Advertisement

Current Treatment Options in Gastroenterology

, Volume 12, Issue 3, pp 310–321 | Cite as

Constipation in Adults: Diagnosis and Management

  • Vanessa C. Costilla
  • Amy E. Foxx-OrensteinEmail author
Geriatrics (S Katz, Section Editor)

Opinion statement

Symptoms of constipation occur at all ages, with the greatest prevalence in individuals older than 60 years of age. It is estimated that 35 million individuals suffer from constipation in the USA, but only a small number will ever be diagnosed. Patients identify constipation symptoms differently than physicians. Whereas a patient may define their constipation by symptoms of bloating, distension, feeling of incomplete evacuation, abdominal discomfort, hard stools, and excessive straining, physicians often interpret prolonged timing between movements as the most essential criteria. An evaluation of constipation begins with a focused history of a person’s bowel habit, medications, diet, physical activity, and an anorectal examination. In the absence of alarm signs, diagnostic testing for constipation is not routinely recommended in the initial evaluation. First-line management includes lifestyle changes of increased physical activity, high-fiber diets, adequate fluid intake, and bowel management techniques such as a straight back sitting position, using known triggers to stimulate bowel contractions, and a foot stool to elevate knees above bottom during toileting. When refractory to initial management, patients should have anorectal manometry to assess outlet function; additional testing may be required. Biofeedback is an effective treatment option for dyssynergic defecation. A range of traditional and new pharmacologic therapies are available to remedy constipation, from stool softeners to agents that increase intestinal transit. Managing the primary and secondary causes of constipation, incorporating effective bowel management techniques, along with the judicious use of laxatives can reduce constipation symptoms and improve quality of life.

Keywords

Chronic constipation Anorectal manometry Pelvic floor dysfunction Outlet dysfunction Delayed transit constipation Constipation management 

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Vanessa C. Costilla declares that she has no conflict of interest.

Amy E. Foxx-Orenstein has received consultancy fees, speaker honorarium, and travel accommodation from Ironwood and Forest.

No funding was received for this paper.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

  1. 1.
    Brandt LJ et al. Systematic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005;100 Suppl 1:S5–21.PubMedCrossRefGoogle Scholar
  2. 2.
    Bharucha AE, Pemberton JH, Locke 3rd GR. American Gastroenterological Association technical review on constipation. Gastroenterology. 2013;144(1):218–38.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.••
    Bharucha AE et al. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013;144(1):211–7. This is the latest guideline published by the American Gastroenterological Association for the management of constipation. It clearly defines chronic constipation and directs physicians on diagnostic work-up and treatment plans. Given its recent publication it includes the latest drugs approved by the FDA for chronic constipation.PubMedCrossRefGoogle Scholar
  4. 4.
    Choung RS et al. Cumulative incidence of chronic constipation: a population-based study 1988-2003. Aliment Pharmacol Ther. 2007;26(11–12):1521–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004;99(4):750–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Bosshard W et al. The treatment of chronic constipation in elderly people: an update. Drugs Aging. 2004;21(14):911–30.PubMedCrossRefGoogle Scholar
  7. 7.
    Talley NJ et al. Constipation in an elderly community: a study of prevalence and potential risk factors. Am J Gastroenterol. 1996;91(1):19–25.PubMedGoogle Scholar
  8. 8.
    Dennison C et al. The health-related quality of life and economic burden of constipation. Pharmacoeconomics. 2005;23(5):461–76.PubMedCrossRefGoogle Scholar
  9. 9.
    Nellesen D et al. A systematic review of the economic and humanistic burden of illness in irritable bowel syndrome and chronic constipation. J Manag Care Pharm. 2013;19(9):755–64.PubMedGoogle Scholar
  10. 10.
    Nellesen D et al. Comorbidities in patients with irritable bowel syndrome with constipation or chronic idiopathic constipation: a review of the literature from the past decade. Postgrad Med. 2013;125(2):40–50.PubMedCrossRefGoogle Scholar
  11. 11.
    Longstreth GF et al. Functional bowel disorders. Gastroenterology. 2006;130(5):1480–91.PubMedCrossRefGoogle Scholar
  12. 12.•
    Gallegos-Orozco JF et al. Chronic constipation in the elderly. Am J Gastroenterol. 2012;107(1):18–25. quiz 26.This article is a very comprehensive review of constipation with a primary focus on the elderly. It provides a thorough review of the pathophysiology of constipation.PubMedCrossRefGoogle Scholar
  13. 13.
    Ness J et al. Anticholinergic medications in community-dwelling older veterans: prevalence of anticholinergic symptoms, symptom burden, and adverse drug events. Am J Geriatr Pharmacother. 2006;4(1):42–51.PubMedCrossRefGoogle Scholar
  14. 14.
    Traube M, McCallum RW. Calcium-channel blockers and the gastrointestinal tract. American College of Gastroenterology's Committee on FDA related matters. Am J Gastroenterol. 1984;79(11):892–6.PubMedGoogle Scholar
  15. 15.
    Rao SS, Singh S. Clinical utility of colonic and anorectal manometry in chronic constipation. J Clin Gastroenterol. 2010;44(9):597–609.PubMedCrossRefGoogle Scholar
  16. 16.
    Fletcher JG et al. Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders. Am J Gastroenterol. 2003;98(2):399–411.PubMedCrossRefGoogle Scholar
  17. 17.
    Diamant NE et al. AGA technical review on anorectal testing techniques. Gastroenterology. 1999;116(3):735–60.PubMedCrossRefGoogle Scholar
  18. 18.
    Saad RJ, Hasler WL. A technical review and clinical assessment of the wireless motility capsule. Gastroenterol Hepatol (N Y). 2011;7(12):795–804.Google Scholar
  19. 19.
    Chiarioni G, Salandini L, Whitehead WE. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 2005;129(1):86–97.PubMedCrossRefGoogle Scholar
  20. 20.
    Gudsoorkar VS, Quigley EM. Emerging treatments for chronic constipation. Expert Opin Emerg Drugs. 2013;18(3):365–73.PubMedCrossRefGoogle Scholar
  21. 21.
    Bijkerk CJ et al. Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial. BMJ. 2009;339:b3154.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Bijkerk CJ et al. Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome. Aliment Pharmacol Ther. 2004;19(3):245–51.PubMedCrossRefGoogle Scholar
  23. 23.
    Voderholzer WA et al. Clinical response to dietary fiber treatment of chronic constipation. Am J Gastroenterol. 1997;92(1):95–8.PubMedGoogle Scholar
  24. 24.
    Xing JH, Soffer EE. Adverse effects of laxatives. Dis Colon Rectum. 2001;44(8):1201–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Szojda MM, Mulder CJ, Felt-Bersma RJ. Differences in taste between two polyethylene glycol preparations. J Gastrointest Liver Dis. 2007;16(4):379–81.Google Scholar
  26. 26.
    Nyberg C, Hendel J, Nielsen OH. The safety of osmotically acting cathartics in colonic cleansing. Nat Rev Gastroenterol Hepatol. 2010;7(10):557–64.PubMedCrossRefGoogle Scholar
  27. 27.
    Ainley EJ, Winwood PJ, Begley JP. Measurement of serum electrolytes and phosphate after sodium phosphate colonoscopy bowel preparation: an evaluation. Dig Dis Sci. 2005;50(7):1319–23.PubMedCrossRefGoogle Scholar
  28. 28.
    Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis. Gut. 2011;60(2):209–18.PubMedCrossRefGoogle Scholar
  29. 29.
    Lacy BE, Levy LC. Lubiprostone: a novel treatment for chronic constipation. Clin Interv Aging. 2008;3(2):357–64.PubMedCentralPubMedGoogle Scholar
  30. 30.
    Gras-Miralles B, Cremonini F. A critical appraisal of lubiprostone in the treatment of chronic constipation in the elderly. Clin Interv Aging. 2013;8:191–200.PubMedCentralPubMedGoogle Scholar
  31. 31.
    Camilleri M et al. Effect of a selective chloride channel activator, lubiprostone, on gastrointestinal transit, gastric sensory, and motor functions in healthy volunteers. Am J Physiol Gastrointest Liver Physiol. 2006;290(5):G942–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Lacy BE, Chey WD. Lubiprostone: chronic constipation and irritable bowel syndrome with constipation. Expert Opin Pharmacother. 2009;10(1):143–52.PubMedCrossRefGoogle Scholar
  33. 33.
    Barish CF et al. Efficacy and safety of lubiprostone in patients with chronic constipation. Dig Dis Sci. 2010;55(4):1090–7.PubMedCrossRefGoogle Scholar
  34. 34.
    Harris LA, Crowell MD. Linaclotide, a new direction in the treatment of irritable bowel syndrome and chronic constipation. Curr Opin Mol Ther. 2007;9(4):403–10.PubMedGoogle Scholar
  35. 35.
    Johnston JM et al. Linaclotide improves abdominal pain and bowel habits in a phase IIb study of patients with irritable bowel syndrome with constipation. Gastroenterology. 2010;139(6):1877–1886 e2.PubMedCrossRefGoogle Scholar
  36. 36.
    Silos-Santiago I et al. Gastrointestinal pain: Unraveling a novel endogenous pathway through uroguanylin/guanylate cyclase-C/cGMP activation. Pain. 2013;154(9):1820–30.PubMedCrossRefGoogle Scholar
  37. 37.
    Lacy BE, Levenick JM, Crowell MD. Linaclotide: a novel therapy for chronic constipation and constipation-predominant irritable bowel syndrome. Gastroenterol Hepatol (N Y). 2012;8(10):653–60.Google Scholar
  38. 38.
    Lembo AJ et al. Efficacy of linaclotide for patients with chronic constipation. Gastroenterology. 2010;138(3):886–95 e1.PubMedCrossRefGoogle Scholar
  39. 39.••
    Rothstein RD, Friedenberg FK. Linaclotide: a novel compound for the treatment of irritable bowel syndrome with constipation. Expert Opin Pharmacother. 2013;14(15):2125–32. This study demonstrated the efficacy of linaclotide and helped it gain FDA approval. Linaclotide is the latest agent approved by the FDA for chronic constipation.PubMedCrossRefGoogle Scholar
  40. 40.
    Thayalasekeran S, Ali H, Tsai HH. Novel therapies for constipation. World J Gastroenterol. 2013;19(45):8247–51.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Camilleri M et al. A placebo-controlled trial of prucalopride for severe chronic constipation. N Engl J Med. 2008;358(22):2344–54.PubMedCrossRefGoogle Scholar
  42. 42.
    Costilla VC, Foxx-Orenstein AE. Constipation: understanding mechanisms and management. Clin Geriatr Med. 2014;30(1):107–15.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2014

Authors and Affiliations

  • Vanessa C. Costilla
    • 1
  • Amy E. Foxx-Orenstein
    • 1
    • 2
    • 3
    Email author
  1. 1.Department of Internal MedicineMayo Clinic in ArizonaScottsdaleUSA
  2. 2.Division of GastroenterologyMayo Clinic in ArizonaScottsdaleUSA
  3. 3.ScottsdaleUSA

Personalised recommendations