Constipation medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Chronic constipation treatment includes both behavioral and pharmacological interventions. Behavioral management mostly consists of life style and dietary modification, while pharmacological interventions are mostly based on laxatives. Increasing physical activity is postulated to improve constipation and colonic transit time in patients with constipation. The most important behavioral treatment for constipation is biofeedback, consisting of teaching the patients how to use their abdominal and pelvic muscles during defecation. Probiotics are live microorganism spores that are given orally to improve the gastrointestinal tract function. Recently, use of probiotics in food industry is growing. Bifidobacterium and Lactobacillus are most studied organisms as probiotics.

Medical Therapy

  • General principles of medical therapy in patients with chronic constipation are as following:[1]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic Constipation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EXCLUDE:
• Inadeqate fiber intake
Medication
Cancer
Stricture
• Systemic or neurologic disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No clinical response
 
 
Fiber supplement, Simple laxatives
 
 
Clinical response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
• Anorectal manometry
• Balloon expulsion test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Colonic transit time
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unclear diagnosis
 
Evacuation disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Delayed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Barium enema
• MR proctography
 
• Pelvic floor retraining
• Psychology
• Diet
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Fiber supplement
• Osmotic laxatives
• Secretagogues
• Prokinetics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinically significant structural disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical response
 
No clinical response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rectal surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Colonic manometry
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Colonic inertia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider colectomy plus ileorectostomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Chronic constipation management

Lifestyle modification

  • Increasing physical activity is postulated to improve constipation and colonic transit time in patients with constipation.[2]
  • Moderate physical exercise as much as 32 min per day have shown significant improvement of quality of life but no significant decrease in laxative need for treatment.[3]
  • Moderate to vigorous training (20-60 min, 3-5 times per week) revealed significant improvement in constipation symptoms in patients with irritable bowel syndrome (IBS).[4]

Dietary interventions

Biofeedback treatment

Pharmacological intervention

Pharmacological intervention for constipation include:[9]

Constipation

  • 1 Adult
    • 1.1 Over the counter medicines
      • 1.1.1 Bulk forming agents
        • Preferred regimen (1): Citrucel 500 mg PO q8-12h
        • Preferred regimen (2): FiberCon 625 mg PO q6-12h
        • Preferred regimen (3): Konsyl 5 g (1 tablespoon) dissolved in 250 mL water PO q8-24h
        • Alternative regimen (1): Metamucil 1000 mg PO q8-12h
      • 1.1.2 Osmotic agents
        • Preferred regimen (1): Cephulac 5 g (1 tablespoon) dissolved in 250 mL water PO q6-8h
        • Preferred regimen (2): Fleet Phospho-Soda 15 mL dissolved in 250 mL water PO q6-8h
        • Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
        • Alternative regimen (1): Miralax 34 g dissolved in 250 mL water PO daily
        • Alternative regimen (1): Sorbitol 30-150 mL (70% solution) once
      • 1.1.3 Stool softeners
      • 1.1.4 Lubricants
        • Preferred regimen (1): Fleet 19 g dissolved in 118-197 mL water enema per rectum daily
        • Preferred regimen (2): Zymenol 133 mL enema per rectum once
      • 1.1.5 Stimulants
    • 1.2 Prescription medicines
      • 1.2.1 Chloride channel activators
        • Preferred regimen (1): Lubiprostone (Amitiza) 24 mcg PO q12h with food and water
      • 1.2.2 Guanylate cyclase-C agonists
  • 2 Pediatrics
    • 2.1 Over the counter medicines
      • 2.1.1 Bulk forming agents
        • Preferred regimen (1): Citrucel 500 mg PO daily
        • Preferred regimen (2): FiberCon 625 mg PO daily
        • Preferred regimen (3): Konsyl 2.5 g (1/2 tablespoon) dissolved in 250 mL water PO q8-24h
        • Alternative regimen (1): Metamucil 500 mg PO q8-12h
      • 1.1.2 Osmotic agents
        • Preferred regimen (1): Cephulac 2.5 g (1/2 tablespoon) dissolved in 250 mL water PO q6-8h
        • Preferred regimen (2): Fleet Phospho-Soda 5-10 mL dissolved in 250 mL water PO q6-8h (not for < 5 years of age)
        • Preferred regimen (3): Milk of Magnesia 5-15 mL PO daily
        • Alternative regimen (1): Miralax 17 g dissolved in 250 mL water PO daily
        • Alternative regimen (2): Sorbitol 2 mL/kg (as 70% solution) once
      • 1.1.3 Stool softeners
      • 1.1.4 Lubricants
        • Preferred regimen (1): Fleet 9.5 g dissolved in 59 mL water enema per rectum daily
        • Preferred regimen (2): Zymenol 51.5 mL enema per rectum once
      • 1.1.5 Stimulants
    • 2.2 Prescription medicines

