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Review ArticleClinical Review

Chronic Constipation: An Evidence-Based Review

Lawrence Leung, Taylor Riutta, Jyoti Kotecha and Walter Rosser
The Journal of the American Board of Family Medicine July 2011, 24 (4) 436-451; DOI: https://doi.org/10.3122/jabfm.2011.04.100272
Lawrence Leung
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Taylor Riutta
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Jyoti Kotecha
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Walter Rosser
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    Figure 1.

    Flow diagram for management of chronic constipation.

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    Table 1.

    Summary of Various Management Options for Chronic Constipation According to the Strength of Recommendations Taxonomy (SORT)81

    TreatmentLevel of RecommendationCommentsReference
    Nonpharmacological
        Increasing dietary fiberCNo RCTs, data from multiple observational studies, results conflicting. More likely to be beneficial in people with fibers deficiency.34,82–87
        Increasing exerciseBTwo small RCTs with opposite results and 2 other cohorts showing benefits. More likely to be beneficial in people with lack of exercise.9,83,88,89
        Increasing fluidsCOne observational study and 1 controlled trial, the latter showing benefits of increased fluids only in presence of sufficient fiber intake.90,91
        BiofeedbackBUseful in pelvic function disorder type of chronic constipation. Benefits reported with both uncontrolled trials and RCTs. However, protocols of biofeedback vary and are heterogeneous in nature; hence recommendation is not standardized.46,92–94
        Bacteriotherapy (probiotics)COne prospective study of bifidobacterium and one uncontrolled trial of Lactobacillus; viability of preparation when consumed is questionable.95–97
        Surgery (colectomy/hemicolectomy)BOne systematic review reported benefits based on case reports and no RCT; quality of studies was heterogeneous.139
        Surgery (partial division of puborectalis)BTwo RCTs randomizing patients to surgical and nonsurgical treatments (biofeedback or Botulinum toxin injection).140,141
    Pharmacological
        PsylliumAAt least 3 well-designed RCTs showing benefits over placebo.98–101
        BranBTwo controlled trials showed benefits in reducing use of laxatives.102,103
        MethylcelluloseBOnly 1 controlled trial of medium quality.104
        PolycarbophilBOnly 1 case series of medium quality.105
        Polyethylene glycolAAt least 3 RCTs showing benefits over placebo.106–108
        LactuloseATwo systematic reviews of RCTs with benefits over placebos.109,110
        SorbitolBOne double-blind RCT showing comparable efficacy of sorbitol with lactulose, not placebo.111
        Magnesium hydroxide (milk of magnesia)CNo evidence of benefits from any studies, with 1 adverse report of overuse.112
        SennaAAt least 3 controlled trials showing benefits over placebo.115–117
        Docusate sodiumBOne double-blind RCT comparing with psyllium.98
        BisacodylAOne double-blind RCT with 1 open-labelled controlled trial.113,114
        LubiprostoneAAt least 3 double-blind RCTs showing benefits over placebo.118–120
        Tegaserod–At least 3 RCTs from different centers showed benefits over placebo. Withdrawn from market by FDA because of concern; 2 recent cohorts claim no association with cardiovascular risks.121–129
        PrucaloprideAAt least 3 RCTs showing benefits over placebo, including severe chronic constipation. At present only marketed in Europe.130–135
        Traditional Chinese medicineBTwo RCTs showing benefits of a particular formula, yet overall quality of studies are heterogeneous.136–138
    • RCT indicates randomized, controlled trial; FDA, Food and Drug Administration.

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The Journal of the American Board of Family Medicine: 24 (4)
The Journal of the American Board of Family Medicine
Vol. 24, Issue 4
July-August 2011
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Chronic Constipation: An Evidence-Based Review
Lawrence Leung, Taylor Riutta, Jyoti Kotecha, Walter Rosser
The Journal of the American Board of Family Medicine Jul 2011, 24 (4) 436-451; DOI: 10.3122/jabfm.2011.04.100272

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Chronic Constipation: An Evidence-Based Review
Lawrence Leung, Taylor Riutta, Jyoti Kotecha, Walter Rosser
The Journal of the American Board of Family Medicine Jul 2011, 24 (4) 436-451; DOI: 10.3122/jabfm.2011.04.100272
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