Constipation resident survival guide: Difference between revisions
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{{SK}} Chronic constipation | {{SK}} Chronic constipation | ||
== | ==Overview== | ||
[[Constipation]] is a syndrome that is characterized by either difficulty in passing [[stool]], infrequent bowel movements, hard stool, or a feeling of incomplete evacuation that occurs either in isolation or secondary to another underlying disorder.<ref name="pmid23261065">{{cite journal| author=Bharucha AE, Pemberton JH, Locke GR| title=American Gastroenterological Association technical review on constipation. | journal=Gastroenterology | year= 2013 | volume= 144 | issue= 1 | pages= 218-38 | pmid=23261065 | doi=10.1053/j.gastro.2012.10.028 | pmc=PMC3531555 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23261065 }} </ref><ref name="pmid16008640">{{cite journal| author=American College of Gastroenterology Chronic Constipation Task Force| title=An evidence-based approach to the management of chronic constipation in North America. | journal=Am J Gastroenterol | year= 2005 | volume= 100 Suppl 1 | issue= | pages= S1-4 | pmid=16008640 | doi=10.1111/j.1572-0241.2005.50613_1.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16008640 }} </ref><ref name="pmid11113098">{{cite journal| author=Locke GR, Pemberton JH, Phillips SF| title=American Gastroenterological Association Medical Position Statement: guidelines on constipation. | journal=Gastroenterology | year= 2000 | volume= 119 | issue= 6 | pages= 1761-6 | pmid=11113098 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11113098 }} </ref> | [[Constipation]] is a syndrome that is characterized by either difficulty in passing [[stool]], infrequent bowel movements, hard stool, or a feeling of incomplete evacuation that occurs either in isolation or secondary to another underlying disorder.<ref name="pmid23261065">{{cite journal| author=Bharucha AE, Pemberton JH, Locke GR| title=American Gastroenterological Association technical review on constipation. | journal=Gastroenterology | year= 2013 | volume= 144 | issue= 1 | pages= 218-38 | pmid=23261065 | doi=10.1053/j.gastro.2012.10.028 | pmc=PMC3531555 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23261065 }} </ref><ref name="pmid16008640">{{cite journal| author=American College of Gastroenterology Chronic Constipation Task Force| title=An evidence-based approach to the management of chronic constipation in North America. | journal=Am J Gastroenterol | year= 2005 | volume= 100 Suppl 1 | issue= | pages= S1-4 | pmid=16008640 | doi=10.1111/j.1572-0241.2005.50613_1.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16008640 }} </ref><ref name="pmid11113098">{{cite journal| author=Locke GR, Pemberton JH, Phillips SF| title=American Gastroenterological Association Medical Position Statement: guidelines on constipation. | journal=Gastroenterology | year= 2000 | volume= 119 | issue= 6 | pages= 1761-6 | pmid=11113098 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11113098 }} </ref> | ||
==Classification== | |||
===Normal Transit Constipation=== | |||
Normal transit constipation refers to constipation in patients with normal anorectal function and normal colonic transit, with or without abnormal colonic motor disturbances and abnormal (ie, reduced or increased) colonic sensations. | |||
===Slow Transit Constipation=== | |||
Slow transit constipation refers to constipation in patients with normal anorectal function but slow colonic transit, with or without abnormal colonic motor disturbances and abnormal (ie, reduced or increased) colonic sensations. | |||
===Defecatory Disorders=== | |||
Defecatory disorders refer to constipation in patients with impaired rectal evacuation from inadequate rectal propulsive forces and/or increased resistance to evacuation during defecation, with or without structural disturbances like [[rectocele]] and [[intussusception]], reduced rectal sensation, and slow colonic transit. Increased resistance to evacuation might follow high anal resting pressure (anismus) and/or incomplete relaxation or paradoxical contraction of the pelvic floor and external anal sphincters (dyssynergia). | |||
===Combination Disorders=== | |||
Combination disorders refer to patients with combination or overlap of disorders (example, slow transit constipation with defecatory disorders), perhaps even an association with features of [[irritable bowel syndrome]]. | |||
==Causes== | ==Causes== | ||
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===Common Causes=== | ===Common Causes=== | ||
* Hardening of the feces: | * Hardening of the feces: Improper [[mastication]], low [[dietary fiber]], [[dehydration]] and medications ([[aluminium]], [[calcium]], [[diuretic]], [[iron]]). | ||
* Paralysis or slowed transit: [[ | * Paralysis or slowed transit: [[Hypothyroidism]], [[hypokalemia]], injured [[Anus|anal sphincter]], medications ([[loperamide]], [[codeine]], [[morphine]], [[tricyclic antidepressants]]) and severe systemic illness due to other causes. | ||
* Constriction, where part of the intestine or rectum is narrowed or blocked: [[ | * Constriction, where part of the intestine or rectum is narrowed or blocked: [[Diverticulosis]], [[pelvic masses]] and [[stenosis]]. | ||
* Psychosomatic constipation: [[ | * Psychosomatic constipation: [[Functional constipation]] and [[irritable bowel syndrome]].<ref>{{cite journal |author=Caldarella MP, Milano A, Laterza F, ''et al'' |title=Visceral sensitivity and symptoms in patients with constipation- or diarrhea-predominant irritable bowel syndrome (IBS): effect of a low-fat intraduodenal infusion |journal=Am. J. Gastroenterol. |volume=100 |issue=2 |pages=383–9 |year=2005 |pmid=15667496 |doi=10.1111/j.1572-0241.2005.40100.x}}</ref> | ||
