Gut, 1984, 25, 1352-1357

Different patterns of intestinal transit time andanorectal motility in painful and painless chronicconstipationG A LANFRANCHI, G BAZZOCCHI, C BRIGNOLA, M CAMPIERI, AND G. LABO

From the Istituto di Clinica Medica e Gastroenterologia dell'Universitd di Bologna, Bologna, Italy

SUMMARY Anorectal motility and gastrointestinal transit time were studied in 25 patientscomplaining of non-organic constipation. Colonic pain was reported by 14 patients, it was absentin the remaining 11. The group with painful constipation was composed of four men and 10women and age onset of the symptom was 22.1±5-1 years. The other group was composed onlyof women and painless constipation was reported to have begun at 7-9±2-2 years previously. Inthe group presenting painful constipation higher values of the anal maximum resting pressure, ofthe amplitude of the rectoanal inhibitory reflex, lower values of sensation threshold, need toevacuate, maximum tolerable volume were recorded, in comparison with those registered in thepainless constipation group. All these differences were significant. In the latter group the totaltransit time was always very slow (186.0±4-7 h), while it was quite variable in the other group, sothat the mean was in the normal range (79.0±10.0 h). The data show that two different patternsof motor abnormalities can be recognised in constipated patients. The presence of colonic paincan suggest the characteristics of the uniderlying motor abnormality.

Chronic functional constipation is caused bydisorders of colonic or rectal motility. Attempts tocharacterise a common underlying motorabnormality have led to disappointing conclusions.The most recent investigations report eitherincreased or reduced, and even normal, intraluminalpressure changes of the sigmoid colon' 2 and thesame results are registered regarding the reactivityof the internal anal sphincter to rectal distension.These contrasting findings may be because of a poordefinition of constipation and to the heterogeneityof the examined patients.The purpose of this study is to look for a

correlation among clinical pictures, gastrointestinaltransit time, and rectal motility in a group ofconstipated patients. It was considered useful todistinguish two groups of constipated patients: onecharacterised by painful constipation, the other bysimple constipation - that is, without abdominalpain. This distinction is generally accepted andreported by several other workers,81 but nodefinite pathophysiological interpretation has ever

Address for correspondence: Prof G A Lanfranchi, Istituto di Clinica Medica eGastroenterologia. Policlinico S. Orsola, Via Massarenti no. 9, 40138Bologna, Italy.Received for publication 21 February 1984

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been given to explain the different symptomato-logical patterns.

Methods

PATIENTSPatients admitted to our clinic complaining ofchronic severe constipation were asked to take partin our research. Twenty seven patients volunteeredto undergo all the following examinations: double-contrast barium enema, proctosigmoidoscopy,evaluation of intestinal transit time, and study ofrectal motility. Selection criteria included patientscomplaining of chronic constipation for more thanfive years, without any other digestive or systemicdisorders. At the end of the preliminary study, twopatients were excluded, one because Hirschprung'sdisease was diagnosed and one because thescheduled examinations were not completed. Thefinal study involved 25 patients.

Detailed information about the following wasobtained: frequency of spontaneous discharges, ageonset of constipation, laxative consumption, colonicpain, according to the criteria of Manning et al,11abdominal distension, and feeling of incompleteevacuation after defaecation. Total and segmentalcolonic transit time were investigated according to

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Different patterns in painful and painless chronic constipation

