From the Guidelines
A tortuous colon can significantly impact bowel emptying dynamics, often leading to constipation, bloating, and incomplete evacuation, and management should focus on a multi-faceted approach including dietary modifications, physical activity, and possibly medications, as outlined in recent guidelines 1. To manage this condition, I recommend increasing fiber intake gradually to 25-30g daily through fruits, vegetables, and whole grains, while maintaining adequate hydration with at least 2 liters of water daily.
- Regular physical activity, particularly walking for 30 minutes daily, can stimulate colonic motility.
- For medication management, osmotic laxatives like polyethylene glycol (MiraLAX, 17g in 8oz water daily) can be effective for regular use, as they increase the amount of water in the large bowel and help soften stool, making it easier to pass through the tortuous colon 1.
- For occasional constipation, stimulant laxatives such as bisacodyl (5-10mg) or senna (8.6-17.2mg) may help, as they increase intestinal motility and can help stimulate the myenteric plexus in the colon 1.
- Positioning during defecation is also important - using a footstool to create a squatting position can straighten the anorectal angle and facilitate emptying. These interventions work by addressing the mechanical challenges of a tortuous colon, where the additional bends and loops can slow transit time and make complete evacuation difficult.
- The increased fiber bulks stool and stimulates peristalsis, while adequate hydration keeps stool soft enough to navigate the tortuous segments more easily.
- Recent studies, such as the one published in Gut in 2020 1, support the use of these management strategies for patients with constipation and bowel dysmotility, and can be applied to patients with a tortuous colon.
From the Research
Implications of a Tortuous Colon on Bowel Emptying Dynamics
The implications of a tortuous colon on bowel emptying dynamics can be understood by examining the effects of colonic pseudo-obstruction and constipation on the colon.
- A tortuous colon can lead to colonic pseudo-obstruction, which is a cause of large intestinal dilation and obstruction without any physical transition point 2.
- Conservative management can be attempted for 48-72 hours in those with cecal diameters < 12 cm and without signs of peritonitis and perforation 2.
- The use of polyethylene glycol (PEG) can help prevent recurrence of colonic pseudo-obstruction after initial resolution 2, 3.
- PEG has been shown to increase stool and flatus evacuations, as well as decrease the diameter of the caecum, ascending and transverse colon, and abdominal circumference 3.
- A study on patients with a colostomy found that dietary modifications alone relieved constipation in more than half of the patients, and the remaining patients required additional treatment with a psyllium-based bulk-forming agent, an osmotic stool softener, and a probiotic, with or without a prokinetic agent such as metoclopramide 4.
- High-resolution manometry has revealed that PEG, bisacodyl, and prucalopride have distinct effects on colonic motility, with PEG increasing the number of low-amplitude long distance propagating contractions, bisacodyl increasing the number of high-amplitude propagating contractions, and prucalopride increasing the amplitude of high-amplitude propagating contractions 5.
Management of Colonic Pseudo-Obstruction
The management of colonic pseudo-obstruction can involve conservative measures, such as the use of neostigmine, colonoscopy, or fluoroscopic decompression, as well as surgical decompression and partial or complete colectomy 2, 6.
- Neostigmine is still a viable option for the treatment of colonic pseudo-obstruction, but there is also promising data on the use of pyridostigmine and prucalopride 2.
- A case study found that a patient with cerebral palsy and chronic intermittent constipation was successfully managed with conservative therapy for massive acute colonic pseudo-obstruction 6.
- The use of PEG, bisacodyl, and prucalopride can have distinct effects on colonic motility, and the combination of prucalopride and bisacodyl may be effective in treating patients with constipation refractory to single medications 5.