themotility ofthe pelvic colon - gut · the colonic musculature and atonic constipation...

Gut, 1962, 3, 342

The motility of the pelvic colonPart IL Paradoxical motility in diarrhoea and constipation

ALASTAIR M. CONNELL

From the M.R.C. Gastroenterology Research Unit, Central Middlesex Hospital, London

EDITORIAL SYNOPSIS The intraluminal pressure changes of the pelvic colon in subjects sufferingfrom active diarrhoea have been compared with those in normal subjects and in subjects withintractable constipation.

Patients studied during a phase of active diarrhoea have significantly fewer intraluminal pressurechanges than normal subjects. Young patients with chronic severe constipation have a tendencyto more active motility than normal subjects, but other constipated persons tend to have hypomotilerecords. The relationship of these pressure changes to the aetiology of diarrhoea and constipationis discussed.

Diarrhoea and constipation are the symptoms mostcommonly associated with colonic dysfunction.Constipation is classified as either spastic or atonicbut the decision into which group to place an indi-vidual case is usually quite arbitrary. Spastic con-stipation is thought to result from overactivity ofthe colonic musculature and atonic constipationfrom underactivity of the muscle. On the other hand,although diarrhoea is said to result from colonichypermotility, the colonic movements which under-lie the symptom are inadequately understood andpoorly studied. Radiological studies of the colonhave been largely concerned with anatomical altera-tion and few functional studies have been reported.Another approach is to measure colonic intraluminalpressures and this method has been adopted in thepresent study. The motility of patients with activediarrhoea and severe constipation has been studiedto observe any changes in the intraluminal pressuresin the distal colon associated with these symptoms.

METHODS

Intraluminal pressures have been measured using minia-ture balloons (7 mm. x 10 mm.) recording on a metalcapsule optical manometer (Rowlands, Honour, Edwards,and Corbett, 1953). Full details of the methods ofobtaining and analysing the records have been publishedelsewhere (Connell, 1961a). Since this publication, how-ever, a second observer has been introduced to analyserecords. This has revealed that not only is there an errorof analysis between different occasions of analysis of thesame record by the same observerbut there are also differ-ences between observers. The disagreement was confined

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to the measurement of the duration of activity andresulted from differences of opinion about whether verylow amplitude waves represented genuine colonic activityor not. In order to eliminate this error any changes inthe records representing pressures of less than 3 cm. ofwater have been excluded from the analysis. Becauseof this change in procedure there are some minor,unimportant differences in the analysis of the normalresults presented in this paper compared with thosepublished previously (Connell, 1961a). All the recordspresented in this study have been analysed by anidentical method and so are strictly comparable with oneanother. The term 'activity', used in this paper in relationto a motility record, refers to intraluminal pressurechanges only and not to any other aspect of motility.

SUBJECTS

Records have been obtained from 86 subjects. Thirty-three complained of persistent and severe constipation,and were studied when the symptom was troublesome.Nineteen patients were studied when active diarrhoeawas present and 32 were either normal subjects or personswith inactive duodenal ulceration. The latter have beendiscussed fully elsewhere (Connell, 1961a).

It is not possible to define constipation more preciselythan to say that it exists when defaecation occurs lessfrequently or with more difficulty than is usual for theperson concerned. In this series all the patients weresufficiently troubled by the symptom, which they con-sidered abnormal, to seek attention and not only so, butthey had been referred to hospital by another practitionerbecause of the particular severity or intractability of thecomplaint. The majority defaecated once a week or less.No case of radiological megacolon nor any person

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The motility of the pelvic colon

known to have aganglionosis of the colon was included.Of the patients suffering from diarrhoea, 14 had noradiological, biochemical, or bacteriological abnormality;three had ulcerative colitis; one diarrhoea after an other-wise successful ileo-transverse colostomy for Crohn'sdisease; and one had taken a large dose of a laxative(Senakot) on the night before the study. All these patientshad at least three watery bowel actions between rising andthe time of the study which was always earlier than 2 p.m.At least four patients had an urgent call to stool beforethe end of the study.

RESULTS

In all three groups the predominant feature of therecords is a slow wave lasting approximately half aminute (Fig. 1). Such waves are the principal wavesof the colon. They vary widely in amplitude andprobably represent independent segmental contrac-tions which tend to be grouped into periods ofactivity alternating in an irregular manner withperiods of relative or complete inactivity. Theycorrespond to type II of the classification ofTempleton and Lawson (1931). Faster waves alsooccur and are more prominent in the constipatedgroup than in either of the other two groups. Largebroad-based waves which correspond to type IV ofSpriggs, Code, Bargen, Curtiss, and Hightower(1951) are occasionally seen and have been recog-nized in all three groups of records and in thisseries were not confined to the patients withdiarrhoea.

SIGMOID COLON IN CONSTIPATED SUBJECTS Thesigmoid colon is active for a greater proportion of

TABLE IDURATION OF ACTIVITY, MEAN AMPLITUDE,

AND PRODUCT AT 20 TO 25 CM. FROM THE ANUS INSUBJECTS WITH DIARRHOEA, CONSTIPATION, AND

NORMAL BOWEL HABIT

No. % Durationof of ActivitySubjects

Diarrhoea 19Constipation 33Normal 32

Mean Product %Amplitude Duration of

Activity xMeanAmplitude

42-2±26-2 10-2±3-4 480±35551 6±26-3 10-9+8 3 650±60847-8±20-8 15 8±9-2 776±523

the time in constipated than in normal subjects butthe total activity (duration of activity X meanamplitude) is less than in normal subjects (Table I).There is a difference in the motility of the sigmoid

colon of young and older persons who are consti-pated and a division has been made between thosewho are 40 years of age or less and those over 40. Ingeneral young persons with constipation have normalor hyperactive records whereas older persons havehypoactive records (Table II). One further importantdifference is that in the constipated subjects a greaterproportion of the activity occurs as bursts of fastwaves. If waves of a frequency of 5/min. or more(Fig. 2) only are considered, a much greater pro-portion of activity is occupied by these waves in theconstipated subjects than in normal subjects. Inrecords from the sigmoid of the 33 constipatedsubjects a mean of 15-4% of the time of analysis isoccupied by fast waves as compared with only 1 8 %in the normal group. Twelve of the 33 constipated

FIG. 1. Normal colonic motility. In this record and in others in this paper the top trace is a respiratory record and thelower ones simultaneous recordings ofcolonic motilityfrom the sigmoid, rectosigmoid, and upper rectum respectivelv. Thevertical lines represent one-minute intervals.

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Alastair M. Connell

TABLE II

DURATION OF ACTIVITY, MEAN AMPLITUDE,AND THE PRODUCT AT 15 TO 20 CM. FROM THE

ANUS IN SUBJECTS WITH DIARRHOEA, CONSTIPATION,AND NORMAL BOWEL HABIT

No. % Durationof of Activitysupjects

MeanAmplitude

Product %Duration ofA5.:..

inactive segment with hyperactive segments im-mediately proximal and distal to it. This is a featureof only two records, one a child of 10 and the othera young woman of 32. Similar segmental inactivityhas been seen in patients with megacolon (Connell,1961b).

MActivny x SIGMOID COLON IN DIARRIOEAL SUBJECTS SubjectsAmplitude with diarrhoea have a shorter duration of inactivity,

a lower mean amplitude, and less total activity than43-8±30-2 8-0±i3-7 409+i43851 5±30 9 9-8±6-2 625+611 either the normal group or the group with consti-40 5±23 1 13 5±8-6 602±561 pation. The total activity of the diarrhoea group is

significantly less than the normal group (p< 1 : 20)subjects had more than 10% of the analysis occupiedby fast waves compared with only one of the 32normal subjects.

UPPER RECTUM IN CONSTIPATED SUBJECTS In consti-pated patients the duration of activity, the meanamplitude, and the total activity (product of durationof activity x mean amplitude) is less than in normalsubjects or even in persons with diarrhoea. Further-more, whereas in the last groups the duration ofactivity tends to increase from sigmoid to rectum, inthe constipated group the activity tends to decrease.This effect is produced by a number of constipatedpatients who have a normal or hyperactive sigmoidcolon but a hypoactive or inactive rectum (TablesI, III, and IV).

SEGMENTAL INACTIVITY IN CONSTIPATED SUBECTSFigure 3 illustrates a record from a constipatedyoung woman in which there is a sharply localized

(Table I). Large broad-based waves were not seenmore commonly than in normal patients.

UPPER RECTUM IN DIARRHOEAL SUBJECTS There is atendency for the duration of activity to increase atpositions nearer to the anus (Tables I, III, IV) al-though the mean amplitude remains the same.

TABLE IIIDURATION OF ACTIVITY, MEAN AMPLITUDE,

AND THE PRODUCT AT 10 TO 15 CM. FROM THEANUS IN SUBJECTS WITH DIARRHOEA, CONSTIPATION,

AND NORMAL BOWEL HABIT

No. % Duration Mean Product %of of Activity Amplitude Duration ofSubjects Activity x

Diarrhoea 18Constipation 24Nornal 25

MeanAmplitude

45-4±21-8 9-7±55- 404±35341-8±30-0 6-8+3-1 343±33853-1 ±26 9-5±5-8 527±353

FIG. 2. Motility of thepelvic colon showingfast waves (>5/min.)from the sigmoid and rectum respectively ofayoungconstipated subject.

Diarrhoea 13Constipation 27Normal 26

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FIG. 3. Motility of the pelvic colon of a young constipated woman showing inactivity at the rectosigmoid with hvper-activity in the sigmoid and rectum. The recording points were 5 cm. apart.

- . ____ ~ ~ ~ ~ ~ ~ - -~~ ___ __ _ _ __ _

FIG. 4. Motility of the pelvic colon in a patient with urgent diarrhoea showing hypomotility at all positions ofrecording.The stethograph is not functioning within the record.

This is in contrast to the normal subjects in whomthe mean amplitude decreases from the sigmoid tothe rectum.

COMPARISON OF DIARRHOEA AND CONSTIPATION Themost unexpected feature of these records is thathypoactivity may be found in association withfrequent bowel actions with loose stools. Figure 4 isa record from a patient who not only had frequentbowel actions but defaecated immediately beforethe study and in whom the study had to be terminated

prematurely because of a further urgent call to stool.A further example is provided by the case of a boyaged 18 with ulcerative colitis. The record on theleft hand side of Fig. 5 was obtained at a time whenhe had an active proctitis and was having eight to10 watery bowel actions a day, passing blood on eachoccasion. One week later, after treatment withPrednisone, he had a granular proctitis and washaving three bowel actions a day with formed stools.The record on the right hand side of Fig. 5 shows themore normal motility record obtained that time.

TABLE IVCOMPARISON OF MOTILITY OF CONSTIPATED PATIENTS OVER 40 YEARS OF AGE AND OF 40 YEAPS OF AGE OR LESS

No. of % Duration ofSubjects Activity

Mean Amplitude Product % Durationof Activity x MeanAmplitude

15 425+24318 59 3+25 1

15 40 0±37-018 43-2±23-0

Age Range (yr.)

At 20 to 25Over 4040 or less

At 10 to 15Over 4040 or less

% Fast Waves

9 1±7-312-3±9-3

6-6±2-87 0±3-5

475 ±373813±693

13-5+ 18-316-9+28-2

327 +260362±400

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Alastair M. Connell

FIG. 5. Sections of two records from the pelvic colon of an 18-year-old boy wit.a dlcerat ve colitis. Ae, t, a.ring a phaseofsevere active colitis showing hypomotility. Right, after treatment with symptomatic and sigmoidoscopic improvementshowing return to a more normal motility pattern.

The contrast between the effect of diarrhoea andconstipation on the motility record is well illustratedby Figure 6. This illustration shows samples of tworecords obtained on consecutive days from a patient,not otherwise included in this study, who had afunctional bowel disorder with alternate diarrhoeaand constipation. The hypermotile record on theleft hand side of the illustration was obtained on aday when the patient had not had a bowel action forfour days. The following day, however, he had fivewatery urgent bowel actions and the right hand traceis typical of the record obtained on that occasion.

However, the correlation between the frequency ofbowel action and the intraluminal pressure records isnot close. The frequency of bowel action dependsnot only on the colonic contractions but also on thevolume and nature of the stool, the threshold fordefaecation, social and personal factors, any ofwhich may mask an association with colonicmotility.

DISCUSSION

The most striking result of the study is that patients

with diarrhoea have less colonic activity than eithernormal subjects or severely constipated persons.Both Spriggs et al. (1951) and Kern, Almy, Abbot,and Bogdonoff (1931) had previously noted areduction in colonic motility in ulcerative colitis andKern et al. showed an inverse relationship betweenthe frequency of bowel action and the total activityof the records. Chaudhary and Truelove (1961) in astudy of colonic motility in ulcerative colitis alsoshowed that patients with mild symptoms had lesstotal activity than either patients with ulcerativecolitis who were free of symptoms or normalsubjects. They found, however. that the mean totalactivity of patients with severe colitis was greaterthan normal. The apparent discrepancy between thisfinding and those of previous workers is resolved byinspection of the individual results given in Chaud-hary and Truelove's paper which show that themean increased activity is entirely due to the effectof one exceptionally high result which is twice thatof any other figures in the whole study, either normalor abnormal. If this exceptional result is excludedthe mean for the other patients with severe ulcerativecolitis is less than that of the normal group or of

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FIG. 6. The motility of the pelvic colon in a man with a functional bowel disorder. Left, constipated with hypermotility.Right, active diarrhoea and hypomotifit.

