ORIGINAL ARTICLE
Six hundred and forty-five patients were referred from general prac-
Additional faecal reservoirs
or hidden constipation:
a link between functional
and organic bowel disease
Dennis Raahave & Franck B. Loud
Department of Organ Surgery/Gastroenterological Clinic, Elsinore Hospital.
Presented as a preliminary communication at meetings in the Danish Surgi-
cal Society 1999.03.31., in the Danish Society of Gastroenterology
2000.04.06., and in part at the international meeting Colorectal Disease, pre-
course symposium, 2000.02.10. Fort Lauderdale, Florida, USA.
Correspondence to: Dennis Raahave, MD, DMSc, Department of Organ Sur-
gery, Elsinore Hospital, Esrumvej 145, 3000 Elsinore, Denmark.
E-mail: dera@fa.dk
ABSTRACT
Introduction: The study was undertaken to test a hypothesis of coexistence
and causality between abdominal and recto-anal symptoms and physical
signs.
Material and methods: A random sample of 251 patients was drawn from 645
referred patients from 12th September 1988 to 19th January 1999. Nineteen
selected symptoms were recorded; abdominal palpation and ano-rectoscopy
were with special reference to identify faecal reservoirs. Barium enema was
used to demonstrate colon pathology. After a combined prokinetic regimen,
symptoms and signs were reassessed. The study was observational and factor
analysis was used to explore the data together with testing after cross tabula-
tions.
Results: One hundred and fiftynine patients were female (63%); neither
bloating (64%), abdominal pressure (60%) and pain (26%) nor right iliac
fossa tenderness (58%) and faecal mass (42%) and meteorism (33%) were
related to age. Patients with additional diverticula and haemorrhoids were
significantly older than patients without these lesions. Bloating was found
together with a reservoir of faeces in ano-rectum in 62% of patients and 51%
had haemorrhoids grade 2 or more and 50% had bloating, faeces in rectum
and a right sided palpable abdominal mass (additional faecal reservoir).
Among 17 factors explaining 68% of the variance in 45 variables, frequent
abdominal and ano-rectal symptoms and physical signs showed substantial
correlations to nine factors, indicating that they belong to the same under-
lying condition. A malignant tumour was found in four patients, polyps in
20 patients, and in 105 patients left sided diverticula were present. After a
prokinetic regimen was conducted the dominant symptoms and signs were
reduced significantly.
Conclusions: Collectively, the data showed significant correlations between
abdominal and anorectal symptoms and signs. Additional faecal reservoirs
were demonstrated in the right colon and the rectum, irrespective of defae-
cation daily. This hidden constipation (faecal retention) gives rise to bloat-
ing, pain and right iliac fossa tenderness and mass, and defaecation disorders
(functional faecal retention) which was confirmed by a significant reduction
in symptoms and physical signs after a propulsive regimen. Also, over the
years, the state of hidden constipation seems to bear a cumulative risk of de-
veloping organic diseases like diverticula, polyps, haemorrhoids and malig-
nancy.
Dan Med Bull 2004;51:422-5.
Abdominal bloating and pain are among the most common symp-
toms in gastro-intestinal disease and are also experienced in normal
populations (1). Defaecation disorders and anal complaints, mostly
in form of haemorrhoids, are also occurring with a high frequency.
However, it is yet not clear if there is a coherence or a causality be-
tween a broader spectrum of abdominal symptoms and physical
signs and those from the rectum and anal area (2). The present
study was therefore undertaken to test a hypothesis of coexistence
between abdominal and recto-anal symptoms and physical signs.
422
MATERIAL AND METHODS
titioners to an outpatient clinic and ambulatory service from 12th
September 1988 to 19th January 1999. They had been referred for
various abdominal symptoms, defaecation disorders including
bleeding and such signs as abdominal distension or haemorrhoids.
A random sample of 251 patients was drawn from the above mater-
ial for a descriptive analysis, representing a 10-year-period. From
the records, a standardized questionnaire was completed for each
