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Introduction and hypothesis Many women with chronic constipation are referred for anorectal function tests (AFT) when they fail initial conservative treatment with lifestyle advice and laxatives. Our goal was to prospectively investigate the diagnostic potential of AFT in women with constipation in order to identify treatable conditions. Methods Between May 2003 and June 2011, all women with constipation referred to our tertiary referral center completed a questionnaire regarding their perianal complaints and underwent physical examination and were evaluated according to our AFT protocol, including anorectal manometry (ARM) and anal endosonography. Results One hundred and thirteen women were referred and classified as having idiopathic constipation ( n  = 100), neurological disorder ( n  = 8), or others ( n  = 5). Of the 100 women with idiopathic constipation, clinical examination identified 25 (25 %) with hypertonia of the pelvic floor (dyssynergic pelvic floor) and 15 (15 %) with a rectocele. In 37/100 women also complaining of impaired evacuation, the yield of rectocele was 15 (41 %) and of hypertonia 5 (14 %). Women with hypertonia were younger (40 vs. 51 years; P  = 0.002) and had no rectoceles identified ( P  = 0.02), and fewer women could relax during straining on ARM (56 % vs. 92 %; P  < 0.001) compared with women without pelvic hypertonia. Other ARM measurements showed no differences between women with evacuation disorders, rectoceles, or hypertonia. Anal endosonography showed no internal sphincter hypertrophia. Conclusion Potentially treatable conditions, such as rectocele and pelvic floor hypertonia, are found on clinical examination in 40 % of women with idiopathic constipation. Impaired evacuation is associated with the presence of a rectocele. AFT contributes little and should be reserved for selected cases.

Chronic constipation is classified into 2 main syndromes, irritable bowel syndrome with constipation (IBS-C) and functional constipation (FC), on the assumption that they differ along multiple clinical characteristics and are plausibly of distinct pathophysiology. Our aim was to test this assumption by applying machine learning to a large prospective cohort of comprehensively phenotyped patients with constipation. Demographics, validated symptom and quality of life questionnaires, clinical examination findings, stool transit, and diagnosis were collected in 768 patients with chronic constipation from a tertiary center. We used machine learning to compare the accuracy of diagnostic models for IBS-C and FC based on single differentiating features such as abdominal pain (a \"unisymptomatic\" model) vs multiple features encompassing a range of symptoms, examination findings and investigations (a \"syndromic\" model) to assess the grounds for the syndromic segregation of IBS-C and FC in a statistically formalized way. Unisymptomatic models of abdominal pain distinguished between IBS-C and FC cohorts near perfectly (area under the curve 0.97). Syndromic models did not significantly increase diagnostic accuracy (P > 0.15). Furthermore, syndromic models from which abdominal pain was omitted performed at chance-level (area under the curve 0.56). Statistical clustering of clinical characteristics showed no structure relatable to diagnosis, but a syndromic segregation of 18 features differentiating patients by impact of constipation on daily life. IBS-C and FC differ only about the presence of abdominal pain, arguably a self-fulfilling difference given that abdominal pain inherently distinguishes the 2 in current diagnostic criteria. This suggests that they are not distinct syndromes but a single syndrome varying along one clinical dimension. An alternative syndromic segregation is identified, which needs evaluation in community-based cohorts. These results have implications for patient recruitment into clinical trials, future disease classifications, and management guidelines.

