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constipation; dyschezia

Fewer than 3 stools/week, passage of hard small stools, straining & the sense of incomplete evacuation. Chronic constipation requires >= 3 months of symptoms Classification: 1) type 1: separate hard lumps, hard to pass 2) type 2: sausage shaped & lumpy 3) type 3: sausage shaped with surface cracks 4) type 4: sausage or snake shaped, smooth & soft 5) type 5: soft blobs with clear-cut edges 6) type 6: fluffy pieces with ragged edges, mushy stool 7) type 7: watery, no solid pieces [3] Etiology: 1) health habits a) low fiber intake b) inactivity 2) pharmacologic agents (most common cause) a) antacids 1] aluminum hydroxide 2] calcium carbonate b) barium sulfate c) ferrous sulfate d) lithium carbonate [12] e) bismuth f) ion exchange (bile) resins (cholestyramine) g) sympathomimetics h) opiates (see opioid-induced constipation) i) anticholinergic agents 1] phenothiazines 2] tricyclic antidepressants (amitriptyline & others) j) antihypertensive agents 1] calcium channel blocker 2] diuretics 3] clonidine k) antipsychotics [12] l) herbal supplements m) antidiarrheal agents n) NSAIDs o) serotonergic antagonists: ondansetron o) chronic stimulant laxative use 1] phenolphthalein (Ex Lax, Correctol) 2] bisocodyl (Dulcolax) 3] Senna (Senokot) 4] Cascara 3) irritable bowel syndrome 4) structural lesions a) tumor, colon carcinoma, intestinal obstruction - lipoma (case report) [22] b) stricture (mesenteric ischemia, Crohn's disease) c) hemorrhoids d) fissure e) rectocele f) endometriosis 5) neurologic a) Parkinson's disease b) multiple sclerosis c) spinal cord lesions d) autonomic neuropathy - diabetes mellitus e) Hirschsprung's disease f) stroke [12] g) intestinal pseudoobstruction 6) inflammatory a) radiation colitis b) inflammatory bowel disease 7) endocrine & metabolic causes a) hypothyroidism b) pregnancy c) premenstrual syndrome d) diabetes mellitus [12] e) hypercalcemia f) hypokalemia g) hypopituitarism [12] h) pheochromocytoma i) glucagonoma j) uremia 8) toxins: lead 9) depression 10) immobility 11) dyssynergic defecation 12) intestinal methanogen overgrowth associated with increased risk & severity of constipation [41] 13) idiopathic Epidemiology: 1) the most common digestive complaint in the USA 2) affects over 2% of the population 3) 2-3 times more common in women than men 4) marked increase after age 65 a) comorbidity b) environmental influences c) over-reporting History: Alarm features 1) history of colectomy 2) history of abdominal cancer or pelvic cancer 3) history of abdominal radiation or pelvic radiation [3] Clinical manifestations: - non-specific abdominal discomfort - liquid stool may be overflow constipation - delirium may occur in constipated elderly * Alarm features 1) rectal bleeding, positive fecal occult blood 2) family history a) colon cancer b) inflammatory bowel disease 3) anemia 4) weight loss 5) sudden change in bowel habits 6) acute onset in an elderly person (> 50 years of age) 7) palpable mass on examination [3] Laboratory: - serum chemistries a) serum Ca+2 b) serum K+ c) serum thyroid-stimulating hormone d) serum glucose e) serum creatinine Special laboratory: 1) colonoscopy a) > 50 years of age & no previous colonoscopy [3] b) alarm feature(s) present [3] 2) full-thickness suction biopsy of the rectum if Hirschsrpung's disease is suspected 3) anorectal manometry & rectal balloon expulsion test - suspected pelvic floor dsyfunction or dyssynergic defecation - perineal couterpressure may aid defecation - digital rectal exam may be normal Radiology: 1) plain abdominal films - initial diagnostic tests of choice [3] 2) barium enema (after relief of obstruction) 3) colonic transit studies using radiographic markers - does not distinguish slow-transit constipation from dyssynergic defecation Complications: 1) hemorrhoids 2) anal fissure 3) rectal prolapse 4) stercoral ulcer 5) melanosis coli 6) cathartic colon 7) fecal impactation - including soft fecal impactation [31] 8) ischemic colitis 9) colonic volvulus 10) colonic perforation 11) fecal incontinence 12) urinary incontinence 13) cardiovascular disorders a) arrhythmias b) syncope c) angina [4] d) heart failure (RR=2.7) [45] e) stroke (RR=2.4) [45] f) acute coronary syndrome or myocardial infarction (RR=1.6) [45] 14) chronic constipation may be associated with cognitive impairment - specific neuroprotective small intestinal bacteria including Butyricicoccus & Ruminococcus may play a role [38] Differential diagnosis: 