patient, covering 19 selected symptoms (Figure 1), and any previous
abdominal and anal operations. Each patient also underwent a
standardized physical examination, including digital exploration of
the ano-rectum followed by an initial ano-rectoscopy without
cleansing to observe eventual rectal constipation. Otherwise, further
investigations were dictated by the patients’ symptoms and signs, for
example colon barium enema, abdominal ultrasound and biochem-
ical tests. Patient treatment was by a fluid and dietary regimen, rich
in fibre and low in fat as advocated by the Danish Nutrition Council.
The diet was supplemented by Ispagula HUSK (Ratje Frøskaller,
Kastrup, Denmark) 5-10 g/day and by cisapride, 5 mg twice daily to
20 mg, three times daily. Finally, symptoms and signs were reas-
sessed two months after start of the treatment. Surgery was done
when necessary.
Statistics: The database was prepared in cooperation with UNI C,
the Danish Electronic Data Processing Center for Research and Edu-
cation (Copenhagen) which subsequently carried out the statistical
analyses. The present study was observational and the analyses,
therefore, will be more of an explorative nature than testing specific
hypotheses, although this also will occur. The frequencies of symp-
toms, physical signs and investigations were determined. Principal
component analysis or factor analysis were chosen as the main sta-
tistical explorative tool. Although factor analysis is not primarily de-
signed for binary variables, it could be used in this context (3). The
method analyses the pattern of correlation coefficients between the
variables and combine groups of highly correlated variables into a
smaller number of independent (uncorrelated) new variables ex-
plaining a major part of the variation (4). In the present study, the
factor analysis could in its best indicate if certain symptoms and
signs (abdominal and recto-anal) are correlated in a way that shows
that they belong to the same underlying disease-dimension. Thus,
the correlation of a variable (symptom, sign or investigation) with
the individual factor was expressed as a factor loading or correlation
coefficient, which could be between –1 and +1; the greater numeric
correlation, the greater the association to the factor. However, factor
loadings of numeric <0.3 are not considered of any practical im-
portance. Also, important findings of symptoms and signs were
cross-tabulated. A p-value of 0.05 or less was considered significant.
RESULTS
Of the 251 patients included in the study, 159 were female (63%)
with a mean age of 49.9 years (range17-85) and 92 were male pa-
tients, mean age 51.7 years (range 24-89). In Figure 1 the symptoms
are listed with declining frequencies. Most patients reported solid
stool with defaecation at least once daily and with relative ease. The
most common abdominal symptoms were bloating, abdominal
pressure, epigastric discomfort, and episodes of colic pain.
Proctalgia were experienced by 28% and 38% reported occa-
sional bleeding. Halitosis was experienced by 14% of the patients;
9% had episodes of feeling feverish, together with sudden nausea,
and dizziness, requiring the patient to lay down for a while until
spontaneous relief. Appendectomy had been performed in 16% and
cholecystectomy in 7% of the patients.
The physical signs were dominated by right iliac fossa tenderness
(58%) a palpaple faecal mass (i.e. additional faecal reservoir) (42%),
meteorism (33%) and epigastric tenderness (15%). Tenderness in
the left fossa was proven in 10% and a mass in 4% of the patients.
Ano-rectoscopy, done at the patient’s first visit, showed a reservoir
DANISH MEDICAL BULLETIN VOL. 51 NO. 47/NOVEMBER 2004
Figure 1. Frequency of symptoms in
251 patients with colo-recto-anal com- Solid faeces
plaints. Symptoms duration >3 months
Defaecation or ≥ 1 per day
Bloating
Abdominal pressure
Defaecation ease
Epigastric discomfort
Bleeding per rectum
Liquid faeces
Defaecation difficult for years
Defaecation incomplete
Proctalgia
Abdominal colics
Defaecation repetitive
Defaecation 1 per 2 days
Soiling
Bad breath
Fever episodes
Defaecation 1 or < for 3 days
0 10 20 30 40 50 60 70 80 90 100
Per cent

