This document discusses constipation, including its definition, diagnostic criteria, types, diagnosis and evaluation, approach, and management. It begins by defining constipation and its most common symptoms. It then discusses the Rome III and ACG diagnostic criteria. It describes the main types of constipation as primary (normal transit, slow transit, defecatory disorders) and secondary. Various diagnostic tests are outlined including colonic transit tests, anorectal manometry, and defecography. The approach prioritizes evaluating for secondary causes and alarming features. The role of endoscopy is to exclude conditions like cancer or Hirschsprung's disease. Management options discussed include lifestyle changes, fiber supplements, laxatives, newer drugs like lub

1. Constipation
Prof. Mazen Naga
Faculty of Medicine, Cairo
University
Egypt

2. Definition
Diagnostic criteria
Types
Diagnosis & evaluation
Approach
Role of Endoscopy
Management

3. Why constipation?!
• Commonly encountered in clinical practice
• Negative impact on quality of life
• Health burden
• Not fully understood
• Mostly, a chronic condition
• Still new in understanding & management

4. Definition

5. Definition
Many symptoms encountered
• Hard stools
• Excessive straining
• Abdominal bloating
• Feeling of incomplete evacuation
• Infrequent bowel movements (<3 DPW)
• Use of digital maneuvers

6. Lee et al, J Neurogastroenterol Motil. 2014 Jul; 20(3): 379–387

7. Definition
Diagnostic criteria

8. Rome III diagnostic criteria of functional
constipation
Must include at least 2 of the following:
+ Loose stools rarely without laxatives
+ Insufficient criteria for IBS
*Criteria for 3 months, onset in 6 months

10. ACG Task Force Diagnostic criteria of Chronic
idiopathic constipation (CIC)
Unsatisfactory defecation
characterized by
-Infrequent stools
-Difficult stool passage
-or Both
Difficult stool passage includes:
-Straining
-Sense of difficulty passing stool
-Incomplete evacuation
-Hard / lumpy stools
-Prolonged time to stool
-Need for manual maneuvers
The presence of these symptoms for at least 3 months

11. Definition
Diagnostic criteria
Types

12. Subtypes of constipation
•Primary constipation
oNormal transit constipation (NTC)
oSlow transit constipation (STC)
oDefecatory Disorders (DDs)
oMixed types
•Secondary constipation
•IBS-C

13. Primary constipation
oNormal transit constipation (NTC)
oSlow transit constipation (STC)
oDefecatory Disorders (DDs)
oMixed types

14. Normal transit constipation (NTC)
Most common type
Stool passes through the colon at a normal rate
Stool frequency is often within the normal range
Patients find it difficult to evacuate their bowels
Patients in this category often overlap with IBS with
constipation (IBS-C)
The usually have psychological distress

15. Slow transit constipation (STC)
Young females
Infrequent bowel movements (typically < 1 /week)
Decreased urgency
Abdominal bloating & palpable stool in the sigmoid colon
Dysfunction of colonic smooth muscle activity, colonic reflexes,
neurotransmitters, or colonic pacemaker cell activity

16. Defecatory Disorders (DDs)
Significant straining
Spending long time on the toilet daily
Manual rectal evacuation using a finger, position changes or
enema
Laxatives are highly ineffective
Many patients had the disorder since childhood, suggesting
impaired learning of defecation

17. Defecatory Disorders (DDs)
• Inability to coordinate abdominal, rectoanal & pelvic floor muscles during
defecation
• Due to -inadequate rectal and/or abdominal propulsive force
-impaired anal relaxation (<20%)
-paradoxical external anal sphincter or puborectalis contraction
• Associated with : weak pelvic floor, rectocele, excessive perineal descent or
solitary rectal ulcer syndrome
• Associated with delayed gastric emptying in 32%, rectal hyposensitivity
(66%) & STC in (50%)

19. Secondary Constipation

20. Secondary Constipation
Medications
-Analgesics:
oNSAIDs
oOpioids
-Antihypertensive agents:
oDiuretics
oCalcium channel blockers
-Antidepressants
-Antihistamines
-Antiparkinson agents
-Metallic ions

21. Secondary Constipation
Metabolic disorders
• Diabetes
• Hypothyroidism
• Hyperparathyroidism
• Metabolic and electrolytes
imbalance Hypocalcaemia
• Hypokalaemia
• Hypomagnesaemia
Neuropathy
• Autonomic neuropathy
• Hirchsprung disease
• Amyloidosis
• CNS lesion

