Practical Approach to Constipation

Educational Objectives

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

1. Perform a diagnostic workup for patients with refractory constipation.
2. Manage constipation with medications.

Summary

Definition and identification: constipation is defined as a frequency of <3 bowel movements per week and a change in stool consistency from baseline (Rome IV criteria); if the symptoms are severe enough to affect daily activities and impair quality of life, it can be diagnosed as constipation; the clinician should take a detailed history, ie, frequency and nature of bowel movements, any changes from normal, and use of over-the-counter medications; rule out alarm signs and family history of colon cancer; identify changes in diet

Forms of constipation: secondary constipation — occurs because of anatomic abnormalities, systemic disease (eg, thyroid disease), and medication adverse effects; primary constipation — occurs because of transit time, defecatory disorders, and/or pain; inflammatory bowel disease (IBD) is predominately differentiated from non-IBD or functional constipation by the presence of pain

Transit time: normal transit constipation — seen in the majority of patients; slow transit constipation — patients report bloating and may present with a chronic history of laxative dependence; they may have gastrointestinal dysmotility (GID) comorbidities, gastroparesis, small intestinal bacterial overgrowth (treated multiple times), or delayed or slow colon transit time in transit studies; constipation with defecation disorders — patients may report incomplete evacuation because of pelvic floor dysfunction, ie, impaired relaxation or paradoxical contraction

Digital rectal examination: has high specificity (≈75%) when compared with anorectal manometry (AM) and helps guide the next step

Initial management: rule out secondary causes; for patients with functional constipation, modify diet and lifestyle and discuss medications; one can initially start with modifying the “3 Fs” for constipation, ie, fluid intake, fitness or activity level, and fiber intake; fiber can be used as a bulking agent; laxatives — include docusate (Colace), osmotic agents, eg, polyethylene glycol 3350 (MiraLax), stimulant laxatives, eg, senna or bisacodyl, and suppositories for patients with defecatory disorders

Further evaluation: if the symptoms do not improve with diet and lifestyle modifications, different diagnostic tools can be used for evaluation; the Rome IV criteria requires 2 of 4 tests for defecatory disorders to be positive to diagnose a pelvic floor issue; colonoscopy is not a part of the algorithm for the evaluation of constipation in the absence of alarm symptoms or age-appropriate colon cancer screening; repeating colonoscopy does not have much diagnostic value

Physiologic testing for refractory constipation: high-resolution anorectal manometry — is used to measure pressures and evaluate internal and external anal sphincters at rest and during simulated defecation; it helps to assess dyssynergia types, the rectum (for force), and the pelvic floor (for relaxation and paradoxical contraction); in addition, it facilitates biofeedback for defecatory disorders and can be used in preoperative evaluation

Balloon expulsion test (BET): is performed in conjunction with AM; the inability to pass a balloon with water placed in the rectum ≤60 sec is considered abnormal; it helps to assess rectal compliance and sensation and to identify defecation disorders

Colon transit study: the colon transit time should be assessed if AM and BET are normal; although colonic manometry can also be performed, the sitz marker study is the most common test (assesses colon motility); the result is considered abnormal if >5 of 24 markers are left in the colon; the location and spread of the retained markers aid in diagnosis, eg, spread throughout the colon (colonic inertia), majority in rectum (a defecatory disorder), or in the stomach or small bowel (additional evaluation for whole gut GID to be performed); the patient’s response to therapy can be assessed with the Bristol stool chart

Magnetic resonance imaging defecography: can be performed when both BET and AM test results are abnormal; it helps to identify pelvic floor disorders and anatomic abnormalities, eg, rectocele or prolapse

Pharmacologic management: lubiprostone (Amitiza) — is a chloride channel activator; linaclotide (Linzess) and plecanatide (Trulance) — activate the guanylate cyclase receptor; they increase the amount of water within the colon and increase intestinal fluid secretion; prucalopride and tegaserod (prokinetics) — are 5-hydroxytryptamine receptor 4 (5-HT4) receptor activators; tegaserod is not approved for chronic idiopathic constipation but is approved for irritable bowel syndrome with constipation (IBS-C); both promote acetylcholine release to help with smooth muscle contraction and peristalsis; tenapanor — is approved only for IBS-C; inhibits the sodium-hydrogen ion exchanger and helps to increase water in transit; elobixibat — is not approved for use in the United States; it is a bile acid transporter inhibitor; increased bile acids in the colon help increase fluid and lead to secretion and improvement

Biofeedback therapy: defecatory disorders can be treated with biofeedback, pelvic therapy, and pelvic floor retraining; best practices — educate patients during evaluation, do an active phase of biofeedback, and encourage patients to do home exercises and come back for reinforcement later

Readings

Alame AM, Bahna H. Evaluation of constipation. Clin Colon Rectal Surg. 2012;25(1):5-11. doi:10.1055/s-0032-130175; Bassotti G, Villanacci V. A practical approach to diagnosis and management of functional constipation in adults. Intern Emerg Med. 2013;8(4):275-282. doi:10.1007/s11739-011-0698-0; Herekar A, Shimoga D, Jehangir A, et al. Tenapanor in the Treatment of Irritable Bowel Syndrome with Constipation: Discovery, Efficacy, and Role in Management. Clin Exp Gastroenterol. 2023;16:79-85. Published 2023 Jun 7. doi:10.2147/CEG.S384251.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Mithani was recorded at the What’s New in GI 2024, held on April 20, 2024, in Dallas, TX, and presented by University of Texas Southwestern Medical Center. For information on upcoming CME activities from this presenter, please visit Cme.utsouthwestern.edu. Audio Digest thanks the speakers and presenters 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 0.50 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 0.50 CE contact hours.

Lecture ID:

GE382402

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.