02 Chronic constipation roleWord下载.docx

1、stico etiolgico da constipao intestinal crnicaAntnio Lacerda-FilhoI, II; Marclio Jos Rodrigues LimaI; Marisa Fonseca MagalhesI; Rodrigo de Almeida PaivaI; Jos Renan da Cunha-MeloI, IIIAlfa Institute of Gastroenterology IIDepartment of Surgery, Federal University of Minas Gerais Medical School, Belo

2、Horizonte, MG, BrazilABSTRACTBACKGROUND: Diagnosis of subtypes of chronic constipation has been considered difficult to achieve even in specialized centers. Although colorectal physiologic tests have brought an important contribution, it remains unclear in which patients these tests should be indica

3、ted for. AIMS: This study aims to establish a differential diagnosis for chronic constipation cases using clinical assessment and physiologic tests and to identify clinical parameters that could predict which patients need physiologic tests. METHODS: One hundred and seventy nine patients （83% female

4、s; mean age, 45） with chronic constipation according to Rome II criteria were initially treated by dietary advice and functional reeducation and those unresponsive （110 or 61.5%） were submitted to colonic transit time, defecography, anorectal manometry and electromyography, as needed. RESULTS: A dif

5、ferential diagnosis was achieved in 63.6% of patients tested. However, 61.5% of 179 patients with chronic constipation （69 with no need to tests and 40 with normal tests） have etiologic diagnosis established only on clinical basis. Irritable bowel syndrome （32%）, pelvic floor dysfunction （29%） and f

6、unctional constipation due to faulty diet and life style habits （22%） were the main causes of chronic constipation. Alternating constipation and nausea/vomiting were symptoms significantly related to the diagnosis of irritable bowel syndrome; younger age, larger intervals between bowel movements, oc

7、currence of fecal impaction and necessity of enema were related to the diagnosis of non-chagasic megacolon and digital assistance to evacuate and large rectocele or spastic pelvic floor on rectal exam were associated to pelvic floor dysfunction. Patients with long-standing constipation, fecal impact

8、ion, abdominal pain not eased after defecation, necessity for enemas, digital assistance and evidence of rectocele tended to be in need for physiologic tests to define the cause of chronic constipation. CONCLUSIONS: The etiologic diagnosis of chronic constipation can be achieved in most of patients

9、on a clinical basis and some symptoms may be significantly related to specific diagnoses. Indications for physiologic tests should be based on specific clinical parameters.Headings: Constipation. Irritable bowel syndrome. Defecation. Gastrointestinal transit.RESUMORACIONAL: O diagnstico dos subtipos

10、 de constipao crnica tem sido considerado difcil de ser estabelecido, mesmo em centros especializados. Embora os testes fisiolgicos tenham trazido uma importante contribuio, ainda h dvidas quanto as suas indicaes. OBJETIVOS: Estabelecer o diagnstico diferencial em casos de constipanica atravs da ava

11、lianica e da utilizao de testes fisiolgicos, procurando-se identificar parmetros clnicos que poderiam predizer quais pacientes necessitariam de tais testes. MTODOS: Cento e setenta e nove pacientes （83% do sexo feminino; mdia de idade de 45 anos） com constipanica de acordo com os critrios de Roma II

12、 foram inicialmente tratados com medidas dietticas e reeducao funcional e aqueles que no responderam （110 ou 61,5%） foram submetidos a tempo de trnsito colnico, defecografia, manometria anorretal e eletromiografia, de acordo com apresentanica da constipanica. RESULTADOS:gico foi obtido em 63.6% dos

13、pacientes testados. Entretanto, em 61,5% （69 que no necessitaram dos testes e 40 que tiveram testes normais）, o diagngico foi estabelecido em bases clnicas. A sndrome do intestino irritvel （32%）, a disfuno do assoalho plvico （29%） e a constipao funcional secundria a inadequao diettica e de hbitos de

14、 vida （22%） foram os principais diagnsticos etiolgicos da constipanica. A alternncia de constipao e a presena de nuseas/vmitos estiveram significativamente relacionadas ao diagnstico de svel; idade precoce, grandes intervalos entre as evacuaes, ocorrncia de impactao fecal e necessidade de enemas est

