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Chronic Constipation: an Evidence-Based Review

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Chronic Constipation: an Evidence-Based Review J Am Board Fam Med: first published as 10.3122/jabfm.2011.04.100272 on 7 July 2011. Downloaded from CLINICAL REVIEW Chronic Constipation: An Evidence-Based Review Lawrence Leung, MBBChir, FRACGP, FRCGP, Taylor Riutta, MD, Jyoti Kotecha, MPA, MRSC, and Walter Rosser MD, MRCGP, FCFP Background: Chronic constipation is a common condition seen in family practice among the elderly and women. There is no consensus regarding its exact definition, and it may be interpreted differently by physicians and patients. Physicians prescribe various treatments, and patients often adopt different over-the-counter remedies. Chronic constipation is either caused by slow colonic transit or pelvic floor dysfunction, and treatment differs accordingly. Methods: To update our knowledge of chronic constipation and its etiology and best-evidence treat- ment, information was synthesized from articles published in PubMed, EMBASE, and Cochrane Database of Systematic Reviews. Levels of evidence and recommendations were made according to the Strength of Recommendation taxonomy. Results: The standard advice of increasing dietary fibers, fluids, and exercise for relieving chronic constipation will only benefit patients with true deficiency. Biofeedback works best for constipation caused by pelvic floor dysfunction. Pharmacological agents increase bulk or water content in the bowel lumen or aim to stimulate bowel movements. Novel classes of compounds have emerged for treating chronic constipation, with promising clinical trial data. Finally, the link between senna abuse and colon cancer remains unsupported. Conclusions: Chronic constipation should be managed according to its etiology and guided by the best evidence-based treatment.(J Am Board Fam Med 2011;24:436–451.) copyright. Keywords: Chronic Constipation, Clinical Review, Evidence-Based Medicine, Family Medicine, Gastrointestinal Problems, Systematic Review The word “constipation” has varied meanings for was established in 1991 by Drossman et al, primar- different individuals. Although medical personnel ily to standardize consensus-derived criteria of define constipation as Ͻ3 bowel movements per functional gastrointestinal disorder, and released http://www.jabfm.org/ week,1,2 patients often equate constipation with the Rome III criteria in 2006 for constipation as stool consistency, feelings of incomplete emptying, having at least 2 of the following: (1) straining 3,4 straining, and urge for defecation. Furthermore, during Ն25% defecation; (2) lumpy or hard stools the normalcy of bowel habit ranges widely from 3 in Ն25% of defecation; (3) sensation of incomplete 5 bowel movements per day to 3 per week, with a evacuation in Ն25% of defecation; (4) sensation of tendency to underestimate while self-reporting6; Ն anorectal obstruction/blockage in 25% of defe- on 29 September 2021 by guest. Protected hence, using defecation frequency alone may not be cation; (5) need for manual maneuvers to facilitate diagnostic of constipation. The Rome Foundation in Ն25% of defecation; and (6) fewer than 3 defe- cations per week.7,8 Also, patients should rarely have loose stools without laxatives and be distinct This article was externally peer reviewed. 8,9 Submitted 13 November 2010; revised 20 February 2011; from having irritable bowel syndrome. For con- accepted 7 March 2011. stipation to be defined as chronic, a patient must be From the Department of Family Medicine (LL, TR, WR) and the Centre of Studies in Primary Care (LL, JK, WR), symptomatic for at least 6 months with applicable Queen’s University, Kingston, Ontario, Canada. criteria for the previous 3 months.3,9 Although the Funding: none. Conflict of interest: none declared. validity of the Rome III criteria for constipation has Corresponding author: Lawrence Leung, Department of been recently questioned,10 with a known disparity Family Medicine, Queen’s University, 220 Bagot Street, Kingston, Ontario, Canada K7L 5E9 (E-mail: leungl@ between self-reported and criteria-based defini- queensu.ca). tions,11 the use of colonic transit time12,13 and 436 JABFM July-August 2011 Vol. 24 No. 4 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2011.04.100272 on 7 July 2011. Downloaded from anorectal function tests14 as diagnostic tools is still rly.17,31–36 Among them, the trio of insufficient controversial. In general, the prevalence of consti- dietary fiber, fluids, and exercise has been widely pation among the general population in North ascribed,37 but in fact the evidence behind these 3 America has been quoted as 1.9% to 27.2%,15,16 factors is inconsistent and of low to medium qual- with 50% to 74% of the institutionalized elderly ity.38 (See Notes section: Diagnostic Approach for