Constipation

CONSTIPATION
Dr SHIVARAJ A
DNB TRAINEE
GASTROENTEROLOGY
AGHL KOLKATA

AGENDA
1. INTRODUCTION
2. CLASSIFICATION AND ETIOLOGY
3. APPROACH TO THE PATIENT
4. MANAGEMENT
5. RECENT UPDATES
6. TAKE HOME MESSAGE AND SUMMARY
Dr Shivaraj Afzalpurkar

INTRODUCTION
• DEFINITION-
Patients description : 52% - Excessive straining,
44% - Hard stools,
34% - Inability to have a bowel movement.
• Healthcare workers : 3 or fewer bowel movements per week.
• The American College of Gastroenterology defines constipation as
unsatisfactory defecation characterized by infrequent stools, difficult stool passage,
or both.
Hindawi : Yvonne Tse et al.Canadian Journal of Gastroenterology and Hepatology Volume
2017,

ROME I
(1994)
ROME
II & III
(99 & 06)
ROME
IV
(May 2016)
ROME CLASSIFICATION OF FUNCTIONAL BOWEL DISORDERS
J Clin med/ pubmed. 2017 Nov; 6(11): 99.
FC- functional constipation, Functional Dr- Diarrhea,Dr Shivaraj Afzalpurkar

ROME IV DIAGNOSTIC CRITERIA
(FUNCTIONAL CONSTIPATION)
1. Two or more of the following 6 must be present:
a) Straining during more than ¼ (25%) of defecations.
b) Lumpy or hard stools in more than ¼ (25%) of defecations.
c) Sensation of incomplete evacuation for more than ¼
(25%) of defecations.
d) Sensation of anorectal obstruction/blockage for more
than ¼ (25%) of defecations.
e) Manual maneuvers to facilitate for more than ¼ (25%) of
defecations (e.g., digital evacuation, support of pelvic floor).
f) Fewer than 3 spontaneous bowel movements per week.
2. Loose stools should rarely
be present without the
use of laxatives.
3. Insufficient criteria for
IBS.
Criteria fulfilled for the
previous 3 months, with
symptom onset at least 6
months prior to diagnosis.

RISK
FACTORS
Advancing age
Female gender
Low level of education
Low level of physical activity
Low socioeconomic status
Nonwhite ethnicity
Drug induced
Suares NC, Ford AC. Prevalence of, and risk factors for, chronic idiopathic constipation in the
community: Systematic review and meta-analysis. Am J Gastroenterol 2011; 106:1582-91;

SECONDARY
CAUSES
Amold Wald, JAMA January 12, 2016 Volume 315,2

Clinical classification of functional constipation
Category Features Physiologic test results
Normal-transit
constipation
Incomplete evacuation, abdominal pain +/- Normal.
Slow-transit constipation Infrequent stools (1/wk),
lack of urge, poor response to fibre and
laxatives, generalised symptoms ;
More prevalent in young women.
Delay in colonic transit.
Defecatory disorder
(pelvic floor dysfunction,
anismus, descending perineum,
rectal prolapse)
Frequent straining, incomplete evacuation,
need manual maneuvers to facilititate
defecation
Abnormal balloon expulsion test
and/or anorectal manometry.
Lewis S, Heaton K. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997; 32:920-4.

FUNCTIONAL
DEFECATION
DISORDER
(Rome IV)
• DIAGNOSTIC CRITERA:- (must include all
of the following)
• The patient must satisfy diagnostic criteria for
functional constipation and/or IBS-C
• During repeated attempts to defecate, there must
be features of impaired evacuation, as
demonstrated by 2 of the following 3 tests:
a. Abnormal balloon expulsion test
b. Abnormal anorectal evacuation pattern with
manometry or anal surface EMG
c. Impaired rectal evacuation by imaging
*Criteria fulfilled for last 3 months with the
symptom onset of at least 6 months prior to diagnosis.

Clinical
Approach
Alarming features
Age ≥ 45 years
Change in stool calibre
Blood in stool
Unintended weight loss
Fever
Abdominal mass
Family history of gastrointestinal cancer
Iron-deficiency anemia
Recent onset constipation
Rectal bleeding
Rectal prolapse
Vomiting
Loss of appetite
Rao SS. Constipation: Evaluation and treatment. Gastroenterol Clin North Am 2003; 32:659-83.