* [[Smoking cessation]]<ref> {{cite web|url=http://www.helpwithsmoking.com/nicotine-withdrawal.php#constipation |title=Nicotine withdrawal symptoms:Constipation |accessdate=2007-06-29 |date=2005 |publisher=helpwithsmoking.com }}</ref> | * [[Smoking cessation]]<ref> {{cite web|url=http://www.helpwithsmoking.com/nicotine-withdrawal.php#constipation |title=Nicotine withdrawal symptoms:Constipation |accessdate=2007-06-29 |date=2005 |publisher=helpwithsmoking.com }}</ref> | ||
* [[Abdominal surgery]] and [[childbirth]] | * [[Abdominal surgery]] and [[childbirth]] | ||
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==Management== | ==Management== | ||
===Diagnostic Approach=== | ===Diagnostic Approach=== | ||
Shown below is an algorithm depicting the diagnostic approach of [[chronic constipation]] in adults based on the [[American Gastroenterological Association]] (AGA) guidelines.<ref name="pmid23261065">{{cite journal| author=Bharucha AE, Pemberton JH, Locke GR| title=American Gastroenterological Association technical review on constipation. | journal=Gastroenterology | year= 2013 | volume= 144 | issue= 1 | pages= 218-38 | pmid=23261065 | doi=10.1053/j.gastro.2012.10.028 | pmc=PMC3531555 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23261065 }} </ref><ref name="Bharucha-2013">{{Cite journal | last1 = Bharucha | first1 = AE. | last2 = Dorn | first2 = SD. | last3 = Lembo | first3 = A. | last4 = Pressman | first4 = A. | title = American Gastroenterological Association medical position statement on constipation. | journal = Gastroenterology | volume = 144 | issue = 1 | pages = 211-7 | month = Jan | year = 2013 | doi = 10.1053/j.gastro.2012.10.029 | PMID = 23261064 }}</ref> | Shown below is an algorithm depicting the diagnostic approach of [[chronic constipation]] in adults based on the 2013 [[American Gastroenterological Association]] (AGA) technical review and medical position statement regarding guidelines on constipation.<ref name="pmid23261065">{{cite journal| author=Bharucha AE, Pemberton JH, Locke GR| title=American Gastroenterological Association technical review on constipation. | journal=Gastroenterology | year= 2013 | volume= 144 | issue= 1 | pages= 218-38 | pmid=23261065 | doi=10.1053/j.gastro.2012.10.028 | pmc=PMC3531555 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23261065 }} </ref><ref name="Bharucha-2013">{{Cite journal | last1 = Bharucha | first1 = AE. | last2 = Dorn | first2 = SD. | last3 = Lembo | first3 = A. | last4 = Pressman | first4 = A. | title = American Gastroenterological Association medical position statement on constipation. | journal = Gastroenterology | volume = 144 | issue = 1 | pages = 211-7 | month = Jan | year = 2013 | doi = 10.1053/j.gastro.2012.10.029 | PMID = 23261064 }}</ref> | ||
{{Family tree/start}} | {{Family tree/start}} | ||
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---- | ---- | ||
'''Consider structural evaluation of the colon:'''<br> | '''Consider structural evaluation of the colon:'''<br> | ||
For patients with clinically alarming symptoms and who have not undergone an age appropriate colon cancer screening procedure | ❑ For patients with clinically alarming symptoms | ||
:❑ Sudden change in bowel habits after the age of 50 years | |||
:❑ Blood in stools | |||
:❑ [[Anemia]] | |||
:❑ [[Weight loss]] | |||
:❑ Family history of [[colon cancer]]<br> | |||
'''and'''<br> | |||
❑ For patients who have not undergone an age appropriate colon cancer screening procedure<br> | |||
'''Include:'''<br> | |||
❑ [[Colonoscopy]] <br> | ❑ [[Colonoscopy]] <br> | ||
❑ [[sigmoidoscopy|Flexible sigmoidoscopy]] <br> | ❑ [[sigmoidoscopy|Flexible sigmoidoscopy]] <br> | ||
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❑ Treat [[Irritable bowel syndrome medical therapy|irritable bowel syndrome]]</div>}} | ❑ Treat [[Irritable bowel syndrome medical therapy|irritable bowel syndrome]]</div>}} | ||
{{familytree | | | |,|-|^|-|.| | | | | | | | | | |}} | {{familytree | | | |,|-|^|-|.| | | | | | | | | | |}} | ||
{{familytree | | | F01 | | F02 | | | | | | | | | |F01= | {{familytree | | | F01 | | F02 | | | | | | | | | |F01=Improvement with trial of fiber and/or laxatives|F02=Failure of improvement with trial of fiber and/or laxatives}} | ||
{{familytree | | | |!| | | |!| | | | | | | | | | |}} | {{familytree | | | |!| | | |!| | | | | | | | | | |}} | ||
{{familytree | | | G01 | | G02 | | | | | | | | | | |G01=[[Constipation resident survival guide#Therapeutic Approach#General Management|General management of constipation]]|G02=<div style="float: left; text-align: left; width: 25em; padding:1em;">❑ Gastroenterology consult<BR> ❑ [[Constipation other imaging findings#Anorectal Function Tests|Anorectal manometry]]<br>❑ [[Constipation other imaging findings#Rectal Balloon Expulsion Test|Balloon expulsion test]]</div>}} | {{familytree | | | G01 | | G02 | | | | | | | | | | |G01=❑ '''[[Constipation resident survival guide#Therapeutic Approach#General Management|General management of constipation]]'''|G02=<div style="float: left; text-align: left; width: 25em; padding:1em;">❑ Gastroenterology consult<BR> ❑ [[Constipation other imaging findings#Anorectal Function Tests|Anorectal manometry]]<br>❑ [[Constipation other imaging findings#Rectal Balloon Expulsion Test|Balloon expulsion test]]</div>}} | ||
{{familytree | | | |,|-|-|-|+|-|-|-|.| | | | | | | | |}} | {{familytree | | | |,|-|-|-|+|-|-|-|.| | | | | | | | |}} | ||
{{familytree | | | H01 | | H02 | | H03 | | | | | | | | |H01=Normal|H02=Inconclusive|H03=Abnormal}} | {{familytree | | | H01 | | H02 | | H03 | | | | | | | | |H01='''Normal'''|H02='''Inconclusive'''|H03='''Abnormal'''}} | ||
{{familytree | | | |!| | | |!| | | |!| | | | | | |}} | {{familytree | | | |!| | | |!| | | |!| | | | | | |}} | ||
{{familytree | | | |!| | | I01 | | |!| | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">❑ [[Constipation other imaging findings#Defecography|Barium defecography]] <BR>'''or'''<BR>❑ [[Constipation other imaging findings#Defecography|MR defecography]]</div>}} | {{familytree | | | |!| | | I01 | | |!| | | | | | |I01=<div style="float: left; text-align: left; width: 25em; padding:1em;">❑ [[Constipation other imaging findings#Defecography|Barium defecography]] <BR>'''or'''<BR>❑ [[Constipation other imaging findings#Defecography|MR defecography]]</div>}} | ||