1) ileus 2) intestinal pseudoobstruction 3) intestinal obstruction Management: 1) general considerations a) disimpactation if indicated - entity of soft fecal impactation [31] b) adequate fluid intake c) adequate dietary fiber d) adequate physical activity [3] - exercise may be an effective treatment option for constipation [32] 2) stepwise management of chronic constipation [11] a) if fecal impactation (stool in vault, including soft stool), enema until clear - apparently there is an entity soft fecal impaction - it would seem a stimulant laxative would be appropriate for soft stool b) stop all medications that may constipate, if possible c) increase dietary fiber intake to 6-25 grams/day; increase fluid intake to >= 1.5 L/day; increase physical activity; bulk laxative may be used provided fluid intake is >= 1.5 L/day d) GRS8 indicates a switch to a high fiber diet is better than an increase in intake of dietary insoluble fiber [11] - contrary to common practice, ref [19] suggests soluble fiber is beneficial for constipation, but data is conflicting for insoluble fiber [19] - wheat bran effective in the short term [20] e) if previous measures fail, add sorbitol 70% 15-30 mL every 12-24 hours; max 150 mL/day f) add stimulant laxative (senna or bisocodyl) 2-3 times per week g) use tap water enema or saline enema twice a week h) oil retention enema for refractory constipation 3) pharmaceutical agents a) bulk-forming laxatives not useful for opioid-induced consipation - psyllium (Metamucil) - methylcellulose (Citrucel) - wheat bran b) osmotic agents - lactulose - as effective as sorbitol, but more expensive - sorbitol (70%) - may cause abdominal bloating & flatulence - glycerin - polyethylene glycol (Miralax) - safe & effective for 6 months in elderly [27,28] - superior to sorbitol in improving stool frequency & consistency & is associated with fewer adverse effects [39] - regular laxative use osmotic laxative associated with increased risk of all-cause dementia [40] c) stool softeners (not usually recommended [3]) - docusate sodium (Colace) - docusate calcium (Surfak) d) stimulants probably don't perpetuate altered colonic motility [5] - bisacodyl 10 mg PO QD effective for chronic constipation [9] - senna, senakot - magnesium-containing products - magnesium hydroxide (milk of magnesia) - magnesium citrate - herbal teas - green kiwifruit [33] - cascara, phenolphthalein removed from US market [5] e) opioid antagonists [11 - alvimopan (Entereg) - methylnaltrexone (Relistor) - naloxegol (Movantik) f) secretagogues - lubiprostone after treatment with at least 2 different laxatives at highest recommended dose for 6 months (NICE) - linaclotide (Linzess) FDA-approved for adults & children >=6 years [36] - plecanatide g) only polyethylene glycol, bisacodyl, sodium picosulfate, linaclotide, plecanatide & prucalopride with strong evidence of efficacy [35] h) regular laxative use associated with increased risk of all-cause dementia, especially with use of multiple laxative types or osmotic laxative [40] i) no specific therapy to prevent constipation in hospitalized elderly has been proven superior to others [11] 4) natural remedies - 2 green kiwifruits/day improved symptoms of constipation [37] - probiotics may be of benefit for infants & in elderly [8,18] 5) enemas for fecal impactation - indicated by abdominal distension & stool in the rectal vault - including entity soft fecal impactation [31] although it would seem a stimulant laxative would be more appropriate for soft stool in the vault 6) bowel retraining, biofeedback for dyssynergic defecation - commonly provided by physical therapist with specialized training [3] 7) perineal acupressure of benefit [21] - electroacupuncture may improve symptoms of chronic constipation [26] 8) FDA approved Vibrant vibrating capsule for chronic idiopathic constipation [34] 9) constipation due to opioids for chronic pain a) senna 1st line - addition of docusate to senna of no benefit [11] b) methylnaltrexone may help relieve constipation in palliative care patients without negating analagesic effect of opioid [3] c) also see opioid-induced constipation

Interactions

disease interactions

Related

diagnostic criteria for constipation ileus intestinal pseudo-obstruction medical conditions associated with constipation pharmaceutical agents associated with constipation

Specific

fecal impactation opioid-induced constipation (OIC)

General

intestinal disease sign/symptom

References

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