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Surgical Evaluation and Management of Constipation Susanna S

Surgical Evaluation and Management of Constipation Susanna S

RESIDENT’S CORNER Surgical Evaluation and Management of Susanna S. Hill, M.D. • Jennifer S. Davids, M.D.

Division of Colon and Rectal , University of Massachusetts Memorial Medical Center, Worcester, Massachusetts

CASE SUMMARY: A 32-year-old otherwise healthy . Here, we focus on the appropriate sur- nulliparous woman presented with chronic severe gical evaluation. constipation, refractory to medical management. She reported straining and incomplete evacuation during bowel movements. Sitz marker abdominal x-rays are shown PRESENTATION AND DIAGNOSIS (Fig. 1). She was diagnosed with pelvic outlet obstruction Proper identification of the etiology of constipation is es- constipation, and her symptoms improved with fiber sential for successful management. Diagnosis and manage- supplementation and physical therapy (PT). ment of constipation require time and commitment from both surgeon and patient. Presenting symptoms may vary widely among patients. Stooling may occur daily to once CLINICAL QUESTIONS every several weeks. Although typically hard, some report •• How should patients with chronic constipation be soft, pasty, or pellet-like consistency. Other common symp- evaluated in the surgical office setting? What are the toms include narrow or altered stool caliber, straining, lack main causes of chronic constipation? of urge to defecate, inability to pass stool despite attempts •• Which patients with constipation are appropriate candi- at , vaginal splinting, or feeling that stool is stuck. dates for surgery, and which operations should be offered? A detailed and thorough history is the first step and must include symptom onset and duration, association with other medical conditions or , dietary BACKGROUND changes, stressors, obstetric history, comorbid psychiatric Constipation is a substantial source of morbidity, partic- conditions, and physical or sexual abuse. ularly in Westernized nations. Although difficult to deter- In-office examination must include abdominal exam- mine, prevalence is estimated at 9% to 20% in the United ination, anorectal examination, and : States, with higher rates in patients who are women, older individuals, and lower socioeconomic status.1 Constipa- (1) should assess for distension, ten- tion is formally defined by the Rome IV criteria (Fig. 2)2; derness, surgical scars, , or any palpable masses. however, as a symptom, constipation is subjective and var- (2) Anorectal examination starts with visual inspection of the ies significantly between patients. anoderm and for scars, perineal body bulk, fis- Generally, patients present to a colon and rectal sur- sures, , and skin tags or other lesions. Digital geon after an initial evaluation by primary care and/or should assess resting and squeeze tone, pelvic floor mechanics with Valsalva, and for masses, stric- Earn Continuing Education (CME) credit online at cme.lww.com. This tures, rectoceles, or enteroceles. Any stool presence and activity has been approved by AMA PRA Category 1 credits.TM consistency should be noted. If rectal or uterovaginal pro- lapse is suspected, the patient should be examined in a Funding/Support: None reported. squatting position or straining over an in-office commode. (3) Anoscopy may reveal stigmata of longstanding consti- Financial Disclosure: None reported. pation and straining, such as enlarged hemorrhoids or Correspondence: Jennifer S. Davids, M.D., 67 Belmont St, Suite 201, mucosal redundancy. Worcester, MA 01605. E-mail: [email protected]. Chronic constipation may be idiopathic, but underlying Twitter: @jennifersdavids causes must be ruled out. The is Dis Colon 2019; 62: 661–666 broad (Fig. 3). DOI: 10.1097/DCR.0000000000001395 Diagnostic testing can consist of , imag- © The ASCRS 2019 ing adjuncts, and physiology testing:

DISEASES OF THE COLON & RECTUM VOLUME 62: 6 (2019) 661 662 HILL AND DAVIDS: SURGICAL EVALUATION AND CONSTIPATION

FIGURE 1. Sitz markers in colonic transit study, days 1, 3, and 5, showing outlet obstruction. Photo credit to W. Brian Sweeney, MD.