{{familytree | | | |!| |,|-|^|-|.| |!| | | | | | |}} | {{familytree | | | |!| |,|-|^|-|.| |!| | | | | | |}} | ||
{{familytree | | | |!| J01 | | J02 |!| | | | | |J01=Normal|J02=Abnormal}} | {{familytree | | | |!| J01 | | J02 |!| | | | | |J01='''Normal'''|J02='''Abnormal'''}} | ||
{{familytree | | | |!| |!| | | |!| |!| | | | | | |}} | {{familytree | | | |!| |!| | | |!| |!| | | | | | |}} | ||
{{familytree | | | | K01 | | | | K02 | | | | | | |K01= ❑ Assess the [[Constipation other imaging findings#Colorectal Transit Study|colonic transit]]|K02='''Defecatory disorder'''}} | {{familytree | | | | K01 | | | | K02 | | | | | | |K01= ❑ Assess the [[Constipation other imaging findings#Colorectal Transit Study|colonic transit]]|K02=❑ '''[[Constipation resident survival guide#Defecatory Disorder|Management of defecatory disorder]]'''}} | ||
{{familytree | | |,|-|^|-|.| | | | | | | | | | | |}} | {{familytree | | |,|-|^|-|.| | | | | | | | | | | |}} | ||
{{familytree | | L01 | | L02 | | | | | | | | | | |L01=Slow|L02=Normal}} | {{familytree | | L01 | | L02 | | | | | | | | | | |L01='''Slow'''|L02='''Normal'''}} | ||
{{familytree | | |!| | | |!| | | | | | | | | | | |}} | {{familytree | | |!| | | |!| | | | | | | | | | | |}} | ||
{{familytree | | M01 | | M02 | | | | | | | | | | |M01='''Slow transit constipation'''|M02='''Normal transit constipation'''}} | {{familytree | | M01 | | M02 | | | | | | | | | | |M01=❑ '''[[Constipation resident survival guide#Normal and Slow Transit Constipation|Management of low transit constipation]]'''|M02=❑ '''[[Constipation resident survival guide#Normal and Slow Transit Constipation|Management of normal transit constipation]]'''}} | ||
{{familytree | | | | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | |}} | ||
{{familytree/end}} | {{familytree/end}} | ||
<span style="font-size:85%">'''BMP:''' Basic metabolic panel; '''CBC:''' Complete blood count; '''TSH:''' Thyroid stimulating hormone </span> | |||
===General Management=== | ===Therapeutic Approach=== | ||
Shown below are algorithms depicting the general as well as different clinical subgroup based therapeutic approaches of [[constipation]] in adults based on the 2013 [[American Gastroenterological Association]] (AGA) technical review and medical position statement regarding guidelines on constipation.<ref name="pmid23261065">{{cite journal| author=Bharucha AE, Pemberton JH, Locke GR| title=American Gastroenterological Association technical review on constipation. | journal=Gastroenterology | year= 2013 | volume= 144 | issue= 1 | pages= 218-38 | pmid=23261065 | doi=10.1053/j.gastro.2012.10.028 | pmc=PMC3531555 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23261065 }} </ref><ref name="Bharucha-2013">{{Cite journal | last1 = Bharucha | first1 = AE. | last2 = Dorn | first2 = SD. | last3 = Lembo | first3 = A. | last4 = Pressman | first4 = A. | title = American Gastroenterological Association medical position statement on constipation. | journal = Gastroenterology | volume = 144 | issue = 1 | pages = 211-7 | month = Jan | year = 2013 | doi = 10.1053/j.gastro.2012.10.029 | PMID = 23261064 }}</ref> | |||
====General Management==== | |||
{{Family tree/start}} | {{Family tree/start}} | ||
{{familytree | | A01 | | A01=<div style="float: left; text-align: left; width: 30em; padding:1em;"> | |||
{{familytree | | A01 | |||
❑ Increase fiber intake in food <br> | ❑ Increase fiber intake in food <br> | ||
❑ Increase fiber intake as supplements | ❑ Increase fiber intake as supplements | ||
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:❑ [[Methylcellulose]]: 1 tsp up to 3 times daily<br> '''or''' <br> | :❑ [[Methylcellulose]]: 1 tsp up to 3 times daily<br> '''or''' <br> | ||
:❑ [[Calcium polycarbophil]]: 2-4 tablets OD <br> | :❑ [[Calcium polycarbophil]]: 2-4 tablets OD <br> | ||
❑ Advise to ingest fiber along with fluids and/or meals <br> | |||
❑ | ❑ Gradually adjust the dose of fiber after 7 to 10 days <br> | ||
❑ Gradually adjust the dose after 7 to 10 days <br> | |||
❑ Continue the adjusted dose for several weeks <br> | ❑ Continue the adjusted dose for several weeks <br> | ||
❑ Recommend increased fluid intake, particularly if dehydration is present | |||
❑ | ❑ Recommend increasing physical activity</div>}} | ||
❑ | {{familytree | | |!| | |}} | ||
{{familytree | | |!| | | | | | | | | | | {{familytree | | B01 | | B01= '''Failure to improve'''}} | ||
{{familytree | | C01 | {{familytree | | |!| | |}} | ||
{{familytree | | C01 | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> | |||
'''Add hyperosmolar agents:'''<br> | '''Add hyperosmolar agents:'''<br> | ||
❑ [[Polyethylene glycol]]: 8-32 oz OD | ❑ [[Polyethylene glycol]]: | ||
:❑ 8-32 oz OD | |||
:❑ 2 weeks to 24 months | :❑ 2 weeks to 24 months | ||
:❑ Polyethylene glycol with electrolyte containing preparation indicated when large volume is used for colonic cleansing <br> | :❑ Polyethylene glycol with electrolyte containing preparation indicated when large volume is used for colonic cleansing <br> | ||
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❑ [[Lactulose]]: 15-30 ml OD or BID<br> '''or''' <br> | ❑ [[Lactulose]]: 15-30 ml OD or BID<br> '''or''' <br> | ||
❑ [[Sorbitol]]: 15-30 ml OD or BID <br> | ❑ [[Sorbitol]]: 15-30 ml OD or BID <br> | ||
<br> | |||
'''Supplement with stimulant laxatives as needed:'''<br> | '''Supplement with stimulant laxatives as needed:'''<br> | ||
❑ [[Bisacodyl]]:<br> | ❑ [[Bisacodyl]]:<br> | ||
:❑ 10 mg suppositories <br> | :❑ 10 mg suppositories <br>'''or'''<br> | ||
:❑ 5-10 mg orally up to 3 times/week<br> | :❑ 5-10 mg orally up to 3 times/week<br> | ||
'''or''' <br> | '''or''' <br> | ||
❑ [[Glycerin]]: Suppository OD <br> | ❑ [[Glycerin]]: Suppository OD <br>'''or''' <br> | ||
'''or''' <br> | ❑ [[Senna (genus)|Senna]] or [[Buckthorn|cascara]]:<br> | ||
❑ [[ | :❑ 2 tablets OD or 4 tablets BID<br>'''or'''<br> | ||
