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==Overview==
[[Endoscopic]] evaluation of patients with constipation include [[flexible sigmoidoscopy]] and [[colonoscopy]]. [[Flexible sigmoidoscopy]] is the direct visualization of the [[rectum]] and [[sigmoid colon]]. However, [[colonoscopy]] is study of the whole [[colon]] [[lumen]]. Every patient with alarm signs have to be evaluated using [[colonoscopy]]. In younger patients, [[flexible sigmoidoscopy]] would be sufficient for further investigation of alarm signs. Colonic [[manometry]] is 24-hour measurement of pressure within the [[large bowel]], using specific [[Probe|probes]] and portable recorders. [[Anorectal]] [[manometry]] is studying the pressure activity of anorectum during rest and [[defecation]], along with [[rectal]] [[sensation]], rectoanal reflexes, and [[anal sphincter]] function. Balloon expulsion test is a simple bedside test to evaluate the ability of patient to evacuate the artificial [[stool]]. Rectal biostat test consists of a very compliant plastic balloon, which is inserted into the [[rectum]], concurrently connected to computer device to measure the [[pressure]].
 
==Other Diagnostic Studies==
==Other Diagnostic Studies==


===Sigmoidscopy===
=== Endoscopy ===
{| align="right"
|{{#ev:youtube|xWxdfhmXcNI|500}}
|}
* [[Endoscopic]] evaluation of patients with constipation include [[flexible sigmoidoscopy]] and [[colonoscopy]]. [[Flexible sigmoidoscopy]] is the direct visualization of the [[rectum]] and [[sigmoid colon]]. However, [[colonoscopy]] is study of the whole [[colon]] [[lumen]].
* Based on American Society of Gastrointestinal [[Endoscopy]] guideline, alarm signs in constipated patients are as following:<ref name="pmid16046978">{{cite journal |vauthors=Qureshi W, Adler DG, Davila RE, Egan J, Hirota WK, Jacobson BC, Leighton JA, Rajan E, Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO |title=ASGE guideline: guideline on the use of endoscopy in the management of constipation |journal=Gastrointest. Endosc. |volume=62 |issue=2 |pages=199–201 |year=2005 |pmid=16046978 |doi=10.1016/j.gie.2005.04.016 |url=}}</ref>
** [[Rectal bleeding]]
** [[Heme]] positive [[stool]]
** [[Iron deficiency anemia]]
** [[Weight loss]]
** Obstructive symptoms
** Recent onset of symptoms
** [[Rectal prolapse]]
** Change in [[stool]] caliber
** Every subjects older than 50 years without previous screening for [[colon cancer]]
* Every patient with alarm signs have to be evaluated using [[colonoscopy]]. In younger patients, [[flexible sigmoidoscopy]] would be sufficient for further investigation of alarm signs.
* [[Colonoscopy]] has lower yield and correlation with [[symptoms]] in patients with constipation alone. Therefore, it is better not to use in patients with [[constipation]] and without any alarm sign.


An examination of the rectum and lower, or sigmoid, colon is called a [[sigmoidoscopy]]. The person usually has a liquid dinner the night before a colonoscopy or sigmoidoscopy and takes an enema early the next morning. An enema an hour before the test may also be necessary.
=== Colonic function tests ===


To perform a sigmoidoscopy, the doctor uses a long, flexible tube with a light on the end, called a [[sigmoidoscope]], to view the rectum and lower [[colon]]. The patient is lightly sedated before the exam. First, the doctor examines the rectum with a gloved, lubricated finger. Then, the sigmoidoscope is inserted through the anus into the rectum and lower colon. The procedure may cause abdominal pressure and a mild sensation of wanting to move the bowels. The doctor may fill the colon with air to get a better view. The air can cause mild cramping.
==== Colonic manometry ====
* Colonic [[manometry]] is 24-hour measurement of pressure within the [[large bowel]], using specific [[Probe|probes]] and portable recorders.
* The colon pressure is studied during different conditions, such as:<ref name="pmid11254489">{{cite journal |vauthors=Rao SS, Sadeghi P, Beaty J, Kavlock R, Ackerson K |title=Ambulatory 24-h colonic manometry in healthy humans |journal=Am. J. Physiol. Gastrointest. Liver Physiol. |volume=280 |issue=4 |pages=G629–39 |year=2001 |pmid=11254489 |doi=10.1152/ajpgi.2001.280.4.G629 |url=}}</ref>
{| align="right"
|{{#ev:youtube|3Wgxhz9DwL8|500}}
|}
** Rest
** During [[sleep]]
** After waking
** After meals
** After provocative stimulation, such as:
*** [[Drugs]]
*** Meal
*** Balloon distensions
* Colonic [[manometry]] findings suggestive of constipation are:<ref name="pmid15571589">{{cite journal |vauthors=Rao SS, Sadeghi P, Beaty J, Kavlock R |title=Ambulatory 24-hour colonic manometry in slow-transit constipation |journal=Am. J. Gastroenterol. |volume=99 |issue=12 |pages=2405–16 |year=2004 |pmid=15571589 |doi=10.1111/j.1572-0241.2004.40453.x |url=}}</ref>
** Fewer pressure waves and lower area under the curve
** Decreased colonic motility induced by waking or meal
** Lower incidence and propagation velocity of high-amplitude propagating contractions (HAPCs)