Probiotics

General treatment priorities in patients with constipation

Flow chart showing general treatment priorities in patient with constipation include:[10]

 
Education
Aknowledgement and attention to patietns' concerns
Guiding and encouraging the patients to participate in the treatment and have realistic goals
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diet and physical activity
Improving the previous habits
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fiber supplementation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Osmotic laxatives
MoM, Lactulose, PEG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prokinetics
Prucalopride
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery
 
 
 

References

  1. 1.0 1.1 Camilleri M, Bharucha AE (2010). "Behavioural and new pharmacological treatments for constipation: getting the balance right". Gut. 59 (9): 1288–96. doi:10.1136/gut.2009.199653. PMC 3189401. PMID 20801775.
  2. Meshkinpour H, Kemp C, Fairshter R (1989). "Effect of aerobic exercise on mouth-to-cecum transit time". Gastroenterology. 96 (3): 938–41. PMID 2604760.
  3. Chin A Paw MJ, van Poppel MN, van Mechelen W (2006). "Effects of resistance and functional-skills training on habitual activity and constipation among older adults living in long-term care facilities: a randomized controlled trial". BMC Geriatr. 6: 9. doi:10.1186/1471-2318-6-9. PMC 1562427. PMID 16875507. Vancouver style error: missing comma (help)
  4. Johannesson E, Simrén M, Strid H, Bajor A, Sadik R (2011). "Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial". Am. J. Gastroenterol. 106 (5): 915–22. doi:10.1038/ajg.2010.480. PMID 21206488.
  5. Emmanuel AV, Tack J, Quigley EM, Talley NJ (2009). "Pharmacological management of constipation". Neurogastroenterol. Motil. 21 Suppl 2: 41–54. doi:10.1111/j.1365-2982.2009.01403.x. PMID 19824937.
  6. Ashraf W, Park F, Lof J, Quigley EM (1995). "Effects of psyllium therapy on stool characteristics, colon transit and anorectal function in chronic idiopathic constipation". Aliment. Pharmacol. Ther. 9 (6): 639–47. PMID 8824651.
  7. Dettmar PW, Sykes J (1998). "A multi-centre, general practice comparison of ispaghula husk with lactulose and other laxatives in the treatment of simple constipation". Curr Med Res Opin. 14 (4): 227–33. doi:10.1185/03007999809113363. PMID 9891195.
  8. Chiarioni G, Salandini L, Whitehead WE (2005). "Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation". Gastroenterology. 129 (1): 86–97. PMID 16012938.
  9. "Treatment for Constipation | NIDDK".
  10. 10.0 10.1 Liu LW (2011). "Chronic constipation: current treatment options". Can J Gastroenterol. 25 Suppl B: 22B–28B. PMC 3206558. PMID 22114754.
  11. Chmielewska A, Szajewska H (2010). "Systematic review of randomised controlled trials: probiotics for functional constipation". World J. Gastroenterol. 16 (1): 69–75. PMC 2799919. PMID 20039451.
  12. Del Piano M, Carmagnola S, Anderloni A, Andorno S, Ballarè M, Balzarini M, Montino F, Orsello M, Pagliarulo M, Sartori M, Tari R, Sforza F, Capurso L (2010). "The use of probiotics in healthy volunteers with evacuation disorders and hard stools: a double-blind, randomized, placebo-controlled study". J. Clin. Gastroenterol. 44 Suppl 1: S30–4. doi:10.1097/MCG.0b013e3181ee31c3. PMID 20697291.



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