02 Chronic constipation roleWord下载.docx

02 Chronic constipation roleWord下载.docx

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sticoetioló

gicodaconstipaç

ointestinalcrô

nica

Antô

nioLacerda-FilhoI,II;

Marcí

lioJosé

RodriguesLimaI;

MarisaFonsecaMagalhã

esI;

RodrigodeAlmeidaPaivaI;

José

RenandaCunha-MeloI,II

IAlfaInstituteofGastroenterology

IIDepartmentofSurgery,FederalUniversityofMinasGeraisMedicalSchool,BeloHorizonte,MG,Brazil

ABSTRACT

BACKGROUND:

Diagnosisofsubtypesofchronicconstipationhasbeenconsidereddifficulttoachieveeveninspecializedcenters.Althoughcolorectalphysiologictestshavebroughtanimportantcontribution,itremainsunclearinwhichpatientsthesetestsshouldbeindicatedfor.

AIMS:

Thisstudyaimstoestablishadifferentialdiagnosisforchronicconstipationcasesusingclinicalassessmentandphysiologictestsandtoidentifyclinicalparametersthatcouldpredictwhichpatientsneedphysiologictests.

METHODS:

Onehundredandseventyninepatients（83%females;

meanage,45）withchronicconstipationaccordingtoRomeIIcriteriawereinitiallytreatedbydietaryadviceandfunctionalreeducationandthoseunresponsive（110or61.5%）weresubmittedtocolonictransittime,defecography,anorectalmanometryandelectromyography,asneeded.

RESULTS:

Adifferentialdiagnosiswasachievedin63.6%ofpatientstested.However,61.5%of179patientswithchronicconstipation（69withnoneedtotestsand40withnormaltests）haveetiologicdiagnosisestablishedonlyonclinicalbasis.Irritablebowelsyndrome（32%）,pelvicfloordysfunction（29%）andfunctionalconstipationduetofaultydietandlifestylehabits（22%）werethemaincausesofchronicconstipation.Alternatingconstipationandnausea/vomitingweresymptomssignificantlyrelatedtothediagnosisofirritablebowelsyndrome;

youngerage,largerintervalsbetweenbowelmovements,occurrenceoffecalimpactionandnecessityofenemawererelatedtothediagnosisofnon-chagasicmegacolonanddigitalassistancetoevacuateandlargerectoceleorspasticpelvicflooronrectalexamwereassociatedtopelvicfloordysfunction.Patientswithlong-standingconstipation,fecalimpaction,abdominalpainnoteasedafterdefecation,necessityforenemas,digitalassistanceandevidenceofrectoceletendedtobeinneedforphysiologicteststodefinethecauseofchronicconstipation.

CONCLUSIONS:

Theetiologicdiagnosisofchronicconstipationcanbeachievedinmostofpatientsonaclinicalbasisandsomesymptomsmaybesignificantlyrelatedtospecificdiagnoses.Indicationsforphysiologictestsshouldbebasedonspecificclinicalparameters.

Headings:

Constipation.Irritablebowelsyndrome.Defecation.Gastrointestinaltransit.

RESUMO

RACIONAL:

Odiagnó

sticodossubtiposdeconstipaç

ocrô

nicatemsidoconsideradodifí

cildeserestabelecido,mesmoemcentrosespecializados.Emboraostestesfisioló

gicostenhamtrazidoumaimportantecontribuiç

o,aindahá

dú

vidasquantoassuasindicaç

õ

es.

OBJETIVOS:

Estabelecerodiagnó

sticodiferencialemcasosdeconstipaç

nicaatravé

sdaavaliaç

nicaedautilizaç

odetestesfisioló

gicos,procurando-seidentificarparâ

metrosclí

nicosquepoderiampredizerquaispacientesnecessitariamdetaistestes.

MÉ

TODOS:

Centoesetentaenovepacientes（83%dosexofeminino;

mé

diadeidadede45anos）comconstipaç

nicadeacordocomoscrité

riosdeRomaIIforaminicialmentetratadoscommedidasdieté

ticasereeducaç

ofuncionaleaquelesquenã

oresponderam（110ou61,5%）foramsubmetidosatempodetrâ

nsitocolô

nico,defecografia,manometriaanorretaleeletromiografia,deacordocomapresentaç

nicadaconstipaç

nica.

RESULTADOS:

gicofoiobtidoem63.6%dospacientestestados.Entretanto,em61,5%（69quenã

onecessitaramdostestese40quetiveramtestesnormais）,odiagnó

gicofoiestabelecidoembasesclí

nicas.Así

ndromedointestinoirritá

vel（32%）,adisfunç

odoassoalhopé

lvico（29%）eaconstipaç

ofuncionalsecundá

riaainadequaç

odieté

ticaedehá

bitosdevida（22%）foramosprincipaisdiagnó

sticosetioló

gicosdaconstipaç

nica.Aalternâ

nciadeconstipaç

oeapresenç

adená

useas/vô

mitosestiveramsignificativamenterelacionadasaodiagnó

sticodesí

vel;

idadeprecoce,grandesintervalosentreasevacuaç

es,ocorrê

nciadeimpactaç

ofecalenecessidadedeenemasestiveramrelacionadasaodiagnó

sticodemegacó

lonnã

o-chagá

sico,enquantoassistê

nciadigitalparaevacuaregranderetoceleouassoalhopé

lvicoespá

sticoaotoqueretalseassociaramà

disfunç

lvico.Pacientescomconstipaç

odelongaduraç

o,impactaç

ofecal,dorabdominalnã

oaliviadapelasevacuaç

es,necessidadedeenemas,assistê

nciadigitalparaevacuarecomevidê

nciaderetoceletendemanecessitardetestesdefisiologiaparadefiniç

odacausadeconstipaç

CONCLUSÕ

ES:

nicapodeserobtidonamaioriadospacientessomenteembasesclí

nicas,sendoquealgunssintomasestã

osignificativamenteassociadosadeterminadosdiagnó

sticos.Aindicaç

odostestesdefisiologia,porsuavez,deveserbaseadaemparâ

nicosespecí

ficos.

