Abstract
INTRODUCTION: Autonomic neuropathy is thought to play a role in the pathogenesis of slow-transit constipation, but other gastrointestinal organs may also be involved, even if they are symptom-free. We investigated whether motility in gastrointestinal organs other than the colon was impaired in patients with slow-transit constipation and whether the autonomic nervous system was involved. METHODS: Twenty-one consecutive patients (18 females; median age, 46 years) with severe chronic constipation (≤2 defecations/week and delayed colonic transit time) were studied. Autonomic neuropathy function was tested with esophageal manometry, gastric and gallbladder emptying (fasting and postprandial motility) by ultrasonography, orocecal transit time (H2-breath test), colonic transit time (radiopaque markers), and anorectal volumetric manometry. The integrity of the autonomic nervous system was assessed by a quantitative sweat-spot test for preganglionic and postganglionic fibers, tilt-table test, and Valsalva electrocardiogram R-R ratio. RESULTS: Esophageal manometry showed gastroesophageal reflux or absence of peristalsis in five of the seven patients examined. Gallbladder dysmotility (i.e., increased fasting, postprandial residual volume, or both) was observed in 6 of 14 (43 percent) patients. Gastric emptying was decreased in 13 of 17 (76 percent) patients. Orocecal transit time was delayed in 18 of 20 (90 percent) patients; median transit time was 160 (range, 90–200) minutes. Median colonic transit time was 97 (range, 64–140) hours. Anorectal function showed abnormal rectoanal inhibitory reflex and decreased rectal sensitivity in 11 of 19 (58 percent) patients. Signs of autonomic neuropathy of the sympathetic cholinergic system were found in 14 of 18 (78 percent) patients. Only one of nine patients had vagal abnormalities detected with the Valsalva test and four of five patients with a history of orthostatic hypotension had a positive tilt-table test. CONCLUSIONS: Slow-transit constipation may be associated with impaired function of other gastrointestinal organs. More than 70 percent of patients with slow-transit constipation present some degree of autonomic neuropathy. Severe constipation may be the main complaint in patients with a systemic disease involving several organs and possibly involving the autonomic nervous system. This should be considered in the management of such cases.
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References
Preston DM, Rees LH, Lennard Jones JE. Gynaecological disorders and hyperprolactinaemia in chronic constipation. Gut 1988;24:A480
Bassotti G, Stanghellini V, Chiarioni G,et al.. Upper gastrointestinal motor activity in patients with slowtransit constipation. Further evidence for an enteric neuropathy. Dig Dis Sci 1996;41:1999–2005.
Camilleri M, Fealey RD. Idiopathic autonomic denervation in 8 patients presenting with functional gastrointestinal disease. A causal association? Dig Dis Sci 1990;35:609–16.
Kerrigan DD, Lucas MG, Sun WM, Donelly TC, Read NW. Idiopathic constipation associated with impaired urethrovescical and sacral reflex function. Br J Surg 1989;76:748–51.
Watier A, Devroede G, Duranceau A,et al. Constipation with colonic inertia. A manifestation of systemic disease? Dig Dis Sci 1983;28:1025–33.
Dodds WJ, Groh WJ, Darweesh RM, Lawson TL, Kishk SM, Kern MK. Sonographic measurement of gallbladder volume. Am J Radiol 1985;145:1009–11.
Portincasa P, Di Ciaula A, Baldassarre G,et al. Gallbladder motor function in gallstone patients: sonographic andin vitro studies on the role of gallbladder, smooth muscle function and gallbladder wall inflammation. J Hepatol 1994;21:430–40.
Bolondi L, Bortolotti MS, Calleti T, Gaiani S, Labò G. Measurement of gastric emtpying by real-time ultrasonography. Gastroenterology 1985;89:752–9.
Portincasa P, Di Ciaula A, Palmieri V,et al. Effects of cholestyramine on gallbladder and gastric emptying in obese and lean subjects. Eur J Clin Invest 1995;25:746–53.
Hveem K, Jones KL, Chatterton BE, Horowitz M. Scintigraphic measurement of gastric emptying and ultrasonographic assessment of antral area: relation to appetite. Gut 1996;38:816–21.
Bond JH, Levitt MD. Investigation of small bowel transit time in man utilizing pulmonary hydrogen (H2) measurement. J Lab Clin Med 1975;85:546–55.
Chaussade S, Roche H, Khyari A, Couturier D, Guerre J. Mesure du temps de transit colique: description et validation d'une nouvelle technique. Gastroenterol Clin Biol 1986;10:385–9.
Metcalf A, Phillips SF, Zinsmeister AR, MacCarty AL, Beart RW, Wolff BG. A simplified assessment of segmental colonic transit. Gastroenterology 1987;92:40–7.
Womack NR, Williams NS, Holmfield JH, Morrison JF, Simpkins KC. New method for the dynamic assessment of anorectal function in constipation. Br J Surg 1985;72:994–8.
