Skip to main content

Advertisement

SpringerLink
Log in

Update on the Management of Chronic Constipation

  • Colon (J Anderson, Section Editor)
  • Published:
Current Treatment Options in Gastroenterology Aims and scope Submit manuscript

Opinion statement

Chronic constipation (CC) is a highly prevalent disorder encountered by health care providers of all specialties. The diagnosis can be confidently made by taking a careful history, evaluating for warning signs and symptoms, performing an examination, including a digital rectal exam, and using the Rome IV criteria. Treatment should begin at the first visit; most patients require few diagnostic tests to make, or confirm, the diagnosis of CC. Assuming that the patient has persistent symptoms of constipation, despite using traditional therapy (fiber, osmotic agents), then patients should be offered one of the newer treatments, rather than repeating prior treatments, which is a common practice. Lubiprostone, a chloride channel activator, has been shown to safely improve symptoms of CC. Its proven track record of success over the last decade is a common reason why many health care providers choose this as a first-line agent. Alternatively, linaclotide, which stimulates guanylate cyclase C receptors, and which has also been shown to improve symptoms of CC in large, randomized trials, is another logical choice. The decision of which agent to use first often depends upon the patient’s co-payment or insurance plan. Either medication should be given a trial of at least 4–6 weeks. If a patient does not respond, then the patient should be treated with the other agent. If symptoms persist, the clinician should consider the possibility of overlapping, or predominant, pelvic floor dysfunction (PFD). The combination of high-resolution anorectal manometry and a balloon expulsion test can be used to make the diagnosis of PFD. If present, patients should be referred to a knowledgeable physical therapist for pelvic floor retraining. New treatment options are available to treat the multiple symptoms of CC. Co-existing pelvic floor dysfunction should be considered in those patients who fail medical therapy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References and Recommended Reading

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

  1. Choung RS. Locke GR,3rd, Schleck CD, Zinsmeister AR, Talley NJ. Cumulative incidence of chronic constipation: a population-based study 1988-2003. Aliment Pharmacol Ther. 2007;26(11–12):1521–8.

    Article  CAS  PubMed  Google Scholar 

  2. Talley NJ, Weaver AL, Zinsmeister AR. Melton LJ,3rd. Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders. Am J Epidemiol. 1992;136(2):165–77.

    Article  CAS  PubMed  Google Scholar 

  3. Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol. 2011;106(9):1582–91. quiz 1581, 1592

    Article  PubMed  Google Scholar 

  4. Dukas L, Willett WC, Giovannucci EL. Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. Am J Gastroenterol. 2003;98(8):1790–6.

    Article  PubMed  Google Scholar 

  5. Chang JY, Locke GR, Schleck CD, Zinsmeister AR, Talley NJ. Risk factors for chronic constipation and a possible role of analgesics. Neurogastroenterology & Motility. 2007;19(11):905–11.

    Article  CAS  Google Scholar 

  6. Sonnenberg A, Koch TR. Physician visits in the United States for constipation: 1958 to 1986. Dig Dis Sci. 1989;34(4):606–11.

    Article  CAS  PubMed  Google Scholar 

  7. Corban C, Sommers T, Sengupta N, Jones M, Cheng V, Friedlander E, et al. Fecal impaction in the emergency department: an analysis of frequency and associated charges in 2011. J Clin Gastroenterol. 2016;50(7):572–7.

    Article  PubMed  Google Scholar 

  8. •• Lacy BE, Mearin F, Chang L, Chey WD, Lembo AJ, Simren M, et al. Bowel Disorders. Gastroenterology. 2016;150(6):1393–407. Updated Rome IV guidelines for chronic constipation

    Article  Google Scholar 

  9. Johanson JF, Kralstein J. Chronic constipation: a survey of the patient perspective. Aliment Pharmacol Ther. 2007;25(5):599–608.

