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  C o n s t i p a t io n S c o r in g S y s te m t o

S i mp l i fy Eva l u a t i on an d M an age me n t

o f C on s t i p a te d P at i e n t s

Feran Agachan M.D. Teng Chen M.D. Johann Pfeifer M.D.

P e t a c h i a R e i s sma n M . D . S t e v e n D . W e x n e r M . D .

From the Department of Colorectal Surgery Cleveland Clinic Florida Fort Lauderdale Florida

P U R P O S E : C o n s t i p a t i o n i s a c o m m o n c o m p l a i n t ; h o w e v e r ,

c l i n i ca l p r esen t a t i o n v a r i es wi t h each i n d iv i d u a l . T h e a im o f

t h i s s t u d y was t o as sess a s t an d ard sco r in g sy s t em fo r ev a l -

u a t i o n o f co n s t i p a t ed p a t i en t s . M ATERIAL S AN D M ETH-

O D S : M I c o n s e c u t i v e p a t i e n t s w i t h i d i o p a t h i c c o n s t i p a t i o n

w h o w e r e r e f e r r e d f o r a n o r e c t a l p h y s i o l o g i c t e s t i n g w e r e

assessed . A su b j ec t i v e co n s t i p a t i o n sco re was ca l cu l a t ed

b a s e d o n a d e t a i l e d q u e s t i o n n a i r e t h a t i n c l u d e d o v e r 1 0 0

c o n s t i p a ti o n - r e la t e d s y m p t o m s . B a s e d o n t h e q u e s t i o n n a i r e ,

s c o r e s r a n g e d f r o m 0 t o 3 0 , w i t h 0 i n d i c a t in g n o r m a l a n d 3 0

i n d i c a ti n g s e v e r e c o n s t i p a t i o n . T h e c o n s t i p a t i o n s c o r e w a s

t h e n c o m p a r e d w i t h t h e o b j e c t iv e f in d i n g s o f t h e p h y s i o l-

o g y te s t s , wh i ch i n c lu d e c o l o n i c t r an s i t t ime (CTT ) , an a l

m a n o m e t r y ( A M ) , c i n e d e f e c o g r a p h y ( C D ) , a n d e l e c t r o m y o -

g ra p h y (EM G) . Co lo n i c i n e r t i a wa s d e f i n ed as d i f fu se m ark er

d e l a y o n C T T w i t h o u t e v i d e n c e o f p a r a d o x i c a l c o n t r a c t i o n

o n A M , C D , o r E M G . P e l v ic o u t l e t o b s t r u c t i o n w a s d e f i n e d

a s p a r a d o x i c a l p u b o r e c t a l i s c o n t r a c t i o n , r e c t a l p r o l a p s e o r

r ec to an a l i n tu ssu scep t i o n , r ec to ce l e , o r s i g mo i d o ce l e . RE-

S ULTS : A to t a l o f 2 3 2 p a t i en t s (1 8 5 f em ales an d 4 7 ma les ) o f

a m e a n a g e o f 6 4 . 9 ( r an g e , 1 4 - 9 2 ) y e a r s w e r e e v a l u at e d . A ll

p a t i e n t s h a d a s c o r e o f m o r e t h a n 1 5; o n e v a l u a t io n o f th e

s i g n if i c a n c e o f d i f f e re n t s y m p t o m s i n t h e c o n s t i p a t i o n s c o r e

wi th t h e P ear so n ' s l i n ea r co r r e l a t i o n t e s t , 8 o f 1 8 f ac to r s

were i d en t i f i ed as s i g n i f i can t (P < 0 .0 5 ) . Th ese f ac to r s

i n c l u d e d f r e q u e n c y o f b o w e l m o v e m e n t s , p a i n fu l e v a cu a -

t io n , i n c o m p l e t e e v a c u a t i o n , a b d o m i n a l p a i n , l e n g t h o f t i m e

p er a t t emp t , a s s i s t an ce fo r ev acu a t i o n , u n su ccess fu l a t -

t e m p t s f o r e v a c u a t i o n p e r 2 4 h o u r s , a n d d u r a t i o n o f c o n s ti -

p a t i o n . Al l 2 3 2 p a t i en t s h ad o b j ec t i v e o b s t ru c t i o n a t t r i b u t -

a b l e t o o n e o r m o r e o f t h e f o l l o w i n g c a u s e s : p a r a d o x i c a l

p u b o rec t a l i s co n t r ac t i o n (8 1 ) , s i g n i f i can t r ec to ce l e o r s i g -

m o i d o c e l e ( 4 8 ) , r e c t o a n a l i n t u s s u s c e p t i o n ( 6 4 ) , a n d r e c t a l

p r o l a p s e ( 9 ). C O N C L U S I O N : T h e p r o p o s e d c o n s t i p a t i o n