of solid faeces in the ano-rectum in 62%, and haemorrhoids grade 2 symptoms and signs; there was no sex-difference in occurrence of
or more in 51%. This examination revealed polyps in 20 patients haemorrhoids or diverticulosis. Since a palpable abdominal mass
and a tumour in three patients. Of the 251 patients, 138 underwent and faeces in the rectum represent faecal reservoirs (fermenting gas
a barium enema which revealed left-sided diverticulosis in 42%, production), these variables were cross-tabulated with bloating to
right-sided diverticulosis in 16%, while a tumour was identified in test for a coexistence (Table 3). Although faeces in the ano-rectum
one patient. Colon elongatum was demonstrated in 16 patients. occurred together with bloating in 62% of patients and 50% had
The data was studied further by cross-tabulation of the variables. bloating, faeces and a palpable abdominal mass, no statistical signif-
It is shown in Table 1 that the occurrence of main abdominal symp- icant differences were found.
toms and signs were not related to age. In contrast, patients with The structure of the data was explored further by factor analysis
haemorrhoids and diverticulosis were significantly older than pa- of the main symptoms, physical signs and paraclinical investigations
tients without these diseases. From Table 2 it is seen that female pa- – a total of 45 variables. The factor analysis was able to reduce these
tients significantly more often than men experienced the dominant variables to 17 factors with an eigenvalue greater than one explain-
ing 68% of the variance in all 45 variables. The nine factors having
Table 1. Mean age (yrs) of patients and symptoms, signs and pathology.
the largest eigenvalues are shown in Table 4, which is a rotated com-
ponent loading matrix. Each loading expresses the correlation be-
Yes No
tween the variable and that particular factor. Bloating, abdominal
n age n age p* pressure and colics, epigastric discomfort and tenderness all showed
Bloating . . . . . . . . . . . . . . . . . . . . . 152 51.7 87 48.5 0.156 substantial correlations to factor A. Variation in stool consistency
Abdominal mass right fossa . . . . . 103 50.4 143 51.0 0.789 and repetetiveness correllated to factor B, as did repetitiveness, in-
Abdominal tenderness . . . . . . . . . 143 50.0 102 51.9 0.392 complete feeling and difficult emptying and proctalgia to factor C.
Faeces ano-rectum . . . . . . . . . . . . 143 51.8 89 48.6 0.166
Haemorrhoids grade 2 . . . . . . . . . 123 53.5 122 47.6 0.007
A proven right-sided abdominal mass correlated with tenderness,
Diverticulosis, left . . . . . . . . . . . . . 58 67.0 80 49.3 0.000 meteorism, fever-episodes and bad breath, and with incomplete de-
Diverticulosis, right . . . . . . . . . . . . 22 65.1 115 55.2 0.010 faecation and difficulty (D). In another factor (E), epigastric and
*) t-test, p<0.05 S.
right fossa tenderness correlated with obesity, the latter also been
correlated with bad breath, weight gain, polyps and haemorrhoids
(G). Abdominal pressure and colics were loaded significantly in an-
Table 2. Occurrence of main symptoms, signs, pathology and sex. other factor (F) with meteorism and fever episodes, negatively with
Male Female
n (%) n (%) p*
Table 3. Cross tabulations of abdominal mass, bloating and faeces in rec-
Bloating Yes 46 (52) 108 (71) 0.003 tum.
No 43 (48) 44 (29)
Abdominal mass
Abdominal mass Yes 26 (28) 78 (50) 0.001
No 66 (72) 78 (50) yes (%) no (%) p*

