J. Coloproctol. (Rio J.) vol.36 número3

jcoloproctol(rioj).2016;36(3):153–156

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

There

is

an

agreement

between

constipation

referred

and

that

documented

by

objective

criteria?

夽

Isaac

José

Felippe

Corrêa

Neto

_,

_Ana

_Luiza

_Chaves

_Maneira

_,

Noelle

Breda

Teixeira

_,

_Beatriz

_Doine

_Vettorato

_,

_Mariana

_Campello

_de

_Oliveira

_,

Tatielle

Alves

Trivelato

Menezes

_,

_Laercio

_Robles

a_{HospitalSantaMarcelina,DepartamentodeCirurgiaGeral,Servic¸odeColoproctologia,SãoPaulo,SP,Brazil}

b_{FaculdadedeSantaMarcelina,SãoPaulo,SP,Brazil}

c_{SociedadeBrasileiradeColoproctologia,Brazil}

d_{ColégioBrasileirodeCirurgiões,Brazil}

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o

Articlehistory:

Received24February2016 Accepted11April2016 Availableonline27April2016

Keywords: Constipation Romecriteria Kappaindex

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Introduction:Chronicconstipationisthemostcommondigestivecomplaintatthedoctor’s office,withhighprevalenceinthepopulation.However,manypatients–andeventhose physiciansnotsofamiliarwithpelvicfloordisorders–defineandconsiderconstipationbased onintestinalfunctionalityandstoolconsistency.Butsymptomsofincompletedefecation, digitalmaneuvers,abdominaldiscomfort,andstrainingshouldnotbeoverlooked. Objectives: Toinvestigatethecorrelationbetweenconstipationreferredanddocumented through objectivecriteria inpatientsadmittedon adaytime-nursingwardbasisatthe HospitalSantaMarcelina,SãoPaulo.

Methodology:Thisisa prospectivestudy ofa randomsampleofpatientsadmittedona daytime-wardhospitalizationbasisatSantaMarcelinaHospitaltoperformminor surgi-calproceduresnotrelatedtofunctionaldisordersofthegastrointestinaltractintheperiod fromSeptember2014toJune2015;theonlyexclusioncriterionwas“notagreedtoparticipate intheinterviewconductedbystudentsofmedicineatSantaMarcelinaMedicalSchool”. Results:102patientswererandomlyanalyzedintheperiodconsidered(51%female)with ameanoverallageof48.6(19–82)years.Constipationhasbeenreportedspontaneouslyby 17.6%ofparticipantsanddeniedby82.4%.WiththeimplementationoftheClevelandClinic’s criteriaforthediagnosisofconstipation,thecompliancewiththereferredsymptomatology

夽

StudyconductedbytheAcademicLeagueofGeneralSurgery,SantaMarcelinaMedicineSchool;andbytheMedicalResidencyProgram ofColoproctology,DepartmentofGeneralSurgery,SantaMarcelinaHospital,SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:isaacneto@hotmail.com(I.J.F.C.Neto).

http://dx.doi.org/10.1016/j.jcol.2016.04.004

154

was88.9%;thesamevaluewasfoundwiththeuseoftheRomeIIIcriteria(Kappa=0.665). Inaddition,ahigherincidenceofconstipationwasobservedinfemalepatients(p=0.002). Conclusion: Ahigherincidenceofconstipationwasobservedinfemaleparticipants,withno statisticaldifferencewithrespecttoage.Furthermore,asubstantialagreementwasfound betweenconstipationreferredandconstipationdocumentedthroughobjectivecriteria.

©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Existe

concordância

entre

constipac¸ão

referida

e

constatada

por

critérios

objetivos?

Palavras-chave: Constipac¸ãointestinal CritériosdeRoma ÍndicedeKappa

r

e

s

u

m

o

Introduc¸ão: Aconstipac¸ãointestinalcrônica representaaqueixadigestivamaiscomum no consultóriocomelevadaprevalência napopulac¸ão.Noentanto,frequentemente, os pacientesemesmoosmédicos, nãotão afeitoscomos distúrbiosdoassoalhopélvico, definemeconsideramconstipac¸ãobaseadosnafuncionalidadeintestinaleconsistência dasfezes.Entretanto,ossintomasdedefecac¸ãoincompleta,manobrasdigitais,desconforto abdominaleesforc¸oevacuatórionãodevemsernegligenciados.

Objetivos:Verificaracorrelac¸ãoentreconstipac¸ãointestinalreferidaeconstatadaatravésde critériosobjetivosempacientesinternadosemregimedeenfermariadianoHospitalSanta Marcelina,SãoPaulo.