(1) Colonoscopy is necessary to rule out mechanical ob- (3) Physiology testing may be informative. Inability to pass struction from mass, , or stricture. Ulceration is a 50-mm3 balloon is highly specific and 50% sensitive sometimes observed as stigmata of chronic constipa- for pelvic outlet dysfunction. tion, which should prompt additional investigation for may identify a hypertrophied internal anal , solitary rectal ulcer syndrome. Bowel preparation suc- suggesting chronic straining. EMG can detect paradox- cessfulness can be informative. Many patients can have ical excitation of the pelvic floor during Valsalva. Cine- a tortuous and redundant colon. (or dynamic pelvic MRI) evaluates def- (2) Imaging adjuncts can help assess motility. Ingestion of a ecation mechanics in real time. This may demonstrate SITZMARKS capsule (Konsyl Pharmaceuticals, Easton, a narrowing or no change of the anorectal angle with MD) containing radiopaque markers and serial abdom- retention of rectal barium paste or identify concurrent inal x-rays on days 1, 3, and 5 evaluates colonic motility. , enterocele, or rectal intussusception. Global GI motility disorder is suggested by postpran- dial distension or pain, and additional studies should be DIAGNOSES ordered: a gastric emptying study, upper GI series with Slow-transit constipation (ie, colonic inertia) is character- small-bowel follow-through, or a SmartPill Motility Testing System (Medtronic, Minneapolis, MN) study ized by inadequate colonic motility resulting in infrequent that measures pH, pressure, and transit time to provide urge to defecate and rare passage of hard stool. Retention gastric, small-bowel, and colonic emptying data. of ≥20% of SITZMARKS markers throughout the colon on day 5 is suggestive of this diagnosis. Pelvic outlet obstruction constipation (ie, paradoxical Rome IV Criteria puborectalis function, obstructive defecation, , or Must include 2 or more of the following: pelvic floor dyssynergia) is when the puborectalis paradox- Straining during >25% of ically contracts or fails to relax during attempted defeca- Lumpy or hard stools >25% of defecations tion. Patients often report incomplete evacuation despite Sensation of incomplete evacuation >25% defecations prolonged straining. Patients frequently have inconclusive Sensation of anorectal blockage/obstruction >25% defecations workup and GI dysmotility, pelvic floor abnormalities, Manual maneuvers to facilitate >25% defecations comorbid psychiatric conditions, situational stressors, or (e.g, digital evacuation, pelvic floor support) sexual abuse comorbidities. These patients have rectosig- <3 spontaneous bowel movements per week moid clustering of their SITZMARKS markers on day 5. Loose stools rarely present without use Ultra-short-segment Hirschsprung disease is a rare Insufficient criteria for cause of lifelong constipation, characterized by attributed to chronic dilation proximal to an aganglionic FIGURE 2. Rome IV criteria.2 and short (2–4 cm) distal rectal segment. Absence of the DISEASES OF THE COLON & RECTUM VOLUME 62: 6 (2019) 663

Differential for Chronic Constipation end sigmoid creation. Those with concomitant Associated pelvic floor conditions slow transit constipation and pelvic dysfunction may ben- pelvic prolapse, rectocele, enterocele, internal rectal intussusception, efit from an .5 In addition, a loop ileostomy can Comorbid conditions , mellitus, Parkinson’s disease, multiple sclerosis, be helpful in those with slow transit constipation to assess Global Gl dysmotility disorder benefit before considering total abdominal . Mechanical obstruction mass, polyp, stricture, Colectomy Medications For patients with slow transit constipation and normal narcotics, , , , barium, , antihypertensives pelvic floor mechanics, total abdominal colectomy with il- Pelvic outlet obstruction Pseudo-obstruction (Ogilvie’s) eorectal (TAC/IRA) can resolve constipation 6 Short-segment Hirschsprung’s symptoms with improved frequency of bowel movements. Slow transit constipation However, symptoms of , , and dis- Small bowel overgrowth tension do not consistently improve. From a technical Structural disorders affecting colonic innervation standpoint, total colectomy is key, because residual sigmoid high spinal cord injury, meningomyelocele colon has been correlated with worse outcomes. Although FIGURE 3. Differential diagnosis for chronic constipation. most patients with concomitant pelvic outlet obstruction have better functional outcomes with an ileostomy, those rectoanal inhibitory reflex on anorectal manometry sug- who respond well to PT and/or Botox may benefit from gests Hirschsprung disease and should be confirmed with TAC/IRA on a case-by-case basis.7 Case series report that full-thickness rectal biopsy demonstrating aganglionosis. slow-transit patients with TAC/IRA who have persistent/ recurrent constipation may experience significant im- MANAGEMENT provement in quality of life with conversion to an IPAA.8 Nonsurgical Ultra-short-segment Hirschsprung disease may re- Once mechanical obstruction has been ruled out, initial quire resection of the aganglionic segment with an ultra- treatment of most patients focuses on medical manage- low anastomosis. Intraoperative frozen section should be ment and optimizing stool texture. Bowel diaries are help- performed to localize the proximal extent of the agan- ful to document symptoms and treatment response. Daily glionosis. Alternatively, strip myomectomy may restore intake of 25 to 50 grams and 1 to 2 liters of function without and is performed by re- 3 water is recommended. However, those with colonic in- secting a 5- to 10-mm–wide strip of internal anal sphinc- ertia may benefit from fiber restriction. , stool ter from the dentate line to grossly normal, ganglionated softeners, , suppositories, and may help; bowel.9 Pull-through procedures (eg, Soave or Swensen) pharmacologic agents such as (Amitiza), are not routinely performed in the adult population be- (Linzess), and plecanatide (Trulance) require careful titration and monitoring of adverse effects. cause of high morbidity and poor function.

