WORKUP J'O'

1
CLASSIFICATION OF FUNCTIONAL CONSTIPATION(TRANSIT
PATTERNS)
Normal Transit Colonic Inertia Outlet Delay
2
AREA OF DELAYED TRANSIT IN CONSTIPATION
Colon Only Rectum Only Possible ?
Peristalsis Dyssynergia Mechanism ?
Segmentation Megarectum
3
COLON MARKER TRANSIT STUDIES CAN DEFINE COLONIC
INERTIA
4
COLONIC INERTIA
Diagnosis Slow colonic transit (incl. right
colon) Normal colon diameter Colon Motility ?
HAPCs ? Response to meals cholinergics
laxatives
5
COLONIC MOTILITY AFTER BREAKFAST
0 - 30 min
MOTILITY INDEX/30 min (postprandial fasting)
DT SF PD DD SIG
6
Lyford, et al, Gut 2002
7
FUNCTIONAL DISORDERS OF DEFECATION
Mechanisms Disorders Weak Propulsion
Megarectum Pain Syndromes
Neuromuscular Diseases Misdirection of
Propulsion Rectocele (occasional) Failure of
IAS Relaxation Hirschsprung Disease Failure of
Muscle Relaxation Pelvic Floor Dyssynergia
8
HIRSCHSPRUNG DISEASE

• Congenital absence of myenteric neurons of distal
  colon
• Reflex inhibition of IAS following rectal
  distension always present absent (corrected
  12/15/2004)
• Confirm with rectal biopsy
• No myenteric neurons
• ? Acetylcholinesterase
• Except ultrashort segment disease

9
HIRSCHSPRUNG DISEASE

• Constipation since birth
• Males gt Females
• Megarectum/Megacolon
• IAS always involved

10
A MUTANT RECESSIVE GENE RESULTS IN PIEBALD COAT
COLORATION AND CONGENTIAL MEGACOLON
(HIRSCHSPRUNGS DISEASE) IN THE MOUSE
Piebald Sibling with Hirschsprungs Disease
Normal Sibling
11
IN THE ABSENCE OF THE ENTERIC NERVOUS SYSTEM,
MYOGENIC MECHANISMS LEAD TO TONIC CONTRACTURE AND
PSEUDOOBSTRUCTION
Piebald Mouse Model
Mouse Model For
Hirschsprungs Disease
For Imperforate Anus

• The two examples of piebald mouse model are from
  siblings

12
RMS NORMAL VS HIRSCHSPRUNGS
? Rectal distension
13
FULL THICKNESS RECTAL BIOPSY
Acetylcholinesterase Stain
Normal
Hirschsprungs Disease
14
PHYSIOLOGY OF DEFECATION
15
Motility Dyssynergia
Rectum
Anal pressure
Anal EMG
16
A Case of Acute Colonic Pseudo-obstruction
(Ogilvie's Syndrome)
A 78 year old otherwise healthy female underwent
an uneventful left hip replacement for
osteoarthritis. Her postoperative recovery was
progressing satisfactorily until the fourth
postoperative day when she abruptly developed
abdominal distension associated with discomfort
and some respiratory difficulty. A nasogastric
tube was in place. Abdominal radiographs were
obtained.
17
 
ACUTE MEGACOLON (Ogilvies Syndrome)
18
LARGE-INTESTINE COLIC DUE TO SYMPATHETIC
DEPRIVATIONA NEW CLINICAL SYNDROMEBYSir
HENEAGE OGILVIE, K.B.E., M.Ch., F.R.CS.Surgeon
to Guys Hospital
What did Ogilvie describe? Case 1 66 y.o. male
with chronic megacolon subsequently found
to have metastatic pancreatic
carcinoma. Case 2 48 y.o. male with recurrent
colic and lower abdominal distention found
to have metastatic adenocarcinoma with
no evidence of intestinal obstruction
19
TREATMENT OF ACUTE MEGACOLON

• Nasogastric suction
• Colonic decompression
• Correct electrolyte deficiencies
• Neostigmine
• Surgery

20
NEOSTIGMINE FOR ACUTE MEGACOLON(PONEC, ET AL
1999)
P lt 0.001
P lt 0.05
(Number of Patients)
Clinical Response Treatment
Failures
21
Algorithm for Management of Acute Colonic
Pseudo-obstruction
CONSERVATIVE MANAGEMENT X 24
HOURS   Success No improvement
or Cecum gt12 cm
or Distention gt3
days     IV Neostigmine  

Success No improvement  

Colonoscopy  
Signs of ischemia or
Perforation No
improvement     Surgical
resection Tube cecostomy
22
TESTS FOR FECAL INCONTINENCE
OF CLINICAL VALUE Anorectal Manometry Anal
Sonography Digital Exam OF QUESTIONABLE
VALUE Dynamic Proctography EMG of EAS and
PRM Pudendal Nerve Latency
23
OVERFLOW INCONTINENCE
Pathophysiology Obstipation/Impaction
Megarectum Blunting of rectal
sensation Diagnosis Digital
Exam Abdominal X-ray Population
Children Institutionalized
elderly Dementia/Psychosis
24
TREATMENT OF OVERFLOW INCONTINENCE
Medical Disimpaction
Bowel cleansing Habit
training Surgical None
25
RESERVOIR INCONTINENCE
Pathophysiology ? Compliance
Rectal resection/tumor Diagnosis
History Sigmoidoscopy Popul
ations IBD Radiation
(pelvic) Rectal surgery
26

• Normal
• Megarectum
• Proctitis

27
TREATMENT OF RESERVOIR INCONTINENCE
Medical Reduce dietary fiber
Treat inflammation Loperamide,
diphenoxylate Surgical
Colostomy
28
INTERAL SPHINCTER INCONTINENCE
Pathophysiology Weakness of IAS a)
Trauma b) Degeneration c)
Autonomic Diagnosis
History (seepage only) Digital
estimation of tone Populations Middle
aged to older adults Scleroderma
Sphincterotomy (fissures)
29
Normal IAS
IAS Degeneration
30
ANORECTAL MANOMETRY
31
PATTERNS OF IDIOPATHIC FECAL INCONTINENCE
Neurogenic IAS Weakness
EAS Trauma Peripheral Central Resting P
? Nl Nl Nl Squeeze P
Nl ? ?
? PRM Nl Nl ?
? Sensation Nl Nl Nl
? Compliance Nl Nl Nl Nl