title: Clinical and investigative assessment of constipation: a study from a referral center in western India.
abstract: BACKGROUND
  Constipation may be primary or secondary. Pathophysiologic subtypes of primary constipation are dyssynergic defecation (DD), slow (STC), and normal transit constipation (NTC). Clinical subtypes are functional constipation (FC) and constipation predominant IBS (C-IBS).
  
  
  OBJECTIVE
  The objectives of this paper are to study the clinical profile, categorize and compare various subtypes of primary constipation, and to assess the success of biofeedback therapy (BFT) in a non-randomized, uncontrolled open-label study among patients with DD.
  
  
  METHODS
  Consecutive constipation patients (April 2011 to December 2012) were evaluated. Patients <18 years and secondary constipation were excluded. FC and C-IBS were classified by Rome III module. All patients, after excluding secondary constipation, underwent anorectal manometry (ARM) with balloon expulsion test and colon transit study (CTS). Patients with DD were given BFT.
  
  
  RESULTS
  Out of 128 patients, 23 %, 58 %, and 19 % had secondary constipation, FC, and C-IBS, respectively. Ninety-nine patients had primary constipation. Among those with primary constipation mean age was 53.5 (21-86) years, (77 % males). Forty-six, 15, and 40 had NTC, STC, and DD, respectively. Out of those with DD, 34 had paradoxical anal contraction and 6 had impaired rectal propulsion. FC and C-IBS were clinically and pathophysiologically similar except for abdominal pain. Patients with DD were more likely to have history of finger evacuation, straining, incomplete evacuation, sensation of anorectal obstruction than no DD. Sixty-nine percent of the patients with STC had ≤3 stools/week compared to 37 % with NTC (p-value 0.018). Thirty out of 40 (75 %) patients with DD underwent BFT but 20 completed ≥4 sessions. Seventy percent with ≥4 sessions had improved complete spontaneous bowel movements (CSBM).
  
  
  CONCLUSIONS
  NTC was the most common subtype of primary constipation. Symptoms of finger evacuation, sensation of anorectal obstruction, incomplete evacuation, and straining were more prevalent in DD. ARM and CTS could easily identify patients with DD and STC.
authors.affiliation: Department of Gastroenterology, Jagjivan Ram Hospital, Maratha Mandir Marg, Mumbai, 400 008, India, drnimishpshah@yahoo.co.in.
authors.forename: Nimish
authors.initials: N
authors.lastname: Shah
authors.forename: Rajiv
authors.initials: R
authors.lastname: Baijal
authors.forename: Praveen
authors.initials: P
authors.lastname: Kumar
authors.forename: Deepak
authors.initials: D
authors.lastname: Gupta
authors.forename: Sandeep
authors.initials: S
authors.lastname: Kulkarni
authors.forename: Soham
authors.initials: S
authors.lastname: Doshi
authors.forename: Deepak
authors.initials: D
authors.lastname: Amarapurkar
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000473:pathology; D001676:Biofeedback, Psychology; D003112:Colonic Pseudo-Obstruction; D003248:Constipation / Q000145:classification / Q000503:physiopathology* / Q000628:therapy; D003672:Defecation / Q000502:physiology*; D005260:Female; D005772:Gastrointestinal Transit / Q000502:physiology*; D006801:Humans; D007194:India; D043183:Irritable Bowel Syndrome / Q000503:physiopathology; D008297:Male; D008365:Manometry / Q000379:methods; D008875:Middle Aged; D011446:Prospective Studies; D012007:Rectum / Q000473:pathology; D012017:Referral and Consultation; D055815:Young Adult