:❑ 2 tablets OD | :❑ 1-2 tsp OD<br>'''or'''<br> | ||
:❑ 1-2 tsp | :❑ 1-2 tablets OD<br> | ||
❑ Administer suppositories 30 minutes after meals<br> | ❑ Administer suppositories 30 minutes after meals<br> | ||
<br> | |||
'''Supplement with stool softener as needed:'''<br> | |||
❑ [[Docusate sodium]]: 100 mg BD<BR> | |||
<BR> | |||
'''If necessary administer:'''<br> | '''If necessary administer:'''<br> | ||
❑ Newer agents | ❑ Newer agents | ||
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::❑ [[Lubiprostone]]: 24 μg BID <br> '''or''' <br> | ::❑ [[Lubiprostone]]: 24 μg BID <br> '''or''' <br> | ||
::❑ Linaclotide: 145 μg daily<br> | ::❑ Linaclotide: 145 μg daily<br> | ||
'''or'''<br> | |||
:❑ Serotonin 5-HT4 receptor agonist: Prucalopridec<br> | :❑ Serotonin 5-HT4 receptor agonist: Prucalopridec<br> | ||
❑ [[Pyridostigmine]] in type 2 diabetes mellitus patients with constipation<br> | ❑ [[Pyridostigmine]] in type 2 diabetes mellitus patients with constipation<br> | ||
❑ [[Misoprostol]]<br> | ❑ [[Misoprostol]]<br> | ||
❑ [[Opioid antagonists]] in patients with opioid induced constipation</div>}} | ❑ [[Opioid antagonists]] in patients with opioid induced constipation</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
===Normal and Slow Transit Constipation=== | <span style="font-size:85%">'''BID:''' Twice a day; '''OD:''' Once daily; '''tsp:''' Teaspoon </span> | ||
====Normal and Slow Transit Constipation==== | |||
{{Family tree/start}} | {{Family tree/start}} | ||
{{familytree | | | | | | | | | | | | | | |}} | {{familytree | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | A01 | | | | | | | | |A01= '''Normal or slow transit constipation'''}} | {{familytree | | | | | A01 | | | | | | | | |A01= '''Normal or slow transit constipation'''}} | ||
{{familytree | | | | | |!| | | | | | | | | |}} | {{familytree | | | | | |!| | | | | | | | | |}} | ||
{{familytree | | | | | B01 | | | | | | | | |B01=<div style="float: left; text-align: left | {{familytree | | | | | B01 | | | | | | | | |B01=<div style="float: left; text-align: left; padding:1em;">'''Administer:'''<br> | ||
---- | ---- | ||
❑ Hyperosmolar agents | ❑ Hyperosmolar agents: | ||
:❑ [[Polyethylene glycol]]: 8-32 oz OD<br> | :❑ [[Polyethylene glycol]]: 8-32 oz OD<br>'''or'''<br> | ||
:❑ [[Lactulose]]: 15-30 ml OD or BID<br> '''or''' <br> | |||
:❑ [[Sorbitol]]: 15-30 ml OD or BID<br> | |||
'''or'''<br> | '''or'''<br> | ||
❑ Saline laxatives | ❑ Saline laxatives: | ||
:❑ [[ | :❑ [[Magnesium]] ([[milk of magnesia]] or milk of magnesia + [[mineral oil]]) : 15-30 mL OD or BID<br> | ||
'''or'''<br> | '''or'''<br> | ||
❑ Stimulant laxatives | ❑ Stimulant laxatives: | ||
:❑ [[Bisacodyl]] | :❑ [[Bisacodyl]]: | ||
::❑ 10 mg suppositories<br> '''or''' <br> | ::❑ 10 mg suppositories<br> '''or''' <br> | ||
::❑ 5-10 mg orally up to 3 times/week</div>}} | ::❑ 5-10 mg orally up to 3 times/week<br>'''or'''<br> | ||
:❑ [[Glycerin]]: Suppository OD <br>'''or''' <br> | |||
:❑ [[Senna (genus)|Senna]] or [[Buckthorn|cascara]]:<br> | |||
::❑ 2 tablets OD or 4 tablets BID<br>'''or'''<br> | |||
::❑ 1-2 tsp OD<br>'''or'''<br> | |||
::❑ 1-2 tablets OD</div>}} | |||
{{familytree | | | |,|-|^|-|.| | | | | | | |}} | {{familytree | | | |,|-|^|-|.| | | | | | | |}} | ||
{{familytree | | | C01 | | C02 | | | | | | |C01=<div style="float: left; text-align: left | {{familytree | | | C01 | | C02 | | | | | | |C01=<div style="float: left; text-align: left; padding:1em;">'''Improvement'''<br> | ||
---- | ---- | ||
❑ Continue the same regimen on a long term basis</div>|C02=<div style="float: left; text-align: left | ❑ Continue the same regimen on a long term basis</div>|C02=<div style="float: left; text-align: left; padding:1em;">'''Failure to improve'''<br> | ||
---- | ---- | ||
❑ Modify the treatment regimen by considering<br> | ❑ Modify the treatment regimen by considering<br> | ||
Line 324: | Line 340: | ||
::❑ Prucalopridec</div>}} | ::❑ Prucalopridec</div>}} | ||
{{familytree | | | | | |,|-|^|-|.| | | | | |}} | {{familytree | | | | | |,|-|^|-|.| | | | | |}} | ||
{{familytree | | | | | D01 | | D02 | | | | |D01=<div style="float: left; text-align: left | {{familytree | | | | | D01 | | D02 | | | | |D01=<div style="float: left; text-align: left; padding:1em;">'''Improvement'''<br> | ||
---- | ---- | ||
❑ Continue the same regimen on a long term basis</div>|D02=<div style="float: left; text-align: left | ❑ Continue the same regimen on a long term basis</div>|D02=<div style="float: left; text-align: left; padding:1em;">'''Failure to improve'''<br> | ||
---- | ---- | ||
❑ Repeat colonic transit test while continuing medications</div> }} | ❑ Repeat colonic transit test while continuing medications</div> }} | ||
{{familytree | | | | | | | |,|-|^|-|.| | | |}} | {{familytree | | | | | | | |,|-|^|-|.| | | |}} | ||
{{familytree | | | | | | | E01 | | E02 | | |E01=<div style="float: left; text-align: left | {{familytree | | | | | | | E01 | | E02 | | |E01=<div style="float: left; text-align: left; padding:1em;">'''Delayed transit'''<br> | ||
---- | ---- | ||
❑ Consider [[Gastroparesis other imaging findings|gastric emptying]]</div>|E02=<div style="float: left; text-align: left | ❑ Consider [[Gastroparesis other imaging findings|gastric emptying]]</div>|E02=<div style="float: left; text-align: left; padding:1em;">'''Normal transit'''<br> | ||
---- | ---- | ||
❑ Adjust medications as needed</div>}} | ❑ Adjust medications as needed</div>}} | ||
{{familytree | | | | | |,|-|^|-|.| | | | | |}} | {{familytree | | | | | |,|-|^|-|.| | | | | |}} | ||
{{familytree | | | | | F01 | | F02 | | | | |F01=<div style="float: left; text-align: left | {{familytree | | | | | F01 | | F02 | | | | |F01=<div style="float: left; text-align: left; padding:1em;">'''Slow emptying'''<br> | ||
---- | ---- | ||
❑ Consider assessment for upper GI motility disorder</div>|F02='''Normal emptying''' }} | ❑ Consider assessment for upper GI motility disorder</div>|F02='''Normal emptying''' }} | ||
{{familytree | | | |,|-|^|-|.| |!| | | | | | |}} | {{familytree | | | |,|-|^|-|.| |!| | | | | | |}} | ||