    Article  CAS  PubMed  Google Scholar 

  10. Snape Jr WJ. Role of colonic motility in guiding therapy in patients with constipation. Dig Dis. 1997;15(Suppl 1):104–11.

    PubMed  Google Scholar 

  11. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014;109(8):1141–57. (Quiz) 1058

    Article  PubMed  Google Scholar 

  12. American Gastroenterological Association, Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013;144(1):211–7.

    Article  Google Scholar 

  13. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32(9):920–4.

    Article  CAS  PubMed  Google Scholar 

  14. Chaussade S, Roche H, Khyari A, Couturier D, Guerre J. Measurement of colonic transit time: description and validation of a new method. Gastroenterol Clin Biol. 1986;10(5):385–9.

    CAS  PubMed  Google Scholar 

  15. Metcalf AM, Phillips SF, Zinsmeister AR, MacCarty RL, Beart RW, Wolff BG. Simplified assessment of segmental colonic transit. Gastroenterology. 1987;92(1):40–7.

    Article  CAS  PubMed  Google Scholar 

  16. Stivland T, Camilleri M, Vassallo M, Proano M, Rath D, Brown M, et al. Scintigraphic measurement of regional gut transit in idiopathic constipation. Gastroenterology. 1991;101(1):107–15.

    Article  CAS  PubMed  Google Scholar 

  17. Barish CF, Drossman D, Johanson JF, Ueno R. Efficacy and safety of lubiprostone in patients with chronic constipation. Dig Dis Sci. 2010;55(4):1090–7.

    Article  CAS  PubMed  Google Scholar 

  18. Johanson JF, Ueno R. Lubiprostone, a locally acting chloride channel activator, in adult patients with chronic constipation: a double-blind, placebo-controlled, dose-ranging study to evaluate efficacy and safety. Aliment Pharmacol Ther. 2007;25(11):1351–61.

    Article  CAS  PubMed  Google Scholar 

  19. • Johanson JF, Morton D, Geenen J, Ueno R. Multicenter, 4-week, double-blind, randomized, placebo-controlled trial of lubiprostone, a locally-acting type-2 chloride channel activator, in patients with chronic constipation. Am J Gastroenterol. 2008;103(1):170–17. Results of key trial demonstrating the efficacy and safety of lubiprostone in chronic constipation

    Article  CAS  PubMed  Google Scholar 

  20. Bryant AP, Busby RW, Bartolini WP, Cordero EA, Hannig G, Kessler MM, et al. Linaclotide is a potent and selective guanylate cyclase C agonist that elicits pharmacological effects locally in the gastrointestinal tract. Life Sci. 2010;86(19–20):760–5.

    Article  CAS  PubMed  Google Scholar 

  21. Busby RW, Bryant AP, Bartolini WP, Cordero EA, Hannig G, Kessler MM, et al. Linaclotide, through activation of guanylate cyclase C, acts locally in the gastrointestinal tract to elicit enhanced intestinal secretion and transit. Eur J Pharmacol. 2010;649(1–3):328–35.

    Article  CAS  PubMed  Google Scholar 

  22. • Lembo AJ, Schneier HA, Shiff SJ, Kurtz CB, MacDougall JE, Jia XD, et al. Two randomized trials of linaclotide for chronic constipation. N Engl J Med. 2011;365(6):527–36. Results of key trial demonstrating the efficacy and safety of linaclotide in chronic constipation

    Article  CAS  PubMed  Google Scholar 

  23. Guanylate CM, Cyclase C. Agonists: emerging gastrointestinal therapies and actions. Gastroenterology. 2015;148(3):483–7.

    Article  Google Scholar 

  24. Shailubhai K, Comiskey S, Foss JA, Feng R, Barrow L, Comer GM, et al. Plecanatide, an oral guanylate cyclase C agonist acting locally in the gastrointestinal tract, is safe and well-tolerated in single doses. Dig Dis Sci. 2013;58(9):2580–6.

