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Constipation – Adults

Constipation is used to describe symptoms that relate to difficulties in defecation. These include infrequent bowel movements , hard lumpy stools , excessive straining , sensation of incomplete evacuation.

 

Common gastrointestinal problem which affects all ages It is estimated that the overall prevalence worldwide is 16 % Data from N America report a prevalence of 12 % to 19 % NICE reports that rates of reported constipation of between 4 % and 20 % in the UK NICE also reports that constipation affects twice as many women as men and older people are 5 times more likely than younger adults to suffer with constipation Maria et el ( 2011 ) in the Canadian J of Gastroenterology report that chronic constipation increases with increasing age particularly after 65 yrs with a prevalence of self reported constipation between 12.5 % and 30 % Chronic constipation is one of the 5 most common symptoms seen by a gastroenterologist Seen more commonly in people with low socioeconomic status , nursing home residents , pregnant women.

 

Less than 3 months can be considered acute and > 3 months chronic Acute constipation can be due to change in diet , travel or stress.

 

Chronic constipation – Subtypes include
○ functional constipation
○ Irritable bowel syndrome with constipation
○ Opioid induced constipation
○ functional defecation disorders including defecatory propulsion and dyssynergic defecation.

 

Primary or functional – the cause of constipation cannot be identified from the clinical history and physical examination contributing factors include disordered regulation of colonic and anorectal neuromuscular functions as well as brain- gut neuroenteric function It is further classified as
o normal transit constipation ( NTC – most common )
o slow transit constipation ( STC )
o colonic inertia
o outlet obstruction or pelvic floor dysfunction
o combined causes.

Secondary constipation – here intestinal or extraintestinal abnormalities are responsible for e.g metabolic or hormonal factors and medications
 these can include causes as

o intestinal causes – tumours , diverticular disease , inflammatory strictures , ischaemia , volvulus , endometriosis , post-operative strictures , fissures, haemorrhoids , mucosal prolapse , ulcerative proctitis

o Medications as antidepressants , antiepileptics , anti histamines , antispasmodics , anticholinergics , Ca channel blockers , calcium and iron supplements and NSAIDs

o Metabolic – hypothyroidism , hypoparathyroidism , hypercalcemia , hypokalaemia , hypomagnesemia , diabetes
o Neuropathies -cerebrovascular diseasea , multiple sclerosi , autonomic neuropathy and Parkinson’s disease

o others – like cognitive impairment , immobility.

 

Why important – Interferes with daily living and well being , working/ school productivity / absenteeism Significant healthcare costs – substantial socioeconomic burden Expenditure on laxatives – runs in millions of dollars Evaluation of constipation is expensive – aside from treatment costs Chronic constipation can lead to
- haemorrhoids and anal fissure
- progressive faecal retention
- rectal distension
- faecal loading and impaction
- diverticular disease
- rectal bleeding
- rectal prolapse
- faecal incontinence
- volvulus , intestinal obstruction.

 

One of the main aim of assessment is to r/o any red flags which would 
necessitate further investigations to exclude colorectal malignancy

 

History The term constipation can be used liberally and symptoms can be non specific and frequently overlap Patients may describe symptoms pertaining to straining , hard stool , abdominal discomfort , bloating , feelings of incomplete bowel evacuation after a bowel movement and infrequent bowel movements Onset , severity , duration H/O ignoring a call to defecate Ask about dietary habits ( e.g fiber , fluid intake ) Faecal consistency ( consider using Bristol stool form scale ) Are they using digital maneuvers Medical / surgical history Obs & Gynae history in women ( ? h/o hysterectomy , mode of delivery ) Family h/o bowel problems ( e.g CRC , inflammatory bowel disease ) Psychiatric history – associated psychological or mental health conditions Medications ( ? polypharmacy ) Lifestyle ( e.g sedentary lifestyle ) Occupation Attempts to treat with OTC laxatives Impact of constipation on QoL Bowel diaries can be helpful.

 

People at higher risk of constipation – Muscular weakness which is disabling Access to toilets particularly less mobile patients who experience a loss of sensation or those who ignore the urge to empty their bowels Change in diet for eg reduced fiber and fluid intake -patient afraid of incontinence Swallowing problems – consumption of thickened fluids and modified consistency diets Dental problems -can impact dietary habits Care – dependent individuals may struggle with assistance during mealtimes Co-morbid medical conditions and poly-pharmacy particularly analgesics and psychotropic medications Mental health conditions as depression , anxiety , dementia ,eating disorders Hospitalization and institutionalization.

