CONSTIPATION – CAUSES, DIAGNOSIS AND TREATMENT Edited by Anthony G. Catto-Smith Constipation – Causes, Diagnosis and Treatment Edited by Anthony G. Catto-Smith Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2012 InTech All chapters are Open Access distributed under the Creative Commons Attribution 3.0 license, which allows users to download, copy and build upon published articles even for commercial purposes, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. After this work has been published by InTech, authors have the right to republish it, in whole or part, in any publication of which they are the author, and to make other personal use of the work. Any republication, referencing or personal use of the work must explicitly identify the original source. 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Publishing Process Manager Martina Blecic Technical Editor Teodora Smiljanic Cover Designer InTech Design Team First published March, 2012 Printed in Croatia A free online edition of this book is available at www.intechopen.com Additional hard copies can be obtained from orders@intechweb.org Constipation – Causes, Diagnosis and Treatment, Edited by Anthony G. Catto-Smith p. cm. ISBN 978-953-51-0237-3 Contents Preface IX Chapter 1 Diagnostic Approach to Constipation in Children 1 Kathleen H. McGrath and Patrina Caldwell Chapter 2 The Role of Diagnostic Tests in Constipation in Children 19 Anthony G. Catto-Smith and Kathleen H. McGrath Chapter 3 The Role of Interstitial Cells of Cajal (ICC) in Gastrointestinal Motility Disorders – What the Gastroenterologist Has to Know 33 Christian Breuer Chapter 4 Skipping Breakfast is Associated with Constipation in Post-Adolescent Female College Students in Japan 47 Tomoko Fujiwara Chapter 5 Irritable Bowel Syndrome and Constipation 55 Brian C. Dobson Chapter 6 Opioid Induced Constipation 81 Caterina Aurilio, Maria Caterina Pace, Vincenzo Pota and Pasquale Sansone Chapter 7 Drugs in Development for Opioid-Induced Constipation 89 Kelly S. Sprawls, Egilius L.H. Spierings and Dustin Tran Chapter 8 Constipation Treatment in Neurological Disorders 99 Gallelli Luca, Pirritano Domenico, Palleria Caterina and De Sarro Giovambattista Chapter 9 Bowel Dysfunction in Persons with Multiple Sclerosis 117 Elsie E. Gulick and Marie Namey VI Contents Chapter 10 Multimodal Treatment of Constipation: Surgery, Rehabilitation or Both? 139 Luigi Brusciano, Crescenzo Di Stazio, Paolo Limongelli, Gian Mattia Del Genio, Salvatore Tolone, Saverio Sansone, Francesco Lucido, Ignazio Verde, Antonio D’Alessandro, Roberto Ruggiero, Simona Gili, Assia Topatino, Vincenzo Amoroso, Pina Casalino, Giovanni Docimo and Ludovico Docimo Chapter 11 Core Aspects of Clinical Development and Trials in Chronic Idiopathic Constipation 147 M. Scott Harris and Oranee T. Daniels Preface Constipation is common in both adults and children. Estimates would suggest a median prevalence of around 12-16% in the general population. 1 While regarded as a minor nuisance in some cases, its consequences can be severe, with a substantial impact on quality of life. 2 Secondary faecal soiling has a profound psychological effect at all ages. This book provides specific contributions which clarify the pathogenesis, diagnosis, and therapy of constipation for the general population and also for certain high risk groups. Surprisingly, consensus definitions of constipation have been hard to achieve, but that achieved by the PACCT group 3 for children included having at least 2 of the following features within the last 8 weeks:  Fewer than 3 bowel movements per week  More than one episode of fecal incontinence per week  Large stools in the rectum or palpable on abdominal examination  Passing of stools so large that they obstruct the toilet  Retentive posturing and withholding behavior  Painful defecation. Importantly, it may not be recognised, only coming to attention because of abdominal pain, soiling or behavioural disturbances. The chapter by Kathleen McGrath critically examines the impact defaecation disorders have in children and the diagnostic criteria used to identify them. Defaecation disorders are also much more prevalent in certain groups. The very young and the elderly 4, 5 are at particular risk. They also pose a particular difficulty for both children and adults with developmental disabilities 6 , neurological dysfunction and spinal cord injury. 