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© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
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© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
in the clinic
Constipation
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
What are major risk factors for constipation?
 Increased age
 Female Gender
 Race – African American
 Nursing home residents
 Low socioeconomic populations
 Decreased physical activity
 Low fluid intake, low fiber diet
 Smoking – inverse association
 Alcohol use – inverse association
 Medications
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
Medications Associated with Constipation
 Calcium channel blockers (nifedipine, verapamil)
 Anti-depressants (tricyclic antidepressants)
 Opiates
 Anticholinergic agents (anticonvulsants, antipsychotics,
antispasmodics)
 Analgesics (opiates, NSAIDS)
 Antiparkinsonian agents
 Diuretics (thiazides, loop diuretics)
 Cation containing agents (calcium iron, aluminum)
 Antidiarrheals (oveuse) (bile acid resins)
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
CLINICAL BOTTOM LINE: Prevention...
 Be vigilant to the risk factors associated with constipation
 Risk factors for constipation
 Increased age
 Many co-morbid conditions
 Array of medications
 Decreased mobility and physical activity
 Consumption of a low fiber diet
 Inadequate hydration
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
What symptoms define constipation?
 Historically: < 3 bowel movements per week
 But infrequency doesn’t necessarily correlate with
pathophysiology or symptoms
 Now: ≥ 2 of the following (for ≥ 3 months with symptom
onset ≥ 6 months prior to diagnosis):
 Straining during ≥ 25% defecations
 Lumpy or hard stools ≥ 25% defecations
 Sensation of incomplete evacuation ≥ 25% of the time
 Sensation of anorectal obstruction/blockage ≥ 25% of time
 Manual maneuvers to facilitate defecation ≥ 25% of the time
 < 3 defecations/week
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
What are the common subtypes of primary
constipation and their distinguishing
pathophysiologic features?
 Normal transit constipation
 Slow transit constipation
 Pelvic floor dysfunction
 “Combination constipation”
 Slow transit constipation and pelvic floor dysfunction
 Dyssynergic defecation
 Functional defecatory disorders defined by alterations of
events that occur during expulsion efforts
 Some have slow transit + defecatory dysfunction
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
What are the characteristic symptoms and
physical exam findings?
 Infrequency
 Difficulty defecating
 Excessive straining
 Hard stools
 Sensation of blockage or incomplete evacuation
 “Diarrhea” or incontinence of stool (with terminal reservoir
syndrome or megarectum)
 Alarm signs or symptoms needing further investigation
 History of rectal bleeding or anemia
 Weight loss, fever
 Family history of colon cancer
 Age > 50 consider secondary causes of constipation
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
 History
 Duration of symptoms and age of onset
 Temporal occurrence to other factors, diet
 History of medications
 Maneuvers to facilitate defecation
 History of sexual abuse
 Bowel and diet diary may help correlate symptoms with diet
 Bristol Stool Form scale may also be helpful
 Physical examination
 Comprehensive abdominal examination
 Comprehensive rectal examination
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
What other conditions should clinicians
consider?
 Diet & lifestyle
 Dehydration or inadequate fluid intake, low fiber diet
 Immobility, poor bowel habits
 Structural
 Neoplasms (colon cancer), colonic stricture or obstruction
 External compression
 Neurologic
 Peripheral: autonomic neuropathy, diabetes mellitus,
Hirschprung disease, American trypanosomiasis
 Central neurologic dysfunction: multiple sclerosis,
Parkinson’s, spinal cord injury, stroke, dementia, TBI
 Colonic pseudoobstruction
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
 Endocrine
 Hypothyroidism, hyperparathyroidism, panhypopituitarism
 Diabetes mellitus, pheochromocytoma, pregnancy
 Metabolic
 CKD, electrolyte abnormalities
 Heavy metal poisoning, porphyria
 Myopathic
 Myotonic dystrophy, scleroderma, amyloidosis
 Psychiatric or Psychosocial
 Depression, anorexia nervosa, dementia, abuse
 Other
 Sarcoidosis
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
What is the role of diagnostic testing?
 No need to perform tests unless history and physical
exam findings suggest potential problem or include
alarm sign or symptom
 Target initial lab tests to the issue
 CBC, basic chemistry panel including glucose, calcium,
and electrolytes, thyroid function tests, urinalysis
 Assess stool for occult blood
 More specific testing for endocrinologic, metabolic,
neurologic, or collagen vascular disorders should be
based on the history and physical examination findings
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
When should clinicians consider obtaining
tests of colonic function?
 When pelvic floor dysfunction is suspected
 When patients fail to respond to therapy
 Tests for evaluation of constipation
 Anorectal Manometry and balloon expulsion testing
 Scintigraphy
 Functional MRI
 Defecography
 Colonic marker studies
 Wireless pH-pressure capsule
 Colonic manometry and Barostat Testing
 EMG
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
When should primary care clinicians
consult with a gastroenterologist or
surgeon for diagnosis?
 If colonoscopy is required
 Patients with “red flag” signs and symptoms
 All patients > 50 years old with constipation
 If additional functional testing are required
 Motility procedures, tests of anorectal function
 Know local resources for patients who may require these
specialized studies and consultative opinions
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
CLINICAL BOTTOM LINE: Diagnosis...