s c o r i n g s y s t e m c o r r e l a t e d w e l l w i t h o b j e c t i v e p h y s i o l o g i c

f i n d in g s i n co n s t i p a t ed p a t i en t s t o a l l o w u n i fo rmi t y i n as -

s e s s m e n t o f t h e s e v e r i ty o f c o n s ti p a t io n . [ K e y w o r d s : C o n -

s t i p a t i o n ; Co lo n i c i n e r t i a ; S i g mo i d o ce l e ; Rec to ce l e ; Rec t a l

p ro l ap se ; Rec to an a l i n t u ssu scep t i o n ; An i smu s ; P a rad o x i ca l

p u b o r e c t a l i s c o n t r a c t i o n ]

Ag a ch an F , Ch en T , P fe i f e r J , Re i s sman P , W ex n er S D. A

c o n s t i p a t i o n s c o r i n g s y s t e m t o s i m p l if y e v a l ua t i o n a n d m a n -

a g e m e n t o f c o n s t i p a t e d p a t ie n t s . D i s C o l o n R e c t u m 1 9 9 6;

3 9 : 6 8 1 - 6 8 5 .

Address reprint requests to Dr. W exner: Department of Colorectal

Surgery, Cleveland Clinic Florida, 3000 West Cypress Creek Road,

Fort Lauderdale, F lorida 33309.

h e c l i n ic a l p r e s e n t a t i o n o f c o n s t i p a t i o n i n c l u d e s

a b r o a d s p e c t r u m o f s y m p t o m s p a r t ia l l y a t tr ib -

u t e d t o t h e m y r i a d e t i o lo g i e s . S p e c i f ic a l ly , c o n s t i p a -

t i o n m a y r e s u l t f r o m s l o w t ra n s it , p e l v i c o u t l e t o b -

s t r u ct i o n , o r o t h e r m e c h a n i c a l , p h a r m a c o l o g i c ,

m e t a b o l i c , e n d o c r i n e , a n d n e u r o g e n i c r e a s on s . 1 '2

G e n e r a l l y , p h y s i c i a n s u s e t h e t e r m c o n s t i p a t i o n t o

d e f i n e i n f r e q u e n t , i n c o m p l e t e , d if fi cu lt , o r p r o l o n g e d

e v a c u a t i o n o r to d e s c r i b e s t o o l s t h a t a r e t o o s m a ll , t o o

h a r d , o r t o o d i f f ic u lt to p a s s . 3 H o w e v e r , m a n y p a t i e n t s

a r e m o r e o b s e s s e d b y t h e a s s oc i a t e d n o n s p e c i f i c

s y m p t o m s o f b l o a ti n g , a b d o m i n a l , a n d p e l v i c p a in

a n d n a u s e a . 4 O t h e r d i ff ic u l t t o c a t e g o r i z e p r o b l e m s ,

s u c h a s in c o n t i n e n c e , h a v e b e e n b e t t e r d e s c r i b e d u s -

i n g a s c o r i n g s y s t e m . 5

T h e r e f o r e , t h e a i m o f t h is s t u d y w a s t o e s t a b l is h a n

o b j e c ti v e c o n s t i p a t io n s c o r i n g s y s te m b a s e d o n p a -

t i e nt s ' c o m p l a i n t s . S p e c i fi c a t te n t i o n w a s p a i d t o b o t h

s u b j e c t i v e s y m p t o m a t i c c o m p l a i n t s a n d p h y s i o l o g i c

f i n d i n g s .

M T E R I L S N D M E T H O D S

A c o n s e c u t i v e s e r i e s o f 2 3 2 c o n s t i p a t e d p a t i e n t s

w e r e e n r o l l e d i n t h is s tu d y . P a t ie n t s w e r e i n t e r v i e w e d

b y a n u r s e o r a r e s i d e n t r e g a r d i n g t h e i r b o w e l h a b i t s .

T h e s t a n d a r d i z e d q u e s t i o n n a i r e c o n c e r n e d 1 2 a d -

d r e s s e d i t e m s , i n c l u d i n g c o n s t i p a t i o n d u r a t i o n a n d

s e v e r it y , b o w e l h a b i t s, s t o o l c o n s i s t e n c y , i n t a k e o f

f ib e r , f r e q u e n c y a n d a m o u n t s o f l a x a ti v e s, s u p p o s i t o -

r ie s , d i g i ta t i o n o r e n e m a s , d u r a t i o n a n d f r e q u e n c y o f

a s s i s ta n c e , l e n g t h o f s tr a i n in g t i m e p e r a t t e m p t , u n -

s u c c e s s f u l a t t e m p t s f o r e v a c u a t i o n p e r 2 4 h o u r s , s e n -

s a t io n o f in c o m p l e t e e v a c u a t i o n , m u c u s d i s ch a r g e ,

r e c ta l b le e d i n g , s e n s a t i o n o f p r o l a p s e , i n c o n t i n e n c e ,

p s y c h o l o g i c , e n d o c r i n o l o g i c , m e t a b o li c , o r n e u r o -

l o g i c h i s to r y , p r e v i o u s a b d o m i n a l , g y n e c o l o g i c , o r

c o l o r e c t a l s u r g e r y , p e l v i c i r r a d i a t i o n , r e g u l a r u s e o f

m e d i c a t i o n , p r e g n a n c y , a n d v a g i n a l d e l iv e r ie s .

