Measure Constipation Scoring System
Measure Constipation Scoring System
682
AGACHAN ET AL
Definitions
Colonic inertia has been defined as the presence of
at least 80 percent of transit markers scattered diffusely throughout the colon on the fifth day after
ingestion. 8 Patients with paradoxical puborectalis
contraction, rectoanal intussusception, sigmoidocele,
rectocele, or rectal prolapse were classified as having
pelvic outlet obstruction. 9-13 Paradoxical puborectalis
contraction was defined by the finding of at least two
of the three following abnormalities: retention of at
least 20 percent of the colonic markers in the rectum
on the fifth day of the colonic transit time study,
inability to achieve rapid and complete evacuation of
200 ml (500 g) of barium paste on CD with lack of a
measurable increase in the anorectal angle between
radiographic views taken at rest and during attempted
evacuation, and a paradoxical increase in puborectalis neuromuscular activity during EMG. Rectoanal
intussusception was defined as a circumferential infolding of more than 4 mm of rectal mucosa. 14 Sigmoidocele was defined as a deep rectovaginal fossa
with an elongated loop of sigmoid extending caudally. 15 It was diagnosed and classified based on the
degree of descent of the lowest portion of the sigmoid
on CD. Rectocele is a herniation of the anterior rectal
and posterior vaginal walls into the lumen of the
vagina. A rectocele was defined as any herniation of 3
cm or more in diameter occurring during defecation
or straining. Rectal prolapse was defined as procidentia of the full thickness of the rectum through the anal
canal. Sigmoidocele, rectocele, intussusception, and
prolapse were all diagnosed by CD.
Statistical Analysis
Pearson's correlation coefficient analysis was used
to compare quantified values and the unpaired t-test
w h e n qualitative data were required. Association of
qualitative values were verified by chi-squared analysis with Yates' correction, w h e n possible. Statistical
significance was P < 0.05.
RESULTS
A total of 232 patients (185 w o m e n and 47 men)
with a mean age of 64.9 (range, 14-92) years was
assessed. All patients had a diagnosis of constipation,
with a mean duration of 16.8 years (range, 3
months-72 years). Colonic transit time, anal manometry, EMG, or CD confirmed the presence of constipation in all patients. Sixty-eight of these 232 patients
had colonic inertia, and 164 had pelvic outlet obstruction attributable to one or more of the following:
paradoxical puborectalis contraction (81), rectoanal
intussusception (64), sigmoidocele (36), rectocele
(48), and rectal prolapse (9).
Based on statistical analysis, eight variables were
selected for the scoring system. These items include
frequency of bowel movements, painful evacuation,
incomplete evacuation, abdominal pain, length of
time per attempt, assistance for defecation, unsuccessful attempts for evacuation per 24 hours, and
duration of constipation (Table 1). A scoring range of
0 to 4 (with the exception of "assistance for defecation," which is 0-2) was derived. The global score was
obtained by adding each individual score. A score of
more than 15 was the definition of the symptom
"constipation" in this study. Patients with etiologies
based on mechanical, pharmacologic, metabolic, endocrine, or neurogenic reasons were excluded.
Pearson's linear correlation test estimated the severity of constipation using these eight parameters; however, these parameters can be biased by the study
groups' criteria and characteristics. To prevent this
error, a validation sample was established. Before
evaluating all cases, pilot groups of 50 constipated
and 50 nonconstipated patients confirmed by physiologic studies were randomly selected. This study
correctly predicted the actual results (Table 2). This
pilot group validated the accuracy of the constipation
scoring system, and subsequently, the entire study
group was assessed. Using the Pearson's linear correlation test, eight of the generated factors had a significance level of P < 0.05; 97 percent of the entire
group had a score greater than 15.
20 -30
More than 30
Assistance: type of assistance
Without assistance
Stimulative laxatives
Digital assistance or enema
Failure: unsuccessful attempts for
evacuation per 24 hours
Never
1-3
3-6
6-9
More than 9
History: duration of constipation (yr)
0
1-5
5-10
10-20
More than 20
Score
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
0
1
2
3
4
0
1
2
3
4
683
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 days) Marginal infrequency 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 abnormalit-y, constipation is considered to be functional, which
makes application of functional tests that assess anal
and anorectal function mandatory for further evaluation.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 ~9reported
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 regarding psychological abnormalities in patients with constipation. 2~ One prior publication included a comparison of symptoms and type of constipation. 24
In 1991, Pemberton e t al. 25 clearly demonstrated
the importance in differentiating between slow transit
constipation and pelvic floor dysfunctions. Specifically, 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 overwhelming 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 symptoms. 24 After a thorough evaluation, the authors were
unable to assign significance to correlation between
684
AGACHAN E T AL
Table 2.
Validation Sample (100 Cases)
Predicted Unpredicted
Constipation Constipation
Confirmed constipation
49
1
Unconfirmed constipation
3
47
A total of 96% of cases were correctly predicted (P <
0.05).
s y m p t o m s and type of constipation. Significant correlation included normal transit constipation with increased depression scores, general severity index
with total colonic transit, and a feeling of anal blockage with pelvic floor dysfunction.
This study demonstrates the use of a constipation
scoring system in assessing patients with constipation.
It also confirms the unreliability of some of the parameters w h e n they are used alone to define constipation. For example, stool frequency is modulated by
the voluntary and subjective c o m p o n e n t s of defecation and does not correlate with transit times, also
taking into account stool weight and thus reflects
better stool output.
The patients in this study s h o w e d two different
profiles. Patients in the colonic inertia group were
predominantly females, with a chronic history of constipation unresponsive to n u m e r o u s treatment regimens. They reported abdominal distention and discomfort b e t w e e n infrequent evacuations. They were
unable to have spontaneous evacuations and generally experienced better results with laxatives than
with enemas, suppositories, or digitation.
In the pelvic outlet group, a combination of findings was observed, including a history of difficult and
incomplete evacuation, which often requiring digitation. This group of patients was unable to have spontaneous b o w e l evacuations and generally experienced better results with enemas, suppositories, and
digitation than with laxatives.
In our series of 232 patients, we defined eight
parameters that were significant in predicting constipation, as described earlier in this study report. After
identifying the significant parameters and establishing
the scoring system, patients w e r e scored. As scores
increased, a corresponding significant increase in severity of constipation was noted, thus validating the
applicability of this constipation scoring system. Thus,
the current study had a different design than either of
the two previous symptom-related surveys. 18' 24
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