© Copyright Annals of Internal Medicine, 2015 Ann Int Med. 162 (4): ITC4-1. * For Best Viewing:...

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in the clinic

Constipation


What are major risk factors for constipation?

Increased age

Female Gender

Race – African American

Nursing home residents

Low socioeconomic populations

Decreased physical activity

Low fluid intake, low fiber diet

Smoking – inverse association

Alcohol use – inverse association

Medications


Medications Associated with Constipation Calcium channel blockers (nifedipine, verapamil)

Anti-depressants (tricyclic antidepressants)

Opiates

Anticholinergic agents (anticonvulsants, antipsychotics, antispasmodics)

Analgesics (opiates, NSAIDS)

Antiparkinsonian agents

Diuretics (thiazides, loop diuretics)

Cation containing agents (calcium iron, aluminum)

Antidiarrheals (oveuse) (bile acid resins)


CLINICAL BOTTOM LINE: Prevention...

Be vigilant to the risk factors associated with constipation

Risk factors for constipation

Increased age

Many co-morbid conditions

Array of medications

Decreased mobility and physical activity

Consumption of a low fiber diet

Inadequate hydration


What symptoms define constipation?

Historically: < 3 bowel movements per week But infrequency doesn’t necessarily correlate with

pathophysiology or symptoms

Now: ≥ 2 of the following (for ≥ 3 months with symptom onset ≥ 6 months prior to diagnosis):

Straining during ≥ 25% defecations

Lumpy or hard stools ≥ 25% defecations

Sensation of incomplete evacuation ≥ 25% of the time

Sensation of anorectal obstruction/blockage ≥ 25% of time

Manual maneuvers to facilitate defecation ≥ 25% of the time

< 3 defecations/week


What are the common subtypes of primary constipation and their distinguishing pathophysiologic features?

Normal transit constipation

Slow transit constipation

Pelvic floor dysfunction

“Combination constipation”

Slow transit constipation and pelvic floor dysfunction

Dyssynergic defecation

Functional defecatory disorders defined by alterations of events that occur during expulsion efforts

Some have slow transit + defecatory dysfunction


What are the characteristic symptoms and physical exam findings? Infrequency

Difficulty defecating

Excessive straining

Hard stools

Sensation of blockage or incomplete evacuation

“Diarrhea” or incontinence of stool (with terminal reservoir syndrome or megarectum)

Alarm signs or symptoms needing further investigation

History of rectal bleeding or anemia

Weight loss, fever

Family history of colon cancer

Age > 50 consider secondary causes of constipation


History

Duration of symptoms and age of onset

Temporal occurrence to other factors, diet

History of medications

Maneuvers to facilitate defecation

History of sexual abuse

Bowel and diet diary may help correlate symptoms with diet

Bristol Stool Form scale may also be helpful

Physical examination

Comprehensive abdominal examination

Comprehensive rectal examination


What other conditions should clinicians consider?

Diet & lifestyle

Dehydration or inadequate fluid intake, low fiber diet

Immobility, poor bowel habits

Structural

Neoplasms (colon cancer), colonic stricture or obstruction

External compression

Neurologic

Peripheral: autonomic neuropathy, diabetes mellitus, Hirschprung disease, American trypanosomiasis

Central neurologic dysfunction: multiple sclerosis, Parkinson’s, spinal cord injury, stroke, dementia, TBI

Colonic pseudoobstruction


Endocrine

Hypothyroidism, hyperparathyroidism, panhypopituitarism

Diabetes mellitus, pheochromocytoma, pregnancy

Metabolic

CKD, electrolyte abnormalities

Heavy metal poisoning, porphyria

Myopathic

Myotonic dystrophy, scleroderma, amyloidosis

Psychiatric or Psychosocial

Depression, anorexia nervosa, dementia, abuse

Other

Sarcoidosis


What is the role of diagnostic testing?

No need to perform tests unless history and physical exam findings suggest potential problem or include alarm sign or symptom

Target initial lab tests to the issue

CBC, basic chemistry panel including glucose, calcium, and electrolytes, thyroid function tests, urinalysis

Assess stool for occult blood

More specific testing for endocrinologic, metabolic, neurologic, or collagen vascular disorders should be based on the history and physical examination findings


When should clinicians consider obtaining tests of colonic function?

When pelvic floor dysfunction is suspected

When patients fail to respond to therapy

Tests for evaluation of constipation

Anorectal Manometry and balloon expulsion testing

Scintigraphy

Functional MRI

Defecography

Colonic marker studies

Wireless pH-pressure capsule

Colonic manometry and Barostat Testing

EMG


When should primary care clinicians consult with a gastroenterologist or surgeon for diagnosis?

If colonoscopy is required

Patients with “red flag” signs and symptoms

All patients > 50 years old with constipation

If additional functional testing are required

Motility procedures, tests of anorectal function

Know local resources for patients who may require these specialized studies and consultative opinions


CLINICAL BOTTOM LINE: Diagnosis...