Pelvic Floor PT Botox Injection Physical therapists specializing in pelvic floor anatomy and Botulinum toxin A (Botox; Allergan, Dublin, Ireland) has biomechanics may help patients with pelvic outlet obstruc- shown benefit in selected patients with pelvic outlet ob- tion constipation. and electromyographic eval- struction.10 Injection into the puborectalis has been asso- uation of the pelvic floor muscles provide quantitative data to ciated with improved manometric puborectalis relaxation document improvement and direct ongoing therapy. Long- and symptoms, although the optimal dose and timing are term efficacy of pelvic floor PT ranged from 69% to 75% in a not well established. Patients with ultra-short-segment 4 meta-analysis of patients with obstructive defecation. Hirschsprung disease may also experience symptom ame- lioration with intersphincteric injection of Botox. Surgical Surgery should be reserved for patients with debilitating Antegrade Colonic Enemas symptoms from constipation that have significant nega- Limited studies exist evaluating the benefit of cecostomy tive effects on their quality of life. A brief overview of the various surgical options follows. or appendicostomy creation for antegrade colonic en- emas. Although a review showed that most studies found Colostomy or Ileostomy improvement, they did not show complete resolution of Patients with normal colonic transit and severe refractory symptoms, and study comparison is complicated by varia- pelvic outlet dysfunction constipation may benefit from tion in outcome measures.11 664 HILL AND DAVIDS: SURGICAL EVALUATION AND CONSTIPATION

CONCLUSIONS efit from other adjunctive medications and/or pelvic PT. Constipated patients who seek surgical evaluation represent Surgery is reserved for a highly select group, generally with a diverse population. There is a wide array of underlying either isolated colonic dysmotility or ultra-short-segment etiologies and extensive differential diagnoses. Diagnostic Hirschsprung disease. In the carefully selected colonic iner- studies should be performed to rule out mechanical ob- tia patient who is refractory to medical management, TAC/ struction, categorize constipation type, and identify poten- IRA can result in long-lasting resolution of constipation tially surgically treatable causes. Treatment is individualized symptoms, with 80% reporting good patient satisfaction at and generally starts with medical management with fiber 3 years and some studies showing sustained benefit out to supplementation to modulate stool texture. Some may ben- 10 years.7,12

EVALUATION AND TREATMENT ALGORITHM

Initial presentation of constipation

Initial evaluation: • Thorough history • In-depth exam including anorectal exam and anoscopy • Colonoscopy, if appropriate

• Optimize fiber and water intake • Minimize medications that exacerbate constipation xxx

Suspected diagnosis of… xxx

Slow transit Pelvic outlet Ultra-short-segment XXX constipation obstruction Hirschsprung’s

• Anorectal manometry • Electromyography • Anorectal manometry Colonic motility study • Balloon evacuation • Cine-defecography • Full-thickness rectal biopsies

• Pelvic floor physical therapy • Consider botulinum therapy

Total abdominal • Consider repair of rectocele, • Intrasphincteric botulinum FIGURE 4. Evaluation and treatment algorithm for constipation. colectomy enterocele, intussception • Strip myomectomy • Fecal diversion with colostomy • Resection of aganglionic segment

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