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com

Management of
constipation: a clinical
dilemma

Decision mnaking in the mnanagemnent

of constipation in the cat PHILIPPA YAM

CONSTIPATION is defined as infrequent or absent defecation associated with the retention of faeces
within the colon and rectum. Megacolon, a condition in which the colon becomes dilated and hypomotile
due to chronic constipation, may be idiopathic or secondary to an underlying cause. The clinician may be
faced with the dilemma of whether to treat such cases medically or surgically. Several factors will influ-
ence that decision, including identification of an underlying cause, the functional ability of the colon and
the response to medical therapy.

PATHOPHYSIOLOGY I
Philippa Yam
graduated from the Dietary Ingestion of hair, bones and foreign
Royal (Dick) School of The colon, the terminal part of the intestine, functions to material
Veterinary Studies, absorb water and electrolytes and acts as a store for Inadequate water intake
Edinburgh, in 1992,
having obtained a dehydrated faeces. Constipation can occur in association
Environmental Dirty litter box
BSc in neuroscience with any disease that impairs the passage of faecal
in 1990. She worked Prolonged inactivity
in the small
material through the colon. When faeces are retained for
Hospitalisation
animal medicine a prolonged period of time, they become progressively
departments at both harder and drier and eventually impacted as the mucosa Change in habit or daily routine
the Dick and at
Glasgow veterinary continues to absorb water and electrolytes from the Painful defecation Anal sac disease
school, gaining the faecal mass. This leads to ineffective transport of faecal Anal stricture, tumour or foreign body
certificate in small
animal medicine in solids and hence constipation. Megacolon is severe dila- Pseudocoprostasis
1995. She is currently tion of the colon and is always accompanied by constipa-
completing a PhD in Obstruction Healed pelvic fracture with narrowed
the faculty of
tion (see box on facing page). lumen
medicine at Glasgow Intrapelvic tumour
University.
Rectal adenocarcinoma
Rectal lymphoma
Neurogenicd Spinal cord disease
muscular Dysautonomia (Key-Gaskell syndrome)
Defintions
Idiopathic megacolon
* Constipation Difficult, infrequent or absent
defecation associated with retention of faeces Fluid and Dehydration
electrolyte
within the colon and rectum abnormalities Hypokalaemia
* Dyschezia Difficult or painful evacuation of Hypercalcaemia
faeces from the rectum, usually associated with Drug induced Diuretics
lesions in or near the anal region Aluminium hydroxide
* Megacolon A disorder in which the colon
Sucralfate
becomes extremely dilated and hypomotile
Obstipation Intractable constipation in which
the colon and rectum become so impacted with
hard faeces that defecation cannot occur AETIOLOGY
* Tenesmus Ineffective or painful straining to

defecate The underlying causes of, and predisposing factors to,

constipation are listed in the table above.

434 In Practice * SEPTEMBER 1997

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Megacolon
Megacolon is characterised by of smooth muscle of the affected colonic smooth muscle contraction
chronic recurrent constipation or segment and subsequent dilation using cisapride may be beneficial
obstipation. It may be either con- of the colon proximal to this site. (see later). Idiopathic megacolon
genital or acquired. has no age, breed or sex predis-
Acquired megacolon position.
Congenital megacolon Acquired megacolon is by far the Acquired megacolon also occurs
Congenital megacolon is well more common form observed in as a sequel to any lesion or disease
described in man (Hirschsprung's the cat. Most cases of acquired that prevents normal defecation for
disease) and has more recently megacolon are idiopathic, the like- a prolonged period of time. If
been recognised in cats (Rosin and ly cause being intrinsic dysfunction megacolon has persisted chronically
others 1988). It occurs in neonates of colonic smooth muscle rather for several months or longer, the
and is characterised by agangli- than a neural defect (Washabau chance of reversing the motility dys-
onosis of a segment of colon, and Stalis 1996). Therefore, treat- function following the correction of
resulting in persistent contraction ment directed at stimulating an underlying cause is unlikely.

