is self-reported and
lowest when the Rome criteria for constipation
are applied. When the Rome II criteria are used to
diagnose constipation, the effects of gender, race,
socioeconomic status, and level of education on
the prevalence of constipation are reduced.

16. Incidence
Talley and colleagues surveyed 690 nonelderly residents
of Olmsted County, Minnesota, at baseline and after 12
to 20 months. Constipation, defined as frequent
straining at stool and passing hard stool, a weekly stool
frequency of fewer than 3, or both, was present in 17%
of respondents on the first survey and 15% on the
second. The rate of new constipation in this study was
50/1000 person-years, whereas the disappearance rate
was 31/1000 person-years. In a similar study, residents
were surveyed at baseline and about 12 years later. The
cumulative incidence of constipation over a 12-year
period was 17.4% and, in subjects younger than age 50,
was higher in women (18.3%) than men (9.2%).

17. Risk Factors for Constipation
• Advanced age
• Female gender
• Low level of education
• Low level of physical activity
• Low socioeconomic status
• Nonwhite ethnicity
• Use of certain medications

18. Classification of constipation in adults
• No gross structural abnormality
• Structural disorders
• Neurological causes
• Endocrine or metabolic causes
• Psychological disorders
• Drug side effects

19. No gross structural abnormality
• Inadequate fibre intake
• Irritable bowel syndrome (associated with
abdominal pain) or functional constipation
• Idiopathic slow-transit constipation (colonic
inertia)
• ‘Obstructed defecation’—pelvic floor dysfunction
(pelvic floor dyssynergia or anismus)

20. Structural disorders
• Anal fissure, infection or stenosis
• Colon cancer or stricture
• Aganglionosis and/or abnormal myenteric
plexus: Hirschsprung’s disease, Chagas’ disease,
neuropathic pseudo-obstruction
• Abnormal colonic muscle: myopathy, dystrophia
myotonica, systemic sclerosis
• Idiopathic megarectum and/or megacolon
• Proximal megacolon

21. Neurologic and Myopathic Disorders
• Amyloidosis
• Autonomic neuropathy
• Chagas’ disease
• Dermatomyositis
• Intestinal pseudo-obstruction
• Multiple sclerosis
• Parkinsonism
• PSS
• Shy-Drager syndrome
• Spinal cord injury
• Stroke

22. Endocrine or metabolic causes
• Diabetes mellitus
• Heavy metal poisoning (e.g., arsenic, lead, mercury)
• Hypercalcemia
• Hyperthyroidism
• Hypokalemia
• Hypothyroidism
• Panhypopituitarism
• Pheochromocytoma
• Porphyria
• Pregnancy

23. Psychological disorders
• Depression
• Anorexia nervosa
• Denied bowel habit

24. Medication Use
• Acetaminophen (>7 tablets weekly)
• Antacids (aluminum containing)
• Anticholinergic agents (e.g., antiparkinsonian drugs,
• antipsychotics,
• antispasmodics, tricyclic antidepressants)
• Anticonvulsants (e.g., carbamazepine, phenobarbital,
• phenytoin)
• Antineoplastic agents (e.g., vinca derivatives)
• Calcium channel blockers (e.g., verapamil)
• Calcium supplements
• Diuretics (e.g., furosemide)
• 5-Hydroxytryptamine antagonists (e.g., alosetron)
• Iron supplements
• NSAIDs (e.g., ibuprofen)
• Mu-opioid agonists (e.g., fentanyl, loperamide, morphine)

25. Public Health Perspective
• Constipation results in more than 555,000 emergency
department visits, 38,000 hospitalizations, and several
hundred million dollars of laxative sales in the United
States each year.
• In a National Canadian Survey, 34% of people who
reported constipation had seen a physician for their
symptoms.
• In 2004, the direct costs for constipation were nearly
$1.6 billion, with indirect costs of $140 million, making
constipation among the top 10 digestive disorders in
attributable direct costs

