ZSFG 8/12 Pearls: Constipation and the retroperitoneum

Thanks to Sara and Emily for presenting a case of a young man with constipation found to have a retroperitoneal mass, likely sarcoma.

The elusive idea of constipation has varying definitions, but Rome III criteria defines functional constipation with any 2 (two) of the following:

  • Straining
  • Lumpy hard stools
  • Sensation of incomplete evacuation
  • Manual maneuvers to facilitate at least 25% of defecations
  • Sensation of anorectal obstruction or blockage with 25 percent of bowel movements
  • Decrease in stool frequency (less than three bowel movements per week)
    • Rome III advocates that the above criteria must be fulfilled for the last three months with symptom onset six months prior to diagnosis, loose stools should rarely be present without the use of laxatives, and there must be insufficient criteria for a diagnosis of irritable bowel syndrome

Because you were wondering, the American College of Gastroenterology Task Force came together to define constipation in more “clinician friendly” way, as…

  • A symptom-based disorder defined as unsatisfactory defecation and is characterized by infrequent stools, difficult stool passage, or both

Constipation can be broken down by…

*Primary: colorectal dysfunction

  • Slow transit constipation: prolonged delay in stool transit throughout the colon
  • Dys-synergic defectation: difficulty with or inability expelling stool from the anorectum
  • Irritable bowel syndrome

*Secondary:
constipation.JPG

Dr. Cello also came prepared with pearls on GI malignancy location, mass origin with regards to respiration, and potential etiologies of retroperitoneal masses…

GI malignancy location relative to symptoms:

  • Right sided colonic lesion: non-obstructive sx’s
  • Left sided lesion (smaller lumen): hematochezia, obstructive sx’s

Abdominal mass origin relative to respiration…let your physical exam guide you. How the GI system reacts to respiration will help you localize a mass adjacent to or arising from a particular anatomical structure

  • Duodenum/most of pancreas/RP structures DO NOT move with respiration
  • Stomach/rest of small bowel/appendix/colon/liver DO move with respiration

 

Solid retroperitoneal (RP) neoplasms divided into four main groups (see below for amazing **review article from Cleveland** which compliments Cello’s pearls)

(a) mesodermal neoplasms: liposarcoma (33% of primary RP sarcomas), leiomyosarcoma (28%), malignant fibrous histiocytomas (19%), less common sarcomas
(b) neurogenic tumors (i.e. schwannoma, neurofibroma, neuroblastoma, malignant nerve sheath tumors)
(c) germ cell, sex cord, and stromal tumors (teratoma, granulosa cell tumor)
(d) lymphoid and hematologic neoplasms (lymphoma, extramedullary plasmacytoma)

 

What does the retroperitoneal space look like? At the level of the kidneys…

retroperitoneal space.jpg

FIGURE: The anterior pararenal space (APRS) is located between the parietal peritoneum (PP) and the anterior renal fascia (ARF) and contains the pancreas (Pan), the ascending colon (AC), and the descending colon (DC). The posterior pararenal space (PPRS) is located between the posterior renal fascia (PRF) and the transversalis fascia (TF). The perirenal space (PRS) is located between the anterior renal fascia and the posterior renal fascia. Ao = aorta, IVC = inferior vena cava, LCF = lateroconal fascia.

 

References:
http://gi.org/wp-content/uploads/2014/08/IBS_CIC_Monograph_AJG_Aug_2014.pdf

**Rajiah et al. Imaging of Uncommon Retroperitoneal masses. RadioGraphics. 2011. DOI: http://dx.doi.org/10.1148/rg.314095132

http://www.uptodate.com/contents/constipation-in-the-older-adult?source=machineLearning&search=constipation+adult&selectedTitle=2%7E150&sectionRank=3&anchor=H29212415#H29212415

 

Evernote link: https://www.evernote.com/shard/s354/sh/ec8f5350-cd18-4d93-b983-34e42db98354/71dbdf1eba4b8254552bb476df8f0cab

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