Constipation is a symptom-based diagnosis

Take a comprehensive history

Perform careful physical examination

Treatment recommendation

Initiate therapy without further testing in patients without alarm signs or symptoms

After discontinuing medications that can result in constipation


What is the overall approach to managing constipation?

Understand etiologies that may contribute to symptoms

Align treatment with underlying mechanism

Discontinue medications that cause constipation and can be safely stopped

Suggest a bowel habit diary and diet history to correlate dietary factors with stool consistency and timing

Determine if there is coexisting defecatory disorder

Outline the expected goals

Provide patient education about treatment rationale


What is the role of dietary modification and exercise? Increasing fiber and fluid intake is mainstay of therapy

Fluid intake alone will not improve symptoms

Fiber improves functional constipation, not IBS

Fiber requires water to work, but exact quantity unclear

Educate patients about soluble vs insoluble fiber

Soluble: oat, psyllium, certain fruits and vegetables

Insoluble: wheat bran, whole grains, dark leafy vegetables

Cramping, bloating may limit compliance: introduce slowly

Fluid intake limited with renal replacement therapy

Patients may not need fiber supplement + increased fluids if they can increase their intake of other sources of fiber


What are the mechanisms of action for constipation treatments?

Stool bulking agents

Increase fecal bulk to increase passage through colon

Stimulant laxatives

Increase colonic peristalsis in order to propel stool forward

Osmotic agents

Draw fluid into lumen leading to more rapid colonic transit

Prokinetic agents

Secretory agents


Which nonprescription medications are useful for managing constipation?

Fiber

Docusate sodium (no data for efficacy)

Castor oil (not recommended due to nutrient malabsorption)

Stimulant laxatives

Osmotic laxatives

Saline laxatives (milk of magnesia)

Magnesium citrate

Polyethylene glycol


When should clinicians consider treatment with prescription medication?

If fiber and nonprescription laxatives fail

Consider patient preference, cost, likelihood of adherence

If patients are severely constipated

No bowel movement for >1 week and not impacted

Prescription strength laxatives or nonprescription laxatives at higher than standard doses

In hospitalized or hospice patients on opiates

If traditional nonprescription remedies have failed

Methylnaltrexone or oral prescription medication


Which prescription medications are useful for managing constipation?

Osmotic agents Lactulose

Sorbitol

Agents targeting cellular mechanisms of colonic physiology

Chloride channel-2 stimulants (lubiprostone)

Guanylate cyclase C activator (linaclotide)

Receptor antagonists (methlynaltrexone )


Is biofeedback effective in the treatment of constipation?

Studied in patients with slow transit constipation and in patients with a defecatory disorder

Most useful in patients with defecatory disorder

50% to 80% effective

Studies have shown efficacy in the elderly population


How should patients with renal insufficiency or renal failure be managed?

Many OTC and prescription laxatives are safe

Osmotic agents have limited AEs for this population

Lactulose may be a safer alternative

Several agents require dose adjustment for use with renal impairment

Avoid some medications

Sodium phosphate based compounds can cause crystalline nephropathy

Magnesium-based products, esp if creatinine >1.5 mg/dL


How should clinicians manage constipation in patients with diabetes or multiple sclerosis?

Diabetes

Focus on glycemic control

Poor glycemic control leads to worse symptoms

Multiple sclerosis

Treatment can lead to incontinence due to alteration in rectal sensation and anorectal muscle function

Pelvic floor dysfunction may also occur

Focus treatment on symptom control

Constipation may be preferable to incontinence as predominant symptom


How does management differ in the elderly?

Etiology of constipation is often multifactorial

Determine which etiologies are modifiable

Defecatory are disorders more common

Medical-functional issues that affect treatment

Important issues: ability to self-manage

Educate patient and caregivers

Laxatives may increase sense of urgency

Limitations in ambulation may mean it takes longer to get to the bathroom

Educate patients adverse events


When should clinicians consult with other providers for treatment of patients with constipation? Gastroenterologist

Colonoscopy for unexplained iron deficiency anemia, rectal bleeding, unexplained weight loss

Motility testing for suspected pelvic floor dysfunction

Health psychologist: to help with severe symptoms

Physical therapist or biofeedback specialist: for dyssynergia

Urogynecologist: for urinary and gynecologic symptoms or pelvic floor dysfunction

Dietician: to help guide treatment


How should clinicians counsel patients about managing constipation?

Educate about etiology of constipation

Explain role of fiber, options for increasing fiber intake

Focus on reasonable goal setting for dietary changes

Provide education about use of nonprescription medications

Set clear medication adjustment guidelines

Provide guidance about when to call for additional help


CLINICAL BOTTOM LINE: Treatment... Treatment requires attention

Lifestyle habits (toileting practice, diet, and activity)

Concurrent medications

Treatment should be individualized to underlying cause

Treat underlying etiology for enduring solution

Select nonprescription medication as a first line option

Escalate to prescription based remedies if needed

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