constipation; dyschezia
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Introduction
Fewer than 3 stools/week, passage of hard small stools, straining & the sense of incomplete evacuation.
Chronic constipation requires >= 3 months of symptoms
Classification
- type 1: separate hard lumps, hard to pass
- type 2: sausage shaped & lumpy
- type 3: sausage shaped with surface cracks
- type 4: sausage or snake shaped, smooth & soft
- type 5: soft blobs with clear-cut edges
- type 6: fluffy pieces with ragged edges, mushy stool
- type 7: watery, no solid pieces[3]
Etiology
- health habits
- low fiber intake
- inactivity
- pharmacologic agents (most common cause)
- antacids
- barium sulfate
- ferrous sulfate
- lithium carbonate[12]
- bismuth
- ion exchange (bile) resins (cholestyramine)
- sympathomimetics
- opiates (see opioid-induced constipation)
- anticholinergic agents
- phenothiazines
- tricyclic antidepressants (amitriptyline & others)
- antihypertensive agents
- antipsychotics[12]
- herbal supplements
- antidiarrheal agents
- NSAIDs
- serotonergic antagonists: ondansetron
- chronic stimulant laxative use
- irritable bowel syndrome
- structural lesions
- neurologic
- inflammatory
- endocrine & metabolic causes
- toxins: lead
- depression
- immobility
- dyssynergic defecation
- intestinal methanogen overgrowth associated with increased risk & severity of constipation[41]
- idiopathic
Epidemiology
- the most common digestive complaint in the USA
- affects over 2% of the population
- 2-3 times more common in women than men
- marked increase after age 65
- comorbidity
- environmental influences
- over-reporting
History
Alarm features
- history of colectomy
- history of abdominal cancer or pelvic cancer
- history of abdominal radiation or pelvic radiation[3]
Clinical manifestations
- non-specific abdominal discomfort
- liquid stool may be overflow constipation
- delirium may occur in constipated elderly
* Alarm features
- rectal bleeding, positive fecal occult blood
- family history
- anemia
- weight loss
- sudden change in bowel habits
- acute onset in an elderly person (> 50 years of age)
- palpable mass on examination[3]
Laboratory
Diagnostic procedures
- colonoscopy
- > 50 years of age & no previous colonoscopy[3]
- alarm feature(s) present[3]
- full-thickness suction biopsy of the rectum if Hirschsrpung's disease is suspected
- anorectal manometry & rectal balloon expulsion test
- suspected pelvic floor dsyfunction or dyssynergic defecation
- perineal couterpressure may aid defecation
- digital rectal exam may be normal
- suspected pelvic floor dsyfunction or dyssynergic defecation
Radiology
- plain abdominal films
- initial diagnostic tests of choice[3]
- barium enema (after relief of obstruction)
- colonic transit studies using radiographic markers
- does not distinguish slow-transit constipation from dyssynergic defecation
Complications
- hemorrhoids
- anal fissure
- rectal prolapse
- stercoral ulcer
- melanosis coli
- cathartic colon
- fecal impactation
- including soft fecal impactation[31]
- ischemic colitis
- colonic volvulus
- colonic perforation
- fecal incontinence
- urinary incontinence
- cardiovascular disorders
- arrhythmias
- syncope
- angina[4]
- heart failure (RR=2.7)[45]
- stroke (RR=2.4)[45]
- acute coronary syndrome or myocardial infarction (RR=1.6)[45]
- chronic constipation may be associated with cognitive impairment
- specific neuroprotective small intestinal bacteria including Butyricicoccus & Ruminococcus may play a role[38]
Differential diagnosis
Management
- general considerations
- disimpactation if indicated
- entity of soft fecal impactation[31]
- adequate fluid intake
- adequate dietary fiber
- adequate physical activity[3]
- disimpactation if indicated
- stepwise management of chronic constipation[11]
- if fecal impactation (stool in vault, including soft stool), enema until clear
- apparently there is an entity soft fecal impaction
- it would seem a stimulant laxative would be appropriate for soft stool
- stop all medications that may constipate, if possible
- increase dietary fiber intake to 6-25 grams/day; increase fluid intake to >= 1.5 L/day; increase physical activity; bulk laxative may be used provided fluid intake is >= 1.5 L/day
- GRS8 indicates a switch to a high fiber diet is better than an increase in intake of dietary insoluble fiber[11]