A l l p a t i e n t s u n d e r w e n t e x t e n s i v e a n o r e c t a l e x a m i -

6 8 1

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682 AGACHAN ET L

Dis Colon Rectum, June 1996

n a t i o n , i n c l u d i n g i n s p e c t i o n , d i g i t a l e x a m i n a t i o n ,

a n o s c o p y , a n d p r o c t o s i g m o i d o s c o p y b e f o r e t re a t-

m e n t . I n a d d i ti o n , p a t ie n t s u n d e r w e n t a n a l a n d c o l o -

r e c t a l p h y s i o l o g i c s t u d i e s i n c l u d i n g c o l o n i c t r a n s i t

t im e , c i n e d e f e c o g r a p h y ( CD ) , a n al m a n o m e t r y , a n d

e l e c t r o m y o g r a p h y (E M G ) . T h e s e s t u di e s w e r e p e r -

f o r m e d a s p r e v i o u s l y d e s c r i b e d . 1' 6, r W h e n i n d i c a t e d ,

a ll p a t i e n ts u n d e r w e n t a c o m p r e h e n s i v e e v a l u a t i o n

s u c h a s b a r i u m e n e m a , c o l o n o s c o p y , b i o c h e m i c a l

a n d m e t a b o l i c p r o f i l e , s m a l l b o w e l t r a n s i t , o r p s y c h i -

a t r ic c o n s u l t a t i o n t o e x c l u d e o r g a n i c c a u s e s o f c o n st i -

p a t i o n .

Def i n i t i ons

C o l o n i c i n e rt ia h a s b e e n d e f i n e d a s t h e p r e s e n c e o f

a t l e a st 8 0 p e r c e n t o f tr a n s it m a r k e r s s c a t t e r e d d if -

f u s e l y th r o u g h o u t t h e c o l o n o n t h e f i ft h d a y a f te r

i n g e s t i o n . 8 P a t i e n ts w i t h p a r a d o x i c a l p u b o r e c t a l i s

c o n t r a c t i o n , r e c t o a n a l i n t u s s u s c e p t i o n , s i g m o i d o c e l e ,

r e c t o c e l e , o r r e c t a l p r o l a p s e w e r e c l a s s i f i e d a s h a v i n g

p e l v i c o u t l e t o b s t r u c t i o n . 9 -1 3 P a r a d o x i c a l p u b o r e c t a l i s

c o n t r a c t i o n w a s d e f i n e d b y t h e f i n d in g o f a t l ea s t t w o

o f t h e t h r e e f o l l o w i n g a b n o r m a l i t ie s : r e t e n t i o n o f a t

l e a st 2 0 p e r c e n t o f th e c o l o n i c m a r k e r s i n th e r e c t u m

o n t h e f i f th d a y o f t h e c o l o n i c t r a n s it t i m e s t u d y ,

i n ab i li ty t o a c h i e v e r a p i d a n d c o m p l e t e e v a c u a t i o n o f

2 0 0 m l ( 5 00 g ) o f b a r i u m p a s t e o n C D w i t h l a c k o f a

m e a s u r a b l e i n c r e a s e i n t h e a n o r e c t a l a n g l e b e t w e e n

r a d i o g r a p h i c v i e w s t a k e n a t re s t a n d d u r i n g a t t e m p t e d

e v a c u a t i o n , a n d a p a r a d o x i c a l i n c r e a s e i n p u b o r e c -

t a l i s n e u r o m u s c u l a r a c t i v i t y d u r i n g E M G . R e c t o a n a l

i n t u s s u s c e p t i o n w a s d e f i n e d a s a c ir c u m f e r e n t i a l i n -

f o l d i n g o f m o r e t h a n 4 m m o f r e c t a l m u c o s a . 14 S ig -

m o i d o c e l e w a s d e f i n e d a s a d e e p r e c t o v a g in a l fo s s a

w i t h a n e l o n g a t e d l o o p o f si g m o i d e x t e n d i n g c a u d a l -

l y. 15 I t w a s d i a g n o s e d a n d c l a s si f ie d b a s e d o n t h e

d e g r e e o f d e s c e n t o f t h e l o w e s t p o r t i o n o f th e s i g m o i d