===Colonoscopy===
=== Anorectal function tests ===
An examination of the rectum and entire colon is called a [[colonoscopy]].
==== Anorectal manometry ====
To perform a colonoscopy, the doctor uses a flexible tube with a light on the end, called a [[colonoscope]], to view the entire colon. This tube is longer than a sigmoidoscope. During the exam, the patient lies on his or her side, and the doctor inserts the tube through the anus and rectum into the colon. If an abnormality is seen, the doctor can use the colonoscope to remove a small piece of tissue for examination (biopsy). The patient may feel gassy and bloated after the procedure.
* [[Anorectal]] [[manometry]] is studying the pressure activity of anorectum during rest and [[defecation]], along with the followings:<ref name="pmid15335368">{{cite journal |vauthors=Karlbom U, Lundin E, Graf W, Påhlman L |title=Anorectal physiology in relation to clinical subgroups of patients with severe constipation |journal=Colorectal Dis |volume=6 |issue=5 |pages=343–9 |year=2004 |pmid=15335368 |doi=10.1111/j.1463-1318.2004.00632.x |url=}}</ref>
* Greater than 50 years old
** [[Rectal]] [[sensation]]
* Present with constipation with no apparent cause
{| align="right"
* Presence of [[blood]] in the [[stool]]
|[[image:PMC2879847 jnm-16-213-g001.png|thumb|700px|Anorectal manometry during simulated defecation in left lateral decubitus position with inappropriate increase of rectal pressure (green color) and no decrease in anal sphincter pressure (yellow to red color) which is consistent with pelvic floor dyssynergia(A); and sitting position with rectal pressure increased (yellow to red color) in coordination with relaxation of the anal sphincter pressure (green color), which is a normal pattern of anorectal manometry(B), via https://openi.nlm.nih.gov]]
|}
:* Rectoanal reflexes
:* [[Anal sphincter]] function
* Anorectal [[manometry]] is used for the diagnosis of defecatory disorder (dyssynergism) and [[Hirschsprung disease]].
* Lack of concordance between [[defecation]] propulsive pressure and reflex relaxation of the [[puborectalis]] and [[Sphincter ani externus muscle|external anal sphincter muscles]] is the primary concern in dyssynergism. Based on [[anorectal]] [[manometry]], there are four types of dyssynergic defecation.<ref name="pmid15500515">{{cite journal |vauthors=Rao SS, Mudipalli RS, Stessman M, Zimmerman B |title=Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus) |journal=Neurogastroenterol. Motil. |volume=16 |issue=5 |pages=589–96 |year=2004 |pmid=15500515 |doi=10.1111/j.1365-2982.2004.00526.x |url=}}</ref>
{|
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Type
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Intrarectal pressure
! style="background:#4479BA; color: #FFFFFF;" align="center" + |Intraanal pressure
|-
| style="background:#DCDCDC;" align="center" + |1
| style="background:#F5F5F5;" align="center" + |↑
| style="background:#F5F5F5;" align="center" + |↑
|-
| style="background:#DCDCDC;" align="center" + |2
| style="background:#F5F5F5;" align="center" + | -
| style="background:#F5F5F5;" align="center" + |↑
|-
| style="background:#DCDCDC;" align="center" + |3
| style="background:#F5F5F5;" align="center" + |↑
| style="background:#F5F5F5;" align="center" + | -
|-
| style="background:#DCDCDC;" align="center" + |4
| style="background:#F5F5F5;" align="center" + | -
| style="background:#F5F5F5;" align="center" + | -
|-
| style="background:#DCDCDC;" align="center" + |Normal [[defecation]]
| style="background:#F5F5F5;" align="center" + |↑
| style="background:#F5F5F5;" align="center" + |↓
|}


