Case Description/Methods: A 64 year-old male with a past medical history of hypertension, atrial tachycardia, and heavy alcohol use was referred for further GI workup by his primary care physician following a 5 month history of worsening constipation after a viral infection. Prior to the infection, he had a bowel movement 2-3 times per week. However, he now describes one Bristol 4 or 7 bowel movement with straining per month. Symptoms were refractory to Dulcolax and Colace. Initial workup included a normal extended electrolyte panel, normal TSH, and negative Celiac disease serologies. A CT abdomen and pelvis revealed extensive dilation of proximal colon, compression of descending and sigmoid colon, and small bowel fecalization. A representative coronal image is shown in Figure 1. Subsequent colonoscopy did not reveal any evidence of obstruction. Anorectal manometry (ARM) findings included elevated resting pressure (74.94 mmHg), decreased sensation, paradoxical contraction with Valsalva, and inability to pass the balloon catheter after 2.5 minutes. Normal rectal capacity (280 mL) and excellent squeeze pressure but paradoxical contraction with Valsalva is consistent with pelvic floor dyssynergia. Biofeedback therapy was recommended. Discussion: Evaluating for secondary causes of CIPO (i.e., obstruction, metabolic disturbances, autoimmune disorders, neurologic disorders, and musculoskeletal disorders) is an important diagnostic step. Key tests include imaging, colonoscopy, electrolytes and autoimmune panels, and anorectal manometry. This case highlights long-standing pelvic floor dyssynergia as an underlying cause of CIPO.[2466] Figure 1. CT abdomen and pelvis with extensive dilation of proximal colon and small bowel fecalization.

Table 1. (continued ) Variable Reference Range, Adults* Result Ferritin (ng/mL) 30-400 284 Iron (mg/dL) 59-158 90 Total iron binding capacity (mg/dL) 250-450 342 HFE gene mutation analysis -Not obtained Alpha-1 antitrypsin antibody (serum) *** 176 Triglycerides (mg/dL) , 150 185 Total cholesterol (mg/dL) , 200 152 LDL-cholesterol (mg/dL) , 100 89 Anti-tissue transglutaminase IgA antibody (U/mL) , 4.0 1.2 Anti-tissue transglutaminase IgG antibody (U/mL) , 6.0 Not obtained Celiac HLA DQ alleles -Negative S3172 Syphilis: "The Great Imitator" Presenting as Acute Hepatitis