Clinical Clues to an Evacuation Disorder
History
• Prolonged straining to expel stool
• Assumption of unusual postures on the toilet to facilitate
stool expulsion
• Support of the perineum, digitation of rectum, or
application of pressure to the posterior vaginal wall to
facilitate rectal emptying
• Inability to expel enema fluid
• Constipation after subtotal colectomy for constipation

History
contd…
• Diet history : The amount of daily fiber and fluid
consumed should be assessed. Many patients tend
to skip breakfast, and this practice may exacerbate
constipation, because the postprandial increase in
colonic motility is greatest after breakfast.
• Past medical history – Obstetric and surgical
histories are particularly important.
• Neurologic disorders may also explain some
cases of constipation.
• Drug history : including use of over-the-counter
laxatives and herbal medications and their
frequency of intake, is important.

DIGITAL RECTAL EXAMINATION

The American Journal of GASTROENTEROLOGY (April 2015)
CONCLUSION- DRE shows high sensitivity and positive predictive value in detecting
dyssynergia compared with HRAM, and could therefore be used as a bedside screening test
for the diagnosis of this disorder.

Rectal Examination
• Inspection-
• Anus “pulled” forward during attempts
to simulate strain during defecation.
• Anal verge descends <1 cm or >4 cm
(or beyond ischial tuberosities) during
attempts to simulate straining at
defecation.
• The perineum balloons down during
straining; rectal mucosa partially
prolapses through anal canal.

Palpation-
High anal sphincter tone at rest precludes easy entry
of the examining finger (in absence of a painful
perianal condition [e.g., anal fissure])
Anal sphincter pressure during voluntary squeeze
only minimally higher than anal pressure at rest
The perineum and examining finger descend <1 cm
or >4 cm during simulated straining at defecation
Tender puborectalis muscle.
Palpable mucosal prolapse during straining .
“Defect” in anterior wall of the rectum, suggestive
of rectocele
Collins J, et al. Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal examination: Ann Intern Med 2005; 142:81-5.

CASE
SCENARIO
35- year old
woman
• Constipation since 3 years.
• Hard stools every 4 days with feeling of incomplete
evacuation and abdominal bloating.
• No other medical problems and takes only occasional
laxatives.
• She has tried over-the-counter regimens
intermittently without resolution of her symptoms.
• Routine investigations and electrolytes are normal
Q: How will you investigate and manage this
patient..?

Tests for Systemic Disease
• Determination of the hemoglobin level, erythrocyte
sedimentation rate, and biochemical screening test levels
(e.g., thyroid function, serum calcium, glucose),
• Other appropriate investigations are indicated if the
clinical picture suggests that symptoms may be due to an
• Inflammatory,
• Neoplastic,
• Metabolic, or
• Other systemic disorder.
# Indian Society of Gastroenterology 2017

Tests for
Structural
Disease
• Imaging of the colon by CT, MRI, or barium
enema study reveals the width and length of the
colon and may be indicated to exclude an
obstructing lesion severe enough to cause
constipation.
• When fecal impaction is present, a limited enema
study with a water-soluble contrast agent
outlines the colon and fecal mass without
aggravating the condition.
• Imaging of the small bowel is indicated only
if obstruction or pseudo-obstruction involving
the small bowel is suspected.
• Endoscopy- indicated if alarming symptoms are
present.

Measurement of Colonic Transit Time
• The American and European Neurogastroenterology and Motility Societies
recommend 3 methods for assessing colonic transit time:
1. Radiopaque markers,
2. Wireless motility capsule, and
3. Scintigraphy.
Rao SS, Camilleri M, Hasler WL, et al. Evaluation of gastrointestinal transit in clinical practice: Position paper of the American and European
Neurogastroenterology and Motility Societies. Neurogastroenterol Motil 2011; 23:8-23.

