Neurogastroenterol Motil. Int J Mol Med. Front Biosci Elite Ed. Mol Med Rep. Tohoku J Exp Med. Whelan K: Probiotics and prebiotics in the management of irritable bowel syndrome: a review of recent clinical trials and systematic reviews. Whorwell PJ: Do probiotics improve symptoms in patients with irritable bowel syndrome? Spiller R: Review article: probiotics and prebiotics in irritable bowel syndrome.
Paediatric constipation: An approach and evidence-based treatment regimen
Gastroenterol Hepatol NY. Gastroenterology Insights. Spiller RC: Upper gut dysmotility in slow-transit constipation: is it evidence for a pan-enteric neurological deficit in severe slow transit constipation? Eur J Gastroenterol Hepatol.
Quigley EM, Vandeplassche L, Kerstens R and Ausma J: Clinical trial: the efficacy, impact on quality of life, and safety and tolerability of prucalopride in severe chronic constipation - a week, randomized, double-blind, placebo-controlled study. Ke M, Zou D, Yuan Y, et al: Prucalopride in the treatment of chronic constipation in patients from the Asia-Pacific region: a randomized, double-blind, placebo-controlled study.
Cited By CrossRef : 0 citations. This article is mentioned in:. Although CC is not known to be associated with the development of serious disease or with excess mortality, it considerably reduces the patients quality of life. In addition, it represents an economic burden to patients and society. The majority of patients with CC successfully manage the disorder by dietary management and the use of laxatives. Furthermore, these patients consume a disproportionate quantity of medical resources.
This drug has also been found to be effective for the treatment of functional CC. In addition, biofeedback and sacral nerve stimulation are effective in the treatment of CC caused by pelvic floor disorders.
Metabolic diseases: Hypothyroidism, hypoparathyroidism, hypercalcemia, hypokalemia, hypomagnesemia, diabetes mellitus, uremia, and heavy metal poisoning.
Approach to the patient with constipation
Neuropathies: Medullar lesions or neoplasia, cerebrovascular disease, multiple sclerosis, autonomic neuropathy, and Parkinson's disease. Frequently, patients and perhaps medical professionals less experienced in disturbances of the pelvic floor define constipation only in terms of evacuatory frequency and the consistency of the feces.
Therefore, with the intention of standardizing the diagnosis and management of intestinal constipation, researchers initially described the criteria of Rome I, 18 which included four symptoms that should be present over the previous 3 months: less than three evacuations per week, straining to evacuate, the presence of hardened feces and a sense of incomplete evacuations. Subsequently, the Rome II criteria 19 encompassed the four aforementioned symptoms and two additional symptoms: a sensation of obstruction or interruption of evacuation and manual maneuvers to facilitate evacuations.
Finally, the Rome III 20 and Rome IV 21 criteria chiefly modified the chronological factor, that is, the symptoms should have originated 6 months before the diagnosis and have been present during the previous three months. The medical history of patients with constipation should be analyzed along with fecal consistency Fig. In the Rome IV consensus, a new syndrome denominated opiate-induced constipation was added, which is associated with the chronic use of these medications.
The Bristol stool form scale may be useful for patients to assess and describe aspects of their feces, facilitating the recognition of the constipation severity. MR, magnetic resonance. Adapted of Bharucha et al. The clinical history obtained and physical examination conducted in patients with intestinal constipation should seek to identify its beginning, the presence of a causal factor and alarming features. A detailed analysis of the clinical history enables the assessment of whether the patient does indeed fulfill the objective clinical criteria for intestinal constipation, such as the aforementioned Rome IV criteria.
Such analysis confirms the presence of risk factors for constipation such as an inadequate diet, low fluid intake, a sedentary lifestyle, psychiatric disease, medication use, comorbidities, prior surgery and symptoms of irritable bowel syndrome. The medical history and proctological examination may suggest the cause of intestinal constipation.
In the case of obstructed defecation, the history verifies the presence of excessive and prolonged evacuatory efforts, low feces volume, the sensation of incomplete evacuation and the need for digital maneuvers of the perineum, anus or vagina, along with a sensation of vaginal bulging. An examination of the perineal region and anus with a digital rectal and vaginal examination may identify sphincter hypertonia, the presence of a rectocele or enterocele, fecal impaction, and secondary causes of constipation anorectal neoplasia, rectal prolapse, anal fissure, stenosis and extrinsic compression.
Fecal, radiological or endoscopic examinations in constipation without alarming features is not routinely indicated. Blood tests: Tests include a complete blood count, serological test for Chagas disease for patients in endemic areas , serum calcium, thyroid, parathyroid and renal function tests, fasting blood glucose levels, and potassium and magnesium levels.
These examinations should be ordered mainly in clinically suspicious cases and not as routine investigations. Barium enema: This examination may be recommended to identify colorectal diseases diverticular disease, neoplasia and megacolon although currently, the test is less frequently used. A complementary workup to investigate constipation should be conducted 12 weeks after clinical treatment, in persistent cases or following a lack of success with dietary measures and functional readjustment. Anorectal manometry: This test should be performed in cases of chronic constipation refractory to medical treatment, with the aim of identifying or excluding aganglionosis chagasic megacolon or Hirschsprung's disease and psychogenic megacolon.
The manometry provides important information about the rectoanal inhibitory reflex, the musculature tone of the internal and external sphincter, and the rectal sensitivity, capacity and complacency. Videodefecography, magnetic resonance defecography or echodefecography: These examinations should be performed to study pelvic floor disturbances, preferably conducted together with anorectal manometry in patients with signs suggesting Obstructed Defecation OD or obstructed exit by history and physical examination. Videodefecography is the radiological study of evacuatory dynamics and is useful to investigate anatomical abnormalities responsible for obstructed exit such as rectocele, intussusception, enterocele, sigmoidocele, anismus and paradoxical contraction of the puborectalis muscle.
Impact and burden of care
Recently, because of its high radiation exposure to young and elderly patients, some authors have performed videodefecography using only video recording, without radiography, whereas others have chosen magnetic resonance defecography or echodefecography, which are well correlated with the results obtained by VDG, without the use of ionizing radiation. Colonic Transit Time CTT : The CTT examination is conducted to assess the time required for elimination of the feces and may be performed with the use of radiopaque markers or by the scintigraphy method.
Normally, less than 5 markers should be seen in the colon. CTT has the advantages of being a low-cost and relatively non-invasive test; its disadvantage is exposure to radiation, albeit in low doses. It should be the first test performed when the clinical and proctologic examination does not indicate outlet obstruction.
CTT may be recommended to assess the response to the clinical or surgical treatment of chronic constipation. Balloon expulsion test: This is a simple and useful method, primarily indicated as a screening test for symptoms of outlet obstruction pelvic floor dyssynergia. A balloon filled with water 50—60 mL is positioned in the rectal ampulla and the patient is asked to make an evacuatory effort to expel it.
When expulsion is achieved, pelvic floor dysfunction may be excluded. This test has been recommended by most constipation evaluation guidelines. Electromyography of the anal sphincter EMG : This method is recommended to diagnose paradoxical contraction of the puborectalis muscle. The test measures the electrical activity of the striated component of the anorectal sphincter during voluntary contraction, at rest, and with coughing and evacuatory effort.
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Its major disadvantage is patient pain due to the needle insertion in the external anal sphincter to obtain the response. Hydrogen breath test: Recommended to assess the orocecal transit time, this test is a valuable aid to differentiate dysmotility of the gastrointestinal tract superior and inferior from isolated colonic inertia. It is recommended for serious and refractory cases of colonic inertia, prior to the indication of a colectomy. The initial management of patients with symptomatic constipation typically includes lifestyle modification, a fiber-rich diet and increased fluid intake.