{{familytree | | G01 | | | G02 |!| | | | |G01=<div style="float: left; text-align: left | {{familytree | | G01 | | | G02 |!| | | | |G01=<div style="float: left; text-align: left; padding:1em;">'''Abnormal'''<br> | ||
---- | ---- | ||
❑ Manage the upper GI motility disorder appropriately</div>|G02='''Normal'''}} | ❑ Manage the upper GI motility disorder appropriately</div>|G02='''Normal'''}} | ||
{{familytree | | | | | | | |!| |!| | | | | | |}} | {{familytree | | | | | | | |!| |!| | | | | | |}} | ||
{{familytree | | | | | | | | G03 | | | | | | |G03=Consider colonic manometry | {{familytree | | | | | | | | G03 | | | | | | |G03=Consider colonic manometry with/without barostat}} | ||
{{familytree | | | | | | |,|-|^|-|.| | | | | |}} | {{familytree | | | | | | |,|-|^|-|.| | | | | |}} | ||
{{familytree | | | | | | H01 | | H02 | | | | |H01=<div style="float: left; text-align: left | {{familytree | | | | | | H01 | | H02 | | | | |H01=<div style="float: left; text-align: left; padding:1em;">'''Normal'''<br> | ||
---- | ---- | ||
❑ Consider temporary loop [[ileostomy]]</div>|H02=<div style="float: left; text-align: left | ❑ Consider temporary loop [[ileostomy]]</div>|H02=<div style="float: left; text-align: left; padding:1em;">'''Abnormal'''<br> | ||
---- | ---- | ||
❑ Consider [[colectomy|subtotal colectomy]] | ❑ Consider [[colectomy|subtotal colectomy]] with ileorectal anastamosis</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
===Defecatory Disorder=== | <span style="font-size:85%">'''BID:''' Twice a day; '''OD:''' Once daily; '''GI:''' Gastrointestinal </span> | ||
====Defecatory Disorder==== | |||
{{Family tree/start}} | {{Family tree/start}} | ||
{{familytree | {{familytree | | | | | | | A01 | | | | | | | | | | | | |A01='''Defecatory disorder'''}} | ||
{{familytree | {{familytree | | | | | | | |!| | | | | | | | | | | | | |}} | ||
{{familytree | {{familytree | | | | | | | B01 | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; width: 17em; padding:1em;">'''Biofeedback-aided pelvic floor training:'''<br> | ||
❑ Record [[anorectal]] and pelvic floor muscle activity through surface electromyographic sensors or manometry <br> | |||
❑ Record [[anorectal]] and pelvic floor muscle activity through surface electromyographic sensors or manometry <br> | |||
❑ Teach patients to appropriately increase intraabdominal pressure and relax the pelvic floor muscles during defecation<br> | ❑ Teach patients to appropriately increase intraabdominal pressure and relax the pelvic floor muscles during defecation<br> | ||
❑ Provide practice of expelling air filled balloon, if necessary with external traction to the patients <br> | ❑ Provide practice of expelling air filled balloon, if necessary with external traction to the patients <br> | ||
Line 366: | Line 382: | ||
❑ Teach [[Kegel exercise]] to improve pelvic floor contractions | ❑ Teach [[Kegel exercise]] to improve pelvic floor contractions | ||
---- | ---- | ||
❑ Request a dietitian consult<br> | |||
❑ | ❑ Request a psychologist consult</div>}} | ||
❑ | {{familytree | | | | | |,|-|^|-|.| | | | | | | | | | |}} | ||
{{familytree | {{familytree | | | | | C01 | | C02 | | | | | | | | | |C01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Improvement'''<br> | ||
{{familytree | |||
---- | ---- | ||
❑ Follow up the patient clinically</div>|C02=<div style="float: left; text-align: left; width: | ❑ Follow up the patient clinically</div>|C02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Failure to improve'''<br> | ||
---- | ---- | ||
❑ Repeat [[Constipation other imaging findings#Rectal Balloon Expulsion Test|balloon expulsion test]]</div>}} | ❑ Repeat [[Constipation other imaging findings#Rectal Balloon Expulsion Test|balloon expulsion test]]</div>}} | ||
{{familytree | | | | | |, | {{familytree | | | | | |,|-|-|-|^|-|-|-|.| | | | | |}} | ||
{{familytree | | | | | D01 | {{familytree | | | | | D01 | | | | | | D02 | | | | |D01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Abnormal'''<br> | ||
---- | ---- | ||
❑ [[Constipation other imaging findings#Defecography|Defecating proctogram]]<br> | ❑ [[Constipation other imaging findings#Defecography|Defecating proctogram]]<br> | ||
'''or'''<br> | '''or'''<br> | ||
❑ [[Constipation other imaging findings#Defecography| | ❑ [[Constipation other imaging findings#Defecography|Magnetic resonance proctogram]]</div>|D02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Normal'''<br> | ||
---- | ---- | ||
❑ [[Constipation other imaging findings#Colorectal Transit Study|Colonic transit]]</div>}} | ❑ [[Constipation other imaging findings#Colorectal Transit Study|Colonic transit]]</div>}} | ||
{{familytree | | | |,|-|^|-|. | {{familytree | | | |,|-|^|-|.| | | |,|-|^|-|.| | | |}} | ||
{{familytree | | | E01 | | E02 | {{familytree | | | E01 | | E02 | | E03 | | E04 | | |E01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Normal anal or pelvic floor relaxation'''<br> | ||
---- | ---- | ||
❑ Consider surgery in case of clinically significant structural abnormalities|E02=<div style="float: left; text-align: left; width: | ❑ Consider surgery in case of clinically significant structural abnormalities</div>|E02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Abnormal anal or pelvic floor relaxation'''<br> | ||
---- | ---- | ||
❑ Reassess biofeedback<br> | ❑ Reassess biofeedback<br> | ||
❑ [[ | ❑ Administer stimulant laxative [[suppositories]] as needed<br> | ||
❑ Consider fallback</div>|E03=<div style="float: left; text-align: left; width: | ❑ Administer [[enema|enemas]] as needed<br> | ||
:❑ Mineral oil retention enema: 199–250 mL OD per rectum<br>'''or'''<br> | |||
:❑ Tap water enema: 500 mL per rectum<br>'''or'''<br> | |||
:❑ Phosphate enema: 1 unit per rectum<br>'''or'''<br> | |||
:❑ Soapsuds enema: 1500 mL per rectum<br> | |||
❑ Consider fallback</div>|E03=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Slow transit'''<br> | |||
---- | ---- | ||
