Constipation and recurrent abdominal distension in a 39-year-old woman with irritable bowel syndrome
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Correspondence to Dr Seth Sweetser, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA; sweetser.seth{at}mayo.edu
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Contributors Seth Sweetser: design, acquisition of data and drafting of manuscript; Archana S. Rao: acquisition of data and drafting; Lawrence A. Szarka: critical revision of the manuscript for important intellectual content.
Clinical presentation
A 39-year-old woman with a previous diagnosis of irritable bowel syndrome presented with progressively worsening episodes of marked abdominal distension and difficulties with defecation. She had a long history of constipation and had tried a variety of laxatives with an unsatisfactory response. Recent colonoscopy was unremarkable. Physical exam revealed a protuberant abdomen with tympany and high-pitched bowel sounds. Inspection of the anus showed no perianal lesions and absent perineal descent with straining at defecation. A digital rectal examination revealed high anal sphincter tone and absence of puborectalis relaxation with simulated defecation. There was no palpable stool in the rectum. Computed tomographic enterography with scout film showed a markedly dilated splenic flexure without obstructing mass or volvulus (Figure 1 and Figure 2). High-resolution anorectal manometry with balloon expulsion revealed high anal sphincter pressures, presence of the rectoanal inhibitory reflex and failure to expel the rectal balloon despite 564 g of traction (normal range <200 g).
Scout film showing a markedly dilated splenic flexure.
Computed tomographic enterography with a markedly dilated splenic flexure without obstructing mass or volvulus.
Question
What is the most likely diagnosis?
See page 107 for the answer
Answer
From the question on page 42
Dyssynergic defecation with resultant splenic flexure syndrome—The splenic flexure syndrome has been historically used to describe upper abdominal pain and bloating thought to be caused by abnormal gas propulsion leading to localised ‘trapping’ of intestinal gas at the splenic flexure region of the colon. It has long been considered a variant of irritable bowel syndrome.1 2 Anatomic factors are believed to predispose to this syndrome. The splenic flexure occupies a position high under the diaphragm and is fixed by a peritoneal fold resulting in sharp angulation from a sagging transverse colon and the weight of a stool-filled descending colon.3 Gas accumulates in this segment, provoking abdominal pain and bloating. More recently, it has been recognised that patients with gas retention and abdominal discomfort may have impaired fecal evacuation. Normally, evacuation of gas results from increased intra-abdominal pressure coupled with anal relaxation.4 Incoordination of this process (dyssynergic defecation) produces functional outlet obstruction with fecal and gas retention. Consequently, there is also increased gas production from prolonged colonic fermentation of retained feces.1 Thus, increased production and retention of gas from dyssynergic defecation may predispose to splenic flexure syndrome. Our patient's symptoms resolved with pelvic floor retraining through biofeedback treatment.
Footnotes
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Competing interests None.
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Patient consent Obtained.
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Ethics approval This study was conducted with the approval of the Mayo Clinic College of Medicine. Institutional review board approval is not required for single case reports.
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Provenance and peer review Not commissioned; internally peer reviewed.