CLINICAL SIGNS * A full history should be taken from the owner to

establish any potential dietary, environmental, behav-
Cats with colonic impaction may be presented with ioural, psychological or medication-related factors or
a history of reduced frequency of defecation or failure to predispositions that might be involved.
defecate for a period of time ranging from days to * Physical examination, including digital anorectal,
weeks. The animal may have been observed to make neurological and orthopaedic examinations, may reveal
frequent but unsuccessful attempts to defecate and to the cause of, or predisposition to, the constipation.
spend a prolonged time in the litter box. The cat may * Abdominal radiographs are useful in the identifica-
also be presented because it is lethargic, inappetent, tion of megacolon, malunion of pelvic fractures and
anorexic and intermittently vomiting. These latter signs abdominal masses.
may be due to the absorption of bacteria and toxins * Biochemical and haematological evaluations and
through the damaged mucosal barrier in the dilated urinalysis should be performed in cats with recurrent
colon. The vomiting reflex is also stimulated by constipation or signs indicating a possible underlying
distension of the colon and irritation of the mucosa. The systemic condition that could cause constipation due to
animal may be in a crouched position indicative of dehydration or electrolyte disturbances.
abdominal discomfort. * Following removal of the faecal mass, barium enema
Although constipation is usually associated with radiography or endoscopy may be necessary to identify
absence of defecation, the impacted faeces can irritate obstructive tumours, strictures or other colonic or rectal
the mucosa inducing secretion of fluid and mucus that lesions.
leaks around the colonic mass to give 'paradoxical diar-
rhoea'. Chronic or persistent straining associated with
constipation may lead to perineal hernia or rectal pro-
lapse (Welches and others 1992).

DIAGNOSIS

Constipation is usually determined from the patient's

history and confirmed by rectal and abdominal palpation
of colonic distension with hard impacted faeces. The
goal of diagnosis is to identify predisposing factors.

I_ 4 I,I 1 F-1 * 0 _.0

Tenesmus
Anorexia
Vomiting - *
Lateral abdominal radiograph of a six-
Weight loss year-old domestic shorthair cat. The colon
is full of faeces and distension of the colon
Depression/lethargy is evident. This was due to the presence of
a foreign body (a piece of cloth) within the
Poor coat condition colon resulting in obstipation and
subsequent megacolon

In Practice * SEPTEMBER 1997 435

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Severe constipation
Measures to prevent recurrence of constipation In more severe cases - where laxative treatment is
unsuccessful and constipation persists - therapy is
If underlying causes or predisposing factors can be identified, they should be directed towards re-establishing normal fluid and
eliminated or corrected if possible. Laxative therapy should be instituted, as electrolyte abnormalities to correct any dehydration; this
required, to help prevent recurrences. Dietary adjustments include the addition may also aid in softening the faeces. If treatment with
of fermentable fibre such as ispaghula, pectin or guar gum. This is now consid- suppositories is unsuccessful, enemas may be needed to
ered to be more important in the treatment of constipation than poorly evacuate the colon. An enema of 5 to 10 ml/kg of warm
fermented fibres, such as wheat bran or methylcellulose, since the former are water or saline should be administered into the colon
broken down to produce gas which breaks up the faecal mass and produce short (slowly, so as not to induce vomiting).
chain fatty acids which are 'colonic fuels'. If obstipation cannot be relieved with enemas alone,
the faecal mass may need to be broken down manually
and the faeces removed either digitally or with the use of
MANAGEMENT OPTIONS sponge forceps. General anaesthesia is required for
these more invasive therapies and the procedure may be
There are two broad management options for cats present- best carried out in stages over several days. Once
ed with constipation: medical or surgical. In most cases, the faecal impaction has been relieved, follow-up
medical management should be tried first and measures oral laxative therapy is instituted. Some cats may
taken to prevent recurrence of the constipation (see box require intermittent treatment at home and for this
above). If an underlying cause can be found it should be purpose lactulose, Peridale capsules or Katalax can be
treated appropriately. However, if constipation becomes a dispensed.
recurrent problem or the response to medical therapy The pathogenesis of megacolon has not been well
becomes refractory, surgery becomes a viable option. understood and for a long time many cats have been
treated empirically. Dietary manipulations, laxatives,
stool softeners, water enemas and manual debulking
MEDICAL MANAGEMENT temporarily relieve signs in some cats, but relapses are
common. However, recent evidence has suggested that
Mild constipation megacolon is due to a defect in colonic smooth muscle
The treatment of constipation varies according to the function (Washabau and Stalis 1996) and
severity and duration of clinical signs. Often episodes of treatments directed at improving colonic smooth
constipation are temporary and resolve without muscle function may improve colonic motility. In this
treatment. Cases of mild or moderate constipation can regard, cisapride may be an effective prokinetic agent
usually be successfully treated on an out-patient basis for the treatment of idiopathic megacolon and initial
by modifying the diet and by using oral laxatives such as clinical trials have been encouraging (Tams 1994,
Katalax (C-Vet) or Peridale capsules (Arnolds) (see box Washabau and Sammarco 1996). Cisapride can be com-
below). bined with oral laxatives such as lactulose.

