if it is inert, why does it move?
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If it is inert, why does it move?
G. BASSOTTI
Clinica di Gastroenterologia ed Epatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita di Perugia, Italy
Chronic constipation is a frequently experienced
symptom, unfortunately there is no single definition
even among health care workers. Some consensus
documents (such as the Rome II criteria1) provided an
opportunity for such a uniform definition, and these
have been embraced, at least for research purposes.
Three main forms of constipation may be identified:
normal transit constipation, disorders of defecation or
rectal evacuation (outlet obstruction), and slow transit
constipation (STC).2 The latter is usually more severe,
often refractory to medical treatment,3 and probably is
a semantic umbrella under which there are patients
with different severity. Notwithstanding this hetero-
geneity, STC has attracted the interest of researchers,
and its pathophysiological basis has been extensively
explored.4 Several mechanisms of colonic motor dys-
function have been documented.5–7 One form of STC is
called colonic inertia (CI), a subtype that should
constitute the extreme expression of colonic motility
impairment, as the term �inertia� implies. However, it
is unclear what proportion of STC demonstrates iner-
tia.
In this issue, Herve and colleagues investigated a
group of severely constipated patients,8 and conclu-
ded that these subjects represented an heterogeneous
cohort, that CI was present in 25% of cases, and that
bisacodyl may be useful to evaluate whether there is
residual propagated contractile activity that can be
elicited in the colon. These results are already partly
established in the literature on chronically constipa-
ted patients, but the authors� main contribution is
that they attempted to develop objective criteria for
diagnosis of CI, based on manometric measurements.
The proposed criteria are a combination of absence of
high amplitude propagated contractions, lack of
colonic response to eating and an overall reduction
of colonic motility during a 24-h period. The validity
of these recommended criteria requires further study.
For example, delayed colonic transit time was less
frequent in these patients compared with transit
time in the other constipated patients (60% vs 76%).
Moreover, 60% of patients classified as having
CI using these criteria were able to have a
contractile response to the endoluminal infusion of
bisacodyl.
There remains a significant problem in assessing
such studies; there is no agreement in the definition
of CI among authors: definitions may be based only on
the assessment of delayed transit in the right colon,9
in the right and left colon,10 or the term is used as an
equivalent of STC.11 Only rarely have more objective
assessments (including manometric, electromyograph-
ic or scintigraphic investigations) been used12–15
Summarizing these observations in the current study
and in the literature, it appears that most of these
patients should be labelled as STC patients, whose
colons are still able to respond (at least partially) to
pharmacological stimulation. Several years ago, Frex-
inos proposed that true CI should be defined by the
objective absence (or severe impairment) of colonic
motility,16 as demonstrated by manometry and/or
electromyography. It is probably time to embrace this
advice and to develop criteria for true CI, to avoid
further confusion.
For instance, based on the literature, the following
criteria would be reasonable: (i) severe constipation;
(ii) delayed colonic transit (> 2 SD from upper normal
limit); (iii) no evidence of evacuation disorder;
(iv) manometric, electromyographic or scintigraphic
evidence of absent or almost absent colonic motility,
including propagated activity and response to meals;
(v) no response to endoluminal pharmacological sti-
mulation (e.g. bisacodyl) or response to parenteral
neostigmine (1 mg intramuscular).
Such criteria would help identify those patients
whose constipation may be truly refractory to med-
ical treatment or rescue, and in whom surgery is
indicated and it is likely to be of benefit, as the term
will really mean what it says: if it is inert, it does not
move.
Address for correspondence
Dr Gabrio Bassotti, Strada del Cimitero,2/a, 06131 San Marco (Perugia), Italy.Fax: +39-075-584-7570; e-mail: gabassot@tin.it
Neurogastroenterol Motil (2004) 16, 395–396 doi: 10.1111/j.1365-2982.2004.00512.x
� 2004 Blackwell Publishing Ltd 395
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2 Lembo A, Camilleri M. Chronic constipation. N Engl
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396 � 2004 Blackwell Publishing Ltd
Editorial Neurogastroenterology and Motility
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