    Article  CAS  PubMed  Google Scholar 

  25. • Miner PB, Surowitz R, Fogel R, Koltun W, Drossman DA, Camilleri M, et al. 925g plecanatide, a novel guanylate cyclase-C (GC-C) receptor agonist, is efficacious and safe in patients with chronic idiopathic constipation (CIC): results from a 951 patient, 12 week, multi-center trial. Gastroenterol. 2013;144(5):S-163. Results of key trial demonstrating the efficacy and safety of plecanatide in chronic constipation.

  26. Miner PB, Lentz JD, Berenguer R, Nualart M, Hickey B, Barrow L, et al. Su1214 efficacy and safety of plecanatide in the treatment of chronic idiopathic constipation (CIC): results from a multicenter phase III study (study-03). Gastroenterology. 2016;150(4):S497–8.

    Article  Google Scholar 

  27. Nualart M, Morgan W, Berenguer R, Nguyen A, Barrow L, Magnus L. Sa1443 effect of plecanatide on patient assessments in chronic idiopathic constipation (CIC): results from two phase III studies. Gastroenterology. 2016;150(4):S317.

    Article  Google Scholar 

  28. Krause R, Foehl H, Koltun W, Barrow L, Griffin P. Sa1444 effect of plecanatide on stool consistency in the treatment of chronic idiopathic constipation (CIC): results from two phase III studies. Gastroenterology. 2016;150(4):S317–8.

    Article  Google Scholar 

  29. Zielinska M, Wasilewski A, Fichna J. Tenapanor hydrochloride for the treatment of constipation-predominant irritable bowel syndrome. Expert Opin Investig Drugs. 2015;24(8):1093–9.

    Article  CAS  PubMed  Google Scholar 

  30. Labonte ED, Carreras CW, Leadbetter MR, Kozuka K, Kohler J, Koo-McCoy S, et al. Gastrointestinal inhibition of sodium-hydrogen exchanger 3 reduces phosphorus absorption and protects against vascular calcification in CKD. J Am Soc Nephrol. 2015;26(5):1138–49.

    Article  CAS  PubMed  Google Scholar 

  31. • Chey WD, Lembo A, Phillips JA, Rosenbaum DP. 1020 efficacy and safety of tenapanor in patients with constipation predominant irritable bowel syndrome: a 12-week, double-blind, placebo-controlled, randomized phase 2B trial. Gastroenterology. 2015;148(4):S-191–2. Results of key trial demonstrating the efficacy and safety of tenapanor in irritable bowel with constipation

    Article  Google Scholar 

  32. • Chiarioni G, Whitehead WE, Pezza V, Morelli A, Bassotti G. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology. 2006;130(3):657–64. One of only two prospective studies demonstrating superiority of biofeedback for pelvic floor dysfunction

    Article  PubMed  Google Scholar 

  33. • Rao SSC, Seaton K, Miller M, Brown K, Nygaard I, Stumbo P, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol. 2007;5(3):331–8. One of only two prospective studies demonstrating superiority of biofeedback for pelvic floor dysfunction

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Medicine, Division of Gastroenterology & Hepatology, Dartmouth Hitchcock Medical Center, 1 Medical Center Dr. 4C, Lebanon, NH, 03766, USA

    Jenna Koliani-Pace MD & Brian E. Lacy PhD, MD

Authors
  1. Jenna Koliani-Pace MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brian E. Lacy PhD, MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jenna Koliani-Pace MD.

Ethics declarations

Conflict of Interest

Jenna Koliani-Pace declares that she has no conflict of interest.

Brian E. Lacy is on the scientific advisory boards for Ironwood, Sahx, Prometheus, and Allergan.

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.

Additional information

This article is part of the Topical Collection on Colon

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Koliani-Pace, J., Lacy, B.E. Update on the Management of Chronic Constipation. Curr Treat Options Gastro 15, 126–134 (2017). https://doi.org/10.1007/s11938-017-0118-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11938-017-0118-2

Keywords

Search

Navigation