Although the efficacy of this approach cannot be estimated reliably because the quality of the evidence is very low 1C. Empirical treatment of constipation comprising an increase in dietary fiber content to approximately 25—30 g per day and increased hydration 2—2.
Thus, the combined beneficial therapeutic effect, low cost, safety and other general health benefits of these methods justify their use as the first step in the treatment of constipation, notably in primary healthcare. When the aforementioned lifestyle and dietary measures fail, the second step in the management of intestinal constipation involves the use of osmotic laxatives, such as polyethylene glycol PEG 1A and lactulose 1C and laxatives associated with the formation of fecal matter psyllium, methylcellulose and polycarbophil 32 — 35 1C.
Osmotic laxatives create an intra-luminal osmotic gradient that increases electrolyte secretion, resulting in reduced fecal viscosity and increased fecal biomass, with beneficial effects on peristalsis. A review of randomized studies that compared polyethylene glycol with lactulose found PEG superior, with better results regarding the frequency and consistency of the feces and fewer abdominal pain symptoms. Stimulating laxatives senna, cascara buckthorn, bisacodyl, sodium picosulfate and anthraquinone derivatives may be used for cases in which fiber and osmotic laxatives have not been successful 1B.
In addition to reducing the absorption of water and stimulating intestinal motility, they also increase prostaglandin release. Their main advantage is the rapid mechanism of action, with evacuation occurring on average within 6—12 h. Because of their collateral effects electrolyte disturbances, hypokalemia and abdominal colic , they should not be used for prolonged periods.
Prokinetic pharmaceuticals such as Tegaserod a 5-HT4 agonist and Prucalopride a highly selective 5-HT4 receptor agonist act to increase peristalsis, thereby accelerating gastrointestinal transit 1B. They are recommended for cases unresponsive to laxatives. Prucalopride may be used at a dose of 2—4 mg per day and has been considered a good option for the treatment of chronic constipation in women who do not respond to fiber and laxatives. In a comparative study with placebo, Prucalopride showed clear superiority and the ability to produce three intestinal movements per week compared to placebo.
Probiotics have been recommended with the aims of restoring the intestinal microbiota, increasing evacuatory frequency, improving fecal consistency and diminishing flatulence 2C. Currently however, scientific evidence confirming their benefit in the treatment of CIC is lacking. Enemas or suppositories may be used in select cases of chronically constipated patients e. Transanal irrigation stimulates the rectum and hydrates the feces, allowing intestinal discharge.
This phase includes providing fiber, water or IV fluids, and oral laxatives, in addition to optimizing the patient's underlying medical condition, she said. If the patient is taking opioids, opiate-receptor antagonists may also be helpful.
Multiple opiate-receptor antagonists have been approved by the FDA, but they may not all be available to prescribe in the hospital. Another challenge with these drugs is the risks they carry. Given this concern, she suggests these medications be administered in consultation with a gastroenterologist. Several of her tips focused on reducing the risk of such adverse outcomes for patients.
Medical Home Portal - Constipation
She encouraged clinicians to always risk-stratify constipation into urgent and emergent cases. Other patients at high risk include those who don't actually have constipation. There'll be a leukocytosis and elevated lactate, altered mental status.
- Diagnosis and treatment of chronic constipation – a European perspective!
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There's often hemodynamic compromise, in the form of tachycardia, tachypnea, hypoxia, and fever. Radiologic imaging and physical exam signs can also help distinguish these diagnoses from constipation. If patients have recently had surgery, ileus will likely be considered in the diagnosis of their constipation. It often occurs in the postoperative state. For four days after surgery, ileus is considered physiologic and normal, she explained.
There are common misconceptions about the location of ileus. Most treatment is supportive and should include IV fluid, electrolyte repletion especially potassium and magnesium , mobilization as tolerated, and nutritional support, she advised.