Descritores:

Constipaç

ointestinal.Sí

vel.Defecaç

o.Trâ

nsitogastrointestinal.

INTRODUCTION

Chronicconstipation（CC）maybedefined,accordingtoRomeIIcriteria,asanindividualfunctionaldisorder–chronicfunctionalconstipation（FC）-oraspartofirritablebowelsyndrome（IBS）,whenabdominalpainordiscomfortispresentandrelatedtosymptomsofconstipation（IBSconstipation-predominant）（20）.Twentypercentofthepopulationsofwesterncountriesareestimatedtobeaffected.Thesymptomsimpairthequalityoflife,causingCCtobecomeanimportanthealthproblem（7）.AnumberofCCpatientsusuallycomplainofsomekindofabdominaldiscomfort（18）,makingthedistinctionbetweenFCandIBSpatientscontroversialandarbitrary.ThismakestheetiologicdiagnosisofCCdifficult,eveninspecializedcenters.AlthoughcolorectalphysiologictestshavebroughtanimportantcontributiontoclarifythefinaldiagnosisofCC,itremainsunclearinwhichpatientsthesetestsshouldbeindicatedfor.

Theaimsofthepresentstudywere:

（1）toestablishetiologicdiagnosisofCCcasesandtodifferentiatepatientswithFCandIBSconstipation-predominantassessedbyRomeIIcriteriaandbyphysiologictests,whenindicated,and

（2）topredictwhichpatientswithCCneedcolorectalphysiologictestsforetiologicdiagnosis.

METHODS

Patients

Onehundredandseventy-ninepatientswithchronicfunctionalconstipationwereretrospectivelyselectedamongatotalof245constipatedpatientsreferredtotheDisordersofDefecationOutpatientClinic,AlfaInstituteofGastroenterology,FederalUniversityofMinasGerais,BeloHorizonte,MG,Brazil,forinvestigationandtreatment,fromJuly1998toJuly2002.ChronicfunctionalconstipationwasdefinedaccordingtoRomeIICriteria

（1）,forbothprimaryFCandIBSwithpredominanceofconstipation（Figure1）.

Theclinicalassessmentwasobtainedusingaspecifically-designedquestionnairefilledoutbyaspecialisteitherinGastroenterologyorColorectalSurgerythatincludedquestionsondurationofsymptoms,intervalbetweenbowelmovements（BM）,feelingofdesiretodefecate,strainduringdefecation,hardstools,feelingofincompleteevacuation,senseofobstructeddefecation,abdominalpainandbloating,nauseaorvomiting,alternatingconstipation,fecalimpaction,necessityofabdominalordigitalmanipulationtoobtaindefecationanduseoflaxativesandenemas.PatientswerealsoaskedaboutdiseasesthatcancauseorpredisposetoCCanduseofpotentialconstipatingdrugs.Acarefulabdominalandrectalexaminationwascarriedoutwithspecialattentiontothepresenceofspasticpelvicfloorandrectocele.

Constipatedpatientswithanalfissureorstricturewereexcluded.Laboratorytests（glycemia,thyroidhormonesandcalcemia）,bariumenemaand/orcolonoscopyruledoutothersecondarycausesforconstipation,suchasendocrinediseases（diabetes,hypothyroidism,andhyperparathyroidism）,tumorsorothersortsofcolonicstricture（diverticulitis,endometriosis,etc）.Patientsobservedwithmegacolonand/ormegarectumonbariumenemaweretestedforChagasdiseaseandthosewithpositiveresultsonserologywerereferredtosurgicaltreatmentandexcludedfromthepresentstudy.Inaddition,patientswithneurologicormentaldiseasesorthoseinuseofpotentiallyconstipatingdrugs（tricycleantidepressants,antipsychoticdrugs,calciumcanalblockers,anticholinergics,etc）werealsoruledout.

All179patientswereaskedtoingesthighfiberdietwithasupplementof30to40g/dayofpurefiber（wheatbran）andaminimumof2000mLofwater/day.Physicalactivitywasadvised,includingregularwalkingandabdominalexercises.PatientswereinstructedtocompleteadietaryanddefecatorydiaryinordertohavethecomplianceofsuchmeasurescheckedandtoverifytheintervalbetweenBM.Thepatientswhodidnotrespondtothisinitialtreatmentafteranintervalof30to45days（stillmaintainingRomeIIcriteriaforFCorIBSconstipation-predominant）wereconsideredrefractoryandreferredtophysiologictests.Thisdiagnosticwork-upwasestablishedinaccordancewithAmericanGastroenterologyAssociationalgorithmforrefractorychronicconstipation（11）.

ThestudywasapprovedbytheEthicalCommitteeforResearchoftheFederalUni