American Gastroenterological AssociationAGA technical review on constipation☆
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).Empty Cell Empty Cell Empty Cell 1 g/serving ≥4 g/serving 2 or 3 g/serving Fruits Vegetables Whole-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.
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