Abdominal tenderness Yes 42 (46) 102 (65) 0.003 Bloating Yes 70 (46) 83 (54) 0.174
No 49 (54) 54 (35) No 31 (37 54 (64)

Faeces anorectum Yes 53 (61) 91 (62) 0.881 Faeces Yes 64 (45) 78 (55) 0.172
No 34 (39) 56 (38) No 32 (36) 58 (64)

Haemorrhoids grade 2 Yes 51 (55) 74 (48) 0.242 Bloating and faeces Yes 44 (50) 44 (50) 0.071
No 41 (45) 81 (52) No 50 (37) 85 (63)
Faeces
Diverticulosis left Yes 20 (38) 38 (45) 0.420
No 33 (62) 47 (55) yes (%) no (%)

Diverticulosis right Yes 11 (21) 11 (13) 0.234 Bloating Yes 88 (62) 55 (38) 0.953
No 42 (79) 73 (87) No 50 (61) 32 (39)
*) Chi-square, p<0.05 S. *) Fisher's exact test, p ≥0.05 NS.

DANISH MEDICAL BULLETIN VOL. 51 NO. 4/NOVEMBER 2004 423

Table 4. Correlation coefficients in fac- Factors
tors of symptoms, signs and investiga-
tion. A B C D E F G H I J

Epigastric discomfort . . . . . . . .770

Epigastric tenderness . . . . . . . .384 .827
Bloating . . . . . . . . . . . . . . . . . . .586
Abdominal pressure . . . . . . . . .688 .315
Abdominal colics . . . . . . . . . . . .541 .338

Stool solid . . . . . . . . . . . . . . . . .876

Stool diarrhoea . . . . . . . . . . . . .911
Defaecation repetitive . . . . . . .612 .054
Defaecation incomplete . . . . . .662 .317
Defaecation ease . . . . . . . . . . . –.856 –.311 .675
Defaecation <3 days . . . . . . . . .459 –.662
Defaecation difficulties, yrs . . .805 .317
Proctalgia . . . . . . . . . . . . . . . . . .439 .766

Abd. mass right fossa . . . . . . . .856

Abd. tenderness right fossa . . .750 .320
Meteorism . . . . . . . . . . . . . . . . .493 .624 –.324
Fever episodes . . . . . . . . . . . . . .321 .663 .840
Bad breath . . . . . . . . . . . . . . . . .305 .348
Obesity . . . . . . . . . . . . . . . . . . . .426 .798
Faeces in rectum . . . . . . . . . . . –.605
Weight gain . . . . . . . . . . . . . . . .870
Polyps (anorectoscopy) . . . . . . .636
Bleeding per rectum . . . . . . . . .440
Haemorrhoids, grade 2 . . . . . . .319 .699 .487

Factor loadings < 0.300 are not shown. Factor analysis, varimax rotation, Kaiser normalization.
See statistics.

