Constipation: Evaluation and Treatment of Colonic and Anorectal Motility Disorders

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This article focuses on the colonic and anorectal motility disturbances that are associated with chronic constipation and their management. Functional chronic constipation consists of three overlapping subtypes: slow transit constipation, dyssynergic defecation, and irritable bowel syndrome with constipation. The Rome criteria may serve as a useful guide for making a clinical diagnosis of functional constipation. Today, an evidence-based approach can be used to treat patients with chronic constipation. The availability of specific drugs for the treatment of chronic constipation, such as tegaserod and lubiprostone, has enhanced the therapeutic armamentarium for managing these patients. Randomized controlled trials have also established the efficacy of biofeedback therapy in the treatment of dyssynergic defecation.

Section snippets

Epidemiology

Recent estimates based on householder surveys in North America suggest a prevalence rate of 15% to 20% for chronic constipation.1, 2, 3 However, other figures have been quoted and the discrepancies in the literature are largely due to how the problem has been defined or reported. The prevalence of constipation increases with age, especially in those over the age of 65 years.4, 5, 6 It also affects work-related productivity and leads to more absences from school.7 Constipation is associated with

Functional Subtypes

There is emerging consensus amongst experts that in the absence of alarm symptoms, such as weight loss, bleeding, recent change in bowel habit, and significant abdominal pain; or secondary causes, such as drugs, metabolic disorders, colorectal cancer, or local painful lesions, such as anal fissure,12 most patients with a complaint of constipation have a functional disorder affecting the colon or anorectum. At least three subtypes have been recognized, although overlap exists. Slow transit

Definition

Recent reviews and guidelines have addressed issues related to the definition of this common complaint.15, 19, 20, 21, 22, 23 Although infrequent defecation has generally been used to define constipation, such symptoms as excessive straining, passage of hard stools, or feeling of incomplete evacuation have only recently been recognized as equally important and perhaps more common.1 Thus, a definition that does not address the heterogeneity of symptoms that affect a patient with constipation is

Pathophysiology

The right colon performs several complex functions that include mixing, fermentation and salvage of the ileal effluent, secretion, and desiccation of the intraluminal contents to form stool. The left colon serves as a conduit for desiccation and more rapid transport of stool and the rectosigmoid region serves as a sensorimotor organ that facilitates the awareness, retention, and evacuation of stool when socially conducive. These functions are regulated by neurotransmitters, such as serotonin,

Clinical Features

Constipated patients present with a constellation of symptoms that include a feeling of incomplete evacuation; excessive straining; passage of hard, pellet-like stool; digital disimpaction or vaginal splinting; a lump-like sensation; or blockage in the anal region.9, 13 Additionally, they may report infrequent defecation, often less than three bowel movements per week; abdominal or anorectal discomfort; pain; or bloating.9 Patients may misrepresent their symptoms or may feel embarrassed to

Physical Examination

A thorough physical examination that includes a detailed neurological examination should be performed to exclude systemic illnesses that may cause constipation. The abdomen must be carefully examined for the presence of stool, particularly in the left or right lower quadrant. A normal physical examination is not uncommon but it is important to exclude a gastrointestinal mass. Anorectal inspection may reveal skin excoriation, skin tags, anal fissure, or hemorrhoids. Perineal sensation and the

Diagnostic Procedures

The first step in making a diagnosis of constipation is to exclude an underlying metabolic or pathologic disorder because constipation may be the first symptom of many organic conditions, such as colon cancer. A complete blood count, biochemical profile, serum calcium, glucose levels, and thyroid function tests are usually sufficient for screening purposes. If there is a high index of suspicion, serum protein electrophoresis, urine porphyrins, serum parathyroid hormone, and serum cortisol

Radiographic Studies

A plain radiograph of the abdomen may provide evidence for an excessive amount of stool in the colon. If colonoscopy has not been performed, a barium enema may be useful for excluding colonic pathology. Patients with constipation may have a redundant sigmoid colon, a megacolon, or megarectum. The presence of Hirschsprung's disease can also be detected by barium enema, although manometry and histology are required to confirm the diagnosis.

Management of Constipation

The first step in managing constipation is to exclude a secondary cause for constipation. This can be accomplished by performing the appropriate tests outlined above. Constipation may be caused by anatomical lesions of the colon or rectum, endocrine or metabolic disorders, neurologic diseases, or a variety of drugs.12 Constipation is a common and often overlooked adverse effect of many drugs. Some drugs have anticholinergic effects, others desiccate stool, and several others, including

Evidence-Based Summary for the Treatment of Constipation

A systematic review of the literature using an evidence-based approach for various treatment options is summarized in Table 2. For each specific content area, the supporting evidence was graded using a three-point graded scale.86 Level 1 evidence was derived from one or more randomized clinical trials. Level 2 evidence was supported by one or more well-designed cohort or case-control studies. Level 3 evidence was derived from expert opinion, based on clinical experience. Evidence was further

Summary

Constipation is a common polysymptomatic clinical disorder that affects up to 20% of the world's population. It leads to significant economic burden, loss of work-related productivity, and diminished quality of life. Studies over the past decade have led to an improved understanding of the underlying mechanisms, especially as they relate to colonic and anorectal function. Although many conditions, such as metabolic problems, fiber deficiency, anorectal problems, and drugs, can cause

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    This article appeared previously in the September 2007 issue of Gastroenterology Clinics of North America (36:3), with permission.

    This work was supported in part by grant DK57100-0441 from the National Institutes of Health and in part by the Department of Internal Medicine, University of Iowa Carver College of Medicine.

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