the method of Arhan et al.12 Briefly, 20 radio-opaque markers (sections of a 3 mm thick radio-opaque polyethylene nasogastric Portex tube of od 5mm) were ingested and plain film of the abdomenwas taken every 24 hours until at least 80% of themarkers was excreted, or for a maximum of eightdays. The markers were counted in three segmentsof the large bowel: right, left, and rectosigmoidarea. The mean transit time of the markers in everysegment of the large bowel was calculated accordingto the method reported by Arhan.12 Anorectalfunction was assessed by means of a constantlyperfused 1.2 mm diameter double lumen tube withside openings of 2 mm od. A third independent tubewas fastened to a rubber balloon (3x4 cm) for rectaldistension. The probe was connected to Beckmantransducers (4-327C) and to a Beckman recorder (R611) and then positioned in the rectal ampulla and inthe upper anal canal. The maximum resting pressurewas considered as the highest pressure in the analcanal at rest, recorded by the pull-throughtechnique. The reported values are the mean ofthree recordings. Rectal distension stimuli wereobtained by inflation of 5-10-20-50 ml air and so onfor 10 seconds with an interval of one minute untilpain sensation was elicited. The followingparameters were evaluated: maximum restingpressure of the anal canal, relaxation amplitude ofthe internal anal sphincter in response to balloondistension (rectoanal inhibitory reflex), rectaldistending volume for rectoanal inhibitory reflexthreshold, sensation threshold (perception of thedistending balloon), evacuation threshold (percep-tion of need to evacuate), maximum tolerablevolume (pain threshold). Treatments with highresidue diet or laxatives were stopped at least 15days before the experiment began.

Transit time data and manometric results werecompared with those previously obtained in acontrol group of 15 subjects without any gastro-intestinal disorder, and balanced for age and sex.The analysis of variance showed that theseparameters were not different from those recordedin the patients group.

Results

On the basis of the presence of colonic pain, it waspossible to distinguish two groups of patients: oneincluding 14 subjects with painful constipation andthe other including 11 subjects with painlessconstipation. In the painful constipation group onlytwo patients reported spontaneous discharges everythree to five days and an irregular use of laxatives orenemas; in the painless constipation group only onepatient reported spontaneous discharge about every

eight days. As for the remaining patients of bothgroups, evacuation was always induced by theregular use of laxatives and enemas. Feeling ofincomplete evacuation after defaecation wasreported by all the patients of the painfulconstipation group except one and abdominaldistension by all of them except two, while in thepainless constipation group these symptoms werereported less frequently, with a statisticallysignificant difference (Fig 1).

FEATURES OF THE GROUPSThe painless constipation group was composed onlyof women: mean age 42*1±6.3 years (range: 16-80years). The painful constipation group wascomposed of 10 women and four men: mean age46.0±2-9 years (range: 23-62 years). The age onsetof constipation is shown in Figure 2. Constipationappearing in the first 10 years of life in 81.8% of thepatients belonging to the painless constipation groupand only in 42.8% of those of the painfulconstipation group (p<005, x2 test with Yates'variation).

INTESTINAL TRANSIT TIMEIn the control population the upper limit of theexcretion of 80% of the radio-opaque markers was96 h (Fig. 3). The mean total transit time recorded in

PC Grou (n=l4) -~PLC Group (n_tl1) apc05 *

_~ ~~~~~~~~~~~~~~~__~~~~~~~~~.

* _ _~~~,

1>

80__

_1

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Fig. 1 Percentage ofpatients related to reported symptomsand to regular use of laxatives and enemas in groups withpainful constipation (PC) and painless constipation (PLC).Difference between the two groups is significant with regardto 'feeling ofincomplete evacuation' and 'abdominaldistension' by X2 with Yates' variation.

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Lanfranchi, Bazzocchi, Brignola Campieri, and Labo'

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50

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20

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Fig. 2 Age onset ofconstipation in the groups withconstipation (PC) and painless constipation (PLC).Difference between the means is significant by Stude,t testfor unpaired data.

