Chronic Constipation

Aka: Chronic Constipation, Functional Constipation, Normal Transit Constipation, Constipation due to Functional Causes, Constipation Management

1. See also
   1. Constipation
   2. Constipation Causes
   3. Constipation in Children
   4. Pediatric Constipation Management
   5. Pediatric Constipation Dietary Management
2. Definition: Chronic Functional Constipation (Rhome II)
   1. Timing Criteria
      1. Symptoms present 12 weeks in prior 12 months
      2. Less than 3 stools per week
   2. Symptoms affect >25% of stools (two or more present)
      1. Straining
      2. Lumpy or hard stools
      3. Sensation of incomplete evacuation
      4. Sensation of anorectal obstruction
      5. Attempts at self disimpaction (manual maneuvers)
   3. Excluding symptoms
      1. No signs Organic Constipation (Acute Constipation)
         1. See Constipation for red flag symptoms
      2. No loose stools present
      3. Irritable Bowel Syndrome
3. Causes
   1. See Constipation Causes
   2. Inadequate water intake
   3. Low fiber dietary intake
   4. Sedentary lifestyle
   5. Altered motility
      1. Irritable Bowel Syndrome
      2. Slow transit
      3. Failure to respond to urge to defecate
4. Symptoms and Signs Suggestive of Functional Constipation
   1. No red flags suggestive of Organic Constipation
      1. See Constipation for list of red flag symptoms
   2. Chronic duration
   3. No Weight loss
   4. No systemic symptoms
5. Diagnostics
   1. Colorectal Transit Time
   2. Colonic Contrast Study (single/double contrast barium)
   3. Evacuation Proctography
6. Management: Initial Symptomatic Treatment
   1. See Laxative
   2. Disimpact stool if Fecal Impaction
   3. Protocol recommended by AGA
      1. Step 1
         1. Milk of Magnesia (Magensium Hydroxide)
         2. Increase Dietary Fiber
         3. Review prevention as described below
      2. Step 2
         1. Add Bisacodyl to Step 1 regimen
      3. Step 3
         1. Add Polyethylene glycol (e.g. Miralax)
   4. Consider bowel evacuation
      1. Evacuation Protocol
         1. Enemas (e.g. Fleet Enema) twice daily for 3 days
      2. Alternative evacuation protocol
         1. Polyethylene glycol 4-8 Liters per day until clean
         2. Contraindicated in Bowel Obstruction, fecal impact
7. Management: Special Circumstances
   1. See Narcotic Related Constipation
   2. Women with refractory chronic Functional Constipation
      1. Colchicine 0.6 mg PO tid (4 weeks of use in trial)
      2. Verne (2003) Am J Gastroenterol 98:1112-6
8. Prevention
   1. Eliminate all Laxative use
      1. Laxatives cause rebound Constipation
      2. Lactulose may be used infrequently prn
      3. Replace all Laxatives with Bulk-Forming agents
      4. Anticipate 1-2 week adjustment period
         1. Use Fleet Enema if no stool q3 days for 1-2 weeks
   2. Increase Dietary Fiber or Bulk-forming agent (Psyllium)
      1. Used with >1.5 L/day fluids to prevent worsening
      2. Increase to 20 grams of Dietary Fiber per day
      3. Anticipate initial bloating with fiber intake
         1. Increase fiber by 5 grams per day per week
      4. May exacerbate atonic colon or slow transit colon
         1. These patients may benefit from low fiber intake
   3. Increase hydration to at least 64 ounces per day
   4. Avoid caffeine
   5. Participate in regular Exercise
   6. Bowel Retraining: Avoid stool retention
      1. Take the time to go to the bathroom regularly
      2. Make use of physiologic bowel cycles
         1. Plan Bowel Movement soon after waking
         2. Plan Bowel Movement 10-30 minutes after meal
      3. Consider initiating program with enema or suppository
         1. Lukewarm enema within one hour of meal
         2. Bisacodyl suppository immediately after meal
      4. Consider enema for no stool in 2 days
9. References
   1. Cheskin in Barker (1995) Ambulatory Medicine, p. 479
   2. Borum (2001) Prim Care 28(3):577-90
   3. Hsieh (2005) Am Fam Physician 72:2277-85
   4. Thompson (1999) Gut 45(suppl 2):1143-7
   5. Wald (2000) Med Clin North Am 84(5):1231-46