Mechanisms, Evaluation, and Management of Chronic Constipation.

Abstract

With a worldwide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics, and is a common source cause for referrals to gastroenterologists and colorectal surgeons in the United States. Symptoms vary among patients; straining, incomplete evacuation, and a sense of anorectal blockage are just as important as decreased stool frequency. Chronic constipation is either a primary disorder (such as normal transit, slow transit, or defecatory disorders) or a secondary one (due to medications or, in rare cases, anatomic alterations). Colonic sensorimotor disturbances and pelvic floor dysfunction (such as defecatory disorders) are the most widely recognized pathogenic mechanisms. Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents. Peripherally acting μ-opiate antagonists are another option for opioid-induced constipation. Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents. Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility. Defecatory disorders often respond to biofeedback therapy. For specific patients, slow-transit constipation may necessitate a colectomy. No studies have compared inexpensive laxatives with newer drugs with different mechanisms. We review the mechanisms, evaluation, and management of chronic constipation. We discuss the importance of meticulous analyses of patient history and physical examination, advantages and disadvantages of diagnostic testing, guidance for individualized treatment, and management of medically refractory patients.

• Authors: Adil E Bharucha, Brian E Lacy
• Journal: Gastroenterology (Gastroenterology) Vol. 158 Issue 5 Pg. 1232-1249.e3 (04 2020) ISSN: 1528-0012 [Electronic] United States
• PMID: 31945360 (Publication Type: Journal Article, Research Support, N.I.H., Extramural, Review)
• Copyright: Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.

Chemical References

• Dietary Fiber
• Laxatives
• Receptors, Opioid, mu
• Secretagogues

Topics

• Chronic Disease (epidemiology, therapy)
• Colon (diagnostic imaging, innervation, metabolism, physiopathology)
• Constipation (diagnosis, epidemiology, etiology, therapy)
• Defecation (physiology)
• Defecography
• Dietary Fiber (administration & dosage)
• Dietary Supplements
• Digital Rectal Examination
• Electromyography
• Gastrointestinal Motility (drug effects, physiology)
• Humans
• Intestinal Mucosa (drug effects, metabolism, physiopathology)
• Laxatives (administration & dosage)
• Magnetic Resonance Imaging
• Manometry
• Pelvic Floor (innervation, physiopathology)
• Prevalence
• Receptors, Opioid, mu (antagonists & inhibitors, metabolism)
• Rectum (diagnostic imaging, innervation, metabolism, physiopathology)
• Secretagogues (administration & dosage)