Metodologia: Estudoprospectivodeamostraaleatóriadepacientesinternadosem enfer-mariadiadoHospitalSantaMarcelinapararealizac¸ãodecirurgiasdepequenoporteenão relacionadasadistúrbiosfuncionaisdetratogastrintestinalnoperíodoentresetembrode 2014ejunhode2015,cujoúnicocritériodeexclusãofoionãoconsentimentoemparticipar daentrevistarealizadapelosalunosdocursodemedicinadaFaculdadeSantaMarcelina. Resultados:Foramanalisadosdeformaaleatória102pacientesnoperíodosendo51%dosexo femininoemédiadeidadeglobalde48,6anos(19-82anos).Aconstipac¸ãofoireferidade formaespontâneaem17,6%enegadaem82,4%.AoseutilizarocritériodaClevelandClinic paraconstatarconstipac¸ãohouveumaconcordânciacomosintomareferidoforade88,9%, commesmovaloraoseutilizaroscritériosdeRomaIII(Kappa=0,665).Alémdisso, verificou-semaiorincidênciadeconstipac¸ãointestinalnospacientesdosexofeminino(p=0,002). Conclusão: Verificou-semaiorincidênciadeconstipac¸ãonosexofemininosemdiferenc¸a estatísticabaseadonaidade.Alémdisso,constatou-seconcordânciasubstancialentrea constipac¸ãoreferidaeadocumentadaatravésdecritériosobjetivos.

©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Introduction

Chronicconstipationisthemostcommondigestivecomplaint inthegeneralpopulation,withhighprevalence,1_affecting16%

ofadultsandupto33%ofthoseagedabove60years,2

espe-ciallyfemalesubjects.3_{Consequently,thisisamorbiditythat}

impliesalargenumberofvisitsformedicalcare,althoughin mostcasesthereisnothreattothepatient’slifenor debilita-tion,butwithachangeinhis/herqualityoflife,especiallyin chroniccases.2,4

Constipation is classified into primary and secondary types. In a primary constipation, one can verify a normal intestinaltransit,outletobstruction,oraslowcolonic tran-sit.On theother hand,the secondary typeofconstipation iscausedbyametabolicdiseaseormayhaveamechanical,

pharmacologicalorpsychiatriccause.5,6 _{Moreover,themain}

riskfactorsforconstipationarealreadyknown:aging,female gender,depression,inactivity,lowcaloricintake,lowincome andloweducationallevel,physicalandsexualabuse,and pre-vioussurgeries.6

Often the patient – and even that physician not so familiar with pelvic floor disorders – defines and consid-ersconstipationbasedonintestinalfunctionalityandstool consistency.7_{Butsymptomsofincompletedefecation,digital}

maneuvers,abdominaldiscomfortandstrainingshouldnot beoverlooked.8

jcoloproctol(rioj).2016;36(3):153–156

155

Purpose

Thisstudyaimedtoverifythecorrelationbetweenreferred versusdocumentedconstipationaccordingtoobjectivecriteria inpatientsadmittedonadaytime-wardhospitalizationbasis atSantaMarcelinaHospital,SãoPaulo.

Patients

and

method

This isa prospective study inwhich a random sample of patientsadmittedonadaytime-nursingwardbasisatSanta MarcelinaHospitaltoperformminorsurgicalproceduresnot related tofunctional disorders ofthe gastrointestinal tract wereinterviewedduringtheperiodfromSeptember2014to June2015.

Theonlyexclusion criterionwas “not agreedto partici-pateintheinterviewconductedbystudentsofmedicineat FaculdadeSantaMarcelina”.

Thesurveyeddatawere:gender,age,comorbidities,and parity.Afterthisgeneralinterview,patientswereaskedtotell whetherornottheyhadconstipationand,atthattime,only ananswer“yes”or“no”wasaccepted.Afterthisspontaneous reportofthecomplaint,atargetedanamnesiswascarriedout, throughtheutilizationoftheRomeIIIcriteria,10_theCleveland

Clinicconstipationindex,Florida11_{andstoolconsistency.}13

Results

Regardinggender,51%werefemaleandthemeanoverallage was48.6(19–82)years,withameanof48.2and48.9yearsfor malesandfemales,respectively.Twenty-ninepercentand6% offemaleandmaleparticipants,respectively,had constipa-tion(p=0.002).Moreover,whenstratifyingtheageingroups of<20years,20–60yearsand>60years,nostatistically sig-nificantdifferencewasfoundbetweenthesesubgroupswith respecttotheincidenceofconstipation(p=0.576)(Fig.1).

Ofthe18 patientswhoreportedconstipation,15 (83.3%) were female, 4 were nulliparous (26.7%) (p=0.036) and the meanagewas51.6years(Table1).Whenstratifyingtheageof constipatedpatients,ameanof48and66.3yearswasfound forfemaleandmalesubjects,respectively.Inthissubgroup, onlytwo(1.9%)patientshadcomorbidconditionswitharisk factorforconstipation(hypothyroidism).

25

20

15

10

5

0

Otorhinolar ingology

Orthopedics Gener

al surger y

Liver biopsyProctology

Vascular surger y

Urology Skin tumors

Other

Number of surger

ies

Fig.1– Distributionofsurgicalproceduretypes.

Table1–Clinicalcharacteristicsofinterviewedsubjects.

