Constipation resident survival guide
Synonyms and keywords: Chronic constipation
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.
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 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 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.
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Atropine poisoning
- Lead poisoning
- Opium poisoning
- Severe dehydration
- Spinal cord injury
- Superior mesenteric artery occlusion
- Hardening of the feces: Improper mastication, low dietary fiber, dehydration and medications (aluminium, calcium, diuretic, iron).
- Paralysis or slowed transit: Hypothyroidism, hypokalemia, injured anal sphincter, medications (loperamide, codeine, morphine, tricyclic antidepressants) and severe systemic illness due to other causes.
- Constriction, where part of the intestine or rectum is narrowed or blocked: Diverticulosis, pelvic masses and stenosis.
- Psychosomatic constipation: Functional constipation and irritable bowel syndrome.
- Smoking cessation
- Abdominal surgery and childbirth
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.
Characterize the symptoms:
❑ Infrequency in passing stool
❑ Abdominal distention
Obtain a detailed history:
❑ Systemic illness
❑ Surgical history
❑ Trauma history ( spinal cord injury)
❑ Social history
Examine the patient:
❑ General examination
❑ Perineal/rectal examination
❑ Abdominal examination
❑ Neurological examination
❑ Cardiovascular examination
❑ Respiratory examination
❑ Skeletal examination
Order laboratory tests:
Consider structural evaluation of the colon:
Consider the diagnostic criteria of constipation
Rome III criteria:
Symptom onset for ≥6 months and ≥2 of the following for the past 3 months:
❑ Adjust or discontinue medications causing constipation
If secondary causes of constipation are uncovered during evaluation:
If organic causes of constipation are uncovered during evaluation:
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|
|❑ Assess the colonic transit||❑ Management of defecatory disorder|
|❑ Management of low transit constipation||❑ Management of normal transit constipation|
BMP: Basic metabolic panel; CBC: Complete blood count; TSH: Thyroid stimulating hormone
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.
❑ Increase fiber intake in food
❑ Advise to ingest fiber along with fluids and/or meals
|Failure to improve|
Add hyperosmolar agents:
❑ Administer suppositories 30 minutes after meals
BID: Twice a day; OD: Once daily; tsp: Teaspoon
Normal and Slow Transit Constipation
|Normal or slow transit constipation|
❑ Hyperosmolar agents:
❑ Continue the same regimen on a long term basis
Failure to improve
❑ Modify the treatment regimen by considering
❑ Continue the same regimen on a long term basis
Failure to improve
❑ Repeat colonic transit test while continuing medications
❑ Consider gastric emptying
❑ Adjust medications as needed
❑ Consider assessment for upper GI motility disorder
❑ Manage the upper GI motility disorder appropriately
|Consider colonic manometry with/without barostat|
❑ Consider temporary loop ileostomy
❑ Consider subtotal colectomy with ileorectal anastamosis
BID: Twice a day; OD: Once daily; GI: Gastrointestinal
Biofeedback-aided pelvic floor training:
❑ Record anorectal and pelvic floor muscle activity through surface electromyographic sensors or manometry
❑ Request a dietitian consult
❑ Follow up the patient clinically
Failure to improve
❑ Repeat balloon expulsion test
❑ Colonic transit
Normal anal or pelvic floor relaxation
❑ Consider surgery in case of clinically significant structural abnormalities
Abnormal anal or pelvic floor relaxation
❑ Consider treatment for slow transit constipation
❑ Consider treatment for normal transit constipation
OD: Once daily
- Perform a careful digital rectal examination that includes assessment of pelvic floor motion during simulated evacuation in the left lateral position, with the buttocks separated, before referral for anorectal manometry. A normal digital rectal examination does not exclude defecatory disorders (strong recommendation, moderate-quality evidence).
- Discontinue medications, if possible even before further testing (strong recommendation, low-quality evidence).
- Order only a complete blood cell count test in the absence of other symptoms and signs of constipation (strong recommendation, low-quality evidence).
- Always recommend a therapeutic trial with fiber supplementation and/or osmotic or stimulant laxatives before further testing.
- Warn patients that fiber supplements may increase gaseousness and that the symptoms often decrease after several days.
- Educate the patient not to expect an immediate response while on fiber supplements and that they should continue the supplements for several weeks.
- Perform a anorectal manometry and a balloon expulsion test in those patients who fail to respond to trail of laxatives (strong recommendation, moderate-quality evidence).
- Perform a colonic transit test, if anorectal test results do not show a defecatory disorder or if symptoms persist despite treating defecatory disorder (strong recommendation, low-quality evidence).
- Treat patients with normal or slow transit constipation refractory to simple laxatives, with newer agents.
- Consider a subtotal colectomy for patients with symptomatic slow transit constipation without a defecatory disorder not responding to medications and always perform a colonic intraluminal testing (manometry, barostat) to document colonic motor dysfunction before colectomy (weak recommendation, moderate-quality evidence).
- Do not order metabolic tests such as blood glucose, calcium, and thyroid stimulating hormone unless the patient has these metabolic disorders related symptoms (strong recommendation, moderate-quality evidence).
- Do not use insoluble fiber like wheat bran for the intial managment of constipation in adults.
- Do not perform a colonoscopy in patients without alarm features (eg, blood in stools, anemia, weight loss, family history of colon cancer or inflammatory bowel disease, positive fecal occult blood test) and unless age-appropriate colon cancer screening has not been performed (strong recommendation, moderate-quality evidence).
- Do not perform a defecography before anorectal manometry and rectal balloon expulsion test (strong recommendation, low-quality evidence).
- 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.
- 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.
- Locke GR, Pemberton JH, Phillips SF (2000). "American Gastroenterological Association Medical Position Statement: guidelines on constipation". Gastroenterology. 119 (6): 1761–6. PMID 11113098.
- 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.
- "Nicotine withdrawal symptoms:Constipation". helpwithsmoking.com. 2005. Retrieved 2007-06-29.
- 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
- 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
- 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