reporting daily use of laxatives.17,18 Women are 2 Chronic Constipation.) The association between to 3 times more likely to have constipation than smoking, alcohol, and body mass index with men in terms of prevalence3,15,19–21 and physical chronic constipation L131(BMI) is inconclu- symptoms.15,20 Possible reasons include higher risk sive.36,39 of injury to the pelvic floor from childbirth22 and the general willingness of women to report their Intrinsic Factors symptoms and respond to surveys.23 Advanced age Normal defecation requires a series of orchestrated is also a risk factor for chronic constipation, with actions, starting with relaxation of the puborectalis the largest increase in prevalence after the age of 70 muscles, descent of the pelvic floor with straight- years.15 This can be due to effects of medication, ening of the anorectal angle, inhibition of segmen- immobility, and blunted urge to defecate. In the tal colonic peristalsis, contraction of the abdominal United States, constipation accounts for 7 million wall muscles, and finally, relaxation of the external physician visits per year24 and is among the top 5 anal sphincter with expulsion of feces. Intrinsic outpatient gastrointestinal diagnoses.25 Annually, factors leading to chronic constipation can be diagnostic workup for constipation averages broadly classified into 2 categories: pelvic floor dys- US$3000 per patient,26 and it takes another function (PFD) and slow colon transit time (STC). US$4500 per person to provide treatment.27 In A retrospective study reported the prevalence of general, constipation has a significant impact on PFD as 37% and STC as 23%,40 based on physi- quality-of-life indicators irrespective of culture and ologic tests. However, a clear distinction between nationalities,28 especially on the elderly.29 A recent the two is often impossible, with an overlap of copyright. systematic review showed that impairment caused up to 55%.40,41 by constipation as measured by Health-Related Anorectal/PFD involves laxity of the pelvic floor Quality of Life scores predominates in the mental muscles, impaired rectal sensation, and decreased health domains and is comparable to that caused by luminal pressure in the anal canal and have been serious chronic conditions such as osteoarthritis documented as causes for chronic constipation in and diabetes.30 the elderly, especially in women.42–44 On the con- trary, paradoxical contraction of the puborectalis http://www.jabfm.org/ Etiology of Chronic Constipation and external anal sphincter during defecation can Extrinsic Factors lead to incomplete emptying45,46 or even functional Low fiber intake, inadequate hydration, reduced outlet obstruction. Finally, anatomic anomalies mobility as the result of general functional decline (such as rectal wall prolapse or rectocele) or peri- and institutionalization, reduced sensation of thirst, neal damage (from traumatic childbirth or sacral electrolyte disturbances (hypercalcemia, hypokale- nerve injury) can also distort the normal functions mia, hypermagnesemia), endocrine and metabolic of the anorectal/pelvic floor unit. on 29 September 2021 by guest. Protected disorders (eg, diabetes mellitus, hyperparathyroid- STC is a poorly understood condition thought ism, hypothyroidism, chronic renal failure), neuro- to be a cause of intractable constipation in chil- logical disorders (eg, dementia, Parkinson disease, dren47 and young women.48 It is characterized by neuropathies, multiple sclerosis, spinal cord inju- reduced high-amplitude propagated contrac- ries, cauda equine syndrome), psychological co- tions49,50 in the colon, leading to slow transit of morbidities (eg, depression, distress, personality feces, bloating, abdominal discomfort, and infre- disorders, or history of abuse), and concurrent quent defecation.51 The protracted time in the co- medications (eg, anticholinergics, diuretics, lon also renders the feces hard and small and fails to ␤-blockers, opiates, iron supplements, calcium mount sufficient rectal pressure to trigger the def- channel blockers, antidepressants, acetaminophen, ecation reflex.52 Often, the pressure required is aspirin and NSAIDs) all are said to contribute to found to be higher than in subjects with normal chronic constipation, especially in the elde- colonic transit.53 Various physiologic and histobio- doi: 10.3122/jabfm.2011.04.100272 Chronic Constipation 437 J Am Board Fam Med: first published as 10.3122/jabfm.2011.04.100272 on 7 July 2011. Downloaded from chemical findings have been postulated to explain Diagnostic Approach and Investigations the phenomenon of slow colonic transit: reduced It is important to conduct a detailed history and cholinergic54,55 and enhanced adrenergic respon- physical examination before proceeding with in- ses55; mitigated gastrocolic reflex56; dysynergy of vestigations.
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