PM1065: Work-up and Management of Patients with Functional Constipation Who Have Failed Medical Management; The Surgeon/gi Motility Collaboration

Background: Some patients with functional constipation do not improve after medical treatment. For these patients, we propose a multidisciplinary work-up and decision-making approach and this abstract describes an algorithm for those with refractory constipation.

Methods: We reviewed all referrals for functional constipation for whom a diagnostic and treatment algorithm was employed at a single institution (2019-2021). All patients had received maximal medical therapy without constipation improvement. We performed a contrast enema to assess for colon dilation, redundant bowel segments, and Hirschsprung disease (HD), and an anorectal manometry (AMAN), done in the operating room, to measure the rectoanal inhibitory reflex (RAIR), external sphincter resting pressure, and pelvic floor dyssynergia. If the RAIR was absent or indeterminate, a full thickness rectal biopsy was done, and if the external sphincter resting pressure high, botulinum toxin was administered into the anal canal. Thus, HD and internal sphincter achalasia could be diagnosed, and the sphincters treated. Those with a RAIR or low resting pressures were treated more aggressively with laxatives. If the symptoms did not improve or the laxatives were not tolerated, colonic motility was evaluated, and a Malone appendicostomy was offered for antegrade flushes.

Results: 21 patients were evaluated using this algorithm. The RAIR was normal in 10 (48%) patients, indeterminate in 10 (45%), and absent in 1 (5%). The patient with an absent RAIR had a negative biopsy and was then managed with laxatives. All patients with an indeterminate RAIR were biopsied; 2/10 (20%) had HD and 80% had normal biopsies and were managed with laxatives alone. 2/10 patients with a normal RAIR had high external sphincter pressure, had negative biopsies, and received botulinum toxin.

Conclusion: The described algorithm allows for an efficient multidisciplinary approach and the ability to differentiate amongst those who would benefit from a surgical intervention, adjustment of laxative regimen, or need a colonic motility evaluation.