faeces in the rectum. Difficult and infrequent defaecation was asso-
ciated with fever episodes (I), and incomplete defaecation with
proctalgia and bleeding, negatively with the ease of defaecation (J).
In another factor (not shown) familiary colon cancer and meteor-
ism were loaded significantly.
Finally the outcome of the treatment was tested on the dominat-
ing symptoms (from Figure 1, Table 5). Thus, a symptom could
have disappeared or still be present or could still be absent or have
arrived. The number of patients eligible for analysis were reduced,
because some patients did not show up for the control or had
moved away. Bloating, abdominal pressure and colics and epigastric
discomfort were all reduced significantly. The process of defaecation
was overall improved by significant reductions in incomplete- and
repetitiveness, and now with ease and no pain and less liquid faeces.
The results of treatment on physical signs and investigations were
also tested. The presence of an abdominal mass in the right fossa fell
from 42% to 17% (p<0.05), the associated tenderness from 58% to
27% (p<0.05) and meteorism from 33% to 18% (p<0.05). Ano-rec-
tal constipation was reduced significantly from 62% to 19%
(p<0.05). Cisapride was administered to 159 patients (64%), minor
headache or dizziness developing in 7%.
Surgery was performed as follows: 76 patients with haemor-
rhoids grade 2 or more underwent banding or a Milligan-Morgan
procedure, further four patients had an anal-fissure operated, and
20 patients had ano-rectal polyps removed; four patients underwent
operation for a carcinoma.
DISCUSSION
In general, the connection between symptoms, clinical signs and
disease has been established empirically. In contrast, factor analysis
was used in this study and identified significant correlations be-
tween different symptoms and signs. Thus, a dominant factor con-
sisted of abdominal mass, tenderness, meteorism, fever episodes and
halitosis, two other factors of defaecation disorders. Not only a
right-sided mass, pressure and tenderness but also epigastric dis-
comfort and tenderness were included in a factor. All the more, a
high proportion of patients was identified with additional faecal ac-
cumulation in the right colon and rectum, so-called additional res-
ervoirs, irrespective of daily emptying. The patients did not fulfil cri-
teria of constipation with at least two defaecations per week (5), but
have nevertheless great accordance in other symptoms. A meaning-
ful interpretation would be that of functional retention of faeces in
various colo-rectal segments, called hidden constipation. Female
patients experienced significantly more often than males, the domi-
nant symptoms and signs which are usual in functional bowel dis-
ease (6). These symptoms were not related to age, in contrast to or-
ganic changes like diverticula and haemorrhoids which occurred
significantly more often with increasing age. Demonstration of co-
lonic pathology relied on barium enema, in contrast to the present
domination of flexible endoscopy. A high proportion of patients at a
higher age had grade 2 haemorrhoids and a faecesfull rectum. This
favours (rectal) constipation as being involved in displacement of
the anal canal i.e. haemorrhoidal disease, in accordance with an

Table 5. Relief of symptoms with a

Start Yes No
dietary/fluid regimen and cisapride.
Symptoms End no (%) yes (%) no (%) yes (%) p*

Bloating . . . . . . . . . . . . . . . . . . . . . . . . 102 (53) 22 (11) 69 (36) 0 (0) 0.000

Abdominal pressure . . . . . . . . . . . . . . . 109 (56) 14 (7) 73 (37) 0 (0) 0.000
Abdominal colics . . . . . . . . . . . . . . . . 49 (25) 1 (1) 143 (74) 1 (1) 0.000
Epigastric discomfort . . . . . . . . . . . . . . 78 (41) 14 (7) 99 (52) 0 (0) 0.000
Solid faeces . . . . . . . . . . . . . . . . . . . . . . 4 (2) 172 (89) 4 (2) 14 (7) 0.031
Liquid faeces . . . . . . . . . . . . . . . . . . . . . 73 (37) 5 (3) 116 (59) 1 (1) 0.000
Defaecation repetitive . . . . . . . . . . . . . 37 (20) 4 (2) 138 (76) 3 (2) 0.000
Defaecation incomplete . . . . . . . . . . . 45 (25) 5 (3) 127 (71) 1 (1) 0.000
Defaecation ease . . . . . . . . . . . . . . . . . 6 (3) 108 (57) 13 (7) 62 (33) 0.000
Proctalgia . . . . . . . . . . . . . . . . . . . . . . . 48 (25) 2 (1) 143 (73) 2 (1) 0.000
Fever episodes . . . . . . . . . . . . . . . . . . . 16 (9) 1 (1) 168 (90) 1 (1) 0.000
Symptoms . . . . . . . . . . . . . . . . . . . . . . . Disappeared Still present Still absent Arrived

*) Mcnemars test, exact computation, p <0.05 S.

