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Despite increased awareness of motility disorders and advances in the availability of instruments, colonic motility may be less well understood than in any other area of the gastrointestinal tract. One of the main reasons is the relative inaccessibility of the colon. Furthermore, recordings of colonic motility are complicated by several technical factors: colonic contents in the nonprepared colon; the influence of colonic preparation, stress, exercise, menstruation, and the use of antidepressants; and the variety of protocols used among institutions.

The investigation of colonic motility involves the study of myoelectric activity and phasic and contractile activity and movement of the intra-luminal contents. For this purpose, manometric or colonic transit studies can be used. Although colonic transit studies are more common and ideal for functional analysis, colonic manometry is becoming more popular, allowing evaluation of contractile activity over prolonged periods.

In general, colonic manometry recordings of motor and myoelectrical activity in animal models have identified three contractile events:

(1) short duration waves of less than 15 seconds,

(2) long-duration waves of 40 to 60 seconds, and

(3) high-amplitude propagating contractions (HAPCs). In humans, reproduction of these motility patterns are more difficult to demonstrate, and reports in the literature have yielded varying results. In general, the most common recognizable events are the high-amplitude propagating contraction, which are associated with either the conscious sensation of urgency or the passage of flatus. Moreover, the absence of HAPCs may serve as a marker of colonic motor dysfunction. The frequency of these contractions varies among individuals and is more common in young children. The contractions usually start in the cecum or ascending colon and are propagated into the sigmoid colon at a rate of 1 cm/minute.

Investigation of colonic motility has increased over the last several years, and interesting findings have been reported to explain the pathophysiology of patients with slow-transit constipation. In a study of 18 patients who underwent 24-hour colonic manometry (eight patients with slow-transit constipation versus 10 controls), Hagger et al30 observed that the frequency of HAPC was reduced in chronic idiopathic constipation, leading to a reduction in the propulsion of intraluminal contents.

In another study, Leroi et al31 evaluated 21 patients with 24-hour colonic manometry: seven patients with constipation secondary to anti-

depressant use, seven constipated patients, and seven controls. The number of HAPC was lower in the two groups of constipated patients.

Colonic motility evaluation by 24-hour manometry can also be helpful in other conditions such as diverticular disease, irritable bowel syndrome, Parkinson's disease, and defecatory disorders in children.

Anorectal motility can be measured by evaluating the activity of the internal anal sphincter. This smooth muscle is responsible for the maintenance of a resting tonus through electrical and mechanical activity, which has a frequency of between 15 and 35 cycles per minute. This activity results in three wave patterns known as slow, intermediate, and ultraslow waves (Fig. 8.11).

The slow waves are the most frequent, from nine to 20 cycles per minute. The intermediate waves have frequencies varying from four to eight cycles per minute and has been noted in patients with neurogenic incontinence and after ileal pouch-anal anastomosis. The ultraslow waves are the second most frequent, with frequencies varying from five to 15 cycles per minute and were associated with the presence of hemorrhoid disease and anal fissures. In addition, the ultraslow waves have been seen in patients with high resting pressures related to chronic constipation (Fig. 8.12).

Figure 8.11. Slow, intermediate, and ultraslow wave patterns of the internal anal sphincter. 1, average pressure; 2, reduced average.

Figure 8.11. Slow, intermediate, and ultraslow wave patterns of the internal anal sphincter. 1, average pressure; 2, reduced average.

Figure 8.12. Ultraslow waves in patients with high resting pressures related to chronic constipation.

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Constipation Prescription

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