===Stool Examination===
==== Balloon expulsion test ====
* To rule out [[ova]] and [[parasites]], a stool examination should be considered
* Balloon expulsion test is a simple bedside test to evaluate the ability of patient to evacuate the artificial [[stool]].
* The balloon filled with 50 cc of warm water or silicone-filled [[stool]]-like device is inserted into the [[rectum]] and the subject is asked to evacuate the balloon in sitting position. Expulsion within 1 minute is assumed as normal.<ref name="pmid10086665">{{cite journal |vauthors=Rao SS, Hatfield R, Soffer E, Rao S, Beaty J, Conklin JL |title=Manometric tests of anorectal function in healthy adults |journal=Am. J. Gastroenterol. |volume=94 |issue=3 |pages=773–83 |year=1999 |pmid=10086665 |doi=10.1111/j.1572-0241.1999.00950.x |url=}}</ref>
* The expulsion test has a [[specificity]] and [[sensitivity]] of 89% and 88%, respectively. While, [[Negative predictive value|negative]] and [[Positive predictive value|positive predictive values]] are 97% and 67%, respectively.<ref name="pmid155005152">{{cite journal |vauthors=Rao SS, Mudipalli RS, Stessman M, Zimmerman B |title=Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus) |journal=Neurogastroenterol. Motil. |volume=16 |issue=5 |pages=589–96 |year=2004 |pmid=15500515 |doi=10.1111/j.1365-2982.2004.00526.x |url=}}</ref>
{| align="right"
|[[image:Barostat Balloon rectal.jpg|thumb|400px|Rectal barostat balloon-By No machine-readable author provided, via Wimimedia commons<ref name="//commons.wikimedia.org/wiki/User:Dbach"><"https://creativecommons.org/licenses/by-sa/2.5" title="Creative Commons Attribution-Share Alike 2.5">CC BY-SA 2.5, <"https://commons.wikimedia.org/w/index.php?curid=489883"></ref>]]
|}
==== Rectal barotest test ====
* Rectal biostat test consists of a very compliant plastic balloon, which is inserted into the [[rectum]], concurrently connected to computer device to measure the [[pressure]].
* First, the balloon is inflated in the [[rectum]] and then the effect of various [[defecation]] maneuvers on the pressure will be recorded.
* Decreased intrarectal pressure during the [[defecation]] is suggestive of constipation secondary to dyssynergism.<ref name="pmid16696790">{{cite journal |vauthors=Gladman MA, Lunniss PJ, Scott SM, Swash M |title=Rectal hyposensitivity |journal=Am. J. Gastroenterol. |volume=101 |issue=5 |pages=1140–51 |year=2006 |pmid=16696790 |doi=10.1111/j.1572-0241.2006.00604.x |url=}}</ref>
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==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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{{WS}}


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Latest revision as of 21:07, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Endoscopic evaluation of patients with constipation include flexible sigmoidoscopy and colonoscopy. Flexible sigmoidoscopy is the direct visualization of the rectum and sigmoid colon. However, colonoscopy is study of the whole colon lumen. Every patient with alarm signs have to be evaluated using colonoscopy. In younger patients, flexible sigmoidoscopy would be sufficient for further investigation of alarm signs. Colonic manometry is 24-hour measurement of pressure within the large bowel, using specific probes and portable recorders. Anorectal manometry is studying the pressure activity of anorectum during rest and defecation, along with rectal sensation, rectoanal reflexes, and anal sphincter function. Balloon expulsion test is a simple bedside test to evaluate the ability of patient to evacuate the artificial stool. Rectal biostat test consists of a very compliant plastic balloon, which is inserted into the rectum, concurrently connected to computer device to measure the pressure.