Medical nuanagement of constipation

Lubricant laxatives tissue into the intestinal lumen. The resulting bowel distension pro-
Lubricant laxatives such as mineral oil can be used to soften and motes peristalsis.
lubricate the faeces to facilitate evacuation. Administration should * eg, Lactulose (non-proprietary, human-licensed preparation), a
be between meals so that they do not interfere with absorption of synthetic disaccharide. Starting dose for most cats is 2 to 3 ml tid
fat-soluble vitamins. Animals given mineral oils are at risk of aspira- by mouth, which is adjusted according to response
tion pneumonia. * eg, Micralax Micro-enema (Evans) is a human-licensed prepara-
* eg, Katalax (C-Vet), 1 to 2 cm of paste sid or bid tion which contains sodium citrate and acts as an osmotic laxative.
One enema as necessary
Bulk forming laxatives
Bulk forming laxatives take up water in the gastrointestinal tract, Modulators of intestinal motility
thereby increasing the volume of the faeces, promote peristalsis Cisapride (Prepulsid; Janssen Pharmaceutica) is a human-licensed
and help ease the passage of a soft stool. Adequate fluid intake prokinetic drug which enhances the transit of material through the
should be provided to avoid dehydration and consequent worsen- gastrointestinal tract, by promoting the release of acetylcholine in
ing of constipation leading to intestinal obstruction. the gut wall, with few side effects. It can be used in conjunction
* eg, Peridale capsules (Arnolds), 1 capsule bid with a stool softener (eg, lactulose) and a fibre-augmented diet.
* eg, Isogel (Charwell), ispaghula husk, 5 ml sid or bid Cisapride is started at 2-5 mg tid, 30 minutes before food. Cats that
respond well can sometimes be maintained on one to two doses of
Osmotic laxatives cisapride per day. Lactulose can be successfully discontinued in
Osmotic laxatives are hypertonic solutions of poorly absorbed some cats, while in others the dose may need to be gradually
substances that retain water and promote its movement from the increased over time.

sid Once daily, bid Twice daily, tid Three times daily

436 In Practice * SEPTEMBER 1997

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SURGICAL MANAGEMENT

Occasionally, constipation due to acquired megacolon

can be intractably recurrent despite medical therapy and
eventually becomes unresponsive to everything but the
physical removal of faeces from the rectum. Morbidity is
a significant problem with megacolon in the cat and
surgical intervention is preferred to long term medical
management; in fact, surgery should be considered a
viable option early in the management of this condition.
Removal of the colon is the generally accepted
procedure, but there is controversy surrounding the best
technique to use.

TECHNIQUES
Excision of the ileocolic junction
When the ileocolic junction is excised, the proximal
colon is also removed and the distal small intestine is
anastomosed to the remaining distal colon (Rosin and
others 1988, Greenfield 1991). Although this is techni-
cally the easier method to perform, due to decreased ten-
sion on the tissues during surgery, removal of the ileo-
colic junction may result in bacterial overgrowth in the
small bowel, deconjugation of bile salts and steator-
rhoea. There have also been reports of greater long-term
incidence of loose stools which may be the result of
reduced colonic capacity for storage or absorption and
decreased transit time (Sweet and others 1994).

