sign in sign up
<<
Home , Bloating, Fecal incontinence, Hematochezia

Diagnostic Approach to Chronic in Adults NAMIRAH JAMSHED, MD; ZONE-EN LEE, MD; and KEVIN W. OLDEN, MD Washington Hospital Center, Washington, District of Columbia

Constipation is traditionally defined as three or fewer bowel movements per week. Risk factors for constipation include female sex, older age, inactivity, low caloric intake, low-fiber diet, low income, low educational level, and taking a large number of medications. Chronic constipa- tion is classified as functional (primary) or secondary. Functional constipation can be divided into normal transit, slow transit, or outlet constipation. Possible causes of secondary chronic constipation include medication use, as well as medical conditions, such as hypothyroidism or . Frail older patients may present with nonspecific symptoms of constipation, such as delirium, anorexia, and functional decline. The evaluation of constipa- tion includes a history and physical examination to rule out alarm . These include evidence of , unintended weight loss, iron deficiency anemia, onset constipation in older patients, and . Patients with one or more alarm signs or symptoms require prompt evaluation. Referral to a subspecialist for additional evaluation and diagnostic testing may be warranted. (Am Fam Physician. 2011;84(3):299-306. Copyright © 2011 American Academy of Family Physicians.) ▲ Patient information: onstipation is one of the most of 1,028 young adults, 52 percent defined A patient education common chronic gastrointes- constipation as straining, 44 percent as hard handout on constipation is 1,2 available at http://family tinal disorders in adults. In a stools, 32 percent as infrequent stools, and doctor.org/037.xml. 1997 epidemiology of constipa- 20 percent as abdominal discomfort.11 The C tion study that surveyed 10,018 persons, Rome III diagnostic criteria are widely used 12 percent of men and 16 percent of women in research and provide a more complete and met criteria for constipation.3 Annually, reproducible definition of functional consti- constipation accounts for 2.5 million physi- pation (Table 1).12 Frequency of bowel move- cian visits and 92,000 hospitalizations in the ments is only one of the criteria. United States.4-6 Constipation compromises quality of life, social functioning, and the Risk Factors ability to perform activities of daily living.7,8 Risk factors for constipation include female These factors are important predictors of sex, older age,13 inactivity, low caloric intake, constipation-associated health care use and low-fiber diet,14,15 taking a large number of resultant health care costs.6,9 This article medications,16 low income, and low educa- reviews an approach for the evaluation of tional level.13,16-22 The incidence of constipa- chronic constipation in adults. tion is three times higher in women,13 and women are twice as likely as men to schedule Definition physician visits for constipation.4,23,24 Stud- Traditionally, physicians have defined con- ies have shown that bowel transit time in stipation as three or fewer bowel movements women tends to be slower than in men, and per week. Having fewer bowel movements is many women experience constipation dur- associated with symptoms of lower abdomi- ing their menstrual period.25-27 Constipation nal discomfort, distension, or .10 is 1.3 times more likely to occur in nonwhites However, patients tend to define constipation than in whites, and is considerably more differently than physicians, and describe it common in families of low socioeconomic in a variety of ways. In a self-reported survey status.23 In the United States, constipation

Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2011 American Academy of Family Physicians. For the private, noncommer- August 1,cial 2011 use of◆ oneVolume individual 84, userNumber of the Web3 site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsAmerican and/or permission Family Physician requests. 299 Constipation SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence Clinical recommendation rating References

A history and physical examination should be performed in C 46 patients with constipation to identify alarm signs or symptoms. Routine use of blood tests, radiography, or endoscopy in patients C 46, 49 with constipation who do not have alarm signs or symptoms is not recommended. Patients with alarm signs or symptoms should undergo C 53 endoscopy to rule out malignancy. The initial management of noncomplicated constipation should B 46, 54, 55 include a high-fiber diet, increased water intake, and exercise. is recommended for treating symptoms of pelvic B 34 floor dysfunction.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, -oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