RADIOPAQUE MARKERS (ROM)
• Radiopaque marker testing is used to distinguish normal from slow colonic
transit, assess segmental transit times, and evaluate the response to new
treatments.
• Colonic transit time is measured by performing abdominal radiography at
predetermined times after the patient ingests plastic beads or rings, and counting
the number of retained markers.
• NOTE- Before the study, patients should be maintained on a highfiber diet and
should avoid laxatives, enemas, or medications that may affect bowel function
Neurogastroenterol Motil (2011) 23, 8–23 Evaluation of gastrointestinal transit in clinical practice: position paper of the American & European Neurogastroenterology and Motility Societies

DIFFERENT PROTOCOLS FOR ROM
MEASUREMENT OF CTT
1. A single capsule containing 24 markers followed by a single abdominal X-ray on day 5
(120 h later). Retention of >5 markers is abnormal. There is limited radiation
exposure; however no quantitative information on CTT is provided.
2. Twenty-four markers of similar or different shapes are ingested daily for 3–6
consecutive days and X-rays are obtained on day 4 and 7 (or only on day 7). Transit
time is quantitated because equilibrium between daily marker output and input is
achieved by the time radiographs are taken.
3. A single dose of markers is ingested and serial X-rays are obtained every 24 h until no
markers are visible. This method is time consuming, inconvenient and produces
greater radiation exposure.
Neurogastroenterol Motil (2011) 23, 8–23 Evaluation of gastrointestinal transit in clinical practice: position paper of the American & European Neurogastroenterology and Motility Societies

Wireless motility capsule
• The wireless motility and pH capsule (WMC) is an orally
ingested, non-digestible capable of measuring gastric
emptying time, small bowel transit time, and colon transit
time as a single study.
• It consists of a single-use capsule measuring 26.8× 11.7
mm, a receiver, and data processing software.
• The capsule possesses sensors that continuously monitor
the temperature, pH, and pressure of its immediate
surrounds which are transmitted via radio waves to an
external receiver kept within 5 ft of the body.
Rao et al. Neurogastroenterol Motil (2011) 23, 8–23

WMC has demonstrated comparable results with traditional radiolabeled and radiographic motility testing
modalities.
WMC should be considered as an alternative for transit testing in suspected cases of gastroparesis, small
bowel dysmotility, and colon transit testing, and considered the test of choice in suspected conditions of
multiregional or generalized motility disorders.

COLON TRANSIT SCINTIGRAPHY
• Transit time is measured by capturing serial abdominal images using a gamma camera
at specified times after ingestion of a labeled meal (111In-DTPA-labeled water with standard
99mTc egg sandwich or 111In-labeled activated charcoal particles contained in a capsule).
• Images of the colon are obtained at specified times over 2-3 days after meal ingestion.
• Using scintigraphy, the mean colonic transit, expressed as the geometric center
(weighted average of the radioactivity distribution within the colon and stool), is 2.7 at
24 hours.
• A 24-hour colonic transit time less than 1.7 is considered slow transit.
Southwell BR, Clarke MC, Sutcliffe J, et al. Colonic transit studies: Normal values for adults and children with comparison of radiological and
scintigraphic methods. 2009; 25:559-72.

COLON TRANSIT SCINTIGRAPHY
Southwell BR, Clarke MC, Sutcliffe J, et al. Colonic transit studies: Normal values for adults and children with comparison of radiological and
scintigraphic methods. 2009; 25:559-72.

• Colonic transit scintigraphy: This shows examples of colonic transit scintigraphic images (A) from a
healthy subject with a normal geometric center (GC) count at 24 and 48 h and (B) from a subject with
constipation showing abnormally low values for geometric center of a isotope meal at 24 and 48 h due to
retention of radioisotope in the colon indicating delayed colonic transit.

Tests to Assess the Physiology of
Defecation
Clinical tests to assess for a defecatory disorder include
1. Defecography,
2. Balloon expulsion test, anorectal manometry and
3. Electromyography (EMG).
• To diagnose dyssynergic defecation, the Rome criteria require abnormality in 2 of the following 3 tests:
1. Impaired evacuation on balloon expulsion or defecography,
2. Inappropriate contraction of the pelvic floor muscles on manometry, imaging, or electromyography, and
3. Inadequate propulsive forces as assessed by manometry or imaging

DEFECOGRAPHY
• Defecography- It evaluates the rate and completeness of rectal emptying, anorectal
angle, and amount of perineal descent and identifies structural abnormalities (e.g.,
large rectocele, internal mucosal prolapse, intussusception).
• Thickened barium is instilled into the rectum, and films or videos are taken during
fluoroscopy with the patient sitting on a radiolucent commode while resting,
deferring defecation, and straining to defecate.
• Magnetic resonance defecography may offer advantages over standard barium
defecography, such as lack of radiation exposure and increased detection of
abnormalities during the defecation phase

