Gastroenterology

Gastroenterology

Volume 119, Issue 6, December 2000, Pages 1766-1778
Gastroenterology

American Gastroenterological Association
AGA technical review on constipation

https://doi.org/10.1053/gast.2000.20392Get rights and content

Abstract

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the Committee on March 4, 2000, and by the AGA Governing Board on May 21, 2000.

GASTROENTEROLOGY 2000;119:1766-1778

Section snippets

Epidemiology of constipation

Before addressing the question “how common is constipation?,” one must first define it, although even this fundamental issue is answerable only imperfectly. The typical medical definition of constipation emphasizes infrequent or difficult evacuation of feces,5 and physicians often define constipation as a bowel movement every 3 to 4 days or less.6 This opinion is likely based on a study of otherwise healthy people in Great Britain that found that 99% of the population had between 3 bowel

Risk factors for constipation

Although absolute prevalence estimated from these studies differs widely, there is good agreement as to the risk factors for constipation.12, 13, 18, 19, 20, 21, 22 Most studies find that self-reported constipation is more common in women than in men and that the prevalence increases with age. In one study, although self-reported constipation and laxative use increased with age, the proportion of subjects with 2 or fewer bowel movements per week was not associated with age.23 Constipation is

Economic impact

Given the number of people who in questionnaires report constipation, it comes as no surprise that this symptom contributes significantly to the costs of health care. Sonnenberg and Koch25 estimated that the condition accounted for 2.5 million physician visits per year; indeed, 1.2% of the U.S. population presented to a physician with constipation in any one year. Consultation was more common among women and increased with age. This rate of visits was stable from 1958 to 1986. Of these

Clinical features and pathophysiology

Although physicians often focus mainly on the infrequency of bowel movements in the definition of constipation, patients have a broader set of complaints. The lower limit of normal stool frequency usually quoted is 3 per week,7 and 2 or fewer stools weekly was included as one of the Rome criteria (Table 1). In this definition, frequency was only 1 of 6 prime features (including straining, hard stools, and a feeling of incomplete evacuation). It has been estimated that the symptoms encompassed

Clinical evaluation

Historical features are key, and the questioning must be specific. What feature does the patient rate as most distressing? Is it infrequency per se, straining, hard stools, unsatisfied defecation, or symptoms that occur between infrequent bowel movements (bloating, pain, malaise)? Strong emphasis on these last characteristics suggests an underlying IBS.10, 57

Pelvic floor dysfunction should be suspected strongly on the basis of a careful history and physical examination. Prolonged and excessive

Secondary encounters and referral consultations

Patients are referred for specialty consultation usually because their complaints continue despite the use of fiber supplementation and simple laxatives, and after conditions to which constipation may be secondary have been evaluated. The gastroenterologist will then need to consider the following major issues:

  • Given the variability of patient recall, a symptom diary may be instituted.

  • Has an underlying metabolic, structural, neurologic, or iatrogenic cause been overlooked? The checklist of

Diagnostic tests

These can be summarized most simply as an algorithm (Algorithm 1; see preceding Medical Position Statement). The sensitivities of these investigations has not been established; indeed, the details of their performances have not been well specified. Although there is general agreement as to the preferred approach,50, 51, 55, 56, 60, 61, 62, 63 our recommendations represent, at this time, the views of the authors. The issue of the best diagnostic approach is compounded further, because

Medical management

Treatment algorithms as included in the Medical Position Statement encapsulate our suggestions, and Table 4 is an extensive listing of common laxative agents including dosages and costs.

As a beginning approach, we suggest a gradual increase in fiber intake. This can be incorporated into the diet (Table 5) or used as standardized fiber supplements (Table 4).

. Content of dietary fiber of common foods

Empty CellEmpty CellEmpty Cell1 g/serving
≥4 g/serving2 or 3 g/servingFruitsVegetablesWhole-grain products
All bran (1/3; cup)10

Surgical treatment of STC

The treatment of colonic inertia, when well documented and assuming failure of an aggressive and prolonged trial of laxatives, fiber, and prokinetics, is total colectomy with ileorectal anastomosis.36, 55, 56 Patients need to be told that the procedure is designed to treat the symptom of constipation (difficult and infrequent evacuation) and that other symptoms (e.g., abdominal pain and bloating) that the patient associates with constipation may not necessarily be relieved by achieving regular

Conclusions

Based on the preceding review, an algorithmic approach to patients with constipation can be devised (see Algorithms 1–3 in the preceding Medical Position Statement).

After the initial history and physical examination, it should be provisionally possible to classify patients into one of several subgroups. Standard blood tests (complete blood count, thyroid-stimulating hormone, calcium) and a colonic structural evaluation (flexible sigmoidoscopy and barium enema or colonoscopy) should be performed

Acknowledgements

The authors thank E. P. Bouras, M. Camilleri, and members of the Mayo Clinic Motility Interest Group for their assistance in developing the algorithms.