also has a distinct geographic distribution. included aluminum-containing , Medicare beneficiary data suggest that in diuretics, , antidepressants, antispas- addition to low socioeconomic status, envi- modics, and anticonvulsants. Beta blockers ronmental risk factors for constipation may and channel blockers were associ- include living in rural areas and in colder ated with constipation, but were not inde- temperatures.24 pendent risk factors.16 A study using data from a general prac- tice research database of more than 20,000 Types of Constipation persons in the United Kingdom found that Chronic constipation can be divided into two female sex, older age, , categories: functional (primary) and second- parkinsonism, and were associ- ary. Functional constipation is defined by the ated with constipation.16 The medications Rome III diagnostic criteria (Table 112) and most strongly associated with constipation can be further divided into normal transit, slow transit, and outlet constipation.28 Sec- ondary constipation is caused by medical conditions or medication use. Table 2 lists Table 1. Rome III Diagnostic Criteria for Functional 17 Constipation selected causes of secondary constipation. NORMAL TRANSIT CONSTIPATION Must include two or more of the following: Normal transit constipation is defined as a Straining during at least 25 percent of perception of constipation on patient self- Lumpy or hard stools in at least 25 percent of defecations report; however, stool movement is normal Sensation of incomplete evacuation for at least 25 percent of 14,29 defecations throughout the colon. Other symptoms Sensation of anorectal obstruction/blockage for at least 25 percent reported by patients with normal transit of defecations constipation include and Manual maneuvers to facilitate at least 25 percent of defecations bloating. Normal transit constipation has (e.g., digital evacuation, support of the ) been associated with increased psycho­social Fewer than three defecations per week stress,14 and usually responds to medical Loose stools are rarely present without the use of therapy, such as fiber supplementation or There are insufficient criteria for irritable bowel syndrome laxatives.30

NOTE: Criteria must be fulfilled for the past three months, with symptom onset at least SLOW TRANSIT CONSTIPATION six months before diagnosis. Slow transit constipation is defined as pro- Adapted with permission from Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders [published correction appears in longed transit time through the colon. This . 2006;131(2):688]. Gastroenterology. 2006;130(5):1486. can be confirmed with radiopaque mark- ers that are delayed on motility study.31

300 American Family Physician www.aafp.org/afp Volume 84, Number 3 ◆ August 1, 2011 Constipation

A prolonged colonic transit time is defined of patients were constipated within three as more than six markers still visible on a months of admission to a nursing home.39 plain abdominal radiograph taken 120 hours Most older persons perceive constipation as after ingestion of one Sitzmarks capsule con- straining during and difficulty in taining 24 radiopaque markers.15 Patients evacuation, rather than decreased frequency with slow transit constipation have normal of bowel movements.40-42 In community- resting colonic motility, but do not have the dwelling adults older than 65 years, about 20 increase in peristaltic activity that should percent have rectal outlet delay with need to occur after meals. In addition, the admin- self-evacuate.20 Other causes of functional istration of (Dulcolax) and cho- constipation in older adults may result from linergic agents does not cause an increase in autonomic neuropathies, such as peristaltic waves as it does in persons without mellitus and Parkinson disease, or from use constipation.32,33 A case series of 64 patients of medications, such as opioids and anticho- found that slow transit constipation was an linergics.43 A prospective study in nursing important cause of constipation in young home residents found that independent risk women with very infrequent bowel move- factors for constipation included poor con- ments.29 Typical symptoms of slow transit sumption of fluids, pneumonia, Parkinson constipation include an infrequent “call to disease, immobility, use of more than five stool,” bloating, and abdominal discomfort. medications, dementia, hypothyroidism, Patients with severe slow transit constipation white race, , arthritis, and hyperten- tend not to respond to fiber supplementation sion.39 Frail older persons may not be able to or laxatives, although one clinical trial dem- report bowel-related symptoms because of onstrated a response to biofeedback.29,30,34 communication or cognitive impairment. They also may have impaired rectal sensa- OUTLET CONSTIPATION tion and inhibited urge to evacuate, and Outlet constipation, also known as , is defined as incoordina- tion of the muscles of the pelvic floor during Table 2. Selected Causes of Secondary Constipation attempted evacuation.35 Outlet constipation is not caused by muscle or neurologic pathol- Medications Medical conditions ogy, and most patients have normal colonic Common Common 35-37 transit. In patients with outlet constipa- Antacids, especially with calcium Cerebrovascular disease tion, stool is not expelled when it reaches Iron supplements the . Common features include pro- Opioids Diabetes mellitus longed or excessive straining, soft stools that Less common Hypothyroidism are difficult to pass, and rectal discomfort. Anticholinergic agents Irritable bowel syndrome It is not uncommon for patients to require Antidiarrheal agents Less common manual aid to evacuate stool from the rec- Antihistamines Anal fissures tum. The exact etiology of outlet constipa- Antiparkinsonian agents tion remains unclear. Defecation disorders Cognitive impairment do not respond to traditional medical treat- Calcium channel blockers Colon cancer ment, but may respond to biofeedback and Calcium supplements Hypercalcemia 38 relaxation training. Diuretics Hypokalemia Nonsteroidal anti-inflammatory Hypomagnesemia CONSTIPATION IN OLDER ADULTS drugs Immobility Constipation is not a normal part of aging. Sympathomimetics Multiple sclerosis A review of the literature found that the Tricyclic antidepressants Parkinson disease prevalence of constipation peaks after 70 years of age, reaching between 8 and 43 percent, depending on the population Information from reference 17. studied.13 One study showed that 7 percent