❑ Consider treatment for slow transit constipation</div>|E04=<div style="float: left; text-align: left; width: | ❑ Consider treatment for slow transit constipation</div>|E04=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Normal transit'''<br> | ||
---- | ---- | ||
❑ Consider treatment for normal transit constipation</div>}} | ❑ Consider treatment for normal transit constipation</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
<span style="font-size:85%">'''OD:''' Once daily </span> | |||
==Do's== | ==Do's== | ||
* | * Perform a careful digital rectal examination that includes assessment of pelvic floor motion during simulated evacuation in the left lateral position, with the buttocks separated, before referral for anorectal manometry. A normal digital rectal examination does not exclude defecatory disorders ([[GRADE system classification scheme|strong recommendation, moderate-quality evidence]]). | ||
* Discontinue medications, if possible even before further testing ([[GRADE system classification scheme|strong recommendation, low-quality evidence]]). | |||
* | |||
* Order only a [[complete blood cell count]] test in the absence of other symptoms and signs of constipation ([[GRADE system classification scheme|strong recommendation, low-quality evidence]]). | * Order only a [[complete blood cell count]] test in the absence of other symptoms and signs of constipation ([[GRADE system classification scheme|strong recommendation, low-quality evidence]]). | ||
* Always recommend a therapeutic trial with fiber supplementation and/or osmotic or stimulant laxatives before further testing. | * Always recommend a therapeutic trial with fiber supplementation and/or osmotic or stimulant laxatives before further testing. | ||
* Warn patients that fiber supplements may increase gaseousness and that the symptoms often decrease after several days. | * Warn patients that fiber supplements may increase gaseousness and that the symptoms often decrease after several days. | ||
* | * Educate the patient not to expect an immediate response while on fiber supplements and that they should continue the supplements for several weeks. | ||
* Perform a [[Constipation other imaging findings#Anorectal Function Tests|anorectal manometry]] and a [[Constipation other imaging findings#Rectal Balloon Expulsion Test|balloon expulsion test]] in those patients who fail to respond to trail of laxatives ([[GRADE system classification scheme|strong recommendation, moderate-quality evidence]]).<ref name="Bharucha-2013">{{Cite journal | last1 = Bharucha | first1 = AE. | last2 = Dorn | first2 = SD. | last3 = Lembo | first3 = A. | last4 = Pressman | first4 = A. | title = American Gastroenterological Association medical position statement on constipation. | journal = Gastroenterology | volume = 144 | issue = 1 | pages = 211-7 | month = Jan | year = 2013 | doi = 10.1053/j.gastro.2012.10.029 | PMID = 23261064 }}</ref> | * Perform a [[Constipation other imaging findings#Anorectal Function Tests|anorectal manometry]] and a [[Constipation other imaging findings#Rectal Balloon Expulsion Test|balloon expulsion test]] in those patients who fail to respond to trail of laxatives ([[GRADE system classification scheme|strong recommendation, moderate-quality evidence]]).<ref name="Bharucha-2013">{{Cite journal | last1 = Bharucha | first1 = AE. | last2 = Dorn | first2 = SD. | last3 = Lembo | first3 = A. | last4 = Pressman | first4 = A. | title = American Gastroenterological Association medical position statement on constipation. | journal = Gastroenterology | volume = 144 | issue = 1 | pages = 211-7 | month = Jan | year = 2013 | doi = 10.1053/j.gastro.2012.10.029 | PMID = 23261064 }}</ref> | ||
* | * Perform a [[Constipation other imaging findings#Colorectal Transit Study|colonic transit test]], if anorectal test results do not show a defecatory disorder or if symptoms persist despite treating defecatory disorder ([[GRADE system classification scheme|strong recommendation, low-quality evidence]]). | ||
* | * Treat patients with normal or slow transit constipation refractory to simple laxatives, with newer agents. | ||
* | * Consider a subtotal colectomy for patients with symptomatic slow transit constipation without a defecatory disorder not responding to medications and always perform a colonic intraluminal testing (manometry, barostat) to document colonic motor dysfunction before colectomy ([[GRADE system classification scheme|weak recommendation, moderate-quality evidence]]).<ref name="Bharucha-2013">{{Cite journal | last1 = Bharucha | first1 = AE. | last2 = Dorn | first2 = SD. | last3 = Lembo | first3 = A. | last4 = Pressman | first4 = A. | title = American Gastroenterological Association medical position statement on constipation. | journal = Gastroenterology | volume = 144 | issue = 1 | pages = 211-7 | month = Jan | year = 2013 | doi = 10.1053/j.gastro.2012.10.029 | PMID = 23261064 }}</ref> | ||
==Dont's== | ==Dont's== | ||
Line 418: | Line 440: | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WikiDoc Help Menu}} | |||
{{WikiDoc Sources}} | |||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Gastroenterology]] | [[Category:Gastroenterology]] | ||
[[Category:Medicine]] | [[Category:Medicine]] | ||
[[Category:Resident survival guide]] | [[Category:Resident survival guide]] | ||
Latest revision as of 21:08, 29 July 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]; Vendhan Ramanujam M.B.B.S [3]
Synonyms and keywords: Chronic constipation
Overview
Constipation is a syndrome that is characterized by either difficulty in passing stool, infrequent bowel movements, hard stool, or a feeling of incomplete evacuation that occurs either in isolation or secondary to another underlying disorder.[1][2][3]
Classification
Normal Transit Constipation
Normal transit constipation refers to constipation in patients with normal anorectal function and normal colonic transit, with or without abnormal colonic motor disturbances and abnormal (ie, reduced or increased) colonic sensations.
