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-Background -Diagnosis of subtypes of chronic constipation has been considered difficult to achieve even in specialized centers.Although colorectal physiologic tests have brought an important contribution, it remains unclear in which patients these tests should be indicated for. Aims -This study aims to establish a differential diagnosis for chronic constipation cases using clinical assessment and physiologic tests and to identify clinical parameters that could predict which patients need physiologic tests. Methods -One hundred and seventy nine patients (83% females; mean age, 45) with chronic constipation according to Rome II criteria were initially treated by dietary advice and functional reeducation and those unresponsive (110 or 61.5%) were submitted to colonic transit time, defecography, anorectal manometry and electromyography, as needed. Results -A differential diagnosis was achieved in 63.6% of patients tested. However, 61.5% of 179 patients with chronic constipation (69 with no need to tests and 40 with normal tests) have etiologic diagnosis established only on clinical basis. Irritable bowel syndrome (32%), pelvic floor dysfunction (29%) and functional constipation due to faulty diet and life style habits (22%) were the main causes of chronic constipation. Alternating constipation and nausea/vomiting were symptoms significantly related to the diagnosis of irritable bowel syndrome; younger age, larger intervals between bowel movements, occurrence of fecal impaction and necessity of enema were related to the diagnosis of non-chagasic megacolon and digital assistance to evacuate and large rectocele or spastic pelvic floor on rectal exam were associated to pelvic floor dysfunction. Patients with long-standing constipation, fecal impaction, abdominal pain not eased after defecation, necessity for enemas, digital assistance and evidence of rectocele tended to be in need for physiologic tests to define the cause of chronic constipation. Conclusions -The etiologic diagnosis of chronic constipation can be achieved in most of patients on a clinical basis and some symptoms may be significantly related to specific diagnoses. Indications for physiologic tests should be based on specific clinical parameters.

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A esclerodermia ou esclerose sistêmica progressiva é uma doença auto-imune de causa desconhecida que se caracteriza por fibrose da pele, vasos sanguíneos e de alguns outros órgãos, como os pulmões, coração, rins e trato gastrintestinal. Sintomas atribuíveis ao comprometimento gastrintestinal podem estar presentes em até 50% dos pacientes, sendo os mais freqüentes, relacionados às manifestações esofagianas e anorretais. Anormalidades na motilidade intestinal com freqüência levam a desnutrição, supercrescimento bacteriano e quadro de pseudo-obstrução ou mesmo semi-obstrução intestinal. É apresentado um caso de paciente com esclerodermia há 43 anos, evoluindo com quadro de semi-obstrução, apresentando distensão abdominal, cólicas recorrentes e desnutrição grave. Sem resposta ao tratamento clínico foi submetida à cirurgia que evidenciou quadro obstrutivo por comprometimento ileal, o qual foi tratado por bypass íleo-cólico. Lesão intestinal por esclerodermia levando a quadro de obstrução é raramente descrita na literatura médica e, portanto, o tratamento de escolha ainda não foi definido.
Scleroderma or progressive systemic sclerosis (PSS) is a self-immune illness of unknown cause that is characterized by fibrosis of the skin, blood vessels and some other tissues like the lungs, heart, kidneys and gastrointestinal system. Attributable symptoms to the gastrointestinal involvement can be present in up to 50% of the patients, esophageal and anorectal manifestations being more frequent. Abnormalities in the intestinal motility frequently lead to malnutrition, bacterial over-growth and intestinal pseudo-obstruction. We report a case of scleroderma with intestinal pseudo-obstruction presenting chronic abdominal cramps, bloating and malnutrition with no response to clinical approach. Patient underwent surgery with diagnosis of intestinal obstruction by annular ileal fibrosis treated by ileocolic bypass. Intestinal injury causing obstruction is rarely described in the literature and therefore the treatment of choice is not yet defined