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the painful constipation group was 79.0 + 10.0 h.The analysis of the trend recorded for each patientshowed that the total transit time was within thenormal limit in 11 patients out of 14: mean 63.3±7.5(range 20-88 h). The total transit time was higherthan 96 h in the remaining three subjects: mean140±2.3 (range 136-144 h). In the painlessconstipation group the total transit time was alwaysbeyond the normal limit: mean 186-0±4.7 (range140-192 h).The study of segmental colonic transit time

showed that in all the three patients of the painfulconstipation group presenting slow total transit time

0 the delay was recorded at the left colon level and inone of them also at the rectosigmoid area level.Furthermore, the markers were retained in the leftcolon for a longer number of hours than in controlsin two patients with normal total transit time. In all

o these five patients the mean transit time in the leftcolon was 65*7±80, while the upper limit in

0 controls was 39 hours. In the painless constipation°°U_ group, segmental transit time was found to be00 delayed in 10 patients out of 11 at the left colon level000O (mean 83-7±9-6 h), but' also at the right colon levelC Group in six of them (mean 78-0±14*6 h, versus an upper

=11l ) normal limit of 38 h) and/or at the rectosigmoid arealevel in four of them (mean 60.6±15.6 h, versus an

painful upper normal limit of 35 h). The transit was slownt's in all the three segments only in two cases, and in

one case it was delayed in the rectosigmoid tract(105.6 h).

n -14)1

Kr

24 48 72 96 120 14 1Tine after gestion ( hors)

Fig. 3 Number ofmarkers retained in large bowel indifferent days ofthe study. Normal range is represented bythe shaded area. In groups with painful constipation (PC)and painless constipation (PLC) results are expressed asmean ± SEM. Differences are always significant, except thefirst day (Student's t testfor unpaired data).

RADIOLOGICAL AND SIGMOIDOSCOPICALFINDINGSBarium enema did not show any organic lesion in allthe patients who were examined: dolicocolon(defined as an elongated, tortuous colon) wasregistered in six cases (42.8%) of the painfulconstipation group and in seven cases (63.9%) of thepainless constipation group. Megarectum (definedas a dilatation of the rectum and sigmoid tract risingout of the pelvis) was recorded in two patients of thepainless constipation group.

Sigmoidoscopy showed only haemorroids, andeven these seldom, with similar severity andfrequency in the two groups (20% in the painfulconstipation group and 32*4% in the painlessconstipation group).

RECTAL MOTILITY STUDYThe anal canal maximum resting pressures areshown in Figure 4. The mean of the painfulconstipation group was much higher than the normalrange and the pressure was within normal limits inonly two patients; the mean of the painlessconstipation group was within the normal range,

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130'

1209

710c

100

mmHg

0

0

0.00

00B

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£01

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*PC &p(ni"

a

0

0

PLC Or~a'S..Fig. 4 Maximum resting pressure ofanal canal in patientswith painful constipation (PC) and with painlessconstipation (PLC). Difference between mean ofthe twogroups is significant by Student's t testfor unpaired data.Shaded area represents range of values recorded in normalgroup.

though a remarkable dispersion of the values wasrecorded.The rectoanal inhibitory reflex amplitude at the

progressive distending volumes was constantlygreater in the painful constipation group than in thepainless constipation group (Fig. 5) at each step ofinflation. The means of the rectoanal inhibitoryreflex amplitudes were, respectively, in the upperand lower areas of the normal range. A linearrelation between the different rectoanal inhibitoryreflex amplitudes and logarithm of rectal distendingvolumes was found in both groups. The rectoanalinhibitory reflex duration (Fig. 6) did not differ inthe two groups and it was always within the normalrange for all the volumes of rectal distension. Alinear relation between the rectoanal inhibitoryreflex duration and the distending volume logarithmwas found. The rectal distending volume necessaryto induce the rectoanal inhibitory reflex appearancewas 12-8±1-4 in the painful constipation group and19-0+±33 ml air in the painless constipation group(Fig. 7).The sensation threshold was reported at 260+±5.5

ml air inflated in the rectal balloon in the painful

0 5 10 20 30 50 70 101502o0-Rectcl dbd olu*m (ml)

Fig. 5 Relation between rectoanal inhibitory reflex (RAIR)amplitude (mean ± SEM) and logarithm ofrectaldistending volume in patients with painful constipation (PC)andpainless constipation (PLC). Difference betweenamplitudes in two groups was significant only at 20 ml andat subsequent volumes by Student's t testfor unpaired data.Shaded area represents range of values ofnormal group.

44 PC Gmp (n14)PLC GrL X(n-11) o

ci

Recl di~sm oke (ml)

Fig. 6 Relation between rectoanal inhibitory reflex (RAIR)duration (mean ± SEM) and logarithm ofrectal distendingvolume in group with painful constipation (PC) and ingroup with painkess constipation (PLC). Shaded arearepresents the range ofthe control group's values.

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*W~ lobgoI .* ..

.0p *0

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550 p

PC Gup(nn14))-PLC Gro (n=11) °pc005 :*Ip<-Ot ***p.0_001 ***

E

40

.7

8

200

100

0

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00

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00.

25 '-,

.RAIR T STm.ET

Fig. 7 Rectal distending volume for rectoanalireflex (RAIR) threshold (RAIR T), sensation thi(ST), evacuation threshold (ET), and maximurrvolume (MTV) in patients with painful constipaiand in patients with painless constipation (PLC)area represents range ofcontrol group's values.,analysis was performed by Student's t testfor un

constipation group and at 49-0±10O4 mlpainless constipation group. The ethreshold was reported at 75*0±12*4 mlpainful constipation group and at 174*0±,in the painless constipation group. Thetolerable volume was at 170.0±11-0 mlpainful constipation group and 372 0±25.the painless constipation group. Forsensory parameters, the differencebetween the two groups was always ssignificant.

Discussion

In our series of patients complaining of co]scattered results were found. If we copresence of colonic pain as a diffeelement, however, then the trend ofclinical and motor parameters seems tomore uniform pattern within the twogroups.The first group (painful constipal

characterised by constipation associatetransit time at an upper limit of nornpatients complained of abdominal diste

o feeling of incomplete evacuation. The tests of rectalsensation and the rectoanal distension reflex showednormal thresholds for rectal sensitivity and rectoanalinhibitory reflex, high maximum resting pressure of

Cooo the anal canal with greater inhibition of internal analsphincter to rectal distension both in patients with

coo normal and with slow transit time. Conversely, thesecond group (painless constipation) was character-ised by constipation associated with a long total

*<<. .Xtransit time. Rectal motility investigations showedhigher thresholds for rectal sensitivity, lowermaximum resting pressure of the anal canal withreduced relaxation amplitude of internal anal

-o'M sphincter to rectal distension. The painfulconstipation group may fit the definition of thecolonic motor disorder used by some workersspastic constipation', which is considered one of thevarious forms of the irritable bowel syndrome. Thehyperactivity of the internal anal sphincter (highmaximum resting pressure and great relaxation)may be regarded as the local aspect of a motor

MTV disorder involving the whole colonic smooth muscle.

nhibitory In this group, a slow intestinal transit time is not an

rnhold important and constant feature, but symptoms suchresroble as pain and abdominal distension are related to a

nton (PC) transient entrapment of gas and stools. The painless). Shaded constipation group may fall within what is calledStatistical 'atonic constipation', or 'idiopathic constipation', oripaired data. 'colonic inertia', or 'simple constipation', and its

pathogenesis may be because of a reduced motoractivity caused, at least in part, by a defect of colonic

air in the wall sensitivity, which we found at the rectalvacuation ampulla level. This deficiency may be the onlyair in the explanation of the reduced resting pressure of the28.0 ml air anal canal and rectoanal inhibitory reflex amplitude,maximum even if the possibility of a primary hypoactiveair in the sphincter cannot be excluded. The peculiar clinical

*5 ml air in feature is the lack of abdominal pain, evenall these distension is rarely reported. The assumption thatregistered the internal anal sphincter pattern reflects a similartatistically motor abnormality of the sigmoid colon seems to be

confirmed in the recent observation reported byPreston and Lennard Jones13 who distinguishbetween constipation with normal and slowintestinal transit: a high motility index of the

nstipation, sigmoid colon was recorded in the first group, whileInsider the a very low motility index was registered in the-rentiating second one.the other In both groups of patients the transit time of theassume a markers from ingestion to the arrival at the largeresulting bowel was always within 24 hours - that is, within

the normal range, which confirms that constipationtion) was is a problem related principally to the colon and thatd with a it does not involve the other segments of themal; most gastrointestinal tract. As regards segmental transitnsion and time, the major role in delaying the progression of

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Different patterns in painful and painless chronic constipation 1357

the markers seemed to be played by the left colon,both in the painful constipation group and in thepainless constipation group. In the latter group theslackening may also be at level of other tracts of thelarge bowel. Dischezia was found only in onepatient; so far, the relevance of 'outlet obstruction'in the pathogenesis of constipation3 is notconfirmed.The prevalence of women patients was

remarkable in the painful constipation group andtotal in the painless constipation group. In the lattergroup constipation was generally reported from thefirst years of life. Therefore, an inherited sex linkedalteration may be inferred. Dolicocolon and mega-rectum were found at radiological examination, innine patients with painless constipation out of 11.

In conclusion, our results suggest the existence oftwo different disorders with two different patho-physiologic mechanisms and stress the importanceof total transit time evaluation in each patientcomplaining of constipation, particularly if painful.Finally, the evaluation of the internal anal sphincterbehaviour may become one of the criteria for thepositive diagnosis of functional chronic constipation.

This paper has been partly submitted as an abstractat the 9th International Symposium on Gastro-intestinal Motility in Aix-en-Provence, France,September 1983, and accepted for oral presentation.

References

1 Meunier P, Rochas A, Lambert R. Motor activity of

the sigmoid colon in chronic constipation: comparativestudy with normal subjects. Gut 1979; 20: 1095-11101.

2 Chowdury AR, Dinoso VP, Lorber SM. Character-isation of hyperactive segment at the rectosigmoidjunction. Gastroenterology 1976; 71: 584-8.

3 Martelli H, Devroede G, Arhan P et al. Mechanism ofidiopathic constipation: outlet obstruction. Gastro-enterology 1978; 75: 623-31.

4 Meunier P, Marechal JM, Jaubert de Beaujeu M.Recto-anal pressures and rectal sensitivity studies inchildhood chronic constipation. Gastroenterology 1979;77: 330-6.

5 Orr WC, Robinson MG. Motor activity of the recto-sigmoid in patients with chronic constipation.[Abstract] Gastroenterology 1981; 80: 1244.

6 Behar J, Biancani P. Rectal motility studies in patientswith chronic functional constipation. [Abstract] Gastro-enterology 1982; 82: 1015.

7 Marzio L, Lanfranchi GA, Trento L, Labo G. Analmanometry in constipated patients. Gastroenterology1979; 76: 1080-1.

8 Bockus HL. Simple constipation. In: Bockus HL, ed.Gastroenterology. Vol. 2. Section IV. Philadelphia,London, Toronto: Saunders, 1976: 936-53.

9 Schuster MM. Megacolon in adults. In: Sleisinger MH.Fordtran JS, eds. Gastrointestinal disease. Philadelphia.London, Toronto: Saunders, 1978: 1812-24.

10 Thompson WG, Heaton KW. Functional bowel dis-orders in apparently healthy people. Gastroenterology1980; 79: 283-8.

11 Manning AP, Thompson WG, Heaton KW, MorrisAF. Towards positive diagnosis of the irritable bowel.Br Med J 1978; 2: 653-4.

12 Arhan P, Devroede G, Jehannin B, et al. Segmentalcolonic transit time. Dis Colon Rectum 1981; 24: 625-9.

13 Preston DM. Lennard Jones JE. Does failure ofbisacodyl-induced colonic peristalsis indicate intrinsicnerve damage? [Abstract] Gut 1982; 23: A891.

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