7 Medical and surgical therapy may also lead to constipation through the use of potent analgesics such as opiods. The chapters by Caterina Aurilio and Kelly Sprawls provide insights into the aetiology of opiod-induced constipation and pharmaceutical approaches to avoiding it and its therapy. Occasionally, constipation may be the presenting feature of another condition such as thyroid disease or colorectal malignancy. 8 The relationship between colorectal tumors and colonoscopy is addressed in the chapter by Brusciano. The chapters by Luca Galleli X Preface and Elsie Gulick provide insights into the impact of the broad spectrum of neurological disorders and multiple sclerosis respectively on colorectal dysfunction. In most situations, constipation occurs in otherwise well individuals. The pathogenesis in these cases is usually proposed to be inadequate dietary fibre, a sedentary lifestyle, or poor toileting techniques. The chapter by Tomoko Fujiwara provides an insightful and unique window into the impact of the all too common habit of skipping breakfast on bowel function. Diagnosis is usually straightforward, but it often helpful to make reference to diagnostic criteria such as that achieved by the PACCT group. Further diagnostic testing is not usually required, but can be invaluable in specific instances. The chapter on diagnostic tests (Catto-Smith et al.) provides a review of the available testing techniques. While abdominal radiography is often employed, it is rarely adds much. Studies of colorectal motility 9, 10 provide an immense amount of information but are either expensive, invasive, or difficult to interpret 11 . However, they have enabled a better understanding of the motility dysfunction responsible for constipation. 12 Sensory dysfunction is clearly important as many patients are unaware of the extent of rectal filling. 13 These type of studies have however meant that entities such as slow transit constipation, anorectal incoordination, sphincteric dysfunction and the basis for constipation in irritable bowel syndrome are now much better understood 14 . The chapter by Brian Dobson provides a novel hypothesis into the pathogenesis of defaecation disorders in irritable bowel syndrome. In many situations, otherwise uncomplicated constipation will respond to simple interventions such as attention to diet 15 and toileting, but in other patients it can be extraordinarily difficult to achieve therapeutic success. Medications generally function through either assisting colorectal contractility or softening the stool. 16 Unfortunately, drugs only offer temporary relief if the primary cause is unable to be improved. Recent interest has centred on possibly dysbiotic colonic flora in the hope that probiotics 17 may be helpful. There are a variety of traditional and complementary medications that are used widely in the community. 18 Behavioural therapies are often very effective in children, 19, 20 and biofeedback modalities have attracted a great deal of interest, particularly in adults. 21 Better understanding of the pathophysiology of defaecation disorders has opened the doors to novel treatments. Abnormalities in the excitatory cells primarily responsible controlling gastrointestinal motility have been postulated to have a major role in certain types of constipation such as slow transit 22 and even that associated with diabetes. 23 The chapter by Christian Breuer provides a good understanding of the Interstitial Cell of Cajal – a central player in gastrointestinal dysmotility and slow transit constipation. Sacral stimulation is certainly effective, but is invasive. A very exciting new area is that of transabdominal electrical stimulation, 24 which appears to offer the unenviable combination of low cost, ease of use, durability of effect to an otherwise treatment-resistant population. 25, 26 [...]