- contrary to common practice, ref[19] suggests soluble fiber is beneficial for constipation, but data is conflicting for insoluble fiber[19]
- wheat bran effective in the short term[20]
- if previous measures fail, add sorbitol 70% 15-30 mL every 12-24 hours; max 150 mL/day
- add stimulant laxative (senna or bisocodyl) 2-3 times per week
- use tap water enema or saline enema twice a week
- oil retention enema for refractory constipation
- if fecal impactation (stool in vault, including soft stool), enema until clear
- pharmaceutical agents
- bulk-forming laxatives not useful for opioid-induced consipation
- osmotic agents
- lactulose
- as effective as sorbitol, but more expensive
- sorbitol (70%) - may cause abdominal bloating & flatulence
- glycerin
- polyethylene glycol (Miralax)
- regular laxative use osmotic laxative associated with increased risk of all-cause dementia[40]
- lactulose
- stool softeners (not usually recommended[3])
- stimulants probably don't perpetuate altered colonic motility[5]
- opioid antagonists [11
- secretagogues
- lubiprostone after treatment with at least 2 different laxatives at highest recommended dose for 6 months (NICE)
- linaclotide (Linzess) FDA-approved for adults & children >=6 years[36]
- plecanatide
- only polyethylene glycol, bisacodyl, sodium picosulfate, linaclotide, plecanatide & prucalopride with strong evidence of efficacy[35]
- regular laxative use associated with increased risk of all-cause dementia, especially with use of multiple laxative types or osmotic laxative[40]
- no specific therapy to prevent constipation in hospitalized elderly has been proven superior to others[11]
- natural remedies
- 2 green kiwifruits/day improved symptoms of constipation[37]
- probiotics may be of benefit for infants & in elderly[8][18]
- enemas for fecal impactation
- indicated by abdominal distension & stool in the rectal vault
- including entity soft fecal impactation[31] although it would seem a stimulant laxative would be more appropriate for soft stool in the vault
- bowel retraining, biofeedback for dyssynergic defecation
- commonly provided by physical therapist with specialized training[3]
- perineal acupressure of benefit[21]
- electroacupuncture may improve symptoms of chronic constipation[26]
- FDA approved Vibrant vibrating capsule for chronic idiopathic constipation[34]
- constipation due to opioids for chronic pain
- senna 1st line
- methylnaltrexone may help relieve constipation in palliative care patients without negating analagesic effect of opioid[3]
- also see opioid-induced constipation
More general terms
More specific terms
Additional terms
- diagnostic criteria for constipation
- ileus
- intestinal pseudo-obstruction
- medical conditions associated with constipation
- pharmaceutical agents associated with constipation
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 297-300
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 4.0 4.1 Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 242-43
- ↑ 5.0 5.1 5.2 Prescriber's Letter 12(3): 2005 Constipation Myths Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=210309&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Journal Watch 25(10):82, 2005 Borowitz SM, Cox DJ, Kovatchev B, Ritterband LM, Sheen J, Sutphen J. Treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome. Pediatrics. 2005 Apr;115(4):873-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15805358
- ↑ Prescriber's Letter 14(5): 2007 Medications for constipation Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=230514&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 8.0 8.1 Coccorullo P et al. Lactobacillus reuteri (DSM 17938) in infants with functional chronic constipation: A double-blind, randomized, placebo- controlled study. J Pediatr 2010 Oct; 157:598. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20542295
- ↑ 9.0 9.1 Kamm MA et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol 2011 Jul; 9:577. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21440672
- ↑ Prescriber's Letter 19(2): 2012 CHART: Treatment of Constipation in Children GUIDELINES: Managing functional constipation in children (2011) GUIDELINES: Evaluation and Treatment of Constipation in Infants and Children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (2006) Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=280207&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 11.0 11.1 11.2 11.3 11.4 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ 12.0 12.1 12.2 12.3 12.4 12.5 Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