26. Gender
• The prevalence of self-reported constipation is 2 to 3
times higher in women than in men.
• The reason for the female predominance is unknown.
Colonic transit time is significantly longer in women
during the luteal phase of the menstrual cycle
compared with the follicular phase, when estrogen
levels are relatively low.
• In addition, over expression of progesterone receptor B
on colonic muscle cells, thereby making them more
sensitive to physiologic concentrations of
progesterone, has been proposed as an explanation for
severe slow-transit constipation in some women

27. Age
• Constipation in older adults is most commonly the result of
excessive straining and hard stools
• Possible causes for the increased frequency of straining in older
adults include decreased food intake, reduced mobility, weakening
of abdominal and pelvic wall muscles, chronic illness psychological
factors, and medications, particularly pain-relieving drugs
Constipation is also common in children younger than age
4. In Great Britain, the frequency of a consultation for constipation
in general practice was 2% to 3% for children aged 0 to
4, about 1% for women aged 15 to 64, 2% to 3% for both
genders aged 65 to 74, and 5% to 6% for patients aged 75 years
or older. Fecal retention with fecal soiling is a common cause
of impaired quality of life and the need for medical attention
in childhood.

28. Ethnicity
In North America, constipation is reported more commonly by
nonwhites than whites. In a survey of 15,014 persons, the
frequency was 17.3% in nonwhites and 12.2% in whites.
Age-specific increases in prevalence were found in both
groups. Data regarding constipation in developing countries
are limited. A study comparing the prevalence in South
America and Asia found comparable frequencies of
constipation, with rates of 21.7% in Colombia and 16.7% in
South Korea.45 In Sri Lanka, constipation (as defined by the
Rome III criteria using a self-administered survey) was
reported by 15.4% of children between 10 and 16 years of
age. The prevalence of constipation was significantly higher in
children with a family history of constipation (49% vs. 14.8%),
those living in a war-affected area (18.1% vs. 13.7%), and
those attending an urban school (16.7% vs. 13.3%)

29. Socioeconomic Class and Education
Level
The prevalence of constipation is influenced by
socioeconomic status. In population-based surveys,
persons with lowerincome status have rates of
constipation higher than those who have higher-
income status. Similarly, persons who have a lower
education level tend to have a prevalence of
constipation higher than those who have a higher
education level. A meta-analysis found an increased
prevalence of constipation in persons of lower
socioeconomic status compared with those of higher
socioeconomic status.

30. Diet and Physical Activity
• increased consumption of fiber decreases colonic
transit time and increases stool weight and
frequency.
• protective effect of physical activity on
constipation, results from trials designed to test
this hypothesis are conflicting. In 1 trial,
symptoms of constipation did not improve after a
4-week exercise program.

31. COLONIC FUNCTION
• Luminal Contents
• The main contents of the colonic lumen are food
residue, water and electrolytes, bacteria, and gas.
Unabsorbed food entering the cecum contains
carbohydrates that are resistant to digestion and
absorption by the small intestine, such as starches
and nonstarch polysaccharides. Some of the
unabsorbed carbohydrate serves as substrate for
bacterial proliferation and fermentation, yielding
short-chain fatty acids and gas. On average, bacteria
represent about 50% of stool weight.

32. Absorption of Water and Sodium
• Increased water absorption can lead to smaller,
harder stools. The colon extracts most of the
1000 to 1500 mL of fluid that crosses the
ileocecal valve and leaves only 100 to 200 mL of
fecal water daily. Less reabsorption of electrolytes
and nutrients takes place in the colon than in the
small intestine, and sodium-chloride exchange
and short-chain fatty acid transport are the
principal mechanisms for stimulating water
absorption.

33. pathophysiologic
mechanism
• pathophysiologic mechanism in slow-transit
constipation is that the lack of peristaltic movement
of contents through the colon allows more time for
bacterial degradation of stool solids and increased
NaCl and water absorption, thereby decreasing
both stool weight and frequency. The volume of
stool water and quantity of stool solids seem to be
reduced proportionally in constipated persons.

