Constipation resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]; Vendhan Ramanujam M.B.B.S [3]

Synonyms and Keywords: Chronic constipation

Overview

Constipation is a syndrome that is characterized by either difficulty in passing stool, infrequent bowel movements, hard stool, or a feeling of incomplete evacuation that occurs either in isolation or secondary to another underlying disorder.[1][2][3]

Classification

Normal Transit Constipation

Normal transit constipation refers to constipation in patients with normal anorectal function and normal colonic transit, with or without abnormal colonic motor disturbances and abnormal (ie, reduced or increased) colonic sensations.

Slow Transit Constipation

Slow transit constipation refers to constipation in patients with normal anorectal function but slow colonic transit, with or without abnormal colonic motor disturbances and abnormal (ie, reduced or increased) colonic sensations.

Defecatory Disorders

Defecatory disorders refer to constipation in patients with impaired rectal evacuation from inadequate rectal propulsive forces and/or increased resistance to evacuation during defecation, with or without structural disturbances like rectocele and intussusception, reduced rectal sensation, and slow colonic transit. Increased resistance to evacuation might follow high anal resting pressure (anismus) and/or incomplete relaxation or paradoxical contraction of the pelvic floor and external anal sphincters (dyssynergia).

Combination Disorders

Combination disorders refer to patients with combination or overlap of disorders (example, slow transit constipation with defecatory disorders), perhaps even an association with features of irritable bowel syndrome.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach of chronic constipation in adults based on the 2013 American Gastroenterological Association (AGA) technical review and medical position statement regarding guidelines on constipation.[1][6]

 
 
 
 
Characterize the symptoms:


Symptoms suggestive of constipation:
❑ Difficulty passing stool

❑ Desire to defecate but inability to pass stool
❑ Straining to begin and/or to end defecation
❑ Prolongation in time to pass stool
❑ Sensation of incomplete emptying of bowel
❑ Sensation of anal blockage during defecation
❑ Difficulty passing soft stool and/or enema fluid
❑ Difficulty passing stool postprandially
❑ Direct digital manipulation to pass stool
❑ Perineal or vaginal pressure to pass stool
❑ Sudden or gradual in onset
❑ Duration ≥ 3 months

❑ Infrequency in passing stool
❑ Hard or lumpy stools
❑ Use of laxatives to pass stool

❑ Type of laxative
❑ Frequency of usage
❑ Dosage

❑ Use of enemas to pass stool
❑ Use of suppositories to pass stool

Symptoms associated with constipation:
Abdominal pain or abdominal discomfort

❑ Associated with change in frequency of stool
❑ Associated with change in consistency of stool
❑ Improved with passage of stool
❑ Occurring during straining
❑ Persisting between bowel movements

Abdominal distention
Abdominal bloating
Diarrhea alternating with constipation
❑ Blood in stools
Fever
Nausea and vomiting
Loss of appetite
Loss of weight
Fatigue
Malaise
Fibromyalgia
❑ Psychosocial distress


Obtain a detailed history:
❑ Diet

Dietary pattern change
Low fiber diet
Food intolerance
Medications

❑ Systemic illness

Diabetes
Hypothyroidism
❑ Gastrointestinal disorders
❑ Neuromuscular disorders

❑ Surgical history

❑ Abdominal surgeries
Caesarean section
❑ Post surgical extended bed rest

❑ Trauma history ( spinal cord injury)
❑ Family history

Colorectal cancer
Pelvic masses
❑ Neuromuscular diseases

❑ Social history

Smoking cessation
Drug abuse
❑ Travel history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ General examination

Pulse rate
Blood pressure
Respiratory rate
Weight
Thyroid
Signs of dehydration

❑ Perineal/rectal examination

❑ Observe perianal skin for evidence of fecal soiling
❑ During stimulated evacuation observe
❑ Anal verge for any patulous opening or prolapse of anorectal mucosa
❑ Descent of the perineum
❑ During a squeeze aimed at retention observe the elevation of perineum
❑ Test anal reflex by a light pinprick or scratch
❑ During digital evaluation
❑ Evaluate the resting tone of the sphincter
❑ Look for puborectalis muscle tenderness
❑ Look for rectocele, hemorrhoids or anal fissure

❑ Abdominal examination

Abdominal mass
Abdominal distension
Abdominal tenderness
Increased or decreased bowel sounds

❑ Neurological examination

Neuropathy
Parkinson's disease
Spinal cord injury
Cerebrovascular disease
Depression
❑ Cognitive impairment

❑ Cardiovascular examination

❑ Cardiac diseases

❑ Respiratory examination

❑ Chronic respiratory diseases

❑ Skeletal examination

❑ Degenerative joint diseases
❑ Immobility
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:

CBC
BMP
TSH
Serum calcium
Serum magnesium
❑ Order additional tests if secondary causes of constipation are suspected


Consider structural evaluation of the colon:
❑ For patients with clinically alarming symptoms

❑ Sudden change in bowel habits after the age of 50 years
❑ Blood in stools
Anemia
Weight loss
❑ Family history of colon cancer

and
❑ For patients who have not undergone an age appropriate colon cancer screening procedure
Include:
Colonoscopy
Flexible sigmoidoscopy
Barium enema

