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Constipation

Definition
Constipation is a symptom-based disorder defined as fewer than 3 bowel movements per week.
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Pathophysiology
Constipation is caused by pelvic floor dysfunction, slow colonic transit, metabolic disorders (hypercalcemia, hypothyroidism), medications (opiates, CCBs, antipsychotics), neurological disorders (diabetes mellitus, Parkinson's disease, spinal cord injury), IBS, and primary colonic disorders (strictures, cancer, anal fissure, proctitis).
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Epidemiology
The overall prevalence of constipation in the US is 16%.
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Disease course
Anomalous regulation of neuromuscular components within the colon and anorectum, and disruption in the corresponding ascending and descending pathways in the brain-gut axis result in infrequent bowel movements, excessive straining, a sense of incomplete evacuation, failed or lengthy attempts to defecate, digital manipulation to evacuate stools, abdominal bloating, and hard consistency of stools.
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Prognosis and risk of recurrence
Chronic constipation decreases QoL and ability to function; however, only approximately 25% of patients consult physicians or use medications to manage associated symptoms.
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Key sources
The following summarized guidelines for the evaluation and management of constipation are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG/AGA 2023), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN 2023), the American College of Gastroenterology (ACG 2021; 2014), the British Society of Gastroenterology (BSG 2021), the European Society of Gastrointestinal Endoscopy (ESGE 2020), the Canadian Association of Gastroenterologists (CAG 2019), the American Gastroenterological Association (AGA 2019; 2014; 2013), the European Society of Medical Oncology (ESMO 2018), the American Society of Colon and Rectal Surgeons (ASCRS 2016), the American Society for Gastrointestinal Endoscopy (ASGE 2014), and the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2014).
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Guidelines

1.Diagnostic investigations

History and physical examination
As per ASCRS 2016 guidelines:
Elicit a directed history and perform a physical examination in patients with constipation.
A
Consider using validated measures assessing the nature, severity and impact of constipation on QoL as part of the medical evaluation for constipation.
C
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  • Laboratory tests

  • Anorectal physiology testing

  • Defecography

2.Diagnostic procedures

Colonoscopy: as per ASCRS 2016 guidelines, do not perform routine endoscopy in patients with constipation in the absence of alarming symptoms, screening recommendations, or other significant comorbidities.
D

3.Medical management

Avoidance of causative agents: discontinue medications that can cause constipation, if feasible, before obtaining further testing for constipation.
B

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  • Laxatives

  • Secretagogues

  • Prokinetics

  • Probiotics

4.Nonpharmacologic interventions

Fiber supplementation: as per ACG 2023 guidelines, consider offering fiber supplementation in adult patients with chronic idiopathic constipation.
C

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  • Suppositories and enemas

5.Therapeutic procedures

Biofeedback therapy: as per ASCRS 2016 guidelines, offer biofeedback therapy as first-line treatment for symptomatic pelvic floor dyssynergia.
B

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  • Sacral nerve stimulation

6.Surgical interventions

Indications for surgery: as per ESGE 2020 guidelines, perform endoscopic cecostomy only after failing conservative management with medical therapies or retrograde lavage.
B
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7.Specific circumstances

Pediatric patients, diagnosis: use theRome IV criteria for the definition of functional constipation.
E
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  • Pediatric patients (evaluation)

  • Pediatric patients (nonpharmacological management)

  • Pediatric patients (pharmacotherapy)

  • Pediatric patients (therapeutic interventions)

  • Patients with IBS-C (polyethylene glycol)

  • Patients with IBS-C (5-HT4 agonists)

  • Patients with IBS-C (guanylate cyclase activators)

  • Patients with IBS-C (lubiprostone)

  • Patients with IBS-C (tenapanor)

  • Patients with opioid-induced constipation

8.Follow-up and surveillance

Evaluation of refractory constipation
Obtain anorectal physiology testing in patients not responding to laxatives.
A
Re-evaluate anorectal physiology and colonic transit in patients with persisting symptoms despite an adequate trial of biofeedback therapy.
B