How Do We Define Constipation

1
How Do We Define Constipation?

• The American College of Gastroenterology (ACG)
  definition of constipation
• Unsatisfactory defecation characterized by
  infrequent stools, difficult stool passage, or
  both. Difficult stool passage includes straining,
  a sense of difficulty passing stool, incomplete
  evacuation, hard/lumpy stools, prolonged time to
  pass stool, or need for manual maneuvers to pass
  stool
• The ACG Chronic Constipation Task Force also
  clarified what is meant by chronic
• Chronic constipation is defined as the presence
  of these symptoms for at least 3 months

American College of Gastroenterology Chronic
Constipation Task Force. Am J Gastroenterol.
2005100(S1)1-4.
2
Constipation Increases With Age and Is More
Common in Women
Study 1 N 42,375 Harari, et al Population NHIS
1989 Criteria self-report
Men
Women
25
12
20
10
8
15
Prevalence of Constipation ()
Prevalence of Constipation ()
6
10
4
5
2
0
0
80
Study 2
Study 3
Study 4
lt 40
40-49
50-59
60-69
70-79
N 5,430 Drossman
N 1,149 Pare
N 10,018 Stewart
Age Group (years)
Sex
NHIS National Health Interview Survey
Higgins PDR, et al. Am J Gastroenterol.
200499750-759.
3
Primary Causes of Chronic Constipation

• Normal-transit constipation
• Slow-transit constipation
• Defecatory disorders
• IBS with constipation

Bosshard W, et al. Drugs Aging.
200421911-930. Hadley S.K, et al. Am Fam
Physician. 2005722501-2506.
4
Combined Risk Factors for Constipation in the
Elderly Population

• Reduced fiber intake
• Reduced liquid intake
• Reduced mobility associated with functional
  decline
• Decreased functional independence
• Pelvic floor dysfunction
• Chronic conditions
• Parkinsons disease
• Dementia
• Diabetes mellitus
• Depression
• Polypharmacy (both over the counter and
  prescription medications, such as NSAIDs,
  antacids, antihistamines, iron supplements,
  anticholinergics, opiates, Ca channel blockers,
  diuretics, antipsychotics, anxiolytics,
  antidepressants)

Bosshard W, et al. Drugs Aging. 200421911-930.
5
Ask the Right Questions

• Define the meaning of constipation
• How long have you experienced these symptoms?
• Frequency of bowel movements?
• Abdominal pain?
• Other symptoms?
• What is most distressing symptom?
• Manual maneuvers to assist with defecation?
• Any limitation of daily activities?
• Are you taking any medications?
• What treatment have you tried?
• What investigations have been done?

Locke GR III, et al. Gastroenterology.
20001191761-1778.
6
Consider Secondary Causes
Drugs Opiates Antidepressants Anticholinergics An
tipsychotics Antacids (Al, Ca) Ca channel
blockers Iron supplements
Psychological Depression Eating disorders
Surgical Abdominal/pelvic surgery Colonic/anorecta
l surgery
Lifestyle Inadequate fiber/fluid Inactivity
Constipation
Metabolic/Endocrine Hypercalcemia Hyperparathyroi
dism Diabetes mellitus Hypothyroidism Hypokalemia
Uremia Addisons Porphyria
Gastrointestinal Colorectal neoplasm, ischemia,
volvulus, megacolon, diverticular
disease Anorectal prolapse, rectocele,
stenosis, megarectum
Neurological Parkinsons Multiple
sclerosis Autonomic neuropathy Aganglionosis (Hirs
chsprungs, Chagas) Spinal lesions Cerebrovascular
disease
Systemic Amyloidosis Scleroderma Polymyositis Pre
gnancy
Gallagher P, et al. Drugs Aging. 200825807-821.
7
Treating Constipation With Laxatives
Gallagher P, et al. Drugs Aging. 200825807-821.
8
Lubiprostone Stool Frequency in Patients Over 65
With Chronic Constipation
Nonelderly lubiprostone 48 µg
Elderly ( 65 years) lubiprostone 48 µg
Elderly placebo
Nonelderly placebo
6




5
P 0.03 P lt 0.0001



4
N 57 (patients aged 65 years vs placebo)
3
Change from Baseline in SBM Frequency
2
1
0
Week 1
Week 4
Week 2
Week 3
SBM spontaneous bowel movement
Johanson J, et al. Am J Gastroenterol.
2008103170-177. Tariq S. J Am Med Dir Assoc.
20078209-218.
9
Suggested Management Algorithm for Chronic
Constipation
Bleeding, anemia, weight loss, sudden change in
stool caliber, abdominal pain
No Alarm Symptoms
Alarm Symptoms
Lifestyle, OTC, stimulant laxative
Directed testing Refer to a specialist as needed
No Response
Trial of lactulose or PEG 3350
Continue regimen
Response
No response
Trial of lubiprostone
No response
OTC over-the-counter therapies (probiotics,
herbal medications, stool softeners docusate
sodium, psyllium, methylcellulose, calcium
polycarbophil, bisacodyl, senna)
Courtesy of Dr. B.D. Cash, MD, National Naval
Medical Center, Bethesda MD
10
Treatment for IBS-C
ACG IBS Task Force. Am J Gastroenterol.
2009104S1-S35.
11
Summary

• Evidence-based therapeutic options for chronic
  constipation include psyllium, lactulose,
  polyethylene glycol, and lubiprostone
• Psyllium, polyethylene glycol, antibiotics,
  probiotics, antispasmodics, antidepressants,
  lubiprostone, and psychotherapy are treatments
  for IBS-C with varying degrees of efficacy
• Long-term safety and efficacy data needed for
  therapeutic options for both chronic constipation
  and IBS-C, particularly in older (gt 65) adults
• Careful recognition, assessment, treatment, and
  monitoring can lead to more effective
  patient-specific interventions that can reduce
  the burden of chronic constipation or IBS-C