This document discusses chronic constipation. It notes that constipation prevalence increases with age and is affected by diet, lifestyle, and medical conditions. Diagnosis involves assessing symptoms, medical history, and tests of colon function. Treatment focuses on dietary fiber, laxatives, newer medications like lubiprostone and linaclotide, biofeedback therapy, and potentially surgery for severe cases not helped by other options.

1. Chronic Constipation
Dr. Imteaz Mahbub
MD Resident (Phase-B)
Department of Gastroenterology
Sir Salimullah Medical College

2. Introduction
 Constipation is the disorder in the gastrointestinal tract,
which can result in the infrequent stools, difficult stool
passage with pain and stiffness.
 Acute constipation may cause closure of the intestine,
which may even require surgery.
 Chronic constipation is a complicated among older
individuals which is characterized by difficult stool passage.

3. Prevalence
 The average prevalence of constipation in adults has been
estimated as 16% worldwide ( varies between 0.7% and
79%); whereas the prevalence of 33.5% was attributed to
adults aged 60 to 110 years.

4. Age and gender distribution
 Constipation among older people is more common.
 Common causes of constipation in the elderly are linked to
several factors including lack of normal bowel movements
or aging, lack of proper diet, lack of adequate fluid intake,
lack of adequate physical activity, illness or the use of drugs.
 Moreover, the prevalence of anatomic abnormalities like
rectocele, pelvic floor dyssynergia, and prolapse, are higher
in elderly people causing constipation.

5. Causes of constipation
 Pathogenesis is multifactorial with focusing on the type of
diet, genetic predisposition, colonic motility, and
absorption, as well as behavioral, biological, and
pharmaceutical factors.
 Moreover, low fiber dietary intake, in adequate water
intake, sedentary lifestyle, irritable bowel syndrome (IBS),
failure to respond to urge to defecate, and slow transit have
been revealed to be associated with predisposition.

7. Diseases and conditions as secondary cause
of constipation
Mechanical cause Colon,rectal, or anal stricture,rectocele and abnormal
narrowing of rectum or intestine.
Organic stenosis Colorectal cancer and tumor, intestinal irradiation,
diverticulitis, volvulus, intestinal masses,inflammatory or
surgical stenosis.
Psychological conditions Depression,anxiety,eating disease
Enteric neuropathies Hirschsprung disease, chronic intestinal pseudo- obstruction
Neurologic disorders MS, Parkinson disease, stroke, spinal cord injury,paraplegia,
spina bifida and autonomic neuropathy.
Endocrine and metabolic disorders DM,hypercalcemia,porphyria,
hypothyroidism,hyperthyroidism.
Myopathic disorders Scleroderma and amyloidosis
Anorectal disorders Anal strictures, fissures, and hemorrhoids
Connective tissue disorders lupus

8. Medications causing Constipation

9. Rectal sensorimotor dysfunction
 A number of factors are involved in functional disorders of
constipation and defined in patients with constipation
including rectal hyposensitivity, altered rectoanal reflex
activity, increased rectal duct capacity, and rectal motor
dysfunction.
 The role of abnormal visceral sensation is currently
considerd to be involved in the development of functional
bowel disorders with considerable attention to visceral
hyposensitivity.

10. Other factors
 Patients with constipation have psychological disorders with
a variety of stressful life events like anxiety, depression,
physical and sexual abuse and anorexia nervosa, as well as a
concomitant eating disorders.
 Low income people are likely to suffer from constipation
than their richer counterparts. On the other hand, a reverse
correlation between parental education and the incidence
of constipation has been found in different studies.

11.  A positive family history of constipation and living in a
densely populated society also play pivotal role in
development of constipation.
 Constipation causes many physical and mental problems for
many patients and can significantly affect the daily life and
well being of constipated individuals.

12. Diagnosis
Clinical presentation and evaluation
 Following inquiries should be done for constipation
-Frequency and consistency of stool
-Stool size
-Duration of symptoms
-Excessive obstruction
-Feeling of incomplete evacuation or the use of hand palpation
during defecation

13. -Any alarming symptoms or signs like
Changes in bowel habit after 50 years,
Acute onset of constipation in older individuals
Blood mixed in the stool
Weight loss
Anaemia
-

14. Inflammatory bowel disease
Symptoms of organic disorder
A strong family history of colorectal cancer
-Medical history
-Any organic causes

15. -Medications
-Exclusion of other secondary causes
 Using of Bristol stool form scale and bowel diaries is a
helpful means to predict colonic transit than self reported
stool frequencies.

17.  After initial history, rectal examination should be performed
in patients with chronic constipation to seek secondary
causes like anal fissure, haemorrhoids or rectocele.
 After history and physical examination, a series of test
should be performed to exclude metabolic or neurologic or
connective tissue disorder

18. -Complete blood count
-Serum electrolytes
-Glucose
-Calcium
-Urine R/E
-Thyroid function test
-Other investigations according to clinical suspicion

19. Special Investigations
 Endoscopy
- Structural procedures including flexible sigmoidoscopy or a
colonoscopy can be very effective in obtaining evidence for
the cause of unexplained symptoms, the use of chronic
laxatives and mucosal lesions
- Diagnostic colonoscopy is only necessary in individuals with
alarm symptoms or patients willing to undergo colonoscopy
for cancer screening.