Ryder RE, Marshall R, Johnson KJ, Ryder AP, Owens DR, Hayes TM: Acetylcholine sweat-spot test for autonomic denervation. Lancet 1988;1:303–5.
Altomare DF. Diagnostic tests of the autonomic nervous system. In: Corazziari E, ed. Neurogastroenterology. Berlin: Walter De Gruyter & Co., 1996: 207–20.
Altomare DF, Pilot M-A, Scott M,et al. Detection of subclinical autonomic neuropathy in constipated patients using a sweat test. Gut 1992;33:1539–43.
Fouad FM, Sitthisook S, Vaneiro G,et al. Sensitivity and specificity of the tilt table test n young patients with unexplained syncope. PACE Pacing Clin Electrophysiol 1993;16:394–400.
Armitage P, Berry G. Statistical methods in medical research. 2nd ed. London: Blackwell Scientific Pubns, Ltd., 1987:296.
Jorge JM, Yang KY, Wexner SD. Incidence and clinical significance of sigmoidocele as determined by new classification. Dis Colon Rectum 1994;37:1112–7.
Bharucha AE, Camilleri M, Low PA, Zinsmeister AR. Autonomic dysfunction in gastrointestinal motility disorders. Gut 1993;34:397–401.
Waldron DJ, Williams NS, Kumar D, Hallan RI, Swash M. Is intractable constipation associated with a systemic autonomic neuropathy? [Abstract]. Br J Surg 1989;76:645.
Surrenti E, Rath DM, Pemberton JH, Camilleri M. Audit of constipation in a tertiary referral gastroenterology practice. Am J Gastroenterol 1995;90:1471–5.
Redmond JM, Smith GW, Barofsky I, Ratych RE, Goldsborough DC, Schuster MM. Physiological tests to predict long-term outcome of total abdominal colectomy for intractable constipation. Am J Gastroenterol 1995;90:748–53.
Heaton KW, Emmett PM, Symes CL, Braddon FE. An explanation for gallstones on normal weight woman: slow intestinal transit. Lancet 1993;341:8–10.
Stolk MFJ, van Erpecum KJ, Samson M,et al. Interdigestive gallbladder emptying, antroduodenal motility and motilin release in cholesterol gallstone patients. In Stolk MF, ed. Pathogenesis of cholesterol gallstones. Utrecht: Thesis Universiteit Utrecht, 1993:65–78.
Jazrawi RP, Pazzi P, Petroni ML,et al. Postprandial gallbladder motor function: refilling and turnover of bile in health and cholelithiasis. Gastroenterology 1995;109:582–91.
Veysey MJ, Gathercole DJ, Mallet A, Murphy GM, Dowling RH. Prolonged large bowel transit is associated with an increase in input rate and pool size of deoxycholic acid. J Hepatol 1997;26:A170.
Ostrow JD. Absorption by the gallbladder of bile salts, sulfobromophtalein and iodipamide. J Lab Clin Med 1969;74:482–94.
Vevsey MJ, Gathercole DJ, Mallet A, Murphy GM, Dowling RH. Prolonged large bowel transit is associated with an increase in the input rate and pool size of deoxycholic acid. J Hepatol 1997;26:A170.
Hemingway DM, Murray WR, Finlay IG. Idiopathic slow transit constipation. Is there also an abnormality of gallbladder and gastric function? Gut 1994;35:S57
Kumar D, Waldron D, Williams NS, Wingate DL. Slow transit constipation: a pan-enteric motor disorder? Gastroenterology 1989;96:A277.
Panagamuwa B, Kumar D, Ortiz J, Keighley MR. Motor abnormalities in the terminal ileum of patients with chronic idiopathic constipation. Br J Surg 1994;81:1685–8.
Reynolds JC, Ouyang A, Lee CA, Baker L, Sunshine AG, Cohen S. Chronic severe constipation. Prospective motility studies in 25 consecutive patients. Gastroenterology 1987;92:414–20.
Camilleri M. Functional gastrointestinal disease and the autonomic nervous system: a way ahead? Gastroenterology 1994;106:1114–8.
Kamm MA, Lennard-Jones JE. Rectal mucosal electrosensory testing—evidence for a rectal sensory neuropathy in idiopathic constipation. Dis Colon Rectum 1990;33:419–23.
Raethjen I, Pilot MA, Anand P, Warner G, Williams NS. Selective autonomic deficits in slow transit constipation. Gut 1994;35:S28
Iovino P, Azpiroz F, Domingo E, Malagelada JE. The sympathetic nervous system modulates perception and reflex responses to gut distention in humans. Gastroenterology 1995;108:680–6.
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Altomare, D.F., Portincasa, P., Rinaldi, M. et al. Slow-transit constipation. Dis Colon Rectum 42, 231–240 (1999). https://doi.org/10.1007/BF02237134
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DOI: https://doi.org/10.1007/BF02237134