Preservation of the ileocolic junction

In this method, the ileocolic junction is not excised and
2 to 3 cm of the proximal colon is preserved in order Following ligation of the appropriate blood vessels (arrows),
to enable a tension-free colocolonic anastomosis. anastomosis is performed between B and C if the ileocolic
junction is left intact (colocolostomy). If the ileocolic
Preservation of the ileocolic junction is advantageous as junction is resected concurrently, lumen continuity is
it is thought to have an important role in maintaining re-established by anastomosing A to C (ileocolostomy)
(Reproduced from Bright and others [1986] with permission of the
normal bowel function and the clinical response is more Journal of the American Veterinary Medical Association)
favourable (Bright and others 1986, Bright 1991, Sweet
and others 1994). For these reasons, most recent reports
suggest that, if technically feasible, the ileocolic junction
should be preserved.

PREOPERATIVE PREPARATION
Any dehydration and electrolyte abnormalities should be
corrected with intravenous fluid therapy before surgery.
Enemas should not be given for one or two days
preceding surgery as they may increase the risk of
intraoperative contamination. Considering the serious Ventrodorsal caudal
consequences of septic peritonitis caused by Gram- abdominal radiograph of a
negative aerobic and anaerobic bacteria from the colon, 12-year-old domestic
shorthair cat. The pelvic
broad-spectrum antibiotics (eg, cephalosporin) should be canal is significantly
started immediately pre-surgery and continued through- narrowed in both depth and
width as a result of the
out the surgical procedure. comminuted pelvic fracture
involving both acetabulae
SURGICAL APPROACH and pelvis. Acquired
megacolon is present.
The colon is exteriorised through a ventral midline cau- Reports suggest that
dal abdominal incision. The appropriate colic and caudal subtotal colectomy should
be performed after six
mesenteric vessels are isolated, ligated and transected to months of constipation
free the segment of colon to be removed. If the ileocolic associated with pelvic
fracture malunion or for
junction is removed, a 0-5 to 1 0 cm segment of the cats developing refractory
descending colon just cranial to the colorectal junction is constipation after pelvic
saved to anastomose to the ileum. When the ileocolic reconstruction. However, for
cats with a history of recent
junction is retained, a short (1 to 2 cm) segment of pelvic trauma (less than six
ascending colon is preserved to accommodate a months) that have early
problems associated with
colocolostomy. An end-to-end anastomosis is used to constipation, pelvic
re-establish bowel continuity. Sutures are not pulled resection is recommended
(Matthiesen and others
excessively tight and an omental patch is placed over the 1991, Schrader 1992)

In Practice 0 SEPTEMBER 1997 437

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Surgical procedure.
(A) Exteriorisation of the
colon through a ventral
anastomotic line. Prior to closure, the abdomen is irrigat- tive adaptive period is likely to be a manifestation of the midline caudal abdominal
incision. The diameter of the
ed with copious amounts of warm saline. reduced capacity of the remaining colon for storage of colon is much greater than
faeces and absorption of water. However, in most cases, that of the small intestine.
POSTOPERATIVE CARE faeces become more formed by two months after surgery, (B) Removal of the colon
with preservation of the
Anorexia is common during the first few postoperative probably due to compensatory changes occurring in the ileocolic junction.
days and parenteral fluids should be administered until bowel. Faecal continence is maintained and weight gain (C) End-to-end
the cat begins eating. Patients usually have a good usually occurs. Although recurrent constipation has been colocolectomy.
(D) The resected colon is
appetite within a few days of surgery. Diarrhoea and reported in some cases, it can often be managed medical- grossly dilated and packed
with faeces
increased frequency of defecation during the postopera- ly. Overall, the long-term prognosis is favourable.