20.  Anorectal Manometry
-It is a diagnostic procedure for measuring pressure activity of
anorectum, which can show rectal reflexes, rectal sensation,
rectal compliance, and the rectosphincteric reflex at rest and
during defecatory maneuvering.
-This procedure benefits from a pressure sensitive catheter
and a balloon at the tip of the tube to evaluate neuromuscular
and sensory abnormality of the anus and rectum.

21. -High resolution manometry has been applied to assess
colonic motor dysfunction in chronic constipation by its closely
spaced pressure sensors.

22.  Balloon expulsion testing
-It is used with manometry for determining dyssynergic
defecation .
-It has been applied as a part of pelvic floor dyssynergia
detection or excluding patient who do not have pelvic floor
dyssynergia.
-The test is performed to measure the amount of time
required to expel a rectal balloon filled with 25 ml or 50 ml
water or air and/or silicone filled stool like device.

23.  Barium enema
-It is a colon x ray procedure to define changes or anatomic
abnormalities of colon filled with a contrast.
-But it cannot be used adequately in clinical evaluation and
diagnosis of organic disease.
 Defecography and magnetic resonance defecography
-It is a radiological imaging that visualizes the anorectum and
pelvic floor.
-Here barium is placed in rectum and images taken when
barium leaves the body through anorectal regional function.

24. -MRD is a non invasive test to illustrate pelvic floor anatomy
and dynamic motion
-It is really useful to define structural abnormalities like
obstructed defecation syndrome and it has high soft
tissue contrast, good resolution, and lack of radiation
exposure.

25.  Colonic transit study
-In this procedure patient swallows a capsule and the progress
of the capsule through colon will be recorded over several
days and be visible on X rays.
-Its high specificity and sensitivity have been reported for
diagnosis of slow transit in constipated patients.

26. Overall approach for managing chronic
constipation
 Dietary fiber
-Fiber intake has been demonstrated to improve functional
constipation.
-It has been indicated that diets with soluble fiber (psyllum
15g daily or ispaghula) may benefit patients suffered from
chronic constipation and IBS.

27. -But there are studies which show less effectiveness of
supplementation specially who are suffering from slow
defecatory or slow transit constipation.
 Laxatives
-Regarding current evidence, osmotic, and stimulant laxatives
should be used as first treatment strategy.
-Inexpensive osmotic agents like Milk of magnesia once or
twice daily or polyethylene glycol (PEG) 17g daily have shown
good efficacy.

28.  Newer Medications
-A newer agent is required when laxatives are ineffective.
-Of the newer drugs, Lubiprostone is a bycyclic fatty acid which
was recommended at dosage of 24 micro gram per orally
twice daily as a gelatin capsule.
-Linaclotide is a guanylate cyclase 2C receptor agonist, which is
recommended for healing secondary endpoints such as stool
consistency, discomfort,bloating and straining.

29. -Prucalopride has been described as a selective high affinity 5-
HT4 receptor agonist which works as simulator of gut motility.
-It had promising effects in patients who did not respond to
conventional laxatives.
-Colchicine is an alkaloid substance, which used as an
inflammatory agent.

30. -It can increase the frequency of bowel movements in chronic
constipation.
-Alvimopan has been recommended for postoperative
paralytic ileus by FDA.
-Methylnaltrexone could be applied for patients suffering from
opioid induced constipation.

31.  Biofeedback therapy
- Biofeedback session implicates placing a probe into the anus
to give feedback of muscle tension using a computer screen.
-It is an efficient and multidisciplinary approach without any
adverse effect.

32. -Biofeedback therapy could be useful for improving bowel
symptoms and dyssynergic defecation with regard to therapist
motivation, training, severity of retaining program,
neuromuscular coordination ,visual , sounds and verbal
feedback methods.
-It has been observed that more than 70% of patients of
chronic constipation get rid of symptoms by this therapy.

33.  Surgical treatment
-Surgical treatment may be used as an option if medical
treatment fails and mechanical emptying of the colon may be
recommended by barium enema.
-Colectomy with ileorectal anastomosis has been introduced
to the treatment options in patients suffering from refractory
slow transit constipation.

34. -Moreover patients suffering from rectocele and
intussusceptions need to be recommended for repair and
pelvic floor training.

36. Conclusion
 The prevalence of chronic constipation is high and
therefore specific diagnostic and therapeutic means are
required for better management.
 Accurate history, along with a complete physical and digital
rectal evaluation and comprehensive approach, can be used
to diagnose acute or chronic constipation, as well as
primary or secondary condition.

37.  Diagnostic evaluation should be done with an appropriate
method to define the nature of colon transit or rectal
evacuation or approving the lack of a primary illness
resulting in constipation symptoms.
 Lubiprostone and Linaclotide can be considered as two
favorable drugs.

38.  Biofeedback therapy is a useful method for improving bowel
symptoms.
 Surgical interventions may be applied if medical treatment
fails , with adequate pelvic floor training and biofeedback
therapy before surgery.