❑ Computed tomographic colonography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the diagnostic criteria of constipation

Rome III criteria:[1][7]

Symptom onset for ≥6 months and ≥2 of the following for the past 3 months:

❑ Straining during at least one-fourth of defecation
❑ Hard or lumpy stools in at least one-fourth of defecation
❑ Sensation of incomplete evacuation for at least one-fourth of defecation
❑ Sensation of anorectal obstruction/blockade for at least one-fourth of defecation
❑ Manual maneuvers to facilitate at least one-fourth of defecation
❑ <3 defecations/week
❑ Without the use of laxatives, loose stools are rarely present
❑ No sufficient criteria for irritable bowel syndrome

or

Pharmacologic studies based criteria:[1][8]
Spontaneous bowel movements <3 per week and ≥1 of the following for at least 12 weeks during the past 12 months:

❑ Straining during more than one-fourth of defecation
❑ Lumpy or hard stools in more than one-fourth of defecation
❑ Sensation of incomplete evacuation in more than one-fourth of defecation
❑ Absence of loose stools or watery spontaneous bowel movements
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Adjust or discontinue medications causing constipation

❑ Administer a trial of fiber and/or osmotic or stimulant laxatives


If secondary causes of constipation are uncovered during evaluation:
Due to metabolic conditions, myopathies, neuropathies, or other conditions
❑ Treat the secondary cause
or
❑ Offer symptomatic treatment


If organic causes of constipation are uncovered during evaluation:
Due to mechanical obstruction or adverse drug effect
❑ Treat mechanical obstruction or remove the drug causing constipation
or
❑ Offer symptomatic treatment


If irritable bowel syndrome is diagnosed during evaluation:

❑ Treat irritable bowel syndrome
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement with trial of fiber and/or laxatives
 
Failure of improvement with trial of fiber and/or laxatives
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
General management of constipation
 
❑ Gastroenterology consult
Anorectal manometry
Balloon expulsion test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Inconclusive
 
Abnormal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Abnormal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess the colonic transit
 
 
 
Management of defecatory disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Slow
 
Normal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Management of low transit constipation
 
Management of normal transit constipation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

BMP: Basic metabolic panel; CBC: Complete blood count; TSH: Thyroid stimulating hormone

Therapeutic Approach

Shown below are algorithms depicting the general as well as different clinical subgroup based therapeutic approaches of constipation in adults based on the 2013 American Gastroenterological Association (AGA) technical review and medical position statement regarding guidelines on constipation.[1][6]

General Management

 

❑ Increase fiber intake in food
❑ Increase fiber intake as supplements

Psyllium: 1 tsp up to 3 times daily
or
Methylcellulose: 1 tsp up to 3 times daily
or
Calcium polycarbophil: 2-4 tablets OD

❑ Advise to ingest fiber along with fluids and/or meals
❑ Gradually adjust the dose of fiber after 7 to 10 days
❑ Continue the adjusted dose for several weeks
❑ Recommend increased fluid intake, particularly if dehydration is present

❑ Recommend increasing physical activity
 
 
 
 
 
 
 
 
Failure to improve
 
 
 
 
 
 
 
 

Add hyperosmolar agents:
Polyethylene glycol:

❑ 8-32 oz OD
❑ 2 weeks to 24 months
❑ Polyethylene glycol with electrolyte containing preparation indicated when large volume is used for colonic cleansing

or
Lactulose: 15-30 ml OD or BID
or
Sorbitol: 15-30 ml OD or BID

Supplement with stimulant laxatives as needed:
Bisacodyl:

❑ 10 mg suppositories
or
❑ 5-10 mg orally up to 3 times/week

or
Glycerin: Suppository OD
or
Senna or cascara:

❑ 2 tablets OD or 4 tablets BID
or
❑ 1-2 tsp OD
or
❑ 1-2 tablets OD

❑ Administer suppositories 30 minutes after meals

Supplement with stool softener as needed:
Docusate sodium: 100 mg BD

If necessary administer:
❑ Newer agents

❑ Secretagogues:
Lubiprostone: 24 μg BID
or
❑ Linaclotide: 145 μg daily

or

❑ Serotonin 5-HT4 receptor agonist: Prucalopridec

Pyridostigmine in type 2 diabetes mellitus patients with constipation
Misoprostol

Opioid antagonists in patients with opioid induced constipation
 

BID: Twice a day; OD: Once daily; tsp: Teaspoon

Normal and Slow Transit Constipation

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal or slow transit constipation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer:

❑ Hyperosmolar agents:

Polyethylene glycol: 8-32 oz OD
or
Lactulose: 15-30 ml OD or BID
or
Sorbitol: 15-30 ml OD or BID

or
❑ Saline laxatives:

Magnesium (milk of magnesia or milk of magnesia + mineral oil) : 15-30 mL OD or BID

or
❑ Stimulant laxatives:

Bisacodyl:
❑ 10 mg suppositories
or
❑ 5-10 mg orally up to 3 times/week
or
Glycerin: Suppository OD
or
Senna or cascara:
❑ 2 tablets OD or 4 tablets BID
or
❑ 1-2 tsp OD
or
❑ 1-2 tablets OD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement

❑ Continue the same regimen on a long term basis
 
Failure to improve

❑ Modify the treatment regimen by considering

❑ Secretagogues
Lubiprostone: 24 μg BID
or
❑ Linaclotide: 145 μg daily

or

❑ Serotonin 5-HT4 receptor agonists
❑ Prucalopridec
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement

❑ Continue the same regimen on a long term basis
 
Failure to improve

❑ Repeat colonic transit test while continuing medications
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Delayed transit

❑ Consider gastric emptying
 
Normal transit

❑ Adjust medications as needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Slow emptying

❑ Consider assessment for upper GI motility disorder
 
Normal emptying
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal

❑ Manage the upper GI motility disorder appropriately
 
 
Normal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider colonic manometry with/without barostat
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal

❑ Consider temporary loop ileostomy
 
Abnormal

❑ Consider subtotal colectomy with ileorectal anastamosis
 
 
 
 

BID: Twice a day; OD: Once daily; GI: Gastrointestinal

Defecatory Disorder

 
 
 
 
 
 
Defecatory disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Biofeedback-aided pelvic floor training:

❑ Record anorectal and pelvic floor muscle activity through surface electromyographic sensors or manometry
❑ Teach patients to appropriately increase intraabdominal pressure and relax the pelvic floor muscles during defecation
❑ Provide practice of expelling air filled balloon, if necessary with external traction to the patients
❑ Teach patients to recognize weaker sensations of rectal filling in case of reduced rectal sensation
❑ Teach Kegel exercise to improve pelvic floor contractions


❑ Request a dietitian consult

❑ Request a psychologist consult
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Improvement

❑ Follow up the patient clinically
 
Failure to improve

❑ Repeat balloon expulsion test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal

Colonic transit
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal anal or pelvic floor relaxation

❑ Consider surgery in case of clinically significant structural abnormalities
 
Abnormal anal or pelvic floor relaxation

❑ Reassess biofeedback
❑ Administer stimulant laxative suppositories as needed
❑ Administer enemas as needed

❑ Mineral oil retention enema: 199–250 mL OD per rectum
or
❑ Tap water enema: 500 mL per rectum
or
❑ Phosphate enema: 1 unit per rectum
or
❑ Soapsuds enema: 1500 mL per rectum
❑ Consider fallback
 
Slow transit

❑ Consider treatment for slow transit constipation
 
Normal transit

❑ Consider treatment for normal transit constipation
 
 


OD: Once daily

Do's

Dont's

References

  1. 1.0 1.1 1.2 1.3 1.4 Bharucha AE, Pemberton JH, Locke GR (2013). "American Gastroenterological Association technical review on constipation". Gastroenterology. 144 (1): 218–38. doi:10.1053/j.gastro.2012.10.028. PMC 3531555. PMID 23261065.
  2. American College of Gastroenterology Chronic Constipation Task Force (2005). "An evidence-based approach to the management of chronic constipation in North America". Am J Gastroenterol. 100 Suppl 1: S1–4. doi:10.1111/j.1572-0241.2005.50613_1.x. PMID 16008640.
  3. Locke GR, Pemberton JH, Phillips SF (2000). "American Gastroenterological Association Medical Position Statement: guidelines on constipation". Gastroenterology. 119 (6): 1761–6. PMID 11113098.
  4. Caldarella MP, Milano A, Laterza F; et al. (2005). "Visceral sensitivity and symptoms in patients with constipation- or diarrhea-predominant irritable bowel syndrome (IBS): effect of a low-fat intraduodenal infusion". Am. J. Gastroenterol. 100 (2): 383–9. doi:10.1111/j.1572-0241.2005.40100.x. PMID 15667496.
  5. "Nicotine withdrawal symptoms:Constipation". helpwithsmoking.com. 2005. Retrieved 2007-06-29.
  6. 6.0 6.1 6.2 6.3 6.4 Bharucha, AE.; Dorn, SD.; Lembo, A.; Pressman, A. (2013). "American Gastroenterological Association medical position statement on constipation". Gastroenterology. 144 (1): 211–7. doi:10.1053/j.gastro.2012.10.029. PMID 23261064. Unknown parameter |month= ignored (help)
  7. Longstreth, GF.; Thompson, WG.; Chey, WD.; Houghton, LA.; Mearin, F.; Spiller, RC. (2006). "Functional bowel disorders". Gastroenterology. 130 (5): 1480–91. doi:10.1053/j.gastro.2005.11.061. PMID 16678561. Unknown parameter |month= ignored (help)
  8. Lembo, AJ.; Kurtz, CB.; Macdougall, JE.; Lavins, BJ.; Currie, MG.; Fitch, DA.; Jeglinski, BI.; Johnston, JM. (2010). "Efficacy of linaclotide for patients with chronic constipation". Gastroenterology. 138 (3): 886–95.e1. doi:10.1053/j.gastro.2009.12.050. PMID 20045700. Unknown parameter |month= ignored (help)

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