Approach to acquired megacolon

Suggestive clinical signs

History, physical examination, radiographs, etc

Megacolon confirmed

Secondary Idiopathic

7*
Treat underlying Medical Surgical
Lateral abdominal radiograph of a four-year-old male
cause management management
Persian cat. The colon is distended with faeces due to
idiopathic megacolon. After failure of empirical medical
management, a successful subtotal colectomy with
preservation of the ileocolic junction was performed. There 100
were no further episodes of constipation

In Practice * SEPTEMBER 1 997 4439

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SUMMARY R. & KUSBA, J. (1988) Subtotal colectomy for treatment of chronic

constipation associated with idiopathic megacolon in cats: 38 cases
(1979-1895). Journal of the American Veterinary Medical
Feline constipation is not an uncommon problem in Association 193, 850-853
practice. If an underlying cause can be identified and SCHRADER, S. C. (1992) Pelvic osteotomy as a treatment for
obstipation in cats with acquired stenosis of the pelvic canal: six
treated, then medical management is often sufficient. In cases (1978-1989). Journal of the American Veterinary Medical
cases of megacolon which have become refractory to Association 200, 208-213
SWEET, D. C., HARDIE, E. M. & STONE, E. A. (1994) Preservation
medical therapy, surgical intervention may be required. versus excision of the ileocolic junction during colectomy for
Although there is some debate about whether the ileocol- megacolon: a study of 22 cats. Journal of Small Animal Practice 35,
358-363
ic junction should be preserved or excised, the prognosis TAMS, T. R. (1994) Cisapride: clinical experience with the newest GI
after either procedure is generally good. However, prokinetic drug. Proceedings of 12th ACVIM Forum, San Francisco,
with increased understanding of colonic smooth muscle California. pp 100-101
WASHABAU, R. J. & SAMMARCO, J. (1996) Effects of cisapride on
function, and the availability of new drugs such as feline colonic smooth muscle function. American Journal of
cisapride, subtotal colectomy may become only rarely Veterinary Research 57, 541-546
WASHABAU, R. J. & STALIS, I. H. (1996) Alterations in colonic
necessary. smooth muscle function in cats with idiopathic megacolon.
American Journal of Veterinary Research 57, 580-587
WELCHES, C. D., SCAVELLI, T. D., ARONSOHN, M. G. & MATTHIESEN,
D. T. (1992) Perineal hernia in the cat: a retrospective study of 40
References cases. Journal of the American Animal Hospital Association 28,
BRIGHT, R. M. (1991) Idiopathic megacolon in the cat. Subtotal 431-438
colectomy with preservation of the ileocolic valve. Veterinary
Medicine Report 3, 183, 186-187 Further reading
BRIGHT, R. M., BURROWS, C. F., GORING, R., FOX, S. & TILMANT, L. BURROWS, C. F. (1991) Constipation, obstipation and megacolon. In
(1986) Subtotal colectomy for treatment of acquired megacolon in Consultations in Feline Internal Medicine. Ed M. S. Lieb.
the dog and cat. Journal of the American Veterinary Medical Philadelphia, W. B. Saunders. pp 445-450
Association 188, 1412-1416 HOLT, D. & JOHNSTON, D. E. (1991) Idiopathic megacolon in cats.
GREENFIELD, C. L. (1991) Idiopathic megacolon in the cat. Subtotal Compendium on Continuing Education for the Practicing
colectomy with removal of the ileocolic valve. Veterinary Medicine Veterinarian 13, 1411-1414, 1416
Report 3, 182, 184-185 SALISBURY, S. K. (1991) Feline megacolon. Veterinary Medicine
MATTHIESEN, D. T., SCAVELLI, T. D. & WHITNEY, W. 0. (1991) Report 3, 131-138 Acknowledgement
Subtotal colectomy for the treatment of obstipation secondary to SHERDING, R. G. (1994) Diseases of the intestines. In The Cat. The author would like to thank
pelvic fracture malunion in cats. Veterinary Surgery 20, 113-117 Diseases and Clinical Management. Ed. R. D. Sherding. New York, Bryden Stanley for providing
ROSIN, E., WALSHAW, R., MEHLHAFF, C., MATTHIESEN, D., ORSHER, Churchill Livingstone. pp 1211-1285 some of the illustrations.

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Decision making in the managemnent of

constipation in the cat

Philippa Yam

In Practice 1997 19: 434-440

doi: 10.1136/inpract.19.8.434

Updated information and services can be found at:

http://inpractice.bmj.com/content/19/8/434

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