o n C D . R e c t o c e l e is a h e r n i a t i o n o f t h e a n t e r i o r r e c t a l

a n d p o s t e r i o r v a g in a l w a l ls i n t o t h e l u m e n o f th e

v a g in a . A r e c t o c e l e w a s d e f i n e d a s a n y h e r n i a t i o n o f 3

c m o r m o r e i n d i a m e t e r o c c u r r i n g d u r i n g d e f e c a t i o n

o r st r a in i n g. R e c t a l p r o l a p s e w a s d e f i n e d a s p r o c i d e n -

t ia o f t h e f u l l t h i c k n e s s o f t h e r e c t u m t h r o u g h t h e a n a l

c a n a l . S i g m o i d o c e l e , r e c t o c e l e , in t u s s u s c e p t i o n , a n d

p r o l a p s e w e r e a l l d i a g n o s e d b y C D .

Cons t i pa t i on Scor i ng Sys t em

T h e c o n s t i p a t i o n s c o r in g s y s t e m w a s d e r i v e d b a s e d

o n a n s w e r s t o t h e q u e s ti o n s i n th e s y m p t o m q u e s t i o n -

n a i r e .

Statistical nalysis

P e a r s o n ' s c o r r e l a t i o n c o e f f i c i e n t a n a l y si s w a s u s e d

t o c o m p a r e q u a n t i f i e d v a l u e s a n d t h e u n p a i r e d t - t e s t

w h e n q u a l i t a t i v e d a t a w e r e r e q u i r e d . A s s o c i a t i o n o f

q u a l i t a ti v e v a l u e s w e r e v e r i f i e d b y c h i - s q u a r e d a n a l -

y s i s w i t h Ya t e s ' c o r r e c t i o n , wh e n p o s s i b l e . S t a t i s t i c a l

s i g n i f i c a n c e wa s P < 0 .05 .

R E S U L T S

A t o ta l o f 23 2 p a ti e n t s ( 1 85 w o m e n a n d 4 7 m e n )

w i t h a m e a n a g e o f 6 4 . 9 ( r a n g e , 1 4 - 9 2 ) y e a r s w a s

a s s e s s e d . A l l p a t i e n t s h a d a d i a g n o s i s o f c o n s t i p a t i o n ,

w i t h a m e a n d u r a t i o n o f 1 6 .8 y e a r s ( r a n g e , 3

m o n t h s - 7 2 y e a r s ) . C o l o n i c t r a n s i t t i m e , a n a l m a n o m -

e t r y , E M G , o r C D c o n f i r m e d t h e p r e s e n c e o f c o n s t i-

p a t i o n i n a l l p a t i e n t s . S i x t y -e i g h t o f t h e s e 2 3 2 p a t i e n t s

h a d c o l o n i c i n e rt ia , a n d 1 6 4 h a d p e l v i c o u t l e t o b s t r u c -

t i o n a t t r ib u t a b l e t o o n e o r m o r e o f t h e f o l l o w i n g :

p a r a d o x i c a l p u b o r e c t a l i s c o n t r a c t i o n ( 8 1 ) , r e c t o a n a l

i n t u s s u s c e p t i o n ( 6 4 ) , s i g m o i d o c e l e ( 3 6 ) , r e c t o c e l e

(4 8 ) , a n d r e c t a l p ro l a p s e (9 ) .

B a s e d o n s t a t i s t i c a l a n a l y s i s , e i g h t v a r i a b l e s we re

s e l e c t e d f o r t h e s c o r i n g s y s te m . T h e s e i t e m s i n c l u d e

f r e q u e n c y o f b o w e l m o v e m e n t s , p a i n f u l e v a c u a t i o n ,

i n c o m p l e t e e v a c u a t i o n , a b d o m i n a l p a i n , l e n g t h o f

t i m e p e r a t t e m p t , a s s i s t a n c e f o r d e f e c a t i o n , u n s u c -

c e s s f u l a t t e m p t s f o r e v a c u a t i o n p e r 2 4 h o u r s , a n d

d u r a t i o n o f c o n s t i p a t i o n ( T a b l e 1 ) . A s c o r i n g r a n g e o f

0 t o 4 ( w i t h t h e e x c e p t i o n o f a s s i st a n c e f o r d e f e c a -

t i o n , w h i c h i s 0 - 2 ) w a s d e r i v e d . T h e g l o b a l s c o r e w a s

o b t a i n e d b y a d d i n g e a c h i n d i v i d u a l s c o r e . A s c o r e o f

m o r e t h a n 15 w a s t h e d e f i n i ti o n o f t h e s y m p t o m

c o n s t i p a t i o n i n t h i s s t u d y . P a t i e n t s w i t h e t i o l o g i e s

b a s e d o n m e c h a n i c a l , p h a r m a c o l o g i c , m e t a b o l i c , e n -

d o c r i n e , o r n e u r o g e n i c r e a s o n s w e r e e x c l u d e d .