- ↑ Prescriber's Letter 20(4): 2013 ALGORITHM: Treatment of Constipation in Adults Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=290122&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ Spiller RC, Thompson WG. Bowel disorders. Am J Gastroenterol. 2010 Apr;105(4):775-85 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20372130
- ↑ Rao SS, Go JT. Update on the management of constipation in the elderly: new treatment options. Clin Interv Aging. 2010 Aug 9;5:163-71. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20711435
- ↑ Patel M, Schimpf MO, O'Sullivan DM, LaSala CA. The use of senna with docusate for postoperative constipation after pelvic reconstructive surgery: a randomized, double-blind, placebo-controlled trial. Am J Obstet Gynecol. 2010 May;202(5):479.e1-5. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20207340
- ↑ van der Spoel JI, Oudemans-van Straaten HM, Kuiper MA et al Laxation of critically ill patients with lactulose or polyethylene glycol: a two-center randomized, double-blind, placebo-controlled trial. Crit Care Med. 2007 Dec;35(12):2726-31. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17893628
- ↑ 18.0 18.1 Zaharoni H1, Rimon E, Vardi H, Friger M, Bolotin A, Shahar DR Probiotics improve bowel movements in hospitalized elderly patients--the PROAGE study. J Nutr Health Aging. 2011 Mar;15(3):215-20. PMID: 21369670
- ↑ 19.0 19.1 19.2 Suares NC, Ford AC. Systematic review: the effects of fibre in the management of chronic idiopathic constipation. Aliment Pharmacol Ther. 2011 Apr;33(8):895-901. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21332763
- ↑ 20.0 20.1 Lawton CL, Walton J, Hoyland A et al Short term (14 days) consumption of insoluble wheat bran fibre-containing breakfast cereals improves subjective digestive feelings, general wellbeing and bowel function in a dose dependent manner. Nutrients. 2013 Apr 22;5(4):1436-55. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23609776
- ↑ 21.0 21.1 Abbott R et al. Effect of perineal self-acupressure on constipation: A randomized controlled trial. J Gen Intern Med 2015 Apr; 30:434 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25403522 <Internet> http://link.springer.com/article/10.1007%2Fs11606-014-3084-6
Abbott R, Hui KK. Perineal Self-Acupressure's Mechanism of Action. J Gen Intern Med. 2015 Apr;30(4):399. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25666212 - ↑ 22.0 22.1 Hardy CL, Goliath G Constipation Associated with a Lipoma. N Engl J Med 2015; 373:656. August 13, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26267625 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMicm1413283
- ↑ Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013 Jan;144(1):218-38 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23261065
- ↑ Singh S, Rao SS. Pharmacologic management of chronic constipation. Gastroenterol Clin North Am. 2010 Sep;39(3):509-27. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20951915
- ↑ American Gastroenterological Association. Bharucha AE, Dorn SD, Lembo A, Pressman A American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23261064
- ↑ 26.0 26.1 Liu Z, Yan S, Wu J et al Acupuncture for Chronic Severe Functional Constipation: A Randomized, Controlled Trial. Ann Intern Med. Published online 13 September 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27618593 <Internet> http://annals.org/article.aspx?articleid=2552074
- ↑ 27.0 27.1 Wald A. Constipation: Advances in Diagnosis and Treatment. JAMA. 2016 Jan 12;315(2):185-91. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26757467
- ↑ 28.0 28.1 Dipalma JA, Cleveland MV, McGowan J, Herrera JL. A randomized, multicenter, placebo-controlled trial of polyethylene glycol laxative for chronic treatment of chronic constipation. Am J Gastroenterol. 2007 Jul;102(7):1436-41. Epub 2007 Mar 31. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17403074
- ↑ Stern T, Davis AM. Evaluation and Treatment of Patients With Constipation. JAMA. 2016 Jan 12;315(2):192-3. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26757468
