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Gastroenterologíayhepatología Document downloaded from http://www.elsevier.es, day 14/02/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Gastroenterol Hepatol. 2017;40(4):303---316 Gastroenterología y Hepatología www.elsevier.es/gastroenterologia REVIEW Clinical practice guidelines for the management of constipation in adults. Part 2: Diagnosis ଝ,ଝଝ and treatment a,∗ b,c d e Jordi Serra , Juanjo Mascort-Roca , Mercè Marzo-Castillejo , Silvia Delgado Aros , f g h Juan Ferrándiz Santos , Enrique Rey Diaz Rubio , Fermín Mearin Manrique a Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain b CAP Florida Sud, Institut Català de la Salut, Hospitalet de Llobregat, Barcelona, Spain c Departament de Ciències Clíniques, Campus Bellvitge, Facultat de Medicina, Universitat de Barcelona, Hospitalet de Llobregat, Barcelona, Spain d Unitat de Suport a la Recerca --- IDIAP Jordi Gol. Direcció d’Atenció Primària Costa de Ponent, Institut Català de la Salut, Comité Científico de semFYC, Barcelona, Spain e Neuro-Enteric Translational Science (NETS) group coordinator. IMIM --- Parc de Salut Mar. PRBB, Barcelona, Spain f Subdirección General de Calidad Asistencial, Consejería de Sanidad, Madrid, Spain g Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain h Instituto de Trastornos Funcionales y Motores Digestivos, Servicio de Aparato Digestivo, Centro Médico Teknon, Barcelona, Spain Received 18 January 2016; accepted 5 February 2016 Available online 31 March 2017 KEYWORDS Abstract Constipation is a very common disorder that adversely affects well-being and quality Constipation; of life. Evidence-based clinical practice guidelines are an essential element for proper patient management and safe, effective treatment. Clinical practice guidelines; The aim of these guidelines is to provide health care professionals who care for patients with chronic constipation with a tool that allows them to make the best decisions about the Chronic disease prevention, diagnosis and treatment of constipation. ଝ Please cite this article as: Serra J, Mascort-Roca J, Marzo-Castillejo M, Delgado Aros S, Ferrándiz Santos J, Diaz Rubio ER, et al. Guía de práctica clínica sobre el manejo del estrenimiento˜ crónico en el paciente adulto. Parte 2: Diagnóstico y tratamiento. Gastroenterol Hepatol. 2017;40:303---316. ଝଝ These clinical practice guidelines have the support of the Asociación Espanola˜ de Gastroenterología (AEG) [Spanish Gastroenterology Association] and the Sociedad Espanola˜ de Medicina Familiar y Comunitaria (semFYC) [Spanish Society of Family and Community Medicine]. ∗ Corresponding author. E-mail address: [email protected] (J. Serra). 2444-3824/© 2016 Elsevier Espana,˜ S.L.U., AEEH and AEG. All rights reserved. Document downloaded from http://www.elsevier.es, day 14/02/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. 304 J. Serra et al. The methodology used to draw up these guidelines is described in the Part 1. In this arti- cle we will discuss the recommendations for the diagnostic and therapeutic management of constipation. © 2016 Elsevier Espana,˜ S.L.U., AEEH and AEG. All rights reserved. Guía de práctica clínica sobre el manejo del estrenimiento˜ crónico en el paciente PALABRAS CLAVE adulto. Parte 2: Diagnóstico y tratamiento Estrenimiento;˜ Guía de práctica Resumen El estrenimiento˜ es un trastorno muy frecuente que afecta negativamente el bien- clínica; estar y la calidad de vida de las personas. Para el correcto manejo y tratamiento eficiente y Enfermedad crónica seguro de los pacientes, las guías de práctica clínica basadas en la evidencia son un elemento esencial. El objetivo de esta guía es proporcionar a los profesionales sanitarios encargados de la asisten- cia a pacientes con estrenimiento˜ crónico una herramienta que les permita tomar las mejores decisiones sobre la prevención, el diagnóstico y el tratamiento del estrenimiento.˜ La metodología utilizada en la elaboración de esta guía de práctica clínica se describe en la Parte 1. En este artículo expondremos las recomendaciones en el manejo, tanto diagnóstico como terapéutico del estrenimiento.