P e a r s o n ' s l i n e a r c o r r e l a t i o n t e st e s t i m a t e d t h e s e v e r -

i t y o f c o n s t i p a t i o n u s i n g t h e s e e i g h t p a r a m e t e r s ; h o w -

e v e r , t h e s e p a r a m e t e r s c a n b e b i a s e d b y t h e s t u d y

g r o u p s ' c r i t e r i a a n d c h a r a c t e r i s t i c s . T o p r e v e n t t h i s

e r r o r , a v a l i d a t i o n s a m p l e w a s e s t a b l i s h e d . B e f o r e

e v a l u a t i n g a l l c a s e s , p i l o t g r o u p s o f 5 0 c o n s t i p a t e d

a n d 5 0 n o n c o n s t i p a t e d p a t ie n t s c o n f i r m e d b y p h y s i -

o l o g i c s t u d i e s w e r e r a n d o m l y s e l e c t e d . T h i s s t u d y

c o r r e c t l y p r e d i c t e d t h e a c t u a l r e s u lt s ( T a b l e 2 ). T h i s

p i lo t g r o u p v a l i d a t e d t h e a c c u r a c y o f t h e c o n s t i p a t io n

s c o r i n g s y s te m , a n d s u b s e q u e n t l y , t h e e n t i r e s t u d y

g r o u p w a s a s s e s s e d . U s i n g t h e P e a r s o n ' s l i n e a r c o r r e -

l a t i o n te s t, e i g h t o f th e g e n e r a t e d f a c t o r s h a d a s i g n if -

i c a n c e l e v e l o f P < 0 .0 5 ; 97 p e r c e n t o f t h e e n t i r e

g r o u p h a d a s c o r e g r e a t e r t h a n 1 5.

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Vol. 39, No. 6

T a b l e 1 .

C o n s t i p a t io n S c o r i n g S y s t e m M i n i m u m S c o r e , 0;

M a x i m u m S c o r e , 3 0 )

CONSTIPATION SCORING SYSTEM 683

samples in both groups had scores under 8, with a

mean score of 2.1 in Group I and 3.4 in Group II.

F r e q u e n c y o f b o w e l m o v e m e n t s S c o r e

1 - 2 t im e s p e r 1 - 2 d a y s 0

2 t im e s p e r w e e k 1

O n c e p e r w e e k 2

L e s s t h an o n c e p e r w e e k 3

L e s s t h a n o n c e p e r m o n t h 4

D i f f i cu l t y : pa i n f u l evacua t i on e f f o r t

N e v e r 0

R a r e l y 1

S o m e t i m e s 2

U s u a l l y 3

A l w a y s 4

C o m p l e t e n e s s : f e e l i n g i n c o m p l e t e

e v a c u a t i o n

N e v e r 0

R a r e l y 1

S o m e t i m e s 2

U s u a l l y 3

A l w a y s 4

P a i n : a b d o m i n a l p a i n

N e v e r 0

R a r e l y 1

S o m e t i m e s 2

U s u a l l y 3

A l w a y s 4

T i m e : m i n u t e s i n l a v a t o r y p e r a t t e m p t

L e s s t h a n 5 0

5 1 0 1

1 0 2 0 2

2 0 - 3 0 3

M o r e t h a n 3 0 4

A s s i s ta n c e : t y p e o f a s s i s ta n c e

W i t h o u t a s s i s t a n c e 0

S t i m u l a t i v e l a x a t iv e s 1

D i g it a l a s s i s t a n c e o r e n e m a 2

F a i l u r e : u n s u c c e s s f u l a t t e m p t s f o r

e v a c u a t i o n p e r 2 4 h o u r s

N e v e r 0

1 - 3 1

3 - 6 2

6 - 9 3

M o r e t h a n 9 4

H i s t o ry : d u r a t i o n o f c o n s t i p a t i o n y r)