15、iveram relacionadas ao diagnstico de megaclon no-chagsico, enquanto assistncia digital para evacuar e grande retocele ou assoalho plvico espstico ao toque retal se associaram disfunlvico. Pacientes com constipao de longa durao, impactao fecal, dor abdominal no aliviada pelas evacuaes, necessidade de

16、 enemas, assistncia digital para evacuar e com evidncia de retocele tendem a necessitar de testes de fisiologia para definio da causa de constipaCONCLUSES:nica pode ser obtido na maioria dos pacientes somente em bases clnicas, sendo que alguns sintomas esto significativamente associados a determinad

17、os diagnsticos. A indicao dos testes de fisiologia, por sua vez, deve ser baseada em parnicos especficos.Descritores: Constipao intestinal. Svel. Defecao. Trnsito gastrointestinal.INTRODUCTIONChronic constipation （CC） may be defined, according to Rome II criteria, as an individual functional disorde

18、r chronic functional constipation （FC） - or as part of irritable bowel syndrome （IBS）, when abdominal pain or discomfort is present and related to symptoms of constipation （IBS constipation-predominant）（20）. Twenty percent of the populations of western countries are estimated to be affected. The sym

19、ptoms impair the quality of life, causing CC to become an important health problem（7）. A number of CC patients usually complain of some kind of abdominal discomfort（18）, making the distinction between FC and IBS patients controversial and arbitrary. This makes the etiologic diagnosis of CC difficult

20、, even in specialized centers. Although colorectal physiologic tests have brought an important contribution to clarify the final diagnosis of CC, it remains unclear in which patients these tests should be indicated for. The aims of the present study were: （1） to establish etiologic diagnosis of CC c

21、ases and to differentiate patients with FC and IBS constipation-predominant assessed by Rome II criteria and by physiologic tests, when indicated, and （2） to predict which patients with CC need colorectal physiologic tests for etiologic diagnosis. METHODSPatientsOne hundred and seventy-nine patients

22、 with chronic functional constipation were retrospectively selected among a total of 245 constipated patients referred to the Disorders of Defecation Outpatient Clinic, Alfa Institute of Gastroenterology, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil, for investigation and treatment

23、, from July 1998 to July 2002. Chronic functional constipation was defined according to Rome II Criteria（1）, for both primary FC and IBS with predominance of constipation （Figure 1）.The clinical assessment was obtained using a specifically-designed questionnaire filled out by a specialist either in

24、Gastroenterology or Colorectal Surgery that included questions on duration of symptoms, interval between bowel movements （BM）, feeling of desire to defecate, strain during defecation, hard stools, feeling of incomplete evacuation, sense of obstructed defecation, abdominal pain and bloating, nausea o

25、r vomiting, alternating constipation, fecal impaction, necessity of abdominal or digital manipulation to obtain defecation and use of laxatives and enemas. Patients were also asked about diseases that can cause or predispose to CC and use of potential constipating drugs. A careful abdominal and rect

26、al examination was carried out with special attention to the presence of spastic pelvic floor and rectocele. Constipated patients with anal fissure or stricture were excluded. Laboratory tests （glycemia, thyroid hormones and calcemia）, barium enema and/or colonoscopy ruled out other secondary causes

27、 for constipation, such as endocrine diseases （diabetes, hypothyroidism, and hyperparathyroidism）, tumors or other sorts of colonic stricture （diverticulitis, endometriosis, etc）. Patients observed with megacolon and/or megarectum on barium enema were tested for Chagas disease and those with positiv

28、e results on serology were referred to surgical treatment and excluded from the present study. In addition, patients with neurologic or mental diseases or those in use of potentially constipating drugs （tricycle antidepressants, antipsychotic drugs, calcium canal blockers, anticholinergics, etc） wer

29、e also ruled out. All 179 patients were asked to ingest high fiber diet with a supplement of 30 to 40 g/day of pure fiber （wheat bran） and a minimum of 2000 mL of water/day. Physical activity was advised, including regular walking and abdominal exercises. Patients were instructed to complete a dieta

30、ry and defecatory diary in order to have the compliance of such measures checked and to verify the interval between BM. The patients who did not respond to this initial treatment after an interval of 30 to 45 days （still maintaining Rome II criteria for FC or IBS constipation-predominant） were considered refractory and referred to physiologic tests. This diagnostic work-up was established in accordance with American Gastroenterology Association algorithm for refractory chronic constipation（11）. The study was approved by the Ethical Committee for Research of the Federal Uni