 

Functional constipation- Functional constipation cannot be evaluated by any specific tests . Established criteria by expert consensus called the Rome criteria which have been sequentially refined over time define functional constipation when atleast 2 out of the 6 criteria listed below are met

 

American Gastroenterology Association classifies constipation based on colonic transit time and anorectal function into

 

Normal transit – most common term used interchangeably with IBS-C , although IBS-C is distinct -differentiation between the two can be difficult

 

Slow transit – also called delayed transit , colonoparesis , colonic inertia and pseudo obstruction can be the result of colonic smooth muscle dysfunction , compromised neural pathways or both

 

Outlet obstruction – also known as pelvic floor dysfunction or defecatory disorder -incomplete rectal evacuation often co-exists with slow transit constipation

 

Symptoms may include
abdominal discomfort / pain
bloating
loss of appetite
nausea and vomiting
urinary incontinence and risk of UTIs
 Abdominal examination for
- mass
- stool in left or right abdominal quadrants
- any scars
 Digital rectal examination to r/o
- skin excoriation , leakage
- skin tags
- anal fissure
- piles
- faecal impaction
- anal pain
- anal wink reflex using a cotton-tipped applicator in all four quadrants around the anus ( an absence of anal contraction may indicate a sacral nerve pathology )

Assess for 
- perineal sensation and anocutaneous reflex
- anal tone during rest and squeezing ( ask to push or bear down )
- check anterior wall for rectocele

DRE is an important part of clinical evaluation

 

FBC Serum calcium , magnesium , thyroid , parathyroid renal function tests , glucose Abdominal XR ( optional ) can be helpful on obese patients where physical examination is difficult In the absence of alarming symptoms , screening recommendations or other significant co-morbidities -> routine use of blood tests , radiographic imaging or endoscopy may not be typically needed Other tests include anorectal manometry & rectal balloon expulsion test , defecography and colonic manometry.

 

NICE GUIDANCE ON LOWER GASTROINTESTINAL TRACT CANCER

 

USC pathway – over 40 and unexplained wt loss and abdominal pain or > 50 with unexplained rectal bleeding or > 60 with
- iron deficiency anaemia or
- change in bowel habit or tests show occult blood in faeces

 

Consider USC- rectal or abdominal mass
Age 50 with rectal bleeding + any of the following
 abdominal pain CIBH weight loss IDAA.

 

Offer Fit test – Adults without rectal bleeding who
 50 and over with unexplained
- abdominal pain or
weight loss or age 60 and under with
- CIBH or
- IDA 60 and over and have anaemia even in absence of iron deficiency

 

Once secondary causes have been ruled out – consider the management as below Lifestyle measures are the first step in management of constipation Provide advice on self management – healthy , balanced diet & regular meals , exercise , timed toilet training ( see links under patient information ) Fibre supplements are often considered the first line this can help patients with normal colonic transit and anorectal function but patients with delayed colonic transit time may not benefit and may even suffer due to increased gas produced There are no standardised diagnostic or therapeutic regimens to guide management Most patients would require laxatives at some point of in their course and treatment with osmotic and stimulant laxatives has been the traditional approach

 

Stepped approach to management

 

Bulk forming laxative Offer a bulk forming laxative as ispaghula Advice on adequate fluid intake

 

Change to osmotic – If stool remains hard or difficult to pass – change to an osmotic laxative 
○ add a macrogol
○ if not successful or not tolerated use lactulose

 

Add a stimulant – stools soft but difficult to pass or feeling of inadequate emptying 
○ add a stimlant laxative as senna , bisacodyl
○ beware may cause abdominal cramps

 

Consider prucalopride- consider use if atleast 2 different class of laxatives have been used for 6/12 at the highest dose tolerated ( both men and women now ) can be initiated in primary care with advice from specialist who deals with chronic idiopathic constipation

 

Opioid induced constipation – up to 40 % of patients taking opioids develop constipation do not use bulk forming laxatives offer an osmotic laxative and a stimulant laxative or consider docusate which is also a stool softener consider newer agents as methylnaltrexone / naloxegol.