DEFECOGRAPHY
Sheo kumar et al, Indian J radiological imaging 2013 Jan-Mar; 23(1): 92–96. doi:

SEVERE RECTAL DESCENT

PELVIC FLOOR WEAKNESS

SIGMOID DIVERTICULAE

MR Defecogram
• Normal position of the anorectal junction at rest (arrow
in a) with mild pelvic floor lift on squeeze (B)
On straining (C) and defecation (D)
• There is mild descent of the anorectal junction, with the
rectum and anal canal aligned in almost a straight line.
• The broken white line in (D) is the pubococcygeal line.
The broken black line is the “H line” corresponding to
the anteroposterior dimension of the hiatus.
• The solid black line is the “M line” which is the
perpendicular distance between the pubococcygeal line
and the posterior anorectal junction

ANORECTAL MANOMETRY
• The resting and maximum squeeze pressures of the anal sphincters,
• Rectoanal inhibitory reflex:- presence or absence of relaxation of the anal
sphincter during balloon distention of the rectum (absence of a rectoanal
inhibitory reflex raises the possibility of Hirschsprung’s disease),
• Rectal sensation, and
• Ability of the anal sphincter to relax during straining- A high resting anal
pressure suggests the presence of an anal fissure or anismus (paradoxical
contraction of the external anal sphincter in response to straining or pressure
within the anal canal).
Noelting J, Ratuapli SK, Bharucha AE, et al. Normal values for high-resolution anorectal manometry in healthy women: Am J Gastroenterol 2012; 107:1530-6

RECTOANAL GRADIENT
• Patients with a defecatory disorder commonly have inappropriate contraction
of the anal sphincter when they bear down.
• A positive rectoanal gradient (i.e., higher rectal than anal pressure) -
necessary for normal defecation,
• Whereas a negative rectoanal gradient- indicates defecatory disorder;
• However, asymptomatic persons often have abnormal anal sphincter
contraction during anorectal manometry.
Noelting J, Ratuapli SK, Bharucha AE, et al. Normal values for high-resolution anorectal manometry in healthy women: Am J Gastroenterol 2012; 107:1530-6

Rectoanal gradient contd…..
• In a study of healthy subjects, 36% had dyssynergia in the left lateral
position, but the presence or absence of dyssynergia did not predict the
ability to expel a balloon1.
• In a subsequent study using high-resolution anorectal manometry, the
rectoanal gradient was negative in a majority of asymptomatic women2.
• Although a negative rectoanal gradient may be supportive of a diagnosis of
dyssynergic defecation, it is not conclusive by itself and should be used
in conjunction with other physiologic testing
1) Rao SS, Kavlock R, Rao S. Influence of body position and stool characteristics on defecation in humans. Am J Gastroenterol 2006; 101:2790-6.
2) Noelting J, Ratuapli SK, Bharucha AE, et al. Normal values for high-resolution anorectal manometry in healthy women: Am J Gastroenterol 2012; 107:1530-6.

DYSSYNERGIC
DEFECATION
• Type 1- Adequate rectal push
effort with paradoxical
sphincter contraction
• Type 2- Inadequate rectal
push effort with paradoxical
anal sphincter contraction.
• Type 3- Adequate rectal push
but inadequate relaxation of
anal sphincter pressure.
• Type 4- Inadequate rectal
push effort plus inadequate
relaxation of anal sphincter.
S. Palit et al, Neurogastroenterol motil (2016)

BALLOON EXPULSION TEST
• It is a simple, office-based test that is indicated as a first-line screening
investigation for assessment of the ability to evacuate.
• With a patient lying in the left lateral position with hips and knees flexed, a
lubricated, preferably non-latex balloon attached to a plastic catheter is inserted into
the rectum and inflated with 50 ml of warm water.
• The patient is then seated on a commode in privacy and asked to expel the balloon.
• The ability (or inability) to expel the balloon and the time taken for expulsion is
recorded.
• The generally accepted limit for expulsion is between 1 and 3 min.
S. Palit et al, Neurogastroenterol motil (2016)

The sensitivity and specificity of BET is variable (ranging between 68–94% and 71–81%, respectively
Thus, BET in isolation is not sufficient to clearly diagnose an evacuation disorder

EMG
(ELECTROMYOGRAPHY)

NATURE REVIEWS | GASTROENTEROLOGY &
HEPATOLOGY VOLUME 15 | MAY 2018 |
Correspondence to E.V.C. 1National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK.

