Current Gastroenterology Reports

, Volume 14, Issue 4, pp 306–312

Recent Advances in the Management of Difficult Constipation

Neuromuscular Disorders of the Gastrointestinal Tract (A Foxx-Orenstein, Section Editor)


Constipation is a highly prevalent disorder. Some patients suffer from acute, intermittent episodes of constipation. Others, however, suffer from chronic constipation, a term that refers to those patients with symptoms of constipation for more than 6 months. In clinical practice, chronic constipation is often used interchangeably with the term functional constipation, which is currently defined using the Rome III criteria. Symptoms can be burdensome, leading to a reduction in patients’ quality of life. In addition, chronic constipation is important because it imposes a significant economic impact to the health care system. Some patients with chronic constipation have persistent symptoms despite implementing lifestyle changes and using either over-the-counter agents or prescription medications. These patients may be categorized as having difficult constipation. This report will focus on recent advances in the management of difficult constipation, and include a discussion of new and upcoming medications as well as new diagnostic tests and procedures.


Anorectal manometry Constipation Defecography Guanylate cyclase Linaclotide Prucalopride Rome criteria Sacral nerve stimulation Wireless motility capsule 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Higgins PDR, Johanson JF. Epidemiology of chronic constipation in North America: a systematic review. Am J Gastroenterol. 2004;99:750–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Gallegos-Orozco JF, Foxx-Orenstein AE, Sterler SM, Stoa JM. Am J Gastroenterol. 2012;107(1):18–25.PubMedCrossRefGoogle Scholar
  3. 3.
    Irvine EJ, Ferrazzi S, Pare P, et al. Health-related quality of life in functional GI disorders: focus on constipation and resource utilization. Am J Gastroenterol. 2002;97:1986–93.PubMedCrossRefGoogle Scholar
  4. 4.
    Sonnenberg A, Koch TR. Physician visits in the United States for constipation: 1958 to 1986. Dig Dis Sci. 1989;34:606–11.PubMedCrossRefGoogle Scholar
  5. 5.
    Whitehead WE, Drinkwater D, Cheskin LJ, et al. Constipation in the elderly living at home: definition, prevalence, and relationship to lifestyle and health status. J Am Geriatr Soc. 1989;37:423–9.PubMedGoogle Scholar
  6. 6.
    O’Keefe EA, Talley NJ, Tangalos EG, Zinsmeister AR. A bowel symptom questionnaire for the elderly. J Gerontol. 1992;47:M116–21.PubMedGoogle Scholar
  7. 7.
    Frank L, Kleinman L, Farup C, Taylor L, Miner Jr P. Psychometric validation of a constipation symptom assessment questionnaire. Scand J Gastroenterol. 1999;34:870–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Wald A, Scarpignato C, Kamm MA, et al. The burden of constipation on quality of life: results of a multinational survey. Aliment Pharmacol Ther. 2007;26:227–36.PubMedCrossRefGoogle Scholar
  9. 9.
    • Sun SX, DiBonaventura M, Purayidathil FW, et al. Impact of chronic constipation on health-related quality of life, work productivity, and healthcare resource use: an analysis of the National Health and Wellness Survey. Dig Dis Sci. 2011;56:2688–95. A nice study on the impact of constipation on quality of life and the health care system. PubMedCrossRefGoogle Scholar
  10. 10.
    Nyrop KA, Palsson OS, Levy RL, et al. Costs of health care for irritable bowel syndrome, chronic constipation, functional diarrhoea and functional abdominal pain. Aliment Pharmacol Ther. 2007;26:237–48.PubMedCrossRefGoogle Scholar
  11. 11.
    Choung RS, Branda ME, Chitkara D, et al. Longitudinal direct medical costs associated with constipation in women. Aliment Pharmacol Ther. 2011;33:251–60.PubMedCrossRefGoogle Scholar
  12. 12.
    Longstreth GF, Thompson WG, Chey WD, et al. Functional bowel disorders. Gastroenterology. 2006;130:1480–91.PubMedCrossRefGoogle Scholar
  13. 13.
    Rao SSC, Kuo B, McCallum RW, et al. Investigation of colonic and whole-gut transit with wireless motility capsule and radiopaque markers in constipation. Clin Gastroenterol Hepatol. 2009;7:537–44.PubMedCrossRefGoogle Scholar
  14. 14.
    • Camilleri M, Thorne NK, Ringel Y, et al. Wireless pH-motility capsule for colonic transit: prospective comparison with radiopaque markers in chronic constipation. Neurogastroenterol Motil. 2010;22:874–82. A recent study comparing the standard of care for the evaluation of colonic transit (radiopaque markers) to the new technology of a wireless motility capsule. PubMedCrossRefGoogle Scholar
  15. 15.
    • Jones MP, Post J, Crowell MD. High resolution manometry in the evaluation of anorectal disorders: a simultaneous comparison with water-perfused manometry. Am J Gastroenterol. 2007;102:850–5. The only study comparing HRAM to standard anorectal manometry. PubMedCrossRefGoogle Scholar
  16. 16.
    Healy JC, Halligan S, Reznek RH, et al. Dynamic MR imaging compared with evacuation proctography when evaluating anorectal configuration and pelvic floor movement. Am J Roentgenol. 1997;169:775–9.Google Scholar
  17. 17.
    • Reiner CS, Tutuian R, Solopova AE, et al. MR defecography in patients with dyssynergic defecation: spectrum of imaging findings and diagnostic value. Br J Radiol. 2011;84:136–44. A new study evaluating the clinical utility of MR defecography. PubMedCrossRefGoogle Scholar
  18. 18.
    Flusberg M, Sahni VA, Erturk SM, Mortele KJ. Dynamic MR defecography: assessment of the usefulness of the defecation phase. Am J Roentgenol. 2011;196:W394–9.CrossRefGoogle Scholar
  19. 19.
    Camilleri M, Kerstens R, Rykx A, Vandeplassche L. A placebo-controlled trial of prucalopride for severe chronic constipation. New Eng J Med. 2008;358:2344–54.PubMedCrossRefGoogle Scholar
  20. 20.
    Tack J, van Outryve M, Beyens G, Kerstens R, Vandeplassche L. Prucalopride (Resolor) in the treatment of severe chronic constipation in patients dissatisfied with laxatives. Gut. 2009;58:357–65.PubMedCrossRefGoogle Scholar
  21. 21.
    • Quigley EMM, Vandeplassche L, Kerstens R, Ausma J. Clinical trial: the efficacy, impact on quality of life, and safety and tolerability of prucalopride in severe chronic constipation—a 12-week, randomized, double-blind, placebo-controlled study. Aliment Pharmacol Ther. 2009;29:315–28. One of the 3 large studies evaluating the efficacy and safety of prucalopride. PubMedCrossRefGoogle Scholar
  22. 22.
    •• Tack J, Camilleri M, Chang L, et al. Systematic review: cardiovascular safety profile of 5-HT4 agonists developed for GI disorders. Aliment Pharmacol Ther. 2012; In press. A comprehensive review of the cardiovascular safety profile of 5-HT 4 agonists. Google Scholar
  23. 23.
    Eutamene H, Bradesi S, Larauche M, et al. Guanylate cyclase C-mediated antinociceptive effects of linaclotide in rodent models of visceral pain. Neurogastroenterol Motil. 2010;22:312–e84.PubMedCrossRefGoogle Scholar
  24. 24.
    Johnston JM, Kurtz CB, Drossman DA, et al. Pilot study of the effect of linaclotide in patients with chronic constipation. Am J Gastroenterol. 2009;104:125–32.PubMedCrossRefGoogle Scholar
  25. 25.
    Lembo AJ, Kurtz CB, MacDougall JE, et al. Efficacy of linaclotide for patients with chronic constipation. Gastroenterology. 2010;138:886–95.PubMedCrossRefGoogle Scholar
  26. 26.
    •• Lembo AJ, Schneier HA, Shiff SJ, et al. Two randomized trials of linaclotide for chronic constipation. New Eng J Med. 2011;365:527–36. Two large well-designed studies demonstrating the safety and efficacy of linaclotide in the treatment of chronic constipation. PubMedCrossRefGoogle Scholar
  27. 27.
    Simren M, Bajor A, Gillberg P-G, et al. Randomized clinical trial: the ileal bile acid transporter inhibitor A3309 vs. placebo in patients with chronic idiopathic constipation—a double-blind study. Aliment Pharmacol Ther. 2011;34:41–50.PubMedCrossRefGoogle Scholar
  28. 28.
    Wong BS, Camilleri M, McKinzie S, et al. Effects of A3309, an ileal bile acid transporter inhibitor, on colonic transit and symptoms in females with functional constipation. Am J Gastroenterol. 2011;106:2154–63.PubMedCrossRefGoogle Scholar
  29. 29.
    Hughes SF, Scott SM, Pilot MA, Williams NS. Electrically stimulated colonic reservoir for total anorectal reconstruction. Br J Surg. 1995;82:1321–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Dinning PG, Fuentealba SE, Kennedy ML, et al. Sacral nerve stimulation induces pan-colonic propagating pressure waves and increases defecation frequency in patients with slow-transit constipation. Color Dis. 2006;9:123–32.CrossRefGoogle Scholar
  31. 31.
    Kamm MA, Dudding TC, Melenhorst J, et al. Sacral nerve stimulation for intractable constipation. Gut. 2010;59:333–40.PubMedCrossRefGoogle Scholar
  32. 32.
    • Govaert B, Maeda Y, Alberga J, et al. Medium-term outcome of sacral nerve modulation for constipation. Dis Colon Rectum. 2012;55:26–31. A just-published study showing that sacral nerve modulation may be effective in some patients with difficult constipation, however, further studies are required. PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Brian E. Lacy
    • 1
  • John Levenick
    • 1
  • Michael Crowell
    • 2
  1. 1.Division of Gastroenterology & HepatologyDartmouth-Hitchcock Medical CenterLebanonUSA
  2. 2.Division of GastroenterologyMayo Clinic ScottsdaleScottsdaleUSA

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