... extrapolated to help assist in the diagnosis of constipation (Table 2) Fig 1 Bristol stool chart (Lewis and Heaton, 1997) 6 Constipation – Causes, Diagnosis and Treatment Bristol stool chart (see Fig 1.) Constipation indicated by Types 1 and 2 (Types 4 > 3 being the ‘ideal stools’ and Types 5 to 7 tending towards diarrhoea) (Lewis & Heaton, 1997) Classic Iowa criteria Paediatric constipation = at least 2 of... Therapeutics, Vol 31, No 9, pp 938-949 16 Constipation – Causes, Diagnosis and Treatment Benninga, M., Candy, D.C., Catto-Smith, A .G., Clayden, G., Loening-Baucke, V., Di Lorenzo, C., Nurko, S., & Staiano, A (2005) The Paris Consensus on Childhood Constipation Terminology (PACCT) Group Journal of Pediatric Gastroenterology and Nutrition, Vol 40, pp 273-275 Boccia, G., Manguso, F., Coccorullo, P., Masi,... Whitlock-Morales, A., McKeand, C., DiFilippo, M & Elitsur, Y (2007) Diagnosis and treatment of constipation in children: a survey of primary care physicians in West Virginia West Virginia Medical Journal, Vol 103, No 4, pp 14-16 18 Constipation – Causes, Diagnosis and Treatment Youssef, N.N., Langseder, A.L., Verga, B.J., Mones, R.L., & Rosh, J.R (2005) Chronic childhood constipation is associated... chronic constipation, a missed diagnosis of constipation may result in treatment failure An accurate diagnosis of constipation is paramount for provision of optimal patient care and quality of life 3 The use of diagnostic criteria in childhood constipation 3.1 Definitions and Historical overview The term constipation derives from the Latin ‘constipare’ meaning to crowd together The accepted understanding... be mistaken by parents as ‘poor wiping technique by the child’ rather than as a manifestation 12 Constipation – Causes, Diagnosis and Treatment of underlying constipation In addition, obstipation (severe persistent constipation) with overflow may present with the passage of soft stools which can be mistaken as diarrhoea or even normal bowel actions Parental under-reporting or misunderstanding of symptoms... child: Physical discomfort associated with constipation Constipation is associated with varying degrees of physical discomfort for children The onset of constipation is often related to experience(s) of painful defaecation This may be caused by the presence of an anal fissure, perianal infection or perianal inflammation due to 2 Constipation – Causes, Diagnosis and Treatment cow’s milk protein intolerance... 2008) 4 Constipation – Causes, Diagnosis and Treatment experience teasing or bullying and social isolation Constant focus on the child’s bowel habits from the parents may distress the child and cause conflict within the home between family members Parents may wrongly ‘blame’ the child for being ‘lazy’ and punish them unnecessarily, causing further emotional distress The child’s degree of distress and low... purely on the basis of its age restrictions (i.e not 10 Constipation – Causes, Diagnosis and Treatment between 1 month and 6 years) This criterion excludes all children greater than 6 years old with constipation regardless of whether they fulfil the other symptom criteria This stringency is likely to fail to diagnose constipation in older children and supports previous opinion that the Rome II criteria... initiated In an appropriate environment and social situation, the external anal sphincter and puborectalis muscle relax and there is simultaneous contraction of the levator ani, abdominal and diaphragm muscles At this time, defaecation occurs and faecal matter is evacuated from the body 20 Constipation – Causes, Diagnosis and Treatment In instances where the environment or social situation is unsuitable for... previous treatment strategies used including response to treatment Questions should be asked directly about stool frequency, consistency (with utilisation of the Bristol Stool Chart as a visual aid), size (e.g whether they obstruct the toilet bowel), shape (are the stools scybalous or pebble-like), straining during bowel movements 14 Constipation – Causes, Diagnosis and Treatment (both painful and non-painful), . CONSTIPATION – CAUSES, DIAGNOSIS AND TREATMENT Edited by Anthony G. Catto-Smith Constipation – Causes, Diagnosis and Treatment Edited by Anthony G. Catto-Smith. orders@intechweb.org Constipation – Causes, Diagnosis and Treatment, Edited by Anthony G. Catto-Smith p. cm. ISBN 978-953-51-0237-3 Contents Preface IX Chapter 1 Diagnostic. Constipation – Causes, Diagnosis and Treatment 6 Bristol stool chart (see Fig. 1.) Constipation indicated by Types 1 and 2 (Types 4 > 3 being the ‘ideal stools’ and Types 5 to 7 tending towards