˜ © 2016 Elsevier Espana,˜ S.L.U., AEEH y AEG. Todos los derechos reservados. Summary of treatment recommendations for Pharmacological measures chronic constipation. Quick reference guide Bulk-forming laxatives Non-pharmacological measures High-fibre diet - Psyllium (plantago ovata) is suggested as a treatment option in people with chronic functional constipation - Consuming foods high in soluble fibre is recom- (low evidence, weak recommendation in favour). mended (fruits, vegetables, greens, legumes, nuts, - The use of methylcellulose is recommended as an rye bread) (moderate evidence, strong recommen- alternative to psyllium (low evidence, strong recom- dation in favour). mendation in favour). - It is advised that fibre-rich foods be introduced grad- ually so that the gastrointestinal tract can adapt. Osmotic laxatives Water intake - Adequate fluid intake is recommended to comple- ment the effects of fibre supplements (low evidence, - Polyethylene glycol is recommended as a treatment weak recommendation in favour). option in people with chronic constipation (moderate evidence, strong recommendation in favour). - Lactulose is recommended as a treatment option in people with chronic constipation (low evidence, Physical exercise strong recommendation in favour). - The use of polyethylene glycol is preferred over lac- tulose (moderate evidence, weak recommendation in favour). - Performing regular physical exercise adapted to the patient’s condition is recommended (low evidence, weak recommendation in favour). Document downloaded from http://www.elsevier.es, day 14/02/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Clinical practice guidelines for the management of constipation in adults. Part 2 305 Emollient and lubricant laxatives Surgery (colectomy) - The use of stimulant laxatives is recommended as a - Colectomy should only be considered as a treatment rescue treatment option (moderate evidence, strong option in people with severe refractory chronic con- recommendation in favour). stipation that does not respond to other treatments - The use of stimulant laxatives is suggested as a treat- and in whom extensive involvement of intestinal ment option in people with chronic constipation who motility has been ruled out using special tests, have not responded to bulk-forming and/or osmotic including gastrointestinal manometry (low evidence, laxatives (moderate evidence, weak recommenda- weak recommendation in favour). tion in favour). Introduction Prokinetic laxatives Constipation is a very common disorder that adversely affects people’s well-being and quality of life. Evidence- based clinical practice guidelines are an essential element - Prucalopride is suggested as a treatment option for proper patient management and safe, effective treat- in women with chronic constipation who have not ment. responded to other treatments (moderate evidence, The aim of these guidelines is to provide health care pro- weak recommendation in favour). fessionals who care for patients with chronic constipation with a tool that allows them to make the best decisions about the prevention, diagnosis and treatment of constipa- Secretory laxatives tion. The methodology used to draw up these guidelines is described in Part 1. In this article, we will discuss the recom- mendations for the diagnostic and therapeutic management of constipation (Figs. 1 and 2, Table 1). - Lubiprostone is not marketed in Spain. - Linaclotide is approved in Spain only for the treat- ment of irritable bowel syndrome with constipation Diagnosis and assessment (IBS-C). Medical history In the vast majority of patients, the diagnosis of chronic idiopathic constipation is based on the description of symp- Other treatments Biofeedback (pelvic floor rehabilitation) Table 1 Classification of different types of laxatives. Recommended dose Bulk-forming Plantago ovata 3.5---10.5 g/day - Biofeedback is recommended as a treatment option Methylcellulose 3---4.5 g/day in people with chronic constipation and pelvic floor Osmotics dyssynergia (low evidence, strong recommendation Polyethylene glycol 3---9 g/day or 250---500 ml/day in favour). Lactulose 15---60 ml Lactitol 20 g or 30 ml Magnesium Sacral neuromodulation Stimulants Bisacodyl 5---10 mg/day Sodium picosulfate 2.5---10 mg/day - Sacral neuromodulation is proposed as a treatment Prokinetics option in people with chronic constipation refractory Prucalopride 2 mg/24 h to other treatments (low evidence, weak recommen- Secretory dation in favour). a Lubiprostone 24 ␮g/12 h Linaclotide 145 ␮g/day a Not marketed in Spain. Document downloaded from http://www.elsevier.es, day 14/02/2018. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. 306 J. Serra et al. Patient with chronic constipation (1.1) Warning signs or symptoms? Yes (1.2) No Organic cause? Start > 50 years? Do not respond to treatment? Exploration, blood test, colonoscopy (1.4) Result Negative Does the patient Positive take drugs that No cause constipation? Yes (1.3) (1.5) Assess withdrawal Advice on lifestyle and dietary and No Yes hygiene measures and reassure Remission? Diagnosis and and inform the patient aetiological treatment No Yes (1.6) Remission? Introduce/add
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