0 0

1 - 5 1

5 - 1 0 2

1 0 - 2 0 3

M o r e t h a n 2 0 4

After establishing the constipation scoring system,

two control groups were created. Group I consisted of

30 patients who were not constipated as confirmed by

physiologic studies. Group II consisted of 30 controls

who did not undergo any physiologic studies. All

DISCUSSION

Constipation is a common clinical complaint but a

poorly defined clinical constellation. It is difficult to

describe normal bowel function but most people

evacuate between three times per day and once every

three day s) Marginal inf requency beyond this may be

attributed to poor diet and frequently responds to

bulk laxatives. Recent demographic studies have

shown that 2 percent of the population in the United

States is affected by constipation.3 If conventional

investigations do not reveal any causative abnormal-

it-y, constipat ion is considered to be functional, which

makes application of functional tests that assess anal

and anorectal function mandatory for further evalua-

tion.16, 17

Several prior attempts have been made to study

constipation. Drossman and coworkers 18 surveyed

789 students and hospital employees and found that

17.5 percent strained at stool more than 25 percent of

the time. Moreover, 4.2 percent reported two or fewer

bowel movements per week. These figures were

slightly higher than Thompson and Heaton ~9 reported

in an earlier survey. Although the survey by Drossman

and colleagues ~s queried abdominal pain, distention,

and incomplete evacuation, it did so in the context of

diagnosis of irritable bowel syndrome rather than

constipation. Much data have been published regard-

ing psychological abnormalities in patients with con-

stipation. 2~ One prior publication included a com-

parison of symptoms and type of constipation. 24

In 1991, Pemberton

e t a l 25

clearly demonstrated

the importance in differentiating between slow transit

constipation and pelvic floor dysfunctions. Specifi-

cally, they found that 10 percent of a group of 277

thoroughly investigated, constipated patients had

slow transit constipation; 13 percent had pelvic floor

dysfunction, and 5 percent had both. The overwhelm-

ing majority of patients 70 percent) had irritable

bowel syndrome. Thus, although the success rate of

surgery for constipation was high in that series, the

authors cautioned against performing such surgery in

patients with irritable bowel syndrome.

Subsequently, that same group sought to classify

184 patients into one of the aforementioned groups

based on psychological distress and colorectal symp-

toms.

4

After a thorough evaluation, the authors were

unable to assign significance to correlation between

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684

AGACHAN

ET L

Dis Colon Rectum, June 1996

Table 2 .

Va l ida t ion Sam ple 100 Cases)

P r e d i c t e d U n p r e d i c t e d

Constipation C o n s t i p a t i o n

C o n f i r m e d c o n s t i p a t i o n 4 9 1

U n c o n f i r m e d c o n s t i p a t i o n 3 4 7

A t o t a l o f 9 6 o f c a s e s w e r e c o r r e c t l y p r e d ic t e d ( P <

0.05).

C O N C L U S I O N

D e v e l o p m e n t o f a c o n s t i p a ti o n s c o r in g s y s t e m w a s

d e r i v e d t o o b t a i n a u n i v e r s a l l y o b j e c t i v e d e f i n i t i o n o f

c o n s t i p a t i o n t o a s s i s t i n t h e d i a g n o s i s a n d t r e a t m e n t

o f c o n s t i p a t e d p a t i e n t s . I n i t i a l c l i n ic a l v a l i d a t i o n

p r o v e d t h i s s c o r in g s y s t e m t o b e a c c u r a te . F u r t he r

p r o s p e c t i v e e v a l u a t i o n i s w a r r a n t e d t o a s c e r ta i n i m -

p a c t o n t h e r a p e u t i c d e c i s i o n - m a k i n g .

s y m p t o m s a n d t y p e o f c o n s t i p a ti o n . S i g ni fi c an t c o r re -

l a t i o n i n c l u d e d n o r m a l t r a n s i t c o n s t i p a t i o n w i t h i n -

c r e a s e d d e p r e s s i o n s c o r e s, g e n e r a l s e v e r i t y i n d e x

w i t h t o t a l c o l o n i c t r a n si t, a n d a f e e l i n g o f a n a l b l o c k -

a g e w i t h p e l v i c f l o o r d y s f u n c t i o n .

T h i s s tu d y d e m o n s t r a t e s t h e u s e o f a c o n s t i p a t io n

s c o r i n g s y s t e m in a s s e s s i n g p a t i e n t s w i t h c o n s t i p a t i o n .

I t a l s o c o n f i r m s t h e u n r e l i a b i l it y o f s o m e o f t h e p a -

r a m e t e r s w h e n t h e y a r e u s e d a l o n e t o d e f i n e c o n s t i -

p a t i on . F o r e x a m p l e , s t o o l f r e q u e n c y i s m o d u l a t e d b y

t h e v o l u n ta r y a n d s u b je c t iv e c o m p o n e n t s o f de f e c a -

t i o n a n d d o e s n o t c o r r e l a t e w i t h t r a n s i t t i m e s , a l s o

t a k i n g i n t o a c c o u n t s t o o l w e i g h t a n d t h u s r e f l e c ts

b e t t e r s t o o l o u t p u t .