August 1, 2011 ◆ Volume 84, Number 3 www.aafp.org/afp American Family Physician 301 Constipation

therefore may not be aware of fecal impac- colonic neuromuscular disorders. Excessive tion. As a result, these patients may experi- straining from constipation can also lead to ence nonspecific symptoms, such as delirium, , anal fissures, and rectal pro- anorexia, and functional decline.44,45 lapse. In some cases, straining can cause Important presentations of constipation syncope or cardiac ischemia.45 in older persons include and secondary to paradoxi- Diagnostic Evaluation cal .40 Patients with fecal impaction Table 3 lists signs and symptoms associ- may present with nonspecific symptoms ated with common causes of constipation. of clinical deterioration, or more specific The evaluation of a patient with constipa- symptoms, such as anorexia, , and tion should include a history and physical abdominal pain. Paradoxical diarrhea may examination46; patients with symptoms of occur when liquid stools from the proximal organic disease may also require diagnostic colon bypass the impacted stool. The impac- testing. tion can lead to diminished rectal sensa- tion and resultant fecal incontinence. Fecal HISTORY impaction can cause and The physician should begin by inquiring ulceration. Risk factors for fecal impac- about which features the patient finds most tion include prolonged immobility, cogni- distressing. If the patient feels pain, bloat- tive impairment, spinal cord disorders, and ing, or intestinal cramping between bowel movements, these could be symptoms of irritable bowel syndrome (Table 412). A his- Table 3. Clinical Findings and Possible Associated Causes tory of prolonged and excessive straining, in Patients with Constipation especially with soft stools, or a need for digital manipulation to pass stools suggests Finding Possible cause pelvic floor dysfunction.

History Bloating, cramping Irritable bowel syndrome Hematochezia Colon cancer, , Table 4. Rome III Diagnostic Criteria inflammatory bowel disease for Irritable Bowel Syndrome New-onset constipation in older Colon cancer patients Recurrent abdominal pain or discomfort* at Prolonged straining, digital evacuation Pelvic floor dysfunction least three days per month in the past three Weight loss of more than 10 lb (4.5 kg) Colon cancer months associated with two or more of the following: Physical examination Improvement with defecation Lack of anal wink Sacral nerve pathology Onset associated with a change in frequency Lack of pelvic lift during DRE Pelvic floor dysfunction of stool Leakage of stool on DRE Fecal impaction, patulous Onset associated with a change in form anus, rectal prolapse (appearance) of stool Pain on DRE , hemorrhoids

Test results NOTE: Criteria must be fulfilled for the past three Elevated serum calcium levels, low Metabolic causes months, with symptom onset at least six months serum potassium levels, low serum before diagnosis. levels *—An uncomfortable sensation not described as pain. Elevated serum ferritin levels (iron Colon cancer In pathophysiology research and clinical trials, a pain/ deficiency anemia) discomfort frequency of at least two days per week during screening evaluation is required for eligibility. Elevated thyroid-stimulating hormone Hypothyroidism level Adapted with permission from Longstreth GF, Thomp- son WG, Chey WD, Houghton LA, Mearin F, Spiller Positive test Colon cancer RC. Functional bowel disorders [published correction appears in Gastroenterology. 2006;131(2):688]. Gas- DRE = digital . troenterology. 2006;130(5):1481.

