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SSAT Patient Care Guidelines

Chronic Constipation

Introduction
Chronic constipation is a common problem in the United States, accounting for an estimated 2.5 million doctor visits per year. The causes of constipation are varied. Though it can be the presenting sign of an underlying metabolic disorder, it is more frequently the result of medications, lifestyle and diet. Chronic constipation can often be treated by simple medical measures; however at times, the evaluation and treatment can be quite complex.

Definition
Constipation is difficult to characterize as it has varied meanings to different people. It is often based on a patient’s impression that their bowel function is not normal. Defining constipation in a scientific manner has been problematic. Currently, the Rome III criteria are the most widely accepted means used to define constipation. At least two of the following conditions must be present for at least 3 months:

  • Straining during defecation > 25% of the time
  • Lumpy or hard stools > 25% of the time
  • Sensation of incomplete evacuation > 25% of the time
  • Sensation of anorectal obstruction > 25% of the time
  • Manual maneuvers to facilitate defecation > 25% of the time
  • < 3 bowel movements/week
Additionally there should be no evidence of an Inflammatory Bowel Syndrome.

Epidemiology
Acute Appendicitis remains a clinical diagnosis directed by the history and physical exam. Characteristically it begins with non-specific abdominal pain that worsens over a 6-24 hour period. Initially, the pain is typically located in a mid-abdominal or periumbilical location– reflecting midgut autonomic afferent pain fiber irritation. It is often crampy in nature, and patients indicate that it does not improve with defecation or urination. Nausea and vomiting occur in the vast majority (75%) of patients. Anorexia is a hallmark, but not universal, symptom. A modest fever (<39°) is usually present. Ultimately, the pain migrates to the right-lower quadrant, which becomes tender to touch as the inflamed appendix produces local parietal inflammation. The patient becomes reluctant to move, immobilized by pain from local peritonitis. However, the actual anatomic position of the appendix in the right-lower quadrant is highly variable and this accounts for atypical presentations of symptoms including right flank, groin, or pelvic pain, as well as diarrhea and urinary frequency.

In advanced cases, particularly with delay in diagnosis, local inflammation may progress to perforation. This occurs in about 25% of the patients and is more common in very young children, pregnant women, and adults over 50 years old. Symptoms tend to be longer in duration and more severe. High fever and tachycardia are common and there is evidence of either local or diffuse peritonitis on exam. Morbidity and mortality are significantly higher when the appendix perforates.

In yet other cases, the appendix may perforate, but be contained within a local phlegmon or abscess (subacute appendicitis). The patient will complain of pain that was initially tolerable and subsequently subsided. Ultimately (5-10 days later) the local infection will manifest with fever, ileus, poor oral intake and chronic pain that forces the patient to seek medical attention.

Diagnosis
There have been wide variations in estimating the incidence of chronic constipation in the United States. An accepted average is about 15%. The prevalence rises with age and female gender. There are associations with low income, poor education and physical inactivity.

Etiology
Constipation can be caused by neurologic and metabolic disorders, congenital disorders, obstructing lesions of the lower GI tract, as well as medications, diet and lifestyle. In women, there is a form of severe idiopathic chronic constipation that often fails treatment with non operative therapies. These are a complex group of disorders that often require specialist evaluation.

Evaluation
The evaluation of a patient with chronic constipation begins with a careful history and physical examination. The history should focus on specific bowel habits and having the patient keep a two week bowel habit diary. Additionally, all medications being taken by the patient should be documented. Of note, any recent change in bowel habits should prompt a thorough colonoscopic examination to rule out malignancy.

The physical examination focuses on the rectal exam which may identify causative pathology (hemorrhoids and fissures), as well as an evaluation of anal sphincter tone. Lower GI endoscopy is very useful and should be utilized early in the evaluation of functional constipation. Imaging studies, such as a barium enema, should be obtained to detect mass lesions, strictures or megacolon.

A normal imaging study and endoscopy should prompt a work up for poor colonic transit and pelvic floor dysfunction. Useful measures include colonic transit studies, defacography and anal manometry. These studies are quite helpful in determining appropriate treatment for functional constipative disorders involving neuromuscular pathology and/or pelvic visceral prolapse.

Treatment
The treatment of chronic constipation can be demanding. Initial efforts should revolve around patient education and realistic expectations regarding bowel habits. Efforts should be made to reduce reliance on laxatives and cathartics and introduce fiber in the form of psyllium or methylcellulose with adequate water intake. If ineffective, stool softeners, saline and stimulant laxatives may be added judiciously. Bowel preparation agents may also be used judiciously.

For very severe constipation that is refractory to aggressive medical management, alternate approaches are employed. Behavioral modification with biofeedback is effective in selected patients with pelvic floor dysfunction. There really is no proven pharmacologic solution available. Botox has been used in selected patients with pubo-rectalis dysfunction with some success.

Surgery should be reserved for patients with chronic and disabling symptoms secondary to slow transit disease. Surgical options include subtotal colectomy with ileorectal anastomosis. Patients with mixed slow transit and pelvic floor dysfunction are particularly difficult to treat. The presurgical evaluation, counseling and treatment of these patients should be left to colorectal surgeons with specific expertise in this area.

Risks and Outcomes
In patients treated with surgery for their constipation, 90% reported an improved quality of life, with a 12% rate of post-operative complications. There are multiple surgical approaches to constipation and most have good results, with an improvement of the bothersome signs and symptoms of constipation.

Qualifications for Surgeons treating chronic constipation:
If surgery is being considered for the treatment of chronic constipation, the surgeon should have specific expertise and training in the evaluation and treatment of constipation. At a minimum, the surgeon should have board certification in General Surgery, and it would be preferable for a colorectal surgeon to be managing these complex patients.

Suggested Readings

  1. Higgins PD, Johanson JF. Epidemiology of Constipation in North America; a systematic review. Am J Gastroenterol 2004; 99(4):750-9.
  2. Muller Lisner SA, Kamm MA, Scarpingnato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol 2005; 100(1):232-42.
  3. Knowles CH, Scott M, Lunniss PJ. Outcome of colectomy for slow transit constipation. Ann Surg 1999; 230(5):627-38.
  4. Tramonte SM, Brand MB, Mulrow CD, et al. The treatment of chronic constipation in adults. A systematic review. J Gen Intern Med 1997; 12(1):15-24.
  5. Hassan I, Pemberton JH, Young-Fadok TM, et al. Ileorectal anastomosis for slow transit constipation: long-term functional and quality of life results. J Gastrointest Surg 2006; 10(10):1330-6.

KeyWords - Chronic Constipation

Board Approved 10/13/08

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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