T h e p a t i e n t s i n t h i s s t u d y s h o w e d t w o d i f f e r e n t

p r o f i l e s . P a t i e n t s i n t h e c o l o n i c i n e r t i a g r o u p w e r e

p r e d o m i n a n t l y f e m a l e s , w i t h a c h r o n i c h i s t o ry o f c o n -

s t i p a t i o n u n r e s p o n s i v e t o n u m e r o u s t r e a t m e n t r e g i -

m e n s . T h e y r e p o r t e d a b d o m i n a l d i s te n t i o n a n d d i s -

c o m f o r t b e t w e e n i n f re q u e n t e v a c u a t io n s . T h e y w e r e

u n a b l e t o h a v e s p o n t a n e o u s e v a c u a t i o n s a n d g e n e r -

a l ly e x p e r i e n c e d b e t t e r r e s u lt s w i t h l a x a t i v es t h a n

w i t h e n e m a s , s u p p o s i t o r i e s , o r d i g i t a t i o n .

I n th e p e l v i c o u t l e t g r o u p , a c o m b i n a t i o n o f f in d -

i n g s w a s o b s e r v e d , i n c l u d i n g a h i s t o r y o f d i ff i cu l t a n d

i n c o m p l e t e e v a c u a t i o n , w h i c h o f t e n re q u i r in g d i gi ta -

t io n . T h is g r o u p o f p a t i e n t s w a s u n a b l e t o h a v e s p o n -

t a n e o u s b o w e l e v a c u a t i o n s a n d g e n e r a ll y e x p e ri -

e n c e d b e t t e r r e s u lt s w i t h e n e m a s , s u p p o s i t o r i e s , a n d

d i g i t a t i o n t h a n w i t h l a x a t i v e s .

I n o u r s e r i e s o f 2 3 2 p a ti e n t s , w e d e f i n e d e i g h t

p a r a m e t e r s t h a t w e r e s i g n i f i c a n t i n p r e d i c t i n g c o n s t i -

p a t i o n , a s d e s c r i b e d e a r l i e r i n t h i s s t u d y r e p o r t . A f t e r

i d e n t i f y i n g t h e s i g n i f i c a n t p a r a m e t e r s a n d e s t a b l i s h i n g

t h e s c o r i n g s y s t e m , p a t i e n ts w e r e s c o r e d . A s s c o re s

i n c r e a s e d , a c o r r e s p o n d i n g s i g n i f i c a n t i n c r e a s e i n s e -

v e r i t y o f c o n s t i p a t i o n w a s n o t e d , t h u s v a l i d a t i n g t h e

a p p l i c a b i l i t y o f t h is c o n s t i p a t i o n s c o r i n g s y s t e m . T h u s ,

t h e c u r r e n t s t u d y h a d a d i f fe r e n t d e s i g n t h a n e i t h e r o f

t h e t w o p r e v i o u s s y m p t o m - r e l a t e d s u r v e y s . 18' 24

R E F E R E N E S

1 . W exner SD, Jage l m an DG. C ons t ipa t ion . Pos t g rad Adv

Colorectal Surg 1989;1:1-22.

2 . Whi tehead WE, Chaussade S, Corazziar i E, Kumar D.

R e p o r t o f a n i nt e rn a t io n a l w o r k s h o p o n m a n a g e m e n t o f

const ipat ion. In t J Ga st roentero l 1991;4:99-113.

3 . Sonne nberg A, Koch TR. Ep i dem i o l ogy o f cons t i pa t i on

in the Uni ted States . Dis Colon Rectum 1989;32:1-8 .

4 . Mann i ng AP, Thompson AG, Heat on KW, Mor r i s AF.

To wa rd posi t ive d iagnosis o f the i r ri table bow el . BMJ

1978;2:653-4.

5 . Jo rge JM, Wexner SD. Et i o l ogy and managemen t o f

fecal incont inence. Dis Colon Rectum 1993;36:77-97.

6 . Wexner SD, Marchet t i F, Salanga VD, Corredor C,

Jage l m an DG. Neurophy s i o l og i c assessmen t o f t he ana l

sphincters . Dis C olon Rectum 1991;34:606--12.

7 . W exn er SD, Marchett i F, Jag elm an DG. T he role o f

sph i nc t e rop l as t y fo r f eca l i ncon t i nence r eeva l ua t ed : a

p rospec t i ve phys i o l og i c and func t i ona l r ev i ew. Di s Co-

lon Rectum 1991;34:22-30.

8 . Hi n t onJM, L ennard - Jones JE , You ng AC. A new m et hod

fo r s t udy ing gu t t r ans i t t i mes us i ng r ad i oop aque mark -

ers. Gut 1969;10:842-7.

9 . Kui jpers JH, Blei jenberg G. The spast ic pelvic f loor

syndrom e: a cause o f cons t ipa t i on . Di s Co l on Rect um

1985;28:669-72.

10. van Tets WF, Kui jpers JH. In ternal rectal in tussuscep-

t ion-fact or fancy? Dis Colon Rectum 1995;38:1080-3.

