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PubMed1994

Evidence for the ambiguity of the term constipation: the role of irritable bowel syndrome.

A satisfactory definition of constipation is elusive. An important and measurable element is slow colonic transit. Whole gut transit time, a proxy for colonic transit time, can be estimated from self recorded data on stool form and frequency. Our aim was to compare whole gut transit time with subjective definitions in the context of the general population. In a community based sample of 731 women aged 25-69 years the estimated whole gut transit time was compared with two subjective assessments of constipation-the woman's own perception and a symptom based definition proposed by an international working team (Rome definition). We have defined slow whole gut transit time as > 2 SD above the mean in women who seldom passed lumpy stools (that is, > 92 hours). Slow transit was present in 9.3% of the sample. Similar numbers met the subjective definitions (8.5% and 8.2%). However, the overlap between the three definitions was poor. Of 68 women with estimated slow transit, 28 had self perceived constipation, 20 had Rome defined constipation, and only 11 had both. Of subjects classified as constipated by the subjective definitions only 37% had slow transit; they had a high prevalence of irritable bowel symptoms. In conclusion, this study showed that the term constipation is ambiguous and often misleading and that attempts to base a definition on symptoms are misguided. In epidemiological studies, conclusions about the prevalence of constipation should be based on records of stool type and timing.

Adult↗
PubMed1994

Discriminant value of psychological distress, symptom profiles, and segmental colonic dysfunction in outpatients with severe idiopathic constipation.

Severe idiopathic constipation can be categorised based on physiological testing into subgroups including slow transit constipation and pelvic floor dysfunction. This study aimed to determine if colonic and psychological symptoms, or rectosigmoid transit times, could discriminate among these subgroups. Patients, categorised according to total colonic transit times and pelvic floor function testing, completed a self report questionnaire that recorded symptoms and psychological distress. Patients with normal transit constipation (n = 60) had significantly increased depression scores compared with those who had slow transit constipation (n = 70) or pelvic floor dysfunction (n = 30). The general severity index (GSI, a measure of overall psychological distress) negatively but weakly correlated with total colonic transit (r = -0.26, p < 0.01). A feeling of anal blockage was the only symptom that was associated with pelvic floor dysfunction (v normal transit constipation). Only a more regular defecation pattern, utilisation of different postures to defecate, and a feeling of incomplete evacuation were associated with slow v normal transit constipation. Psychological or colonic symptoms were not, however, significant discriminators in a multivariate analysis. Rectosigmoid transit times at 80% sensitivity had very poor specificity for discriminating pelvic floor dysfunction from other subgroups. It is concluded that clinical symptoms, psychological distress, and rectosigmoid transit times cannot be used to identify subgroups of patients with intractable constipation.

Adult↗
PubMedDate not supplied

Alleviating constipation in the elderly improves lower urinary tract symptoms.

BACKGROUND: Constipation and lower urinary tract symptoms (LUTS) very frequently occur in the elderly, and several reports have suggested that dysfunction in either one of these systems may affect the other. Most studies correlating rectal and bladder dysfunction, however, have been carried out in children or young women. OBJECTIVE: To examine the effect of alleviating constipation on LUTS in the elderly. METHODS: Fifty-two patients aged 65-89 (mean 72 +/- 13) years with chronic constipation and LUTS participated in this prospective cohort study. Before treatment of constipation was initiated and on their monthly visits, patients completed a questionnaire regarding their constipation pattern, urinary symptoms, sexual function and mood, and underwent urinalysis. Urinary tract anatomy and residual urine were evaluated by abdominal ultrasound at the commencement and completion of the study. Patients were followed up for 4 months. RESULTS: Treatment of constipation increased the number of weekly defecations from 1.5 +/- 0.9 to 4.7 +/- 1.2 (p < 0.001). Patients spent less time on the toilet (25 +/- 2.1 versus 63 +/- 1.9 min, p < 0.0001). Fewer patients reported urgency (16 versus 34, p < 0.001), frequency (25 versus 47, p < 0.001) and burning sensation during urination (6 versus 17, p < 0.05). There was improvement in the scoring of urgency, frequency and burning sensation (from a baseline of 52 to 126, 131 and 95, respectively, p < 0.001). Urinary stream disturbances improved in 32 of the 52 patients (p < 0.001). Residual urine volume decreased from 85 +/- 39.5 to 30 +/- 22.56 ml (p < 0.001). There was also a significant decrease in the number of patients with bacteriurial events (5 versus 17, p < 0.001), and an improvement in sexual activity and mood (p < 0.05). CONCLUSIONS: Our data demonstrated that medical relief of constipation significantly improves LUTS in the elderly which, in turn, improves the patient's mood, sexual activity and quality of life.