34. Diameter and Length
• A wide or long colon may lead to a slow colonic
transit rate . Although only a small fraction of
patients with constipation have megacolon or mega
rectum, most patients with dilatation of the colon
or rectum report constipation.
• A colonic width of more than 6.5 cm at the pelvic
brim on a barium enema film is abnormal and has
been associated with chronic constipation

35. Motor Function
• Colonic muscle has 4 main functions
1. Delays passage of the luminal contents to allow time for water
absorption,
(2) mixes the contents and allows contact with the mucosa,
(3) allows the colon to store feces between defecations,and
(4) propels the contents toward the anus.
Muscle activity is affected by sleep and wakefulness, eating, emotion,
• colon contents, and drugs. Neural control is partly intrinsic
• and partly extrinsic by the sympathetic nerves and the
parasympathetic
• sacral outflow

36. Neural control
Neural control is
partly intrinsic and partly extrinsic by the
sympathetic nerves and the parasympathetic
sacral outflow

37. Muscle activity is affected
• sleep and wakefulness,
• eating,
• emotion,
• colon contents
• drugs

38. Colonic propulsions
• 2 basic types:
• low-amplitude propagated contractions
(LAPCs)
• High-amplitude propagated contractions
(HAPCs).

39. Innervation and the Interstitial
Cells of Cajal
• Proximal colonic motility is under the involuntary
control of the enteric nervous system, whereas
defecation is voluntary. Slow-transit constipation
may be related to autonomic dysfunction.
Histologic studies have shown abnormal numbers
of myenteric plexus neurons involved in
excitatory or inhibitory control of colonic
motility, thereby resulting in decreased amounts
of the excitatory transmitter substance P75 and
increased amounts of the inhibitory transmitters
vasoactive intestinal polypeptide (VIP) or nitric
oxide (NO)

40. Interstitial Cells of Cajal
• The interstitial cells of Cajal (ICCs) are intestinal pacemaker cells and play an
important role in regulating GI motility
They facilitate conduction of electric current and mediate neural signaling
between enteric nerves and muscles. ICCs initiate slow waves throughout
the GI tract. Confocal images of ICCs in patients with slow-transit
constipation show not only reduced numbers but also abnormal
morphology of ICCs, with irregular surface markings and a decreased
number of dendrites. In patients with slow-transit constipation, the number
of ICCs has been shown to be decreased in the sigmoid colon77 or the
entire colon.78,79 Pathologic examination of colectomy specimens of 14
patients with severe intractable constipation has revealed decreased
numbers of ICCs and myenteric ganglion cells throughout the colon .

41. Defecatory Function
The process of defecation in healthy persons begins with a
predefecatory period during which the frequency and amplitude
of propagating sequences (3 or more successive pressure waves)
are increased. Stimuli such as waking and meals (gastroileal reflex,
also referred to as gastrocolic reflex) can stimulate this process. In
patients with slow-transit constipation, this predefecatory period
is blunted and may be absent.71 The gastroileal reflex is also
diminished in persons with slow-transit constipation. Stool is often
present in the rectum before the urge to defecate arises. The urge
to defecate is usually experienced when stool comes into contact
with receptors in the upper anal canal. When the urge to defecate
is resisted, retrograde movement of stool may occur, and
transit time increases throughout the colon

42. Size and Consistency of Stool
Human stools may vary in consistency from small hard
lumps to liquid. The water content of stool determines
consistency. Rapid colonic transit of fecal residue leads
to diminished water absorption and (perhaps
counterintuitively) an increase in the bacterial content
of the stool. The Bristol Stool Scale is used in the
assessment of constipation and is regarded as the best
descriptor of stool form and consistency . Stool
consistency appears to be a better predictor
of whole-gut transit time than of defecation frequency
or stool volume

43. Clinical classification

44. Stool chart

46. Room III criteria