22. Secondary Constipation
Idiopathic and other associated conditions
• Parkinson disease
• Paraneoplastic syndromes
• Eating disorders
• Diet: low fibre, low intake, high protein
• Colonic obstructions Mass lesions
• Pseudo-obstruction

23. IBS-C

24. IBS-C
Rome III criteria stated that individuals with chronic
constipation should do not fulfill criteria for IBS
In practice, a clear separation between CIC and IBS-C with
constipation may be challenging
Studies have shown considerable overlap between them
entities & significant tendency for patients to migrate
between these diagnoses over time

25. Rome III criteria of IBS
Recurrent abdominal pain or discomfort at least 3 days / month in
the past 3 months associated with > 2 of the following:
- Improvement with defecation
- Onset associated with a change in frequency of stool
- Onset associated with a change in form (appearance) of stool
These criteria should be fulfilled for the past 3 months with
symptom onset at least 6 months before diagnosis

27. Definition
Diagnostic criteria
Types
Diagnosis & evaluation

28. Diagnosis & evaluation
1st step >>> Detailed History
- Alarming features : Bleeding
Weight loss
New onset > 50yr
Anaemia
Obstructive symptoms

29. Detailed History
• OCD
• Frequency
• Straining or not?
• Time spent in the toilet ?
• Stools shape & consistency ?
• Postural or digital manoeuvres to assist defecation ?
• complete or incomplete evacuation ?
• Use of laxatives ? Response?
• Exclude secondary causes

31. 2nd step >>> Rectal Examination
• Inspection >> hemorrhoids,
fissures, scars or skin
excoriation
• Digital Examination>> stricture,
spasm, tenderness, mass or
stool
• Lack of awareness of stool
can indicate rectal
hyposensitivity

32. Ask the patient to push
Normally >>>
o relaxation of the external anal sphincter
o relaxation of puborectalis
o perineal descent
o tightening of abdominal muscles
Dyssynergia >> one or more of these responses are absent

33.  Digital rectal examination >>
Dyssynergia
Sensitivity (75%)
Specificity (87%)
 Unfortunately, digital rectal
examination is not performed by
most physicians !

34. 7- Day Stool Diary
• Number of bowel movements per day
• Stool consistency (Bristol stool form type 1–7)
• Level of straining, use of digital maneuvers
• Feelings of incomplete evacuation
• Presence of pain and bloating
Predicts colonic transit time and therapeutic responsiveness
Törnblom H et al Am J Gastroenterol. 2012 May;107(5):754-60

35. Diagnostic colonic and anorectal tests
• Anorectal manometry
• Colonic transit assessment
• Balloon expulsion test
• Defecography and MR defecography
• Wireless motility capsule test
• Colonic manometry

36. Anorectal manometry
Assess >>resting & squeeze sphincter tone
rectoanal reflexes
rectal sensation
pressure changes during attempted defecation
Defecation >>intrarectal pressure increases (≥40 mmHg) &
external anal sphincter pressure decreases
Dyssynergia >> this response is impaired or uncoordinated

37. Type I: adequate rectal push effort with paradoxical anal sphincter
contraction
Type II: inadequate rectal push effort with paradoxical anal sphincter
contraction

38. Type III: adequate rectal push effort but inadequate relaxation (<20%) of anal
sphincter pressure
Type IV: inadequate rectal push effort and also inadequate relaxation (<20%) of
anal sphincter pressure

39. Colonic manometry
Assess>> resting colonic motility & pressure changes after
provocative stimulations such as meals or drugs
Slow-transit constipation who has failed to respond to
medical therapy
Multisensor solid state probe and ambulatory recorder or
with a stationary water perfusion system for 8 h

41. Colonic manometry
Selection of patients with STC for surgery
-Studies showed it helped to diagnose patients with colonic neuropathy
-Only 15% of these patients with colonic neuropathy responded to
medical or behavioral therapy >>> better surgical outcome
Selection of patients with STC who can respond to medical TT
- 64% of patients with normal colonic motility and with colonic myopathy
responded to aggressive medical treatment, including biofeedback
therapy

42. Colonic transit assessment
-Radio-opaque marker test
-Ingest one capsule 24 radio-opaque
markers on day 0
-120 h later (on day 5) a radiograph of
the abdomen is taken
-A colonic transit study is considered
abnormal if more than five (>20%)
markers are retained in the colon