 

Pregnancy- bulk forming 1st line lactulose if stool remains hard offer short term senna if stool is soft but difficult to pass and there is a sensation of incomplete evacuation consider glycerol suppository if above measures fail.

 

Referral – Red flags or a secondary cause which is difficult to manage in primary care You are not able to relieve the problem despite optimum management Patient starts to suffer with complications as faecal incontinence Pain , bleeding on defecation ( for e,g anal fissure ) is severe and management in 1 ary care has not been successful.

PATIENT INFORMATION

Guts UK on constipation https://gutscharity.org.uk/advice-and-information/symptoms/constipation/

Lifestyle advice on constipation from National Institute of Diabetes and Digestive and Kidney Diseases NIH https://www.niddk.nih.gov/health-information/digestive-diseases/constipation/treatment

NHS Walsall Commissioning Group self-care tips for constipation https://walsallccg.nhs.uk/stay-well-walsall/self-care/self-care-button-board/constipation-self-care-information/

Sheffield Teaching Hospital- how to manage constipation guide for patients, a well written 32 page guide https://publicdocuments.sth.nhs.uk/pil4337.pdf

 

REFERENCES

  1. Prichard D, Norton C, Bharucha AE. Management of opioid-induced constipation. Br J Nurs. 2016 May 26-Jun 8;25(10):S4-5, S8-11. doi: 10.12968/bjon.2016.25.10.S4. PMID: 27231750.
    ( Abstract )
  2. Hayat U, Dugum M, Garg S. Chronic constipation: Update on management. Cleve Clin J Med. 2017 May;84(5):397-408. doi: 10.3949/ccjm.84a.15141. PMID: 28530898.
  3. Black CJ, Ford AC. Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management. Med J Aust. 2018 Jul 16;209(2):86-91. doi: 10.5694/mja18.00241. PMID: 29996755. ( Abstract )
  4. Rao SS, Rattanakovit K, Patcharatrakul T. Diagnosis and management of chronic constipation in adults. Nat Rev Gastroenterol Hepatol. 2016 May;13(5):295-305. doi: 10.1038/nrgastro.2016.53. Epub 2016 Apr 1. PMID: 27033126. ( Abstract )
  5. Jani, Bhairvi, and Elizabeth Marsicano. “Constipation: Evaluation and Management.” Missouri medicine vol. 115,3 (2018): 236-240.
  6. BNF Prucalopride via https://bnf.nice.org.uk/drug/prucalopride.html
  7. Paquette IM, Varma M, Ternent C, Melton-Meaux G, Rafferty JF, Feingold D, Steele SR. The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Evaluation and Management of Constipation. Dis Colon Rectum. 2016 Jun;59(6):479-92. doi: 10.1097/DCR.0000000000000599. PMID: 27145304.
  8. CKS NHS Constipation in adults https://cks.nice.org.uk/topics/constipation/
  9. NHS Kernow Clinical Commissioning
  10. Guido Basilisco, Marina Coletta, Chronic constipation: A critical review, Digestive and Liver Disease, Volume 45, Issue 11, 2013, Pages 886-893, ISSN 1590-8658,
    https://doi.org/10.1016/j.dld.2013.03.016.
  11. Sanchez, Maria Ines Pinto, and Premysl Bercik. “Epidemiology and burden of chronic constipation.” Canadian journal of gastroenterology = Journal canadien de gastroenterologie vol. 25 Suppl B,Suppl B (2011): 11B-15B. doi:10.1155/2011/974573
  12. Forootan, Mojgan MDa; Bagheri, Nazila MDb; Darvishi, Mohammad MDc,* Chronic constipation, Medicine: May 2018 – Volume 97 – Issue 20 – p e10631 doi: 10.1097/MD.0000000000010631
  13. Update on the Management of Chronic Idiopathic Constipation March 27, 2019 Brian E. Lacy, MD, PhD, FACG

  14. Prather CM. Subtypes of constipation: sorting out the confusion. Rev Gastroenterol Disord. 2004;4 Suppl 2:S11-6. PMID: 15184810. ( Abstract )
  15. NICE Suspected cancer recognition and referral https://www.nice.org.uk/guidance/ng12
  16. Andrews, Christopher N, and Martin Storr. “The pathophysiology of chronic constipation.” Canadian journal of gastroenterology = Journal canadien de gastroenterologie vol. 25 Suppl B,Suppl B (2011): 16B-21B.

 

 

 

 

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