 Constipation is a symptom-based diagnosis
 Take a comprehensive history
 Perform careful physical examination
 Treatment recommendation
 Initiate therapy without further testing in patients without
alarm signs or symptoms
 After discontinuing medications that can result in
constipation
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
What is the overall approach to managing
constipation?
 Understand etiologies that may contribute to symptoms
 Align treatment with underlying mechanism
 Discontinue medications that cause constipation and
can be safely stopped
 Suggest a bowel habit diary and diet history to correlate
dietary factors with stool consistency and timing
 Determine if there is coexisting defecatory disorder
 Outline the expected goals
 Provide patient education about treatment rationale
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
What is the role of dietary modification
and exercise?
 Increasing fiber and fluid intake is mainstay of therapy
 Fluid intake alone will not improve symptoms
 Fiber improves functional constipation, not IBS
 Fiber requires water to work, but exact quantity unclear
 Educate patients about soluble vs insoluble fiber
 Soluble: oat, psyllium, certain fruits and vegetables
 Insoluble: wheat bran, whole grains, dark leafy vegetables
 Cramping, bloating may limit compliance: introduce slowly
 Fluid intake limited with renal replacement therapy
 Patients may not need fiber supplement + increased fluids if
they can increase their intake of other sources of fiber
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
What are the mechanisms of action for
constipation treatments?
 Stool bulking agents
 Increase fecal bulk to increase passage through colon
 Stimulant laxatives
 Increase colonic peristalsis in order to propel stool forward
 Osmotic agents
 Draw fluid into lumen leading to more rapid colonic transit
 Prokinetic agents
 Secretory agents
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
Which nonprescription medications are
useful for managing constipation?
 Fiber
 Docusate sodium (no data for efficacy)
 Castor oil (not recommended due to nutrient malabsorption)
 Stimulant laxatives
 Osmotic laxatives
 Saline laxatives (milk of magnesia)
 Magnesium citrate
 Polyethylene glycol
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
When should clinicians consider treatment
with prescription medication?
 If fiber and nonprescription laxatives fail
 Consider patient preference, cost, likelihood of adherence
 If patients are severely constipated
 No bowel movement for >1 week and not impacted
 Prescription strength laxatives or nonprescription laxatives
at higher than standard doses
 In hospitalized or hospice patients on opiates
 If traditional nonprescription remedies have failed
 Methylnaltrexone or oral prescription medication
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
Which prescription medications are useful
for managing constipation?
 Osmotic agents
 Lactulose
 Sorbitol
 Agents targeting cellular mechanisms of colonic
physiology
 Chloride channel-2 stimulants (lubiprostone)
 Guanylate cyclase C activator (linaclotide)
 Receptor antagonists (methlynaltrexone )
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
Is biofeedback effective in the treatment
of constipation?
 Studied in patients with slow transit constipation and in
patients with a defecatory disorder
 Most useful in patients with defecatory disorder
 50% to 80% effective
 Studies have shown efficacy in the elderly population
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
How should patients with renal insufficiency or
renal failure be managed?
 Many OTC and prescription laxatives are safe
 Osmotic agents have limited AEs for this population
 Lactulose may be a safer alternative
 Several agents require dose adjustment for use with renal
impairment
 Avoid some medications
 Sodium phosphate based compounds can cause crystalline
nephropathy
 Magnesium-based products, esp if creatinine >1.5 mg/dL
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
How should clinicians manage constipation in
patients with diabetes or multiple sclerosis?
 Diabetes
 Focus on glycemic control
 Poor glycemic control leads to worse symptoms
 Multiple sclerosis
 Treatment can lead to incontinence due to alteration in
rectal sensation and anorectal muscle function
 Pelvic floor dysfunction may also occur
 Focus treatment on symptom control
 Constipation may be preferable to incontinence as
predominant symptom
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
How does management differ in the elderly?
 Etiology of constipation is often multifactorial
 Determine which etiologies are modifiable
 Defecatory are disorders more common
 Medical-functional issues that affect treatment
 Important issues: ability to self-manage
 Educate patient and caregivers
 Laxatives may increase sense of urgency
 Limitations in ambulation may mean it takes longer to get
to the bathroom
 Educate patients adverse events
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
When should clinicians consult with other
providers for treatment of patients with
constipation?
 Gastroenterologist
 Colonoscopy for unexplained iron deficiency anemia,
rectal bleeding, unexplained weight loss
 Motility testing for suspected pelvic floor dysfunction
 Health psychologist: to help with severe symptoms
 Physical therapist or biofeedback specialist: for
dyssynergia
 Urogynecologist: for urinary and gynecologic symptoms
or pelvic floor dysfunction
 Dietician: to help guide treatment
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
How should clinicians counsel patients
about managing constipation?
 Educate about etiology of constipation
 Explain role of fiber, options for increasing fiber intake
 Focus on reasonable goal setting for dietary changes
 Provide education about use of nonprescription
medications
 Set clear medication adjustment guidelines
 Provide guidance about when to call for additional help
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.
CLINICAL BOTTOM LINE: Treatment...
 Treatment requires attention
 Lifestyle habits (toileting practice, diet, and activity)
 Concurrent medications
 Treatment should be individualized to underlying cause
 Treat underlying etiology for enduring solution
 Select nonprescription medication as a first line option
 Escalate to prescription based remedies if needed
© Copyright Annals of Internal Medicine, 2015
Ann Int Med. 162 (4): ITC4-1.