44. Balloon expulsion test
Expulsion time of >2 min
is considered abnormal
High specificity (80-90%)
& low sensitivity (50%)
for Dyssynergia

45. Defecography
150 ml of barium paste is
placed in the rectum & the
patient is asked to expel the
barium in a sitting position on
a special commode

46. Pros:
• Provides useful information about anatomical changes such as
rectocele, rectal prolapse and intussusception
• Dynamic changes such as descending perineum syndrome &
dyssynergic defecation
Cons:
• Radiation
• Poor agreement exists between observers
• Patients feel embarrassed during the test

47. MR Defecography
• Pros
-No radiation exposure
-More precise
-Reproducible measurements
-Excellent details of all pelvic floor compartments, muscles,
soft tissue & supporting structures
-When performed in the open system the patient is seated
(more physiological)
• Cons
-More expensive
-When performed in a closed setting, the patient is lying
position

48. Rest
Straining
Squeeze
Defecation

49. Wireless motility capsule test (WMC)
• Patients ingests a
wireless capsule that
is detected in stools
within 24-48 hrs
• Measures pH,
temperature &
pressure

50. Wireless motility capsule test (WMC)
• FDA approved
• Recommended by the American and European Neuro-
gastroenterology and Motility Societies
• No radiation exposure
• Assesses regional (gastric, small bowel and colonic) & also
whole-gut transit time
• Normal colonic transit time <59 h
• Whole gut transit time is <73 h

51. Definition
Diagnostic criteria
Types
Diagnosis & evaluation
Approach

52. AGA Medical Position Statement on Constipation
Alarming features >>
Colonoscopy
Exclude 2nd causes

53. Definition
Diagnostic criteria
Types
Diagnosis & evaluation
Approach
Role of Endoscopy

54. 1. Alarming features
2. To exclude obstruction from cancer, stricture, and extrinsic
compression
3. Prior to surgery for constipation
4. In younger patients, a flexible sigmoidoscopy may be
sufficient to exclude distal disease
5. Suspected Hirschsprung’s disease requires deep biopsy

55. 6. Patients aged > 50 years who have not had prior colorectal
cancer screening should undergo colonoscopy
7. Percutaneous endoscopic cecostomy or colostomy in
children with severe refractory constipation e.g neurogenic
bowel
8. In adults with acute colonic pseudo-obstruction and
neurogenic bowel, percutaneous endoscopic cecostomy
may be effective when conservative treatment fails

56. Definition
Diagnostic criteria
Types
Diagnosis & evaluation
Approach
Role of Endoscopy
Management

58. Patient education

59. Life style modification
8
>25
30

60. Adverse eventsActionDrugsLaxatives
Flatulence, bloating, abdominal
distension; rarely causing
mechanical obstruction
Retaining water in stool,
increasing stool bulk and
improving consistency
Psyllium, calcium
polycarbophil,
methylcellulose,
bran
Bulk (fibre)
laxatives
Intestinal cramping; irritation
of throat (liquid formulation)
Promoting luminal water
binding by detergent-like
action,increasing stool bulk
Docusate sodium,
docusate calcium
Stool
softeners
Abdominal discomfort, rarely
electrolytes disturbance,
melanosis coli
Increasing intestinal peristalsis
by acting on myenteric nerve
plexus, decreasing large
intestinal water absorption
Senna, aloe, bisacodyl,
sodium picosulfate
Stimulant
laxatives
Bloating, flatulence, abdominal
cramping; in rare instances,
electrolytes disturbances
Osmotic water bindingPEG, lactulose, sorbitol,
milk
of magnesia,
magnesium citrate
Osmotic
Laxatives
Flatulence, bloatingStool bulking and osmotic
action
Dried plumsMixed
laxatives

61. New Drugs
1. Colonic Secretagogues
Lubiprostone
Linaclotide
Plecanatide

62. Lubiprostone
• Action: Selective activation of intestinal epithelial
chloride channel 2 >> increasing chloride secretion

63. Lubiprostone
•Approved for CIC & IBS-C
• Dose : 24 μg twice daily; orally
• Not studied in hepatic & renal patients
• Avoided in pregnancy & lactation
• Adverse events : nausea, diarrhea &
headache ?dyspnea

64. Linaclotide
• Guanylate cyclase C activators
• Activation of guanylate
cyclase C receptor on
enterocytes, increasing cGMP,
activating CFTR, increasing
luminal chloride and/or
bicarbonate secretion;
ameliorating visceral
hypersensitivity