302 American Family Physician www.aafp.org/afp Volume 84, Number 3 ◆ August 1, 2011 Constipation

Additional questions should focus on strain to attempt to expel the examiner’s fin- how often the patient feels the need to have ger. A normal response is relaxation of the a bowel movement, and whether he or she anal sphincter and puborectalis muscle with feels a sense of incomplete evacuation. It is a 1- to 3.5-cm descent of the . In important to remind the patient that after addition, when the patient contracts the pel- a complete evacuation, it takes several days vic floor muscles, there should be a lift to the for accumulation that produces a normal pelvic floor. The absence of these findings fecal mass development. It is useful to ask suggests pelvic floor dysfunction.48 if the patient is using laxatives, and if so, at what dosage. Physicians should also ask DIAGNOSTIC TESTING about other treatments being used, includ- Diagnostic tests (e.g., blood tests, radiogra- ing complementary and alternative medicine phy, endoscopy) are not routinely recom- therapies. Additionally, the patient should be mended in the initial evaluation of a patient asked to describe the stool caliber. The Bris- with chronic constipation in the absence tol Stool Scale is a useful tool to assess stool of alarm signs or symptoms.46,49 However, type and to tailor and monitor treatment if the history and physical examination (Figure 1).47 elicit symptoms of organic disease, such as In older patients, the history must include asking about medication use, including over- the-counter medications, and performing Separate hard lumps, like Type 1 a nutritional assessment that evaluates the nuts (difficult to pass) patient’s ability to chew and swallow. If clini- cally indicated, consider evaluating the patient for cognitive impairment and depression. Type 2 Sausage-shaped but lumpy PHYSICAL EXAMINATION The physical examination should include an abdominal and rectal examination, looking Like a sausage or snake but Type 3 for signs of anemia, weight loss, abdomi- with cracks on its surface nal masses, enlargement, or a palpable colon. The perineum should be inspected for hemorrhoids, skin tags, fissures, rectal pro- Like a sausage or snake, Type 4 lapse, or anal warts. Ask the patient to strain smooth and soft as if having a bowel movement, and look for leakage of stool secondary to fecal impac- tion, rectal prolapse, or a patulous anus. The Soft blobs with clear-cut next step is to test the anal wink reflex. This Type 5 is done using a cotton pad or a cotton-tipped edges (passed easily) applicator in all four quadrants around the anus. The absence of an anal contraction may indicate sacral nerve pathology. Fluffy pieces with ragged Type 6 The examination should be completed edges, a mushy stool with a digital rectal examination. Palpation should not elicit pain; the presence of pain with gentle palpation suggests the presence Watery, no solid pieces Type 7 of an anal fissure. Further palpation should (entirely liquid) assess the resting sphincter tone before assessing all walls of the rectum for masses and fecal impaction, especially in patients Figure 1. for identifying stool type. older than 40 years. To test for pelvic floor Adapted from Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit dysfunction, the patient should be asked to time. Scand J Gastroenterol. 1997;32(9):921.

August 1, 2011 ◆ Volume 84, Number 3 www.aafp.org/afp American Family Physician 303 Constipation

hypothyroidism, it is reasonable to obtain Table 5. Indications for Endoscopy further diagnostic tests. Physicians should in Patients with Constipation also be alert for red flags, such as hematoche- zia, unintended weight loss of 10 lb (4.5 kg) Age older than 50 years with no previous or more, a family history of colon cancer, screening iron deficiency anemia, positive fecal occult Before surgery for constipation blood tests, or acute onset of constipation in Change in stool caliber an older patient.46,50-52 If one or more of these Heme-positive stools features are present, endoscopic evaluation Iron deficiency anemia may be necessary to rule out malignancy Obstructive symptoms or other serious conditions.53 The Ameri- Recent onset of constipation can Society for Gastrointestinal Endoscopy published guidelines in 2005 on the use of Rectal prolapse endoscopy in the management of constipa- Weight loss tion (Table 5).53 Note that colonoscopy is not routinely recommended for all patients with Information from reference 53. constipation. If the patient has symptoms of outlet con- stipation or has not responded to reasonable therapy, testing for pelvic floor dys- Initial Management of Functional Constipation function is warranted. This is usually done in specialty centers by confirming inappro- Patient presents with chronic priate contraction or failure of pelvic floor constipation muscle relaxation while attempting to def- Red flags* or other indications ecate; radiography, manometry, or electro- for endoscopy (Table 5)? myography may be used.38