- ↑ Wald A. Update on the Management of Constipation. JAMA. Published online November 4, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31682683 https://jamanetwork.com/journals/jama/fullarticle/2754106
- ↑ 31.0 31.1 31.2 31.3 Frank C, Molnar F, Spence M Fecal incontinence in older adults. Can Fam Physician. 2020 66(4):264 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32273412 PMCID: PMC7145116 Free PMC article
- ↑ 32.0 32.1 Gao R, Tao Y, Zhou C et al Exercise therapy in patients with constipation: a systematic review and meta-analysis of randomized controlled trials Scand J Gastroenterol. 2019 Feb;54(2):169-177 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30843436 https://www.tandfonline.com/doi/abs/10.1080/00365521.2019.1568544
- ↑ 33.0 33.1 Gearry R, Fukudo S, Giovanni B et al Consumption of 2 Green Kiwifruits Daily Improves Constipation and Abdominal Comfort - Results of an International Multicenter Randomized Controlled Trial. Am J Gastroenterol. 2023. Jan 9 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36537785 https://journals.lww.com/ajg/Fulltext/9900/Consumption_of_two_green_kiwifruit_daily_improves.592.aspx
- ↑ 34.0 34.1 Rao SSC et al. Randomized placebo-controlled phase 3 trial of vibrating capsule for chronic constipation. Gastroenterology 2023 Jun; 164:1202. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36822371 https://www.gastrojournal.org/article/S0016-5085(23)00149-X/fulltext
- ↑ 35.0 35.1 Chang L et al. American Gastroenterological Association-American College of Gastroenterology clinical practice guideline: Pharmacological management of chronic idiopathic constipation. Gastroenterology 2023 Jun; 164:1086. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37211380 https://www.gastrojournal.org/article/S0016-5085(23)00513-9/fulltext
- ↑ 36.0 36.1 Brooks M FDA Approves First Treatment for Constipation in Kids. Medscape. June 12, 2023 https://www.medscape.com/viewarticle/993074
- ↑ 37.0 37.1 Gearry R et al. Consumption of 2 green kiwifruits daily improves constipation and abdominal comfort
Results of an international multicenter randomized controlled trial. Am J Gastroenterol 2023 Jun; 118:1058 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36537785 PMCID: PMC10226473 Free PMC article https://journals.lww.com/ajg/Fulltext/2023/06000/Consumption_of_2_Green_Kiwifruits_Daily_Improves.26.aspx - ↑ 38.0 38.1 AMA Morning Rounds. July 20, 2023 American Medical Association
- ↑ 39.0 39.1 Lucak S, Lunsford TN, Harris LA. Evaluation and treatment of constipation in the geriatric population. Clin Geriatr Med. 2021;37:85-102. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33213776
- ↑ 40.0 40.1 40.2 Yang Z, Wei C, Li X et al Association Between Regular Laxative Use and Incident Dementia in UK Biobank Participants. Neurology. 2023 Apr 18;100(16):e1702-e1711. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36813729 PMCID: PMC10115504 Free PMC article.
- ↑ 41.0 41.1 Mehravar S, Takakura W, Wang J, Pimentel M, Nasser J, Rezaie A. Symptom Profile of Patients With Intestinal Methanogen Overgrowth: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol. 2024 Aug 10:S1542-3565(24)00716-X. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39147218 Review.
- ↑ Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology. 2020 Apr;158(5):1232-1249.e3. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31945360 PMCID: PMC7573977 Free PMC article. Review.
- ↑ Tantiphlachiva K, Rao P, Attaluri A, Rao SS. Digital rectal examination is a useful tool for identifying patients with dyssynergia. Clin Gastroenterol Hepatol. 2010 Nov;8(11):955-60. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20656061
- ↑ Wlodarczyk J, Wasniewska A, Fichna J et al Current Overview on Clinical Management of Chronic Constipation. J Clin Med. 2021 Apr 16;10(8):1738. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33923772 PMCID: PMC8073140 Free PMC article. Review.
- ↑ 45.0 45.1 45.2 45.3 Zheng T, et al. Constipation is associated with an increased risk of major adverse cardiac events in a UK population. Am J Physiol Heart Circ Physiol. 2024 Oct 1;327(4):H956-H964. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39150392
- ↑ National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Constipation https://www.niddk.nih.gov/health-information/digestive-diseases/constipation