Slow Transit Constipation
Slow transit constipation refers to constipation in patients with normal anorectal function but slow colonic transit, with or without abnormal colonic motor disturbances and abnormal (ie, reduced or increased) colonic sensations.
Defecatory Disorders
Defecatory disorders refer to constipation in patients with impaired rectal evacuation from inadequate rectal propulsive forces and/or increased resistance to evacuation during defecation, with or without structural disturbances like rectocele and intussusception, reduced rectal sensation, and slow colonic transit. Increased resistance to evacuation might follow high anal resting pressure (anismus) and/or incomplete relaxation or paradoxical contraction of the pelvic floor and external anal sphincters (dyssynergia).
Combination Disorders
Combination disorders refer to patients with combination or overlap of disorders (example, slow transit constipation with defecatory disorders), perhaps even an association with features of irritable bowel syndrome.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Atropine poisoning
- Hypokalemia
- Lead poisoning
- Opium poisoning
- Severe dehydration
- Spinal cord injury
- Superior mesenteric artery occlusion
Common Causes
- Hardening of the feces: Improper mastication, low dietary fiber, dehydration and medications (aluminium, calcium, diuretic, iron).
- Paralysis or slowed transit: Hypothyroidism, hypokalemia, injured anal sphincter, medications (loperamide, codeine, morphine, tricyclic antidepressants) and severe systemic illness due to other causes.
- Constriction, where part of the intestine or rectum is narrowed or blocked: Diverticulosis, pelvic masses and stenosis.
- Psychosomatic constipation: Functional constipation and irritable bowel syndrome.[4]
- Smoking cessation[5]
- Abdominal surgery and childbirth
Management
Diagnostic Approach
Shown below is an algorithm depicting the diagnostic approach of chronic constipation in adults based on the 2013 American Gastroenterological Association (AGA) technical review and medical position statement regarding guidelines on constipation.[1][6]
Characterize the symptoms:
❑ Infrequency in passing stool
❑ Use of enemas to pass stool
❑ Abdominal distention Obtain a detailed history:
❑ Systemic illness
❑ Surgical history
❑ Trauma history ( spinal cord injury)
❑ Social history
| |||||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ General examination ❑ Perineal/rectal examination
❑ Abdominal examination
❑ Neurological examination
❑ Cardiovascular examination
❑ Respiratory examination
❑ Skeletal examination
| |||||||||||||||||||||||||||||||||||||||||
Order laboratory tests: ❑ CBC Consider structural evaluation of the colon:
and | |||||||||||||||||||||||||||||||||||||||||
Consider the diagnostic criteria of constipation Rome III criteria:[1][7] Symptom onset for ≥6 months and ≥2 of the following for the past 3 months:
or
| |||||||||||||||||||||||||||||||||||||||||
❑ Adjust or discontinue medications causing constipation ❑ Administer a trial of fiber and/or osmotic or stimulant laxatives If secondary causes of constipation are uncovered during evaluation: If organic causes of constipation are uncovered during evaluation: If irritable bowel syndrome is diagnosed during evaluation: ❑ Treat irritable bowel syndrome | |||||||||||||||||||||||||||||||||||||||||
Improvement with trial of fiber and/or laxatives | Failure of improvement with trial of fiber and/or laxatives | ||||||||||||||||||||||||||||||||||||||||
❑ General management of constipation | |||||||||||||||||||||||||||||||||||||||||
Normal | Inconclusive | Abnormal | |||||||||||||||||||||||||||||||||||||||
Normal | Abnormal | ||||||||||||||||||||||||||||||||||||||||
❑ Assess the colonic transit | ❑ Management of defecatory disorder | ||||||||||||||||||||||||||||||||||||||||
Slow | Normal | ||||||||||||||||||||||||||||||||||||||||
❑ Management of low transit constipation | ❑ Management of normal transit constipation | ||||||||||||||||||||||||||||||||||||||||
BMP: Basic metabolic panel; CBC: Complete blood count; TSH: Thyroid stimulating hormone
Therapeutic Approach
Shown below are algorithms depicting the general as well as different clinical subgroup based therapeutic approaches of constipation in adults based on the 2013 American Gastroenterological Association (AGA) technical review and medical position statement regarding guidelines on constipation.[1][6]
General Management
❑ Increase fiber intake in food
❑ Advise to ingest fiber along with fluids and/or meals | |||||||||||
Failure to improve | |||||||||||
Add hyperosmolar agents:
or
or
❑ Administer suppositories 30 minutes after meals
or
❑ Pyridostigmine in type 2 diabetes mellitus patients with constipation | |||||||||||
BID: Twice a day; OD: Once daily; tsp: Teaspoon
Normal and Slow Transit Constipation
Normal or slow transit constipation | |||||||||||||||||||||||||||||||||
Administer: ❑ Hyperosmolar agents:
or
or | |||||||||||||||||||||||||||||||||
Improvement ❑ Continue the same regimen on a long term basis | Failure to improve ❑ Modify the treatment regimen by considering
or
| ||||||||||||||||||||||||||||||||
Improvement ❑ Continue the same regimen on a long term basis | Failure to improve ❑ Repeat colonic transit test while continuing medications | ||||||||||||||||||||||||||||||||
Normal transit ❑ Adjust medications as needed | |||||||||||||||||||||||||||||||||
Slow emptying ❑ Consider assessment for upper GI motility disorder | Normal emptying | ||||||||||||||||||||||||||||||||