Other Diagnostic Studies

Endoscopy

xWxdfhmXcNI|500}}

Colonic function tests

Colonic manometry

  • Colonic manometry is 24-hour measurement of pressure within the large bowel, using specific probes and portable recorders.
  • The colon pressure is studied during different conditions, such as:[2]
3Wgxhz9DwL8|500}}
    • Rest
    • During sleep
    • After waking
    • After meals
    • After provocative stimulation, such as:
      • Drugs
      • Meal
      • Balloon distensions
  • Colonic manometry findings suggestive of constipation are:[3]
    • Fewer pressure waves and lower area under the curve
    • Decreased colonic motility induced by waking or meal
    • Lower incidence and propagation velocity of high-amplitude propagating contractions (HAPCs)

Anorectal function tests

Anorectal manometry

Anorectal manometry during simulated defecation in left lateral decubitus position with inappropriate increase of rectal pressure (green color) and no decrease in anal sphincter pressure (yellow to red color) which is consistent with pelvic floor dyssynergia(A); and sitting position with rectal pressure increased (yellow to red color) in coordination with relaxation of the anal sphincter pressure (green color), which is a normal pattern of anorectal manometry(B), via https://openi.nlm.nih.gov
Type Intrarectal pressure Intraanal pressure
1 ↑ ↑
2 - ↑
3 ↑ -
4 - -
Normal defecation ↑ ↓

Balloon expulsion test

  • Balloon expulsion test is a simple bedside test to evaluate the ability of patient to evacuate the artificial stool.
  • The balloon filled with 50 cc of warm water or silicone-filled stool-like device is inserted into the rectum and the subject is asked to evacuate the balloon in sitting position. Expulsion within 1 minute is assumed as normal.[6]
  • The expulsion test has a specificity and sensitivity of 89% and 88%, respectively. While, negative and positive predictive values are 97% and 67%, respectively.[7]
Rectal barostat balloon-By No machine-readable author provided, via Wimimedia commons[8]

Rectal barotest test

  • Rectal biostat test consists of a very compliant plastic balloon, which is inserted into the rectum, concurrently connected to computer device to measure the pressure.
  • First, the balloon is inflated in the rectum and then the effect of various defecation maneuvers on the pressure will be recorded.
  • Decreased intrarectal pressure during the defecation is suggestive of constipation secondary to dyssynergism.[9]






References

  1. ↑ Qureshi W, Adler DG, Davila RE, Egan J, Hirota WK, Jacobson BC, Leighton JA, Rajan E, Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO (2005). "ASGE guideline: guideline on the use of endoscopy in the management of constipation". Gastrointest. Endosc. 62 (2): 199–201. doi:10.1016/j.gie.2005.04.016. PMID 16046978.
  2. ↑ Rao SS, Sadeghi P, Beaty J, Kavlock R, Ackerson K (2001). "Ambulatory 24-h colonic manometry in healthy humans". Am. J. Physiol. Gastrointest. Liver Physiol. 280 (4): G629–39. doi:10.1152/ajpgi.2001.280.4.G629. PMID 11254489.
  3. ↑ Rao SS, Sadeghi P, Beaty J, Kavlock R (2004). "Ambulatory 24-hour colonic manometry in slow-transit constipation". Am. J. Gastroenterol. 99 (12): 2405–16. doi:10.1111/j.1572-0241.2004.40453.x. PMID 15571589.
  4. ↑ Karlbom U, Lundin E, Graf W, Påhlman L (2004). "Anorectal physiology in relation to clinical subgroups of patients with severe constipation". Colorectal Dis. 6 (5): 343–9. doi:10.1111/j.1463-1318.2004.00632.x. PMID 15335368.
  5. ↑ Rao SS, Mudipalli RS, Stessman M, Zimmerman B (2004). "Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus)". Neurogastroenterol. Motil. 16 (5): 589–96. doi:10.1111/j.1365-2982.2004.00526.x. PMID 15500515.
  6. ↑ Rao SS, Hatfield R, Soffer E, Rao S, Beaty J, Conklin JL (1999). "Manometric tests of anorectal function in healthy adults". Am. J. Gastroenterol. 94 (3): 773–83. doi:10.1111/j.1572-0241.1999.00950.x. PMID 10086665.
  7. ↑ Rao SS, Mudipalli RS, Stessman M, Zimmerman B (2004). "Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (Anismus)". Neurogastroenterol. Motil. 16 (5): 589–96. doi:10.1111/j.1365-2982.2004.00526.x. PMID 15500515.
  8. ↑ <"https://creativecommons.org/licenses/by-sa/2.5" title="Creative Commons Attribution-Share Alike 2.5">CC BY-SA 2.5, <"https://commons.wikimedia.org/w/index.php?curid=489883">
  9. ↑ Gladman MA, Lunniss PJ, Scott SM, Swash M (2006). "Rectal hyposensitivity". Am. J. Gastroenterol. 101 (5): 1140–51. doi:10.1111/j.1572-0241.2006.00604.x. PMID 16696790.

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