KEY POINTS OF THE ARTICLE
• No single investigation can fully assess anorectal function; for this reason, a range of
techniques are generally used to characterize the pathophysiology and aetiology of
symptoms.
• Anal endosonography and anorectal manometry (ARM) provide an assessment of
sphincter structure and function in patients with symptoms of faecal incontinence; ARM
with balloon expulsion and defecography identifies functional and/or structural
pathology in patients with evacuation disorders.
• Owing to the overlap of normal and abnormal values, the results of such functional
investigations should be interpreted carefully, taking into context the clinical picture and
the multifactorial aetiology of anorectal disorders.

HIGH RESOLUTION ANORECTAL MANOMETRY
Manometric equipment can record pressure data from single points in the anal canal (termed
‘conventional anal manometry’) or can record and display detailed information simultaneously from the
whole anal canal and distal rectum (high-resolution manometry)
Increased usage of the more detailed high-resolution solid-state methodology, probably in part due to the
ability of this technique to more accurately characterize sphincteric function
3D-HR-ARM records point pressures longitudinally and radially from sensors mounted on a rigid probe
with morphology represented in both 2 and 3 dimensions

ENDOANAL ULTRASONOGRAPHY
a | The mid-anal canal in a healthy volunteer,
demonstrating an intact internal anal sphincter
(IAS) (arrow) appearing hypoechoic and an
intact external anal sphincter (EAS)
(arrowhead) appearing hyperechoic.
b | Mid-anal canal in a patient with faecal
incontinence, demonstrating an IAS defect
between the 1 o’clock and 5 o’clock positions
(between the arrows).
c | Mid-anal canal in a patient with faecal
incontinence demonstrating an EAS defect,
evident as an area of hypoechoic discontinuity
between the 12 o’clock and 2 o’clock positions
(extent of defect between dashed lines).
d | Mid-anal canal in a patient with faecal
incontinence demonstrating IAS atrophy
(global thinning of the smooth muscle ring,
which is of mixed echogenicity and is difficult
to distinguish from surrounding structures;
arrow). The EAS is intact.

CASE
SCENARIO
contd….
35- year old
woman
• Constipation since 3 years.
• Hard stools every 4 days with feeling of incomplete evacuation and
abdominal bloating.
• No other medical problems and takes only occasional laxatives.
• She has tried over-the-counter regimens intermittently without resolution
of her symptoms.
• Routine investigations and electrolytes are normal.
• Investigation- radio opaque marker test revealed slow
whole gut transit.
• She was tried with laxatives and newer drugs in a step
wise manner but had no relief and hence referred to
you for further management ?
• What one history/investigation u ask to address her
sufferings.???
• Personal/ Social history- The patient gave a
history of substantial parental conflict throughout
her childhood and teenage years. She had a poor
relationship with her mother, whom she described
as lacking in emotional warmth

Behavioral Treatment Including Biofeedback
and Habit Training
• Most women have tried dietary manipulation and over-the-counter laxatives
by the time they reach a specialist. They often have found that laxatives lose
their effect over time.
• Patients are taught about bowel anatomy and function, and how to normalize
evacuation, sometimes with the aid of an intrarectal balloon to restore the
rectal sensation of the need to defecate
• The patient also is taught about toileting behavior, including regular timing
and position, and abdominal pressure.
Rao, S.S., Kinkade, K.J., Schulze, K.S., M.B.Biofeedback therapy for dyssynergic constipation randomized controlled trial
Gastroenterology. 2005; 128: A-269

AGA INSTITUTE
GUIDELINES
(2014)
Treatment of
Chronic Constipation
CLINICAL DECISION
SUPPORT TOOL

AGA INSTITUTE
GUIDELINES
2014
Treatment of NTC
and STC
CLINICAL DECISION
SUPPORT TOOL

AGA INSTITUTE
GUIDELINES
2014
Treatment for Defecating
Disorders
CLINICAL DECISION
SUPPORT TOOL

Hindawi : Yvonne Tse et al.Canadian Journal of Gastroenterology and Hepatology Volume 2017,