424 DANISH MEDICAL BULLETIN VOL. 51 NO. 47/NOVEMBER 2004

earlier study (7). In all, approximately one half of the patients had a
fully developed hidden constipation syndrome.
Bowel symptoms are common in industrial populations with the
irritable bowel syndrome having prevalence rates from 6.6% to
25.0% (6). However, our patients did not have abdominal pain re-
lieved by defaecation, and although they experienced bloating and
some reported repetitiveness and incompleteness, they did not fulfil
established criteria for having IBS (6).
In the present study a rather high proportion of patients had un-
derwent appendectomy and cholecystectomy. Recent evidence
seems to show that formation of gallstones are related to slow transit
or an “indolent intestine” (8, 9). Analyses in this study seem to show
difficulties in transportation of faeces, resulting in formation of ad-
ditional faecal reservoirs in the right-sided colon and rectum. At this
stage, the condition is solely functional. However, if it remains for
years, an overloaded large bowel seems to lead into organic colorec-
tal disease. Because of a daily emptying, neither the patient nor the
physician at first suspect the symptoms of being originated from the
large bowel. However, some events would often have pointed to-
wards an overloaded colon like defaecation urge during a meal, and
soiling, or a more putrid smell from faeces and flatus. Also more fre-
quent defaecations during workfree weekends seem to occur, prob-
ably representing a natural release of the overload. It follows from
this that a situation of bowel overload could start insidiously before
detected after years of aggravation or finding of a definite patholo-
gical lesion. It is also clear that the frequency of defaecation does not
reflect the overload or hidden constipation.A constipated colon
bears in itself several potential risks. Intraluminal pressure-rising
could lead to increasing numbers of diverticula and polyps and ma-
lignancies are more frequent (10, 11, 12), as in this study with four
malignancies detected out of 251 patients. It should also be noted
that the proven additional faecal reservoirs of the right colon and
rectum correspond well with the more frequent occurrence of ma-
lignancies in these parts of the bowel. On this line it was recently ob-
served that patients with the irritable bowel syndrome were more
likely to have a subsequent diagnosis of a colorectal tumour (13).
Thus, hidden constipation could be “The common cause” of tu-
mours (benign, malign), diverticular disease and appendicitis,
which Burkitt searched for (14). The condition is suspected to be
widespread in western populations with many people not seeking
medical advice, and thereby having an increased risk of these dis-
eases over the years.
The present study was interventional and not a therapeutic trial of
different regimens. Thus, an established bowel stimulatory treat-
ment was initiated with a diet rich in fibre and low in fat, an in-
creased fluid intake and supplementary fleawort-seed, since high in-
take of dietary fibre is associated with more rapid transit time (15,
16) and also is associated with a lower frequency of bowel cancer.
Also, the patients were encouraged to exercise (17). Cisapride was
used in varying doses, since it increases bowel transit in normal vol-
unteers, in chronic constipation (18, 19) and in constipation domi-
nant irritable bowel patients (20). Thus bloating, abdominal pres-
sure and colics were reduced significantly, as were defaecation disor-
ders, constipation-fever episodes and proctalgia. The physical signs
were reduced to a lesser degree, although still significant. This
means that the effect of the propulsive regimen verified in itself the
preexisting faecal overload (retention) in reservoirs in the individual
patient. The dietary regimen and increased fluid intake had to con-
tinue while adjuvant cisapride often could be reduced to a single
daily dose of 10-20 mg, or ceased. Recently, cisapride has been with-
drawn from the market because of the risk of fatal cardiac ar-
rhytmia.
In conclusion, this study has shown correlation between abdom-
inal and recto-anal symptoms and physical signs. Especially, addi-
tional faecal reservoirs were demonstrated in the right colon and
rectum i.e. a constipated colon in spite of daily emptying. This hid-
den constipation gives rise to bloating, pain, and tenderness, and a
DANISH MEDICAL BULLETIN VOL. 51 NO. 4/NOVEMBER 2004
palpable mass in the right iliac fossa. Also, hidden constipation
seems over the years to bear a cumulative risk of developing gall-
stones, diverticula, polyps, haemorrhoids and malignancy, thus be-
ing a link between functional and organic disease. A combined pro-
kinetic regimen should therefore be initiated and continued.
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