patients with ulcerative colitis in remission. In thesame study patients with non-specific diarrhoea withsymptoms had less activity than those withoutsymptoms. Thus there is general agreement in thepublished work that there is a reduction of totalmotility (although not a striking one) in patientswith diarrhoea if the record is obtained at a timewhen they have symptoms.As was previously reported (Connell, 1961), the

duration of activity of the sigmoid in constipatedsubjects is greater than normal and this finding isconfirmed by the present study where the selection ismore rigorous. If, however, the patients withconstipation are separated according to age markeddifferences occur. Young persons usually havehyperactive records and older persons hypoactiverecords. This difference may represent a naturalprogression of the disorder which results in thesymptom of constipation from an initial phase ofspasm and hypermotility to a phase of atony andhypomotility. Another possibility is that the later

hypomotility is secondary to the excessive use oflaxatives in the early stages of the disorder. In thisrespect it is of interest that the most inactive recordswere obtained from patients who had habituallytaken large doses of laxative. One patient whoserecord showed no pressure changes at all had formany years used i lb. of senna leaves per day.The apparent paradox that diarrhoea can be

associated with hypomotility on the one hand andconstipation with hypermotility on the other, issimplified by a consideration of the mechanics ofintraluminal pressure recording. In order to achievea rise of intraluminal pressure there must be both acontraction of the wall of the viscus together with aresistance to the escape of the contents of the seg-ment in which the recording device is placed. If thecontents of the active segment are free to escape theforce generated by the contraction will be utilizedin movement and will not result in any marked risein pressure. If the contents of the contractingsegment are not free to escape the force generated by

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348 Alastair M. Connell

the contraction will cause a rise in pressure. Con-versely, therefore, intraluminal pressures reflect notonly contraction of the wall of the viscus but alsoincreased resistance to the escape of content whichmust be associated with delay in transit. On the otherhand where the barium enema presents a 'drain pipe'appearance, as in active ulcerative colitis, there isunlikely to be resistance to the flow of faeces andconsiderable local contraction of the wall of theviscus may occur without effecting any significantalteration in the total volume of the lumen of thecolon or in the intraluminal pressure.

In this study large waves were seen in all groups ofpatients studied. These waves, described as type IV,were considered by Code, Hightower, and Morlock(1952) to be associated specifically with diarrhoealstates and it has been suggested that they representpowerful peristaltic movements resulting indiarrhoea. While it is likely that when they occurthey propel the faeces distally it is probable that amuch more important factor in the production ofdiarrhoea is the loss of the normal segnenting con-tractions which delay the distal transport of stool.In this event the faeces passively trickle along thebowel to reach the sensory area for the defaecationreflex in the recto-sigmoid largely under the in-fluence of gravity. This hypothesis also explains thewell-known beneficial effect of recumbency on thesymptom of diarrhoea and assists in explainingthe disappointing effect of antispasmodics (Connelland Kellock, 1959). While this defect in motor

function of the colon is important, in diarrhoealstates, if the stool is loose or watery, there must alsobe a defect (possibly the primary one) in waterabsorption which suggests an abnormality of thefunction of the proximal colon or even smallintestine.

REFERENCES

Chaudhary, N. A., and Truelove, S. C. (1961). Human colonicmotility: A comparative study of normal subjects, patientswith ulcerative colitis, and patients with the irritable colonsyndrome. Gastroenterology, 40, 1-17.

Code, C. F., Hightower, N. C. Jr., and Morlock, C. G. (1952).Motility of the alimentary canal in man. Amer. J. Med., 13,328-351.

Connell, A. M. (1961). Colonic motility in chronic constipation. InProceedings of the International Congress of Gastroenterology.Leyden, 1960, p. 3-10. (Excerpta medica: Int. Congr. Ser. No.31.)

(1961a). The motility of the pelvic colon; I Motility in normalsand in patients with asymptomatic duodenal ulcer. Gut, 2,175-186.

(1961b). Colonic motility in megacolon. Proc. roy. Soc. Med., 54,1040.1043.

- and Kellock, T. D. (1959). Treatment of chronic non-specificdiarrhoea. Brit. med. J., 1, 151-153.

Kern, F. Jr., Almy, T. P., Abbot, F. K., and Bogdonoff, M. D. (1951).The motility of the distal colon in non-specific ulcerative colitis.Gastroenterology, 19, 492-503.

Rowlands, E. N., Honour, A. J., Edwards, D. A. W., and Corbett,B. D. (1953). Metal-capsule optical manometer for measuringpressure in the human gut with an open-ended tube. Clin.Sci., 12, 299-306.

Spriggs, E. A., Code, C. F., Bargen, J. A., Curtiss, R. K., andHightower, N. C. (1951). Motility of the pelvic colon andrectum of normal persons and patients with ulcerative colitis.Gastroenterology, 19, 480.491.

Templeton, R. D., and Lawson, H. (1931). Studies in the motoractivity of the large intestine. I Normal motility in thedog, recorded by the tandem balloon method. Amer. J. Physiol.,96, 667-676.



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