65. Linaclotide
• Approved for CIC & IBS-C
• Dose : 145 μg daily; orally
• Not studied in hepatic & renal patients
• Avoided in pregnancy, not studied in
breast feeding
• Adverse events : diarrhea
• Improves abdominal pain

66. Plecanatide
• Uroguanylin analogue, dependent. Activation of guanylate cyclase C
receptor on enterocytes, increasing cGMP, activating CFTR, increasing
luminal chloride and/or bicarbonate secretion; ameliorating visceral
hypersensitivity

67. Plecanatide
• Approved for CIC & IBS-C
• Dose : 3-6 mg; orally
• Not studied in hepatic & renal
patients
• Not studied in pregnancy & breast
feeding
• Adverse events : diarrhea
• Improves abdominal pain

68. New Drugs
2. Opioid receptor antagonists
Methylnaltrexone
Alvimopan
Naloxegol

69. • Enteric opioid receptor antagonism, with minimal absorption and not
crossing blood–brain barrier
• All approved in Opiate-induced constipation
• Methylnaltrexone & Alvimopan used in postoperative ileus
•

70. NaloxegolAlvimopanMethylnaltrexone
12.5–25 mg; orally6–12 mg twice daily, 30–
300 mins prior to surgery
then twice daily for 7
days
0.15–0.3 mg/ kg) every
other day, SC
N/AAvoidHalf dose in severe renal
and hepatic
Abdominal pain,
diarrhoea, nausea,
vomiting, headache,
flatulance
Nausea, vomitingAbdominal cramping,
flatulence, nausea

71. New Drugs
3. Serotonergic agonists
Prucalopride

72. Prucalopride
• Selective 5-HT4 receptor activation with
enhancement of gut motility by contraction of
proximal smooth muscles and relaxation of distal
smooth muscles, cAMP mediated colonic chloride
secretion
• CIC & IBS-C 2 mg daily Dose
• Adjustment in severe renal and hepatic failure
• Adverse: Headache, nausea, diarrhoea, abdominal
pain; unfounded concerns for ischaemic colitis
• Avoid in pregnancy & breast feeding

73. Management of dyssynergic defecation
Biofeedback
The goal is to correct and
restore the dyssynergic
behaviour and restore normal
defecation and to improve
rectal sensory perception

74. Management of dyssynergic defecation
Biofeedback is an instrument-
based ‘operant conditioning’
technique
The instruments include a
manometry probe,
electromyography probe,
simulated balloon or home
biofeedback training device

75. Management of dyssynergic defecation
• Typically, the device is placed
in the rectum
• Diaphragmatic muscle
training with simulated
defecation, manometry-
guided pelvic floor training &
simulated defecation training
• The simulated defecation
training can be performed
with a water-filled balloon

76. Biofeedback therapy
• Few studies, proved efficacy for >2 years
• Sensory retraining might be required to improve bowel function in
patients with impaired rectal sensation
• The success of biofeedback therapy depends on both the patient’s
motivation & the skill of the therapist
• Grade A recommendation for the treatment of dyssynergic defecation
by the American Neurogastroenterology and Motility Society & the
European Society of Neurogastroenterology and Motility

77. Surgical options
- Colectomy
- Cecostomy
- Sacral nerve stimulation

80. Take home message
• Constipation is common, impairs quality of
life and consumes health-care resources
• Recognition of whether constipation is
primary or secondary is key for appropriate
management
• A detailed history &
physical examination
including digital rectal
examination is
important and can
identify an evacuation
disorder

81. Take home message
• Physiological tests such as colonic transit assessment, anorectal
manometry and the balloon expulsion test can facilitate
stratification of patients with different constipation subtypes
• Newer drugs, such as linaclotide and lubiprostone, laxatives, and
biofeedback therapy can considerably improve symptoms in
patients with chronic constipation

88. Modified Rome III diagnostic criteria
The criteria should be fulfilled for the past 3 months with symptom onset
at least 6 months before diagnosis
There are
insufficient criteria
for IBS
Must include > 2: (at least 25% of defecations)
• Straining
• Lumpy or hard stools
• Sensation of incomplete evacuation
• Sensation of anorectal obstruction and/or
blockage
• Manual maneuvers to facilitate
Loose stools are
rarely present
without use of
laxatives