Management of chronic constipation in adults
- Arnold Wald, MD
Arnold Wald, MD
- Professor of Medicine
- University of Wisconsin School of Medicine and Public Health, Madison
Constipation is a common complaint that may be due to a variety of causes. Appropriate management requires an evaluation for secondary etiologies, such as systemic disorders and drugs (table 1A-B). Once secondary causes have been eliminated, idiopathic constipation may be associated with normal or slow colonic transit, defecatory dysfunction (pelvic floor dysfunction), or both.
This topic review will discuss the management of idiopathic chronic constipation. The etiology and evaluation of chronic constipation, as well as the management of constipation related to chronic opiates, are discussed elsewhere. (See "Etiology and evaluation of chronic constipation in adults" and "Cancer pain management with opioids: Prevention and management of side effects".)
The approach to a patient with chronic constipation will depend on whether studies indicate normal or slowed colonic transit and whether there is a defecatory dysfunction (algorithm 1). The specific choice of agents and order of their introduction varies with the etiology of the condition.
●Management of chronic constipation includes patient education, behavior modification, dietary changes, and laxative therapy. Severe, intractable, slow transit constipation is rare and may be treated with surgery, but with extreme caution; patients should be referred to specialized centers for a full evaluation prior to surgery. Treatment for normal or slow transit constipation is shown in an algorithm (algorithm 2).
●Management of defecatory dysfunction involves suppositories, biofeedback, or botulinum toxin injections into the puborectalis muscle (algorithm 3).
- Tramonte SM, Brand MB, Mulrow CD, et al. The treatment of chronic constipation in adults. A systematic review. J Gen Intern Med 1997; 12:15.
- Badiali D, Corazziari E, Habib FI, et al. Effect of wheat bran in treatment of chronic nonorganic constipation. A double-blind controlled trial. Dig Dis Sci 1995; 40:349.
- Müller-Lissner SA. Effect of wheat bran on weight of stool and gastrointestinal transit time: a meta analysis. Br Med J (Clin Res Ed) 1988; 296:615.
- Petticrew M, Watt I, Sheldon T. Systematic review of the effectiveness of laxatives in the elderly. Health Technol Assess 1997; 1:i.
- Attaluri A, Donahoe R, Valestin J, et al. Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther 2011; 33:822.
- Floch MH, Wald A. Clinical evaluation and treatment of constipation. Gastroenterologist 1994; 2:50.
- Voderholzer WA, Schatke W, Mühldorfer BE, et al. Clinical response to dietary fiber treatment of chronic constipation. Am J Gastroenterol 1997; 92:95.
- Anti M, Pignataro G, Armuzzi A, et al. Water supplementation enhances the effect of high-fiber diet on stool frequency and laxative consumption in adult patients with functional constipation. Hepatogastroenterology 1998; 45:727.
- Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003; 349:1360.
- Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology 2013; 144:218.
- Ramkumar D, Rao SS. Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. Am J Gastroenterol 2005; 100:936.
- American College of Gastroenterology Chronic Constipation Task Force. An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol 2005; 100 Suppl 1:S1.
- Corazziari E, Badiali D, Bazzocchi G, et al. Long term efficacy, safety, and tolerabilitity of low daily doses of isosmotic polyethylene glycol electrolyte balanced solution (PMF-100) in the treatment of functional chronic constipation. Gut 2000; 46:522.
- Dipalma JA, Cleveland MV, McGowan J, Herrera JL. A randomized, multicenter, placebo-controlled trial of polyethylene glycol laxative for chronic treatment of chronic constipation. Am J Gastroenterol 2007; 102:1436.
- Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus Polyethylene Glycol for Chronic Constipation. Cochrane Database Syst Rev 2010; :CD007570.
- Dupont C, Campagne A, Constant F. Efficacy and safety of a magnesium sulfate-rich natural mineral water for patients with functional constipation. Clin Gastroenterol Hepatol 2014; 12:1280.
- Mueller-Lissner S, Kamm MA, Wald A, et al. Multicenter, 4-week, double-blind, randomized, placebo-controlled trial of sodium picosulfate in patients with chronic constipation. Am J Gastroenterol 2010; 105:897.
- Kamm MA, Mueller-Lissner S, Wald A, et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol 2011; 9:577.
- Heizer WD, Warshaw AL, Waldmann TA, Laster L. Protein-losing gastroenteropathy and malabsorption associated with factitious diarrhea. Ann Intern Med 1968; 68:839.
- Wald A. Is chronic use of stimulant laxatives harmful to the colon? J Clin Gastroenterol 2003; 36:386.
- Müller-Lissner SA, Kamm MA, Scarpignato C, Wald A. Myths and misconceptions about chronic constipation. Am J Gastroenterol 2005; 100:232.
- Ori Y, Rozen-Zvi B, Chagnac A, et al. Fatalities and severe metabolic disorders associated with the use of sodium phosphate enemas: a single center's experience. Arch Intern Med 2012; 172:263.