PurposeAbdominal pain is not used to characterize constipated patients. This study aimed to compare clinical, psychological, and physiological features in patients with IBS-constipation (IBS-C) with those in patients with functional constipation (FC) according to the intensity of abdominal pain.MethodsAll patients filled a standard Rome III questionnaire. In addition, they indicated the intensity of constipation, diarrhea, bloating, and abdominal pain on a 10-point Likert scale, and their stool form with the Bristol Stool Form Scale. Anxiety and depression were assessed with the Beck Depression Inventory and the State-Trait Anxiety Inventory. Physiological evaluation included anorectal manometry and total and segmental colonic transit time.Main ResultsA total of 546 consecutive patients, 245 with IBS-C and 301 with FC, were included. Painful constipation (PFC) was found by cluster analysis and subsequently defined as having a value over four on the Likert scale for abdominal pain. PFC was found in 67% of IBS-C patients and in 22% of FC patients. PFC patients have digestive disorders with greater frequency and report higher levels of constipation and bloating, despite similar stool form. They have higher scores of depression, state and trait anxiety, and shorter terminal transit time than mild-pain constipated patients. Compared to IBS-C patients, PFC patients report higher levels of abdominal pain (P < 0.001). Psychological and physiological parameters were similar in PFC and IBS-C patients.ConclusionPainful constipation and mild-pain constipation could be an alternative way to identify constipated patients than using the diagnosis of IBS-C and FC for clinical evaluation and drug studies.

The Rome III classification system treats functional constipation (FC) and irritable bowel syndrome with constipation (IBS-C) as distinct disorders, but this distinction appears artificial, and the same drugs are used to treat both. This study's hypothesis is that FC and IBS-C defined by Rome III are not distinct entities. In all, 1,100 adults with a primary care visit for constipation and 1,700 age- and gender-matched controls from a health maintenance organization completed surveys 12 months apart; 66.2% returned the first questionnaire. Rome III criteria identified 231 with FC and 201 with IBS-C. The second survey was completed by 195 of the FC and 141 of the IBS-C cohorts. Both surveys assessed the severity of constipation and IBS, quality of life (QOL), and psychological distress. (i) Overlap: if the Rome III requirement that patients meeting criteria for IBS cannot be diagnosed with FC is suspended, 89.5% of IBS-C cases meet criteria for FC and 43.8% of FC patients fulfill criteria for IBS-C. (ii) No qualitative differences between FC and IBS-C: 44.8% of FC patients report abdominal pain, and paradoxically IBS-C patients have more constipation symptoms than FC. (iii) Switching between diagnoses: by 12 months, 1/3 of FC transition to IBS-C and 1/3 of IBS-C change to FC. Patients identified by Rome III criteria for FC and IBS-C are not distinct groups. Revisions to the Rome III criteria, possibly including incorporation of physiological tests of transit and pelvic floor function, are needed.

Non-invasive biomarkers which identify different mechanisms of disease in subgroups of irritable bowel syndrome (IBS) could be valuable. Our aim was to seek useful magnetic resonance imaging (MRI) parameters that could distinguish each IBS subtypes. 34 healthy volunteers (HV), 30 IBS with diarrhea (IBS-D), 16 IBS with constipation (IBS-C), and 11 IBS with mixed bowel habit (IBS-M) underwent whole-gut transit and small and large bowel volumes assessment with MRI scans from t=0 to t=360 min. Since the bowel frequency for IBS-M were similar to IBS-D, IBS-M and IBS-D were grouped together and labeled as IBS non-constipation group (IBS-nonC). Median (interquartile range): fasting small bowel water content in IBS-nonC was 21 (10-42), significantly less than HV at 44 ml (15-70), P<0.01 as was the postprandial area under the curve (AUC) P<0.01. The fasting transverse colon volumes in IBS-C were significantly larger at 253 (200-329) compared with HV, IBS-nonC whose values were 165 (117-255) and 198 (106-270) ml, respectively, P=0.02. Whole-gut transit time for IBS-C was prolonged at 69 (51-111), compared with HV at 34 (4-63) and IBS-D at 34 (17-78) h, P=0.03. Bloating score (VAS 0-10 cm) correlated with transverse colon volume at t=405 min, Spearman r=0.21, P=0.04. The constricted small bowel in IBS-nonC and the dilated transverse colon in IBS-C point to significant differences in underlying mechanisms of disease.

Constipation is traditionally defined as three or fewer bowel movements per week. Risk factors for constipation include female sex, older age, inactivity, low caloric intake, low-fiber diet, low income, low educational level, and taking a large number of medications. Chronic constipation is classified as functional (primary) or secondary. Functional constipation can be divided into normal transit, slow transit, or outlet constipation. Possible causes of secondary chronic constipation include medication use, as well as medical conditions, such as hypothyroidism or irritable bowel syndrome. Frail older patients may present with nonspecific symptoms of constipation, such as delirium, anorexia, and functional decline. The evaluation of constipation includes a history and physical examination to rule out alarm signs and symptoms. These include evidence of bleeding, unintended weight loss, iron deficiency anemia, acute onset constipation in older patients, and rectal prolapse. Patients with one or more alarm signs or symptoms require prompt evaluation. Referral to a subspecialist for additional evaluation and diagnostic testing may be warranted.

IntroductionConstipation may be primary or secondary. Pathophysiologic subtypes of primary constipation are dyssynergic defecation (DD), slow (STC), and normal transit constipation (NTC). Clinical subtypes are functional constipation (FC) and constipation predominant IBS (C-IBS).AimsThe objectives of this paper are to study the clinical profile, categorize and compare various subtypes of primary constipation, and to assess the success of biofeedback therapy (BFT) in a non-randomized, uncontrolled open-label study among patients with DD.Material and MethodsConsecutive constipation patients (April 2011 to December 2012) were evaluated. Patients <18 years and secondary constipation were excluded. FC and C-IBS were classified by Rome III module. All patients, after excluding secondary constipation, underwent anorectal manometry (ARM) with balloon expulsion test and colon transit study (CTS). Patients with DD were given BFT.ResultsOut of 128 patients, 23 %, 58 %, and 19 % had secondary constipation, FC, and C-IBS, respectively. Ninety-nine patients had primary constipation. Among those with primary constipation mean age was 53.5 (21–86) years, (77 % males). Forty-six, 15, and 40 had NTC, STC, and DD, respectively. Out of those with DD, 34 had paradoxical anal contraction and 6 had impaired rectal propulsion. FC and C-IBS were clinically and pathophysiologically similar except for abdominal pain. Patients with DD were more likely to have history of finger evacuation, straining, incomplete evacuation, sensation of anorectal obstruction than no DD. Sixty-nine percent of the patients with STC had ≤3 stools/week compared to 37 % with NTC (p-value 0.018). Thirty out of 40 (75 %) patients with DD underwent BFT but 20 completed ≥4 sessions. Seventy percent with ≥4 sessions had improved complete spontaneous bowel movements (CSBM).ConclusionNTC was the most common subtype of primary constipation. Symptoms of finger evacuation, sensation of anorectal obstruction, incomplete evacuation, and straining were more prevalent in DD. ARM and CTS could easily identify patients with DD and STC.

Purpose Pelvic ultrasound (US) has been used in various different ways to assess severity of constipation. We evaluated the use of a new US scoring system to determine if there is any correlation between symptom severity and US findings. Methods Data were collected prospectively on all children attending the constipation clinic from January 2007 to July 2008. All patients completed a standardised symptom severity score sheet (SSS) for constipation. US was done with the probe placed 2 cm above the pubic symphysis. A new US scoring system designed to assess the faecal loading and its effect on the bladder was used. Patients with severe symptoms were followed up with few patients requiring as many as four follow up visits. During each follow-up visit SSS and US scoring was completed. Results A total of 500 patients were studied (male 317, female 183) with a median age of 8 years (8 months, 18 years). Statistical analysis was done using SPSS software (version 15.0). Pearson’s correlation was used to assess the correlation between SSS and US score. P value <0.05 was considered to represent a statistically significant correlation between symptoms and ultrasound findings. Conclusion US is an easy and quick tool that can be used in the out-patient setting to assess severity of constipation. The new US scoring system is a reliable method that can be used in conjunction with clinical examination for assessing the long-term improvement of children who are undergoing treatment for chronic constipation.