Altomare D F, Portincasa P, Rinaldi M, Di Ciaula A, Martinelli E, Amoruso A, Palasciano G, Memeo V
Istituto di Clinica Chirurgica, University of Bari Medical School, Italy.
Dis Colon Rectum. 1999 Feb;42(2):231-40. doi: 10.1007/BF02237134.
Autonomic neuropathy is thought to play a role in the pathogenesis of slow-transit constipation, but other gastrointestinal organs may also be involved, even if they are symptom-free. We investigated whether motility in gastrointestinal organs other than the colon was impaired in patients with slow-transit constipation and whether the autonomic nervous system was involved.
Twenty-one consecutive patients (18 females; median age, 46 years) with severe chronic constipation (< or = 2 defecations/week and delayed colonic transit time) were studied. Autonomic neuropathy function was tested with esophageal manometry, gastric and gallbladder emptying (fasting and postprandial motility) by ultrasonography, orocecal transit time (H2-breath test), colonic transit time (radiopaque markers), and anorectal volumetric manometry. The integrity of the autonomic nervous system was assessed by a quantitative sweat-spot test for preganglionic and postganglionic fibers, tilt-table test, and Valsalva electrocardiogram R-R ratio.
Esophageal manometry showed gastroesophageal reflux or absence of peristalsis in five of the seven patients examined. Gallbladder dysmotility (i.e., increased fasting, postprandial residual volume, or both) was observed in 6 of 14 (43 percent) patients. Gastric emptying was decreased in 13 of 17 (76 percent) patients. Orocecal transit time was delayed in 18 of 20 (90 percent) patients; median transit time was 160 (range, 90-200) minutes. Median colonic transit time was 97 (range, 64-140) hours. Anorectal function showed abnormal rectoanal inhibitory reflex and decreased rectal sensitivity in 11 of 19 (58 percent) patients. Signs of autonomic neuropathy of the sympathetic cholinergic system were found in 14 of 18 (78 percent) patients. Only one of nine patients had vagal abnormalities detected with the Valsalva test and four of five patients with a history of orthostatic hypotension had a positive tilt-table test.
Slow-transit constipation may be associated with impaired function of other gastrointestinal organs. More than 70 percent of patients with slow-transit constipation present some degree of autonomic neuropathy. Severe constipation may be the main complaint in patients with a systemic disease involving several organs and possibly involving the autonomic nervous system. This should be considered in the management of such cases.
自主神经病变被认为在慢传输型便秘的发病机制中起作用，但即使没有症状，其他胃肠道器官也可能受累。我们研究了慢传输型便秘患者结肠以外的胃肠道器官运动功能是否受损以及自主神经系统是否参与其中。
对21例连续性严重慢性便秘患者（18例女性；中位年龄46岁，排便次数≤2次/周且结肠传输时间延迟）进行研究。通过食管测压、超声检查胃和胆囊排空情况（空腹及餐后运动）、口盲肠传输时间（氢气呼气试验）、结肠传输时间（不透X线标志物）以及肛门直肠容积测压来检测自主神经病变功能。通过定量汗斑试验检测节前和节后纤维、倾斜试验以及瓦尔萨尔瓦动作心电图R-R比值来评估自主神经系统的完整性。
食管测压显示，在接受检查的7例患者中，有5例存在胃食管反流或无蠕动。14例患者中有6例（43%）观察到胆囊运动障碍（即空腹、餐后残余容积增加或两者均增加）。17例患者中有13例（76%）胃排空减少。20例患者中有18例（90%）口盲肠传输时间延迟；中位传输时间为160（范围90 - 200）分钟。结肠中位传输时间为97（范围64 - 140）小时。19例患者中有11例（58%）肛门直肠功能显示直肠肛门抑制反射异常且直肠敏感性降低。18例患者中有14例（78%）发现交感胆碱能系统自主神经病变的体征。在9例患者中，只有1例通过瓦尔萨尔瓦试验检测出迷走神经异常，5例有直立性低血压病史的患者中有4例倾斜试验呈阳性。
慢传输型便秘可能与其他胃肠道器官功能受损有关。超过70%的慢传输型便秘患者存在一定程度的自主神经病变。严重便秘可能是涉及多个器官且可能累及自主神经系统的全身性疾病患者的主要主诉。在处理此类病例时应考虑到这一点。
