RESIDENT’S CORNER Surgical Evaluation and Management of Constipation Susanna S. Hill, M.D. • Jennifer S. Davids, M.D. Division of Colon and Rectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts CASE SUMMARY: A 32-year-old otherwise healthy gastroenterology. 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 pelvic floor 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 defecation, 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 medications, 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 anoscopy: States, with higher rates in patients who are women, older individuals, and lower socioeconomic status.1 Constipa- (1) Abdominal examination should assess for distension, ten- tion is formally defined by the Rome IV criteria (Fig. 2)2; derness, surgical scars, hernias, 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 perineum for scars, perineal body bulk, fis- Generally, patients present to a colon and rectal sur- sures, hemorrhoids, and skin tags or other lesions. Digital geon after an initial evaluation by primary care and/or rectal examination 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 differential diagnosis is Dis Colon Rectum 2019; 62: 661–666 broad (Fig. 3). DOI: 10.1097/DCR.0000000000001395 Diagnostic testing can consist of colonoscopy, 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, polyp, 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. Anorectal manometry tion, which should prompt additional investigation for may identify a hypertrophied internal anal sphincter, 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. defecography (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. rectocele, 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, anismus, or Must include 2 or more of the following: pelvic floor dyssynergia) is when the puborectalis paradox- Straining during >25% of defecations 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 laxative use Ultra-short-segment Hirschsprung disease is a rare Insufficient criteria for irritable bowel syndrome cause of lifelong constipation, characterized by megacolon 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 colostomy creation. Those with concomitant Associated pelvic floor conditions slow transit constipation and pelvic dysfunction may ben- pelvic organ prolapse, rectocele, enterocele, internal rectal intussusception, rectal prolapse efit from an ileostomy.5 In addition, a loop ileostomy can Comorbid conditions hypothyroidism, diabetes mellitus, Parkinson’s disease, multiple sclerosis, pregnancy be helpful in those with slow transit constipation to assess Global Gl dysmotility disorder benefit before considering total abdominal colectomy. Mechanical obstruction mass, polyp, stricture, volvulus Colectomy Medications For patients with slow transit constipation and normal narcotics, antiemetics, antidepressants, antacids, barium, antihistamines, antihypertensives pelvic floor mechanics, total abdominal colectomy with il- Pelvic outlet obstruction Pseudo-obstruction (Ogilvie’s) eorectal anastomosis (TAC/IRA) can resolve constipation 6 Short-segment Hirschsprung’s symptoms with improved frequency of bowel movements. Slow transit constipation However, symptoms of abdominal pain, bloating, 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