- Mendoza J, Legido J, Rubio S, Gisbert JP. Systematic review: the adverse effects of sodium phosphate enema. Aliment Pharmacol Ther 2007; 26:9.
- Levine MD, Bakow H. Children with encopresis: a study of treatment outcome. Pediatrics 1976; 58:845.
- Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol 2007; 5:331.
- Heymen S, Scarlett Y, Jones K, et al. Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type constipation. Dis Colon Rectum 2007; 50:428.
- Bassotti G, Chistolini F, Sietchiping-Nzepa F, et al. Biofeedback for pelvic floor dysfunction in constipation. BMJ 2004; 328:393.
- Heymen S, Jones KR, Scarlett Y, Whitehead WE. Biofeedback treatment of constipation: a critical review. Dis Colon Rectum 2003; 46:1208.
- Chiarioni G, Salandini L, Whitehead WE. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology 2005; 129:86.
- Chiarioni G, Whitehead WE, Pezza V, et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology 2006; 130:657.
- Lee BH, Kim N, Kang SB, et al. The Long-term Clinical Efficacy of Biofeedback Therapy for Patients With Constipation or Fecal Incontinence. J Neurogastroenterol Motil 2010; 16:177.
- FDA approves Linzess to treat certain cases of irritable bowel syndrome and constipation. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm317505.htm (Accessed on September 04, 2012).
- Lembo AJ, Schneier HA, Shiff SJ, et al. Two randomized trials of linaclotide for chronic constipation. N Engl J Med 2011; 365:527.
- Johanson JF, Ueno R. Lubiprostone, a locally acting chloride channel activator, in adult patients with chronic constipation: a double-blind, placebo-controlled, dose-ranging study to evaluate efficacy and safety. Aliment Pharmacol Ther 2007; 25:1351.
- Lang L. The Food and Drug Administration approves lubiprostone for irritable bowel syndrome with constipation. Gastroenterology 2008; 135:7.
- Roarty TP, Weber F, Soykan I, McCallum RW. Misoprostol in the treatment of chronic refractory constipation: results of a long-term open label trial. Aliment Pharmacol Ther 1997; 11:1059.
- Wald A. Slow Transit Constipation. Curr Treat Options Gastroenterol 2002; 5:279.
- Taghavi SA, Shabani S, Mehramiri A, et al. Colchicine is effective for short-term treatment of slow transit constipation: a double-blind placebo-controlled clinical trial. Int J Colorectal Dis 2010; 25:389.
- Quigley EM, Vandeplassche L, Kerstens R, Ausma J. Clinical trial: the efficacy, impact on quality of life, and safety and tolerability of prucalopride in severe chronic constipation--a 12-week, randomized, double-blind, placebo-controlled study. Aliment Pharmacol Ther 2009; 29:315.
- Müller-Lissner S, Rykx A, Kerstens R, Vandeplassche L. A double-blind, placebo-controlled study of prucalopride in elderly patients with chronic constipation. Neurogastroenterol Motil 2010; 22:991.
- Camilleri M, Van Outryve MJ, Beyens G, et al. Clinical trial: the efficacy of open-label prucalopride treatment in patients with chronic constipation - follow-up of patients from the pivotal studies. Aliment Pharmacol Ther 2010; 32:1113.
- Cinca R, Chera D, Gruss HJ, Halphen M. Randomised clinical trial: macrogol/PEG 3350+electrolytes versus prucalopride in the treatment of chronic constipation -- a comparison in a controlled environment. Aliment Pharmacol Ther 2013; 37:876.
- Maria G, Cadeddu F, Brandara F, et al. Experience with type A botulinum toxin for treatment of outlet-type constipation. Am J Gastroenterol 2006; 101:2570.
- Wofford SA, Verne GN. Approach to patients with refractory constipation. Curr Gastroenterol Rep 2000; 2:389.
- Nyam DC, Pemberton JH, Ilstrup DM, Rath DM. Long-term results of surgery for chronic constipation. Dis Colon Rectum 1997; 40:273.
- Knowles CH, Scott M, Lunniss PJ. Outcome of colectomy for slow transit constipation. Ann Surg 1999; 230:627.
- Pikarsky AJ, Singh JJ, Weiss EG, et al. Long-term follow-up of patients undergoing colectomy for colonic inertia. Dis Colon Rectum 2001; 44:179.
- GENERAL APPROACH
- INITIAL MANAGEMENT
- Patient education
- Dietary changes and bulk-forming laxatives
- - Fiber
- - Bulk-forming laxatives
- Other laxatives
- - Surfactants
- - Osmotic agents
- - Stimulant laxatives
- MANAGEMENT OF SEVERE CONSTIPATION
- Behavioral approaches
- - Biofeedback
- Pharmacologic therapy
- - Linaclotide
- - Lubiprostone
- - Misoprostol
- - Colchicine
- - Prucalopride
- Botulinum toxin
- Other surgical approaches
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS