Evaluation of Constipation

Educational Objectives

The goal of this program is to improve the surgical management of constipation. After hearing and assimilating this program, the clinician will be better able to:

1. Follow an algorithm for evaluation of patients with constipation.

2. Obtain a thorough history from a patient with constipation.

Summary

Constipation in Western countries: prevalence — 2% to 28%; ≈30 million affected (50% of women and 33% of men by age 65 yr); costs — $29 billion annually in United States

Normal function: includes colonic and rectal motility, reservoir function of rectum, rectal sensation, and ability to relax muscles and expel stool

Etiology: lifestyle (diet and weight); medications; neurologic, endocrine, metabolic, and psychiatric illnesses; primary diseases of colon — cancer; Hirschsprung disease; proctitis; anal fissures; pelvic floor dysfunction (PFD)

Diagnostic algorithm: let patient define constipation; assess duration and factors associated with symptoms to rule out nonsurgical disease; consider whether patient fits criteria for true constipation (vs change in bowel habits, which may still require evaluation, but of different nature than that for constipation); determine whether constipation primary disease or symptom of another condition (look for primary treatable disorder vs multifactorial disease)

Rome criteria: duration >3 mo; onset of symptoms ≥6 mo before diagnosis; <3 bowel movements per week; ≥2 of symptoms 25% of time (excessive straining, lumpy or hard stools, sensation of incomplete evacuation, anorectal obstruction); consider whether symptoms consistent with disorder of primary motility or of pelvic floor; patients who do not fit any specific category (≈10%) most likely to require further testing

Chronic idiopathic: irritable bowel syndrome constipation (IBS-C) — includes most patients with constipation; characterized by pain and irregular bowel habits; rectal function and motility normal; treated with laxatives and/or change in diet; testing may be required to confirm; functional pelvic outlet obstruction — eg, paradoxical contraction of puborectalis muscle; less common than IBS-C; patients have difficulty evacuating, rectal spasms, dyspareunia, and tightness of rectal floor; treated with physical therapy and laxatives; slow-transit constipation (STC) — does not respond to conservative treatment (requires surgery); effects small percentage of patients

History and physical: ask time of onset of symptoms, relationship to illness or occurrences, and duration; get description of symptoms or maneuvers required for bowel movement; listening to problem often helpful to patient, even if surgery not indicated; psychiatric history — rectal prolapse in young patients often associated with history of bulimia, anorexia, or sexual abuse; review of medications — eg, calcium supplements, antidepressants, anticholinergic agents, may cause constipation; anatomic problems — rectocele; intussusception; perineal descent; physical examination (PE) can confirm history and guide differential diagnosis

Cases: 1) 32-yr-old woman with constipation since childhood; ≤3 wk between bowel movements; strains and has rectal pain despite 30 tablets of sennosides (eg, ex-lax, Senna-Lax, Senokot) daily; stool soft; PE normal; problem due to motility; consideration of surgical options reasonable; 2) 62-yr-old woman with straining and hard stool; uses fingers and pressure on vagina to evacuate; has daily incomplete bowel movements; anatomic problem likely; use PE to confirm; consider further testing; surgery recommended

Readings

Bharucha AE et al: American Gastroenterological Association position statement on constipation. Gastroenterology 144:211, 2013; Borie F et al: Laparoscopic ventral rectopexy for the treatment of outlet obstruction associated with recto-anal intussusception and rectocele: A valid alternative to STARR procedure in patients with anal sphincter weakness. Clin Res Hepatol Gastroenterol Jan 29 [E-pub ahead of print] 2014; Brandt LJ et al: Systemic review on the management of chronic constipation in North America. Am J Gastroenterol 100 Suppl 1: S5, 2005; Chey WD et al: Linaclotide for irritable bowel syndrome with constipation: a 26-week, randomized, double-blind, placebo-controlled trial to evaluate efficacy and safety. Am J Gastroenterol 107:1702, 2012; Drossman DA, Dumitrascu DL: Rome III: New standard for functional gastrointestinal disorders. J Gastrointesin Liver Dis 15:237, 2006; Hassan I et al: Ileorectal anastomosis for slow transit constipation: long-term functional and quality of life results. J Gastrointest Surg 10:1330, 2006; Karram M, Maher C: Surgery for posterior vaginal wall prolapse. Int Urogynecol J 24:1835, 2013; Knowles CH et al: Outcome of colectomy for slow transit constipation. Ann Surg 230:627, 1999; Kolowski NA et al: Impact of persistent constipation on health-related quality of life and mortality in older community-dwelling women. Am J Gastroenterol 108: 1152, 2008; Leung L et al: Chronic constipation: an evidence-based review. J Am Board Fam Med. 24:436, 2011; Maher C et al: Surgical management of pelvic organ prolapse in women: a short version Cochrane review. Neurourol Urodyn 27:3, 2008; Patel CB et al: Patient satisfaction and symptomatic outcomes following stapled transanal rectal resection for obstructed defecation syndrome. J Surg Res 165:e15, 2011; Pikarsky AJ et al: Long-term follow-up of patients undergoing colectomy for colonic inertia. Dis Colon Rectum 44:179, 2001; Rao SS: Constipation: evaluation and treatment of colonic and anorectal motility disorders. Gastrointest Endosc Clin N Am 19:117, 2009; Rauck RL et al: Treatment of opioid-induced constipation: focus on the peripheral μ-opioid receptor antagonist methylnaltrexone. Drugs 73: 1297, 2013; Suares NC, Ford AC: Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis. Am J Gastroenterol 106:1582, 2011; Thomas GP et al: Sacral nerve stimulation for constipation. Br J Surg 100:174, 2013; Zutshi M et al: Surgery for slow transit constipation: are we helping patients? Int J Colorectal Dis 22:265, 2007.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Gurland is a consultant for Medtronic, Pacira Pharmaceuticals, and Salix Pharmaceuticals. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Gurland was recorded at An Overview of Evaluation and Treatment of Posterior Pelvic Floor, held March 28, 2014, in Cleveland, OH, and sponsored by the Cleveland Clinic Center for Continuing Education. Information on meetings presented by Cleveland Clinic can be found at ClevelandClinicMedEd.com. The Audio-Digest Foundation thanks the speaker and the Cleveland Clinic Center for Continuing Education for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS611201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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