Non-constipated Constipated

Female 71.2% 28.8%

Male 94% 6%

Meanglobalage 47.9years 51.6years

Nulliparouswomen 21.1% 26.7%

Bristol13 _{Most3and4 Most1and2}

Agreementwithcriteria 90.5% 88.9%

Constipation hasbeen referred spontaneously in17.6%, and82.4%deniedthiscondition.WhenusingtheCleveland Clinic criteria12 _{for the establishment of constipation, an}

agreement of88.9%was achievedwiththat symptom, and the same valuewas obtainedusing the Rome III criteria11

(Kappa=0.665).Anagreementof90.5%wasachievedbetween thereferreddenialforconstipationversusabsenceof consti-pationwiththeapplicationoftheRomeIIIcriteria.Regarding stoolconsistency,13_{67.5%ofrespondentsreportedtype3or}

4. Ontheother hand,amongtheconstipatedpatients 69% reportedtype1or2.

Discussion

Theprevalenceofconstipationisvariable intheliterature, dependingmainlyontheagechosentoobtainthesevalues. Thus,itisknownthatthisvariationcovers2–35%ofthe pop-ulation, withamean of2.5million clinicalconsultationsa year.14–16 _{Moreover,theprevalenceishigherinfemales(this}

was alsodemonstrated inourstudy),institutionalized per-sons,andintheelderly.6,17

Obtainingahistoryofconstipationofapatientisa debat-abletopicwithregardtowhataretheauxiliarymeanstobe usedinthedecision-makingprocess.However,withthe com-pletion ofa detailed history, onecan determineif,infact, the patient meets the objective criteria ofconstipation, as establishedbytheRomeortheClevelandCliniccriteria(cited above).Moreover,thephysiciancaninferwhetherhe/sheis facingacasesuggestiveofoutletobstruction,bydetermining theoccurrenceofmultiplebowelmovementsandsmallfecal volumes,afeelingofincompleteevacuation,andtheneedto adigital(perineal,analorvaginal)maneuver,aswellasthe feelingofvaginalbulgingduringevacuation.18,19

The clinical history also enables an assessmentof risk factors,suchaspoordiet,lowfluidintake,immobility, psychi-atricillness,medicationuse,comorbidities,previoussurgery, andsymptomsofirritablebowelsyndrome.15,20,21_Finally,the

clinical history allows the identification of warning signs such as hematochezia, a significant weight loss, a family history ofcancer, anemia, anal bleeding, and a change in bowelhabits–indicatingthetimelinessofacolonicstudyby colonoscopyand/orsomeradiologicalprocedurewithout pro-pedeuticintentwithrespecttoconstipation,butinorderto excludesecondarycausesforthiscondition.3

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adoptingthedefinitionofthepathologyinaccordancewith whathe/shebelievestobeanadequatebowelhabit.22

Ontheotherhand,theRomeconsensus11_andthe

consti-pationindex12 _{havebeendevelopedinordertostandardize}

thedefinitionofconstipationinepidemiologicalstudies,and alsoforthediagnosisofthisconditioninclinicalpractice.

Colletteetal.,21_{intheirdemographicsurveyforthe}

pres-enceofconstipationinthepopulationofPelotas,RS,found aprevalenceof26.9%,moreoftenoccurringinwomen;and aninvolvementof37%amongthoseindividualswithalower socioeconomic status.These authors also showedthat the correlationbetweenself-reportedconstipationandthe estab-lishmentofconstipationaccordingtotheRomeIIIconsensus achievedanoverallKappaindexof0.59(0.41formenand0.61 forwomen).Inthissameline,Garriguesetal.23_demonstrated

a substantial agreement between self-reported constipa-tion and theRome I criteria(Kappa=0.68) and amoderate agreementwhenusingtheRomeIIcriteria(Kappa=0.55), con-cludinginfavoroftheusefulnessofself-reportedinformation ofconstipationbytheinterviewee,notwithstandingits sub-jectivenatureandrelianceonmultiplefactors.

Inourstudy,wefoundasignificantcorrelation between constipationreferredandthatestablishedthroughobjective criteria,withaKappaindexof0.665,andthefemale involve-mentwithconstipationwassimilartothatintheliterature, aswellastheevidencethatthevastmajorityofconstipated patientswerewomen–afindingwithstatisticalsignificance (p=0.002). However,when stratifyingthe ageingroups<20 years,20–60years,and>60years,nostatisticallysignificant differencebetweenthesesubgroupswasfoundwithrespect totheincidenceofconstipation(p=0.576).

Althoughtheprevalenceofconstipationinmalepatients hasbeenquitelow,themalesubjectsinoursampleweremore agedversusfemales.Thisfindingissimilartodatafromsome publishedstudies,showingthatwomenareaffectedbythis morbidityinanearlierage.21,24

Conclusion

In the present study, a predominance of constipation in women was noted, without difference in terms of mean age between constipated versus non-constipated patients. Furthermore,therewasasubstantialagreementbetween con-stipationreferredandthatdocumentedbyobjectivecriteria.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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