11. H offm an MJ, Ko dne r IJ , F1T RD. In ternal in tussu scep-

t i on o f t he r ec t um: d i agnos i s and su rg ica l manage me n t .

Dis C olon R ectum 1984;27:435-41.

12. Joh ans son C, Ni l sson BY, Ho lst r6m B, Dolk A, Mel tgren

A . A s s o c i a t i o n b e t w e e n r e c t o c e l e a n d p a r a d o x i c a l

sphincter response. Dis Colon Rectum 1992;35:503-9.

13 . F rykman HM, Go l dberg SM. The su r i ga l t r ea t men t o f

rectal procident ia. Surg Gynecol Obstet 1969;129:

1225-30.

14. Jorg e JM, W exn er SD, Marchett i F, Rosato GO , Sul livan

M, Jage l man DG. How re l i ab l e a r e cu r r en t l y ava i l ab l e

me t hods o f measu r i ng t he ano rec t a l ang le? Di s Co l on

Rectum 1992;35:332-8.

15. J orge JM, Ya ng Y-K, W exn er SD. Incidenc e an d cl in ical

8/17/2019 Measure Constipation Scoring System

5/5

Vol. 39 No. 6

s i g n if i c an c e o f s i g m o i d o c e l e s a s d e t e r m i n e d b y a n e w

c l a s s i f i c a t i o n s y s t e m . D i s C o l o n R e c t u m 1 9 9 4 ; 3 7 :

1112-7 .

1 6 . M o o re -Gi l l o n V . Co n s t i p a t i o n : wh a t d o es t h e p a t i en t

mean ? J R S o c M ed 1 9 8 4 ; 7 7 :1 0 8 -1 0 .

1 7. M acD o n a ld A Bax t e r JN F in l ay 1 G. Id io p a t h i c s l o w

transi t const ipa t ion . B r J Surg 1993;80 :1107-11 .

1 8. Dro ssm an DA S an d i e r RS M cK ee DC L o v i t z AJ . Bo w el

p a t t e r n s a m o n g s u b j e c t s n o t s e e k i n g h e a l t h c a r e . G a s -

t ro en t e ro lo g y 1 9 8 2 ;8 3 :5 2 9 -3 4 .

1 9. T h o m p s o n W G H e a t o n K W . F u n c t i on a l b o w e l d i s o r-

d e r s i n a p p a r e n t l y h e a l t h y p e o p l e . G a s t r o e n t e r o l o g y

1980;79 :283-8 .

2 0. D e v r o e d e G R o y T B o u c h o u c h a M

et al

I d i o p a t h i c

co n s t i p a t i o n b y co lo n i c d y s fu n c t i o n : r e l a t i o n sh ip wi th

p er so n a l i t y an d an x i e t y . D i g Di s S c i 19 8 9 ;3 4 :1 4 2 8 -3 3 .

2 1. F I e y m e n S W e x n e r S D G u l i e d g e A D . M M P I a s s e s s m e n t

C O N S T I P A T I O N S C O R I N G S Y S T E M

6 8 5

o f p a t i en t s wi th fu n c t i o n a l b o w el d i so rd er s . D i s Co lo n

Rec tu m 1 9 9 3 ;3 6 :5 9 3 -6 .

2 2 . Wa ld A Bu rg io K Ho le v a K Lo ch er J . P sy ch o lo g i ca l

ev a lu a t i o n o f p a t ien t s wi th sev ere i d io p a th i c c o n s t i p a -

t i o n : wh ich i n s t ru men t t o u se . AmJ Gas t ro en t e ro l 1 9 9 2 ;

8 7 :9 7 7 -8 0 .

2 3 . W ald A Hin d s JP Caru a n a BJ. P sy ch o lo g i ca l an d p h y s -

i o lo g i ca l ch a rac t e r i s ti c s o f p a t ien t s wi th sev ere i d io -

p a th i c co n s t i p a t i o n . Gas t ro en t e ro lo gT 1989;97 :932-7 .

2 4 . Gro t z RL P e mb er to n JH Ta l l ey NJ Ra th DM Z in smei s -

t e r AR. Di sc r imin an t v a lu es o f p sy ch o lo g i ca l d i s t r es s

s y m p t o m p r o fi le s a n d s e g m e n t a l c o lo n i c d y s f u n c t i o n

in o u t p a t i en t s wi th sev ere i d io p a th i c co n s t i p a t i o n . Gu t

1994;35 :798-802 .

2 5. P e m b e r t o n J H R a t h D M I l s t m p D M . E v a l u a t io n a n d

su rg i ca l t r ea tm en t o f sev ere co n s t i p a t i o n . A n n S u rg

1991;214:403-11 .