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Exhaust conservative therapies: colectomy may work for chronic constipation.

FORT LAUDERDALE, FLA. -- Some patients with severe, chronic constipation may benefit from colectomy once they have exhausted conservative therapies.

But these patients must be selected carefully to ensure that they are likely to have improvement in bowel movements and quality of life, several speakers said at a colorectal disease symposium sponsored by the Cleveland Clinic Florida.

The clinical presentation of constipated patients is quite variable, noted Dr. Johann Pfeifer of the University of Graz (Austria). Some patients might define their constipation as a feeling of incomplete evacuation. Others might describe their constipation as infrequent evacuation, associate it with abdominal or rectal pain or hard stool consistency, or cite the need for straining or manual assistance with evacuation.

The most widely accepted clinical definition must include two or more of these symptoms for at least 12 months when the patient is not taking laxatives:

* Straining on more than 25% of bowel movements.

* Feeling of incomplete evacuation after more than 25% of bowel movements.

* Hard stools on greater than 25% of bowel movements.

* Fewer than two bowel movements per week with or without symptoms of constipation.

On the first visit, it helps to use "some kind of checkup list like a constipation scoring system," Dr. Pfeifer said. It's important to ask if the patient had a hysterectomy or other procedures performed in the abdomen, because they may alter structures within the pelvis.

Patients with chronic constipation may have a normal colon, a morphologic disorder, or a functional disorder.

During a digital rectal exam, the patient should squeeze, push down, and relax. Nonrelaxation of the pelvic floor muscles may help to diagnose pelvic outlet obstruction, Dr. Pfeifer said.

Once the physician performs other tests, such as proctoscopy without bowel preparation, colonoscopy and/or a barium enema, abdominal ultrasound, and a workup of blood chemistry (including serum calcium, potassium, and thyroxin levels), conservative therapy may begin: a high-fiber diet, plenty of fluids, exercise, and possibly suppositories to initiate evacuation.

If this conservative therapy does not work, the patient should undergo physiologic testing, although an ideal test is not available. The tests--colonic motility study, anorectal manometry, defecography, electromyography and pudendal nerve terminal motor latency--serve to differentiate a pelvic outlet obstruction, which is the problem in a majority of patients, from colonic inertia.

When routine conservative therapy does not work, Dr. Pfeifer asks patients to keep a bowel movement diary because they may not have reported their history accurately. He also gives these patients "all the [appropriate] medications we can think of," plus psychiatric support and biofeedback.

In a study of 100 patients with severe, intractable constipation, 57% reported improvement with biofeedback and 55% felt that biofeedback helped (Gut 42[4]:517-21, 1998). Overall, 65% of the patients had colonic inertia and 59% had pelvic outlet obstruction.

If the patient really wants to proceed to surgery, "we do all the physiologic tests, but we are aware this does not guarantee a successful outcome," Dr. Pfeifer said. "I would like to stress that we should not be forced by the patient."

In the literature, the success rate for subtotal colectomy with ileorectal anastomosis is about 75% in patients with colonic inertia with or without megabowel. Most of these patients were females around 20-35 years old, he said.

In one study, subtotal colectomy with ileorectal anastomosis worked well for 90% of patients. The other 10% did poorly and had an upper GI evaluation with electrogastrography and esophageal manometry. They had an additional problem in the upper GI tract (GI dysmotility) and may not benefit from surgery, he said.

The biggest complication from subtotal colectomy is small bowel obstruction. In a review of 25 papers, Dr. Pfeifer reported an overall rate of small bowel obstruction of 18%, with 12% requiring further surgery (Dis. Colon Rectum 39[4]:444-60, 1996).

Segmental resections for severe constipation generally have poor results, but several small case series have reported 75%-100% success rates. It appears that these patients had idiopathic megasigmoid, he said.

"When you think about this, you should really keep it in the context of the fact that operating on people for constipation is really doing surgery for a quality of life issue," Dr. Robert D. Madoff said in a separate presentation. With this in mind, quality of life is the main end point.

A review of 31 case series in the literature found that the overall patient satisfaction rate was 86%, but varied widely, ranging from 39% to 100%. Some of the variation may have been due to methodologic differences in acquisition and analysis, noted Dr. Madoff of the University of Minnesota, St. Paul. To determine success, 14 of the studies used patient judgment, 6 used bowel function, and another 5 used a combination of the two methods.

After subtotal colectomy, patients had a median of three bowel movements per day, 9% had persistent constipation, 41% had persistent abdominal pain, 14% had diarrhea, and 14% had incontinence (Ann. Surg. 230[5]:627-38, 1999).

In their own study, Dr. Madoff and his colleagues surveyed 112 patients who underwent subtotal colectomy for slow-transit constipation several years earlier. The 75 patients who responded had a mean score of 103 on the modified Gastrointestinal Quality of Life Index, which has a range of 0 (worst) to 144 (best). In comparison, healthy patients who took the GIQLI during validation studies had a mean score of 126. Although he did not have values for the quality of life of the patients before surgery, Dr. Madoff noted that other studies have found that chronically constipated individuals have a lower quality of life than do healthy controls.

Low quality of life for subtotal colectomy patients was correlated significantly with persistent abdominal pain, incontinence, and frequency of new onset diarrhea (Dis. Colon Rectum 46[4]:433-40, 2003).

BY JEFF EVANS

Senior Writer
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Title Annotation:Gastroenterology
Author:Evans, Jeff
Publication:Internal Medicine News
Date:Apr 15, 2004
Words:963
Previous Article:Clinical capsules.
Next Article:Stimulation procedure: sacral nerve may hold key to refractory constipation.


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