The Clinical Practice and Practice Economics Committee acknowledges the following individuals whose critiques of this review paper provided valuable guidance to the authors: John Johanson, M.D., Arnold Wald, M.D., and William Whitehead, Ph.D.

References (95)

  • AM Metcalf et al.

    A simplified assessment of segmental colonic transit

    Gastroenterology

    (1987)
  • JB Knowles et al.

    Reliability of a modified sitz mark study of whole gut transit time (abstr)

    Gastroenterology

    (1998)
  • JA Kiernan et al.

    Sennosides do not kill myenteric neurons in the colon of the rat or mouse

    Neuroscience

    (1989)
  • DA Drossman et al.

    U.S. householder survey of functional gastrointestinal disorders

    Dig Dis Sci

    (1993)
  • JF Johanson

    Constipation

  • MJ Herz et al.

    Constipation: a different entity for patients and doctors

    Fam Pract

    (1996)
  • AM Connell et al.

    Variation of bowel habit in two population samples

    BMJ

    (1965)
  • RS Sandler et al.

    Bowel habits in young adults not seeking health care

    Dig Dis Sci

    (1987)
  • WG Thompson et al.

    Functional bowel disease and functional abdominal pain

    Gastroenterol Int

    (1992)
  • WG Thompson et al.

    Functional bowel disorders and functional abdominal pain

    Gut

    (1999)
  • A Sonnenberg et al.

    Epidemiology of constipation in the United States

    Dis Colon Rectum

    (1989)
  • JE Everhart et al.

    A longitudinal study of self-reported bowel habits in the United States

    Dig Dis Sci

    (1989)
  • WF Stewart et al.

    Epidemiology of constipation (EPOC) Study in the United States: Relation of clinical subtypes to socioeconomic features

    Am J Gastroenterol

    (1999)
  • R Jones et al.

    Irritable bowel syndrome in the general population

    BMJ

    (1992)
  • NJ Talley et al.

    Constipation in an elderly community: a study of prevalence and potential risk factors

    Am J Gastroenterol

    (1996)
  • AJ Campbell et al.

    Factors associated with constipation in a community based sample of people aged 70 years and over

    J Epidemiol Community Health

    (1993)
  • RB Stewart et al.

    Correlates of constipation in an ambulatory elderly population

    Am J Gastroenterol

    (1992)
  • RS Sandler et al.

    Demographic and dietary determinants of constipation in the US population

    Am J Public Health

    (1990)
  • WE Whitehead et al.

    Constipation in the elderly living at home. Definition, prevalence, and relationship to lifestyle and health status

    J Am Geriatr Soc

    (1989)
  • D Harari et al.

    Bowel habit in relation to age and gender. Findings from the National Health Interview Survey and clinical implications

    Arch Intern Med

    (1996)
  • AM Leroi et al.

    Prevalence of sexual abuse among patients with functional disorders of the lower gastrointestinal tract

    Int J Colorectal Dis

    (1995)
  • A Sonnenberg et al.

    Physician visits in the United States for constipation: 1958-1986

    Dig Dis Sci

    (1989)
  • SH Landis et al.

    Cancer statistics, 1998

    CA Cancer J Clin

    (1998)
  • PC Rantis et al.

    Chronic constipation—is the work-up worth the cost?

    Dis Colon Rectum

    (1997)
  • P Ghadirian et al.

    Epidemiology of sociodemographic characteristics, lifestyle, medical history, and colon cancer: a case-control study among French Canadians in Montreal

    Cancer Detect Prev

    (1998)
  • KW Heaton et al.

    Defecation frequency and timing, and stool form in the general population—a prospective study

    Gut

    (1992)
  • NJ Talley et al.

    Functional constipation and outlet delay: a population-based study

    Gastroenterology

    (1999)
  • DM Neims et al.

    Incidence of laxative abuse in community and bulimic populations: a descriptive review

    Int J Eat Disord

    (1995)
  • RM Mollen et al.

    The evaluation and treatment of functional constipation

    Scand J Gastroenterol

    (1997)
  • DM Preston et al.

    Anismus in chronic constipation

    Dig Dis Sci

    (1985)
  • DC Nyam et al.

    Long-term results of surgery for chronic constipation

    Dis Colon Rectum

    (1997)
  • S Chaussade et al.

    Determination of total and segmental colonic transit time in constipated patients. Results in 91 patients with a new simplified method

    Dig Dis Sci

    (1989)
  • JRM van der Sijp et al.

    Radioisotope determination of regional colonic transit in severe constipation: comparison with radio-opaque markers

    Gut

    (1993)
  • JB Wyman et al.

    Variability of colonic function in healthy subjects

    Gut

    (1978)
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