No Yes Initial Management

Recommend lifestyle modification Refer to subspecialist Figure 2 provides an algorithm for the ini- with high-fiber diet, exercise, and for further management tial management of functional constipation. increased fluid intake After ruling out secondary causes of con- stipation and determining that diagnostic

Symptoms resolved? testing is unnecessary, the physician should encourage lifestyle modification, which includes a high-fiber diet, exercise, and Yes No increased water intake.46,54,55 There are con- flicting data about the benefits of fluid intake Continue current Initiate trial of laxatives management and exercise in relieving constipation. How- ever, even though not statistically signifi- Symptoms resolved? cant, a high-fiber diet has shown a decrease in abdominal pain from constipation in many patients.15 In patients with pelvic floor Yes No dysfunction, biofeedback therapy has shown Continue current Refer to subspecialist for a success rate of 35 to 90 percent.34,56 management further management If the patient’s constipation does not *—Red flags include hematochezia, unintended weight loss, family history of colon respond to lifestyle modifications and cancer, iron deficiency anemia, positive fecal occult blood test, and acute onset of fiber, an osmotic agent such as magnesium constipation in an older patient. hydroxide or may help. If osmotic agents do not work, the next step is polyeth- Figure 2. Algorithm for the initial management of functional ylene glycol (Miralax), which hydrates the constipation. stool without causing electrolyte shifts. If

304 American Family Physician www.aafp.org/afp Volume 84, Number 3 ◆ August 1, 2011 Constipation

there is still no response, referral to a subspe- focus on constipation and resource utilization. Am J cialist for further workup and management Gastroenterol. 2002;97(8):1986-1993. is appropriate. This may include additional 10. Johanson JF, Sonnenberg A, Koch TR. Clinical epide- miology of chronic constipation. J Clin Gastroenterol. pharmacotherapy, endoscopy, anorectal 1989;11(5):525-536. manometry, balloon expulsion testing, defe- 11. Sandler RS, Drossman DA. Bowel habits in young adults cography, and colon transit testing. not seeking health care. Dig Dis Sci. 1987;32(8):841-845. 12. Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders [pub- The Authors lished correction appears in Gastroenterology. 2006; 131(2):688]. Gastroenterology. 2006;130(5):1480-1491. NAMIRAH JAMSHED, MD, is director of geriatric education 13. McCrea GL, Miaskowski C, Stotts NA, Macera L, Varma for the Internal Medicine Residency Program at Washing- MG. A review of the literature on gender and age differ- ton (DC) Hospital Center, and assistant professor of clinical ences in the prevalence and characteristics of constipa- medicine at Georgetown University School of Medicine, tion in North America. J Pain Symptom Manage. 2009; Washington, DC. 37(4):737-745. ZONE-EN LEE, MD, is completing a fellowship in gastroen- 14. Wald A, Hinds JP, Caruana BJ. Psychological and physio- terology at the Washington Hospital Center/Georgetown logical characteristics of patients with severe idiopathic constipation. Gastroenterology. 1989;97(4):932-937. University School of Medicine. 15. Rao SS. Constipation: evaluation and treatment of KEVIN W. OLDEN, MD, was director of gastroenterol- colonic and anorectal motility disorders. Gastroenterol ogy at the Washington Hospital Center/Georgetown Clin North Am. 2007;36(3):687-711. University School of Medicine at the time the article was 16. Talley NJ, Jones M, Nuyts G, Dubois D. Risk factors for written. chronic constipation based on a general practice sam- ple. Am J Gastroenterol. 2003;98(5):1107-1111. Address correspondence to Namirah Jamshed, MD, 17. Locke GR III, Pemberton JH, Phillips SF. AGA technical Georgetown University School of Medicine, 110 Irving review on constipation. American Gastroenterological St. NW, EB 3114, Washington, DC 20010 (e-mail: Association. Gastroenterology. 2000;119(6):1766-1778. [email protected]). Reprints are not available from 18. Sonnenberg A, Koch TR. Epidemiology of constipation the authors. in the United States. Dis Colon Rectum. 1989;32(1):1-8. Author disclosure: No relevant financial affiliations to 19. Everhart JE, Go VL, Johannes RS, Fitzsimmons SC, disclose. Roth HP, White LR. A longitudinal survey of self- reported bowel habits in the United States. Dig Dis Sci. 1989;34(8):1153-1162. REFERENCES 20. Talley NJ, Fleming KC, Evans JM, et al. Constipation in an elderly community: a study of prevalence and poten- 1. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder tial risk factors. Am J Gastroenterol. 1996;91(1):19-25. survey of functional gastrointestinal disorders. Preva- lence, sociodemography, and health impact. Dig Dis Sci. 21. Campbell AJ, Busby WJ, Horwath CC. Factors associ- 1993;38(9):1569-1580. ated with constipation in a community based sample of people aged 70 years and over. J Epidemiol Community 2. Higgins PD, Johanson JF. Epidemiology of constipation Health. 1993;47(1):23-26. in North America: a systematic review. Am J Gastroen- terol. 2004;99(4):750-759. 22. Sandler RS, Jordan MC, Shelton BJ. Demographic and dietary determinants of constipation in the US popula- 3. Stewart WF, Liberman JN, Sandler RS, et al. Epidemiol- tion. Am J Public Health. 1990;80(2):185-189. ogy of constipation (EPOC) study in the United States: relation of clinical subtypes to sociodemographic fea- 23. Gleeson GA. Interviewing methods in the health inter- tures. Am J Gastroenterol. 1999;94(12):3530-3540. view survey. Vital Health Stat 2. 1972;(48):1-86. 4. Sonnenberg A, Koch TR. Physician visits in the United 24. Johanson JF. Geographic distribution of constipation in the States for constipation: 1958 to 1986. Dig Dis Sci. 1989; United States. Am J Gastroenterol. 1998;93(2):188-191. 34(4):606-611. 25. Wyman JB, Heaton KW, Manning AP, Wicks AC. Vari- 5. Singh G, Lingala V, Wang H, et al. Use of health care ability of colonic function in healthy subjects. Gut. 1978; resources and cost of care for adults with constipation. 19(2):146-150. Clin Gastroenterol Hepatol. 2007;5(9):1053-1058. 26. Gear JS, Brodribb AJ, Ware A, Mann JI. Fibre and bowel 6. Lembo A, Camilleri M. Chronic constipation. N Engl J transit times. Br J Nutr. 1981;45(1):77-82. Med. 2003;349(14):1360-1368. 27. Rees WD, Rhodes J. Altered bowel habit and menstrua- 7. O’Keefe EA, Talley NJ, Zinsmeister AR, Jacobsen SJ. tion. Lancet. 1976;2(7983):475. Bowel disorders impair functional status and quality of 28. Drossman DA, Dumitrascu DL. Rome III: New standard life in the elderly: a population-based study. J Gerontol for functional gastrointestinal disorders. J Gastrointestin A Biol Sci Med Sci. 1995;50(4):M184-M189. Liver Dis. 2006;15(3):237-241. 8. Chang L. Review article: epidemiology and quality of life 29. Preston DM, Lennard-Jones JE. Severe chronic constipa- in functional gastrointestinal disorders. Aliment Pharma- tion of young women: ‘idiopathic slow transit constipa- col Ther. 2004;20(suppl 7):31-39. tion.’ Gut. 1986;27(1):41-48. 9. Irvine EJ, Ferrazzi S, Pare P, Thompson WG, Rance L. 30. Voderholzer WA, Schatke W, Mühldorfer BE, Klauser Health-related quality of life in functional GI disorders: AG, Birkner B, Müller-Lissner SA. Clinical response to

August 1, 2011 ◆ Volume 84, Number 3 www.aafp.org/afp American Family Physician 305 Constipation

treatment of chronic constipation. Am J 45. Gallagher P, O’Mahony D. Constipation in old age. Best Gastroenterol. 1997;92(1):95-98. Pract Res Clin Gastroenterol. 2009;23(6):875-887. 31. Stivland T, Camilleri M, Vassallo M, et al. Scintigraphic 46. Ternent CA, Bastawrous AL, Morin NA, et al; Standards measurement of regional gut transit in idiopathic con- Practice Task Force of the American Society of Colon stipation. Gastroenterology. 1991;101(1):107-115. and Rectal Surgeons. Practice parameters for the evalu- 32. Preston DM, Lennard-Jones JE. Pelvic motility and ation and management of constipation. Dis Colon Rec- response to intraluminal bisacodyl in slow-transit con- tum. 2007;50(12):2013-2022. stipation. Dig Dis Sci. 1985;30(4):289-294. 47. Lewis SJ, Heaton KW. Stool form scale as a useful 33. Bassotti G, Chiarioni G, Imbimbo BP, et al. Impaired guide to intestinal transit time. Scand J Gastroenterol. colonic motor response to cholinergic stimulation in 1997;32(9):920-924. patients with severe chronic idiopathic (slow transit 48. Talley NJ. How to do and interpret a rectal examina- type) constipation. Dig Dis Sci. 1993;38(6):1040-1045. tion in gastroenterology. Am J Gastroenterol. 2008; 34. Chiarioni G, Whitehead WE, Pezza V, Morelli A, Bassotti G. 103(4):820-822. Biofeedback is superior to laxatives for normal transit 49. Rao SS, Ozturk R, Laine L. Clinical utility of diagnostic constipation due to pelvic floor . Gastroen- tests for constipation in adults: a systematic review. Am terology. 2006;130(3):657-664. J Gastroenterol. 2005;100(7):1605-1615. 35. Rao SS, Welcher KD, Leistikow JS. Obstructive defeca- 50. Brandt LJ, Prather CM, Quigley EM, Schiller LR, Schoen- tion: a failure of rectoanal coordination. Am J Gastroen- feld P, Talley NJ. Systematic review on the management terol. 1998;93(7):1042-1050. of chronic constipation in North America. Am J Gastro- 36. Sagar PM, Pemberton JH. Anorectal and pelvic floor enterol. 2005;100(suppl 1):S5-S21. function. Relevance of continence, incontinence, and 51. Winawer S, Fletcher R, Rex D, et al.; Gastrointestinal constipation. Gastroenterol Clin North Am. 1996;25(1): Consortium Panel. Colorectal cancer screening and 163-182. surveillance: clinical guidelines and rationale—update 37. Bassotti G, Crowell MD, Whitehead WE. Contractile based on new evidence. Gastroenterology. 2003; activity of the human colon: lessons from 24 hour stud- 124(2):544-560. ies. Gut. 1993;34(1):129-133. 52. Rex DK, Johnson DA, Anderson JC, et al. American 38. Bassotti G, Chistolini F, Sietchiping-Nzepa F, de Roberto College of Gastroenterology guidelines for colorectal G, Morelli A, Chiarioni G. Biofeedback for pelvic floor cancer screening 2009 [published correction appears in dysfunction in constipation. BMJ. 2004;328(7436): Am J Gastroenterol. 2009;104(6):1613]. Am J Gastro- 393-396. enterol. 2009;104(3):739-750. 39. Robson KM, Kiely DK, Lembo T. Development of con- 53. Qureshi W, Adler DG, Davila RE, et al. ASGE guideline: stipation in nursing home residents. Dis Colon Rectum. guideline on the use of endoscopy in the manage- 2000;43(7):940-943. ment of constipation. Gastrointest Endosc. 2005;62(2): 40. De Lillo AR, Rose S. Functional bowel disorders in the 199-201. geriatric patient: constipation, fecal impaction, and fecal 54. De Schryver AM, Keulemans YC, Peters HP, et al. Effects incontinence. Am J Gastroenterol. 2000;95(4):901-905. of regular physical activity on defecation pattern in mid- 41. Spinzi GC. Bowel care in the elderly. Dig Dis. 2007; dle-aged patients complaining of chronic constipation. 25(2):160-165. Scand J Gastroenterol. 2005;40(4):422-429. 42. Morley JE. Constipation and irritable bowel syndrome in 55. Anti M, Pignataro G, Armuzzi A, et al. Water supple- the elderly. Clin Geriatr Med. 2007;23(4):823-832. mentation enhances the effect of high-fiber diet on 43. Talley NJ, O’Keefe EA, Zinsmeister AR, et al. Prevalence of stool frequency and laxative consumption in adult gastrointestinal symptoms in the elderly: a population- patients with functional constipation. Hepatogastroen- based study. Gastroenterology. 1992;102(3):895-901. terology. 1998;45(21):727-732. 44. Fillit HM, Rockwood R, Woodhouse K, eds. Brocklehurst’s 56. Chiarioni G, Heymen S, Whitehead WE. Biofeedback Textbook of Geriatric Medicine and Gerontology. 7th therapy for dyssynergic defecation. World J Gastroen- ed. Philadelphia, Pa.: Saunders; 2010. terol. 2006;12(44):7069-7074.

306 American Family Physician www.aafp.org/afp Volume 84, Number 3 ◆ August 1, 2011