•The American Journal of Gastroenterology Supplements vol 2, pages38–46 (10 September 2016)

• Novel secretory drugs and high-affinity seratonin agonists remain a second-tier choice for CIC but
may have a more primary role in irritable bowel syndrome with constipation.
• Patients with CIC refractory to available laxatives should be tested for a defecation disorder using both
balloon expulsion testing and anorectal manometry before measuring colonic transit times. This is
important because functional defecatory disorders can often be treated effectively with biofeedback
techniques.
KEY POINTS
• The development of peripherally restricted μ-opiate receptor antagonists represents a major
advance in the treatment of OIC.
• It emphasizes the desirability of studies to compare new laxatives with established and inexpensive
laxatives, such as bisacodyl and PEG 3350, to help guide laxative use in CIC.

• In adults with STC, 6 days of FMT increase CSBMs per week, soften stool, speed up transit, and
improve symptoms of constipation, with a cure rate of 30% higher than conventional treatment.
• FMT is a promising cure in 1/3 of adult patients with STC.
• Optimizing treatment could result in further improvement.
Limitations:- First, the follow-up was limited to 12 weeks after the last FMT, which is insufficient to
evaluate the long-term safety of two treatments.
Second, this was a single-center study, and the sample size of this trial was relatively small.
Third, more comprehensive evaluation of the intestinal microbiome needs to be performed, such as using
16S ribosomal RNA and whole genome shotgun sequencing.

The squatting posture for defecation is more physiological, as shown in a few studies.
In a study by Sakakibara et al., comparing three postures during defecation (sitting,
sitting on a low chair, and squatting) showed that squatting required the shortest time
and least
effort to pass stool, which might be related to augmented abdominal pressure and
wider recto-anal angle

TAKE
HOME
MESSAGE
• Constipation has multiple symptoms,
mechanisms and etiopathology.
• The Bristol Stool Form Scale helps patients
and physicians to identify their stool form and
can be useful to assess colonic transit time
because very loose or hard stools correlate with
either rapid or slow colonic transit
• A detailed history, stool diary, digital Rectal
Exam and Colonic transit study are the
important preliminary steps in diagnosis.
• A careful perianal and digital rectal examination
is very important, as in many instances it is the
most revealing part of clinical evaluation

TAKE
HOME
MESSAGE
Contd…
• The first consultation is critical. Symptoms should
be acknowledged as real. Inquiring about adverse
life events should form part of the first
consultation.
• Anorectal manometry and balloon expulsion
test are useful for the diagnosis of dyssynergic
defecation.
• Colonic manometry helps to rule out underlying
neuromuscular pathology and facilitate selection
of patients for colon surgery.
• Wireless Motility Capsule is a novel technique
for assessment of colonic, whole gut and regional
gastrointestinal transit.

· Fiber, milk of magnesia
· Add lactulose/PEG
· Add bisacodyl/sodium picosulfate
· Adjust medication as needed
Standard blood test and colonic anatomic evaluation
to rule out organic causes; manage the underlying
constipation causing the pathology
Uncomplicated normal-
transit constipation
without alarm symptoms
In treatment-resistant
constipation,
Treatment of Slow
transit constipation
· Fiber, milk of magnesia, bisacodyl/sodium picosulfate
· Prucalopride, lubiprostone
· Add lactulose/PEG if no improvement
· In refractory constipation, a few highly selected
patients may benefit from surgery
SUMMARY OF TREATMENT (WGO GUIDELINES 2010)

THANK YOU

WGO GUIDELINES
(chronic constipation without alarm symptoms and no suspicion of an evacuation disorder)
Level 1—
limited resources
a) Dietary advice
(fiber and fluid)
b) Fiber
supplementation
c) Milk of
magnesia
d) Stimulant
laxatives (bisacodyl
better than senna)
for temporary use
Level 2—
medium resources
a) Dietary advice
(fiber and fluid)
b) Fiber
supplementation,
psyllium
c) Milk of
magnesia,
lactulose,
macrogol
d) Stimulant
laxatives for
temporary use
Level 3—
extensive resources
a) Dietary advice
(fiber and fluid)
b) Psyllium or
lactulose
c) Macrogol or
lubiprostone
d) Prokinetics
(prucalopride)
e) Stimulant
laxatives
(bisacodyl or
sodium
picosulfate)

Constipation

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