How Many Chronic Functional Constipations?
Enrico Corazziari, Danilo Badiali
Department of Gastroenterology I, University of Rome La Sapienza, Italy
Year of publication of this section : 1997
Chronic functional constipation is a symptomatologic manifestation that is not related to a single pathological entity, but rather represents the clinical expression of one or more alterations in the chain of processes which begin with the propulsion of the contents through the colon and end with fecal expulsion.
It presents with one or more symptomatologic manifestations which tend to characterize subgroups of patients. However different pathogenetic mechanisms may manifest with similar clinical symptoms which can, sometimes, be differentiated by the seriousness of the illness, the response to therapy, and different expressions of single symptoms. On the other hand patients with different clinical manifestations present with identical physiopathological alterations. The Rome Criteria (9) allow to identify patients with chronic constipation, basing exclusively on symptoms, but they, however, do not distinguish between the different forms of chronic constipation, nor these from dischezia and the constipation variant of the irritable intestine syndrome (Table 1).
It is therefore not surprising that expert clinicians have tried to identify different forms of chronic constipation based on symptoms, and that other attempts at classifying chronic constipation have been made on a physiopathologic basis in relation to functional alterations. These proposals and attempts at identifying have indeed undoubtably broadened the understanding of chronic constipation, but have also provided us with a series of terms which not only have never been satisfactorily organized in any classification, but which have been used interchangeably and whose meanings sometimes even clash, while physiopathologic criteria and purely clinical ones are frequently used indifferently within the same classification. This fact has added to the confusion over the definitions, clinical terms, and physiopathologic alterations which sometimes superimpose while at other times contrast, thus creating a virtual Tower of Babel where it is becoming more and more difficult to find a common language.
The current trend of clinical researchers is to interpret constipation as consequence of
- transit slowing through the colon
- alteration of the mechanisms of anorectal expulsion
- consequences of environmental factors
- psycological alterations
Even if the variety of terms used to define different subtypes of functional chronic constipation has added to our understanding of the complexity of this disturbance, there has not yet been a standardized classification of patients with constipation and this fact has added to the confusion over the definitions, and the problem of determining a common terminology and a standard model for patient management remains. It is not clear, for example, if it would be advantageous to try a purely clinical and/or physiopathologic approach to classification. An international group proposed19 a diagnostic approach based on classification steps:
1° step: to identify the presence or absence of constipation using the Rome Criteria
2° step: to evaluate possible transit slowing
3° step: to study the physiopathological mechanisms upon which therapy is based
However, this approach is also unable to overcome some relative inconsistencies:
Is transit time a reliable and repeatable measure ?
Is any physiopathological alteration pathogenetically relevant?
delayed colonic transit could be secondary to voluntary inhibition to defecate (12)
the study of pelvic-abdominal dissynergy is not always seen in the same patient and it is not always clinically relevant (13) (unpublished personal data).
ANEMGI is pleased to supports this interactive forum at its internet site so that a dialogue can be opened based on scientific criteria, or on a consensus basis where these criteria are missing, following these objectives:
- Acquire a common terminology for functional chronic constipation and its subtypes
- Propose a standard clinical approach for patients with chronic constipation
- Identify clinically relevant functional examinations
- Identify the physiopathologic alterations with pathogenetic value and differentiate them from secondary ones
- Propose a standard therapeutic approach