Aged↗
PubMed2006

Variability in the management of childhood constipation.

To assist primary care providers, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) published clinical practice guidelines for management of childhood constipation. A cross-sectional survey of pediatricians from across the United States was conducted to assess pediatricians' constipation management strategies, whether pediatricians are familiar with the NASPGHAN constipation guidelines, and reasons pediatricians refer constipated patients to a pediatric gastroenterologist. Overall, 75% of pediatricians used polyethylene glycol without electrolytes to treat childhood constipation, 8% of pediatricians were aware NASPGHAN had published constipation guidelines, and parental pressure was just one reason pediatricians referred constipated patients to a pediatric gastroenterologist.

Child, Preschool↗
PubMed2002

Economic impact of low dose polyethylene glycol 3350 plus electrolytes compared with lactulose in the management of idiopathic constipation in the UK.

OBJECTIVE: To estimate the economic impact of using low dose polyethyene glycol 3350 (PEG 3350) plus electrolytes (PEG+E) compared with lactulose in the treatment of idiopathic constipation in ambulant patients. DESIGN AND PERSPECTIVE: This was a decision analytic modelling study performed from the perspective of the UK's National Health Service (NHS). METHODS: The clinical outcomes from a previously reported single-blind, randomised, multicentre trial were used as the clinical basis for the analysis. These data were combined with resource utilisation estimates derived from a panel of six general practitioners (GPs) and four nurses enabling a decision model to be constructed depicting the management of idiopathic constipation with either PEG+E or lactulose over 3 months. The model was used to estimate the expected 3-monthly NHS cost of using either laxative to manage idiopathic constipation. MAIN OUTCOME MEASURES AND RESULTS: The expected 3-monthly NHS cost of using PEG+E or lactulose to manage idiopathic constipation was estimated to be 85 pound sterling and 96 pound sterling per patient, respectively (1999/2000 values). However, significantly more patients were successfully treated with PEG+E than lactulose (53% versus 24%; p < 0.001) at 3 months. GP visits were the primary cost driver for both PEG+E- and lactulose-treated patients, accounting for 56% (2.9 visits) and 73% (4.4 visits), respectively, of the expected NHS cost per patient at 3 months. Among PEG+E-treated patients, the acquisition cost of PEG+E was the secondary cost driver, accounting for 30% of the expected NHS cost per patient at 3 months, whereas the acquisition cost of lactulose accounted for only 11% of the expected NHS cost per lactulose-treated patient. District nurse domiciliary visits accounted for 4% and thyroid function tests for 2%. The costs of switched laxatives, concomitant laxatives, and gastroenterologist and colorectal surgeon visits collectively accounted for up to 9% of the total. CONCLUSIONS: The true cost of managing idiopathic constipation is impacted on by a broad range of resources and not only laxative acquisition costs. This study indicated that managing idiopathic constipation with PEG+E instead of lactulose reduces the expected 3-monthly NHS cost by 11 pound sterling per patient. Moreover, using PEG+E instead of lactulose is expected to double the percentage of patients successfully treated at 3 months. Hence, PEG+E is a dominant treatment compared with lactulose. This suggests that the decision to use either PEG+E or lactulose to treat idiopathic constipation should be based on efficacy, safety, patient preferences and total management costs, and not drug acquisition costs.

Adult↗
PubMed1995

Complaints of constipation in obsessive-compulsive disorder.

Psychoanalytic observation has launched a long tradition in medical literature that links constipation with obsessive-compulsive traits. This association, however, has never been tested empirically. The current investigation sought to test this hypothesized association empirically using a large, randomly sampled population database. Data from the Epidemiologic Catchment Area project collected with the Diagnostic Interview Schedule were analyzed to determine the association, if any, of complaint of medically unexplained constipation (ascertained from the somatization disorder section of the interview) with a DIS diagnosis of obsessive compulsive disorder (OCD). Reported history of constipation was significantly associated with a lifetime diagnosis of OCD in women (not men), even when controlling for symptom-reporting biases using number of other positive somatoform symptoms. This association was specific to constipation and OCD and did not apply to other functional bowel symptoms including diarrhea, bloating (gas), and abdominal pain. Other psychiatric disorders commonly implicated with functional bowel complaints--major depression and panic disorder--were not significantly associated with constipation controlling for effects of other somatoform symptoms. The lack of association of constipation with OCD in men in a general population sample fails to support psychoanalytic concepts that historically have linked these two phenomena, but a special relationship of OCD with constipation was present in women.

Constipation↗
PubMed2005

Differing coping mechanisms, stress level and anorectal physiology in patients with functional constipation.

AIM: To investigate coping mechanisms, constipation symptoms and anorectal physiology in 80 constipated subjects and 18 controls. METHODS: Constipation was diagnosed by Rome II criteria. Coping ability and anxiety/depression were assessed by validated questionnaires. Transit time and balloon distension test were performed. RESULTS: 34.5% patients were classified as slow transit type of constipation. The total colonic transit time (56 h vs 10 h, P<0.0001) and rectal sensation including urge sensation (79 mL vs 63 mL, P = 0.019) and maximum tolerable volume (110 mL vs 95 mL, P = 0.03) differed in patients and controls. Constipated subjects had significantly higher anxiety and depression scores and lower SF-36 scores in all categories. They also demonstrated higher scores of 'monitoring' coping strategy (14+/-6 vs 9+/-3, P = 0.001), which correlated with the rectal distension sensation (P = 0.005), urge sensation (P=0.002), and maximum tolerable volume (P = 0.035). The less use of blunting strategy predicted slow transit constipation in both univariate (P = 0.01) and multivariate analysis (P = 0.03). CONCLUSION: Defective or ineffective use of coping strategies may be an important etiology in functional constipation and subsequently reflected in abnormal anorectal physiology.

Adaptation, Psychological↗
PubMedDate not supplied

Idiopathic chronic constipation: pathophysiology, diagnosis and treatment.

Constipation is one of the most common disease in Western countries. Its prevalence is widely variable (5-30%), depending on criteria utilized for diagnosis. Usually constipated patients have mild-moderate symptoms and are self-treated. Only patients that do not benefit from simple therapy (dietary supplementation of fiber and water, laxatives) need examinations such as blood tests, colonoscopy, radiography with bario-enemas, intestinal transit time and manometry. These tests are able to differentiate idiopathic from secondary constipation. Idiopathic chronic constipation is a collective term that involves different functional disorders. More specific investigations (oro-cecal transit time, manometry, electromyography) allow one to distinguish between two different patterns of idiopathic chronic constipation (slow transit constipation and pelvic floor disease) and to utilize the appropriate treatment of disease. The aims of this paper are to review the recent world literature on chronic constipation and to propose a diagnostic and a therapeutic flow chart for this disorder.

Chronic Disease↗
PubMed2002

Evaluation of constipation.

Constipation is the reason for 2.5 million physician visits per year in the United States, with more than one half of these visits to primary care physicians. Patients and physicians frequently define constipation differently. To determine the underlying cause of constipation, it is important to evaluate the patient's general health, psychosocial status, medical illnesses, dietary fiber intake, and use of constipating medications. The differential diagnosis of constipation and the approach to its evaluation differ in adults and children. Tests of physiologic function are usually reserved for constipation that does not respond to conventional therapy. Family physicians can effectively manage most patients who have constipation.

Adult↗
PubMedDate not supplied

[Constipation in children].

Constipation is a common disease in paediatric age, with an incidence ranging from 0.3 to 8% in paediatric patients, and from 10 to 25% among paediatric gastroenterological patients. In 90-95% of cases constipation is a functional, and often due to an exclusively milky diet or, in advanced age, to an inadequate fibres intake. Among the organic forms causing constipation, especially in new-born age, Hirshsprung disease, anorectal malformations, intestinal atresiae and stenosis are frequent. Moreover, recent studies have shown that constipation is often the symptom of a cow's milk proteins intolerance, that leadis to colorectal mucosa inflammation, with peristalsis decrease and fecal slackness. In these patients a milk's proteins free diet recovers constipation. In most persistent forms, total intestinal transit time (TITT), anorectal manometry, sphynteric muscles electromyografy and defecofraphy are useful to the diagnosis. In more than 90% of cases simple diet revisions, fecal softening, evacuative suppositories and enemas recovers constipation, some times a psychological approach is useful. Furthermore, excellent results can be obtained by giving low doses of polietiltnglycol (PEG), which has been recently introduced for the treatment of functional chronic constipation.

Child↗
PubMed2001

Adult constipation: a review and clinical guide.

Constipation is a common complaint that can be a symptom of serious disease. Awareness of the potential etiologies can help direct the history, physical exam and subsequent work-up for the presenting individual. This article details the differential diagnosis and pathophysiology of constipation based on a review of the literature. The article is also designed to be useful as a guide to the work-up of constipation. Key elements of the history, physical exam and testing are outlined. Included is a detailed flow diagram to guide the work-up of constipation. Testing methods and their value in the evaluation of chronic idiopathic constipation are discussed. Finally, although the focus of this article is the evaluation of constipation, a section on the treatment of constipation is included.

Adult↗
PubMed2004

Occult constipation: a common cause of recurrent abdominal pain in childhood.

BACKGROUND: An estimated 10% of all children are subject to recurrent attacks of abdominal pain of unknown origin. When no organic cause is found, the working diagnosis is usually functional abdominal pain. OBJECTIVES: To investigate the possible causative role of occult constipation. METHODS: We defined occult constipation as the absence of complaints of constipation on initial medical history or of symptoms to indicate the presence of constipation. The diagnosis was made by rectal examination and/or plain abdominal X-ray. RESULTS: Occult constipation was found to be the cause of RAP in 42.6% of children examined. Treatment consisted of paraffin oil and phosphate enema. In 82.84% of cases the abdominal pain subsided considerably or disappeared within 2 weeks to 3 months of treatment. On telephone interview of the parents at 1-1.5 years after discharge, 96.5% reported that both the abdominal pain and constipation had subsided or disappeared. CONCLUSIONS: Occult constipation can be easily identified and treated in a large number of children with RAP who were diagnosed as having functional abdominal pain.

Abdominal Pain↗
PubMed2004

[Clinical characteristics of patients with chronic constipation after radical hysterectomy or delivery].

BACKGROUND/AIMS: This study was aimed to analyze the clinical characteristics of patients who developed constipation after radical hysterectomy or delivery and to investigate the results of biofeedback therapy for these patients. METHODS: Thirty-five chronic constipation patients with radical hysterectomy (radical hysterectomy group), 27 chronic constipation patients with delivery (delivery group) and 27 constipation patients with no history of hysterectomy or delivery (control group) were included. