Treatment of Intractable Constipation – Gastrocure West Orange, NJ
Intractable constipation is a major colon motility disorder. This prolonged constipation does not resolve with dietary changes or other simple therapeutic measures. Causes vary, but intractable constipation may be caused by several factors:
• Abnormal colon contractions
• Anal sphincter spasm leading to a functional obstruction
• Dysfunctional innervation of colonic, anal sphincter, or pelvic floor muscles. These abnormalities can lead to an uncoordination among the colon, anal sphincter, and pelvic floor.
Normal defecation involves coordination between colonic contractions and relaxation of three muscles—the puborectalis, the internal anal sphincter, and the external anal sphincter—allowing stool to pass. Some patients with intractable constipation are unable to relax these usually contracted muscles to defecate successfully.
Intractable constipation motility conditions include:
• Abnormal colon contractions — chaotic and non-propulsive colon contractions do not allow for natural movement of materials through the colon.
• Dysfunctional colonic nerves or muscles — absence of colonic contractions due to altered neuromuscular function delays colonic transit or slow movement of materials through the colon and leads to severe constipation. Some patients with this dysfunction also complain of incomplete bowel movements.
• Anal sphincter functional obstructions — partial or complete failure to relax the sphincter blocks bowel content movement through the anus.
• Pelvic floor dyssynergia (anismus) — failure of pelvic floor muscles to have coordinated relaxation or contraction preventing normal stool elimination. In children, failure of anal sphincter relaxation can be from Hirschsprung’s disease. In adults, this is often due to the lack of relaxation of puborectalis or external anal sphincter.
Diagnostic motility testing for colon motility disorders allows physicians to visualize colonic transit and muscle condition.
• Colonic transit studies — Colon transit time is measured by following the movement of ingested markers with a series of x-rays. The patient swallows 24 radio-opaque markers. The markers are followed through x-rays until all the markers are eliminated or for five days. This technique allows for identification of slow or normal transit constipation, determination of site of slow transit, and follow-up of the patient’s response to treatment.
• Colon motility — Using a manometry pressure tube, the colon muscle strength and responsiveness to stimulation are measured. In colonic inertia the colon cannot generate contractions. This group of patients may require total abdominal colectomy for treatment of their intractable constipation. Patients with excessive contractions can be treated with medications.
• Colonic barostat testing — Using a barostat, the tone and stretch of colon muscles and coordination of colon muscles are measured.
It is important to determine whether a patient has slow or normal transit constipation. Normal transit constipation may be a problem with visceral sensitivity rather than a disorder of luminal propulsion. In patients with slow transit constipation, colonic motility studies demonstrate what types of medications can stimulate the colon, as various stimulants are given during the study. Since colonic motility is measured in all parts of the colon, local disturbances in motility can be identified. In some patients, increased colon tone leads to an increased discomfort sensation, whereas in patients with decreased tone there may be a decrease of propulsive activity.
Ileorectal anastomosis surgery, often performed laparoscopically, can be the best option for patients with colonic inertia who do not have contractions of the colon after pharmacological stimulation. Patients with poor anal sphincter relaxation and evacuation disturbances can be treated using anal sphincter retraining.