Abnormal ❑ Manage the upper GI motility disorder appropriately | Normal | ||||||||||||||||||||||||||||||||
Consider colonic manometry with/without barostat | |||||||||||||||||||||||||||||||||
BID: Twice a day; OD: Once daily; GI: Gastrointestinal
Defecatory Disorder
Defecatory disorder | |||||||||||||||||||||||||||||||||||||||||||
Biofeedback-aided pelvic floor training: ❑ Record anorectal and pelvic floor muscle activity through surface electromyographic sensors or manometry ❑ Request a dietitian consult | |||||||||||||||||||||||||||||||||||||||||||
Improvement ❑ Follow up the patient clinically | |||||||||||||||||||||||||||||||||||||||||||
Normal anal or pelvic floor relaxation ❑ Consider surgery in case of clinically significant structural abnormalities | Abnormal anal or pelvic floor relaxation ❑ Reassess biofeedback
| Slow transit ❑ Consider treatment for slow transit constipation | Normal transit ❑ Consider treatment for normal transit constipation | ||||||||||||||||||||||||||||||||||||||||
OD: Once daily
Do's
- Perform a careful digital rectal examination that includes assessment of pelvic floor motion during simulated evacuation in the left lateral position, with the buttocks separated, before referral for anorectal manometry. A normal digital rectal examination does not exclude defecatory disorders (strong recommendation, moderate-quality evidence).
- Discontinue medications, if possible even before further testing (strong recommendation, low-quality evidence).
- Order only a complete blood cell count test in the absence of other symptoms and signs of constipation (strong recommendation, low-quality evidence).
- Always recommend a therapeutic trial with fiber supplementation and/or osmotic or stimulant laxatives before further testing.
- Warn patients that fiber supplements may increase gaseousness and that the symptoms often decrease after several days.
- Educate the patient not to expect an immediate response while on fiber supplements and that they should continue the supplements for several weeks.
- Perform a anorectal manometry and a balloon expulsion test in those patients who fail to respond to trail of laxatives (strong recommendation, moderate-quality evidence).[6]
- Perform a colonic transit test, if anorectal test results do not show a defecatory disorder or if symptoms persist despite treating defecatory disorder (strong recommendation, low-quality evidence).
- Treat patients with normal or slow transit constipation refractory to simple laxatives, with newer agents.
- Consider a subtotal colectomy for patients with symptomatic slow transit constipation without a defecatory disorder not responding to medications and always perform a colonic intraluminal testing (manometry, barostat) to document colonic motor dysfunction before colectomy (weak recommendation, moderate-quality evidence).[6]
Dont's
- Do not order metabolic tests such as blood glucose, calcium, and thyroid stimulating hormone unless the patient has these metabolic disorders related symptoms (strong recommendation, moderate-quality evidence).
- Do not use insoluble fiber like wheat bran for the intial managment of constipation in adults.
- Do not perform a colonoscopy in patients without alarm features (eg, blood in stools, anemia, weight loss, family history of colon cancer or inflammatory bowel disease, positive fecal occult blood test) and unless age-appropriate colon cancer screening has not been performed (strong recommendation, moderate-quality evidence).
- Do not perform a defecography before anorectal manometry and rectal balloon expulsion test (strong recommendation, low-quality evidence).[6]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Bharucha AE, Pemberton JH, Locke GR (2013). "American Gastroenterological Association technical review on constipation". Gastroenterology. 144 (1): 218–38. doi:10.1053/j.gastro.2012.10.028. PMC 3531555. PMID 23261065.
- ↑ American College of Gastroenterology Chronic Constipation Task Force (2005). "An evidence-based approach to the management of chronic constipation in North America". Am J Gastroenterol. 100 Suppl 1: S1–4. doi:10.1111/j.1572-0241.2005.50613_1.x. PMID 16008640.
- ↑ Locke GR, Pemberton JH, Phillips SF (2000). "American Gastroenterological Association Medical Position Statement: guidelines on constipation". Gastroenterology. 119 (6): 1761–6. PMID 11113098.
- ↑ Caldarella MP, Milano A, Laterza F; et al. (2005). "Visceral sensitivity and symptoms in patients with constipation- or diarrhea-predominant irritable bowel syndrome (IBS): effect of a low-fat intraduodenal infusion". Am. J. Gastroenterol. 100 (2): 383–9. doi:10.1111/j.1572-0241.2005.40100.x. PMID 15667496.
- ↑ "Nicotine withdrawal symptoms:Constipation". helpwithsmoking.com. 2005. Retrieved 2007-06-29.
- ↑ 6.0 6.1 6.2 6.3 6.4 Bharucha, AE.; Dorn, SD.; Lembo, A.; Pressman, A. (2013). "American Gastroenterological Association medical position statement on constipation". Gastroenterology. 144 (1): 211–7. doi:10.1053/j.gastro.2012.10.029. PMID 23261064. Unknown parameter
|month=
ignored (help) - ↑ Longstreth, GF.; Thompson, WG.; Chey, WD.; Houghton, LA.; Mearin, F.; Spiller, RC. (2006). "Functional bowel disorders". Gastroenterology. 130 (5): 1480–91. doi:10.1053/j.gastro.2005.11.061. PMID 16678561. Unknown parameter
|month=
ignored (help) - ↑ Lembo, AJ.; Kurtz, CB.; Macdougall, JE.; Lavins, BJ.; Currie, MG.; Fitch, DA.; Jeglinski, BI.; Johnston, JM. (2010). "Efficacy of linaclotide for patients with chronic constipation". Gastroenterology. 138 (3): 886–95.e1. doi:10.1053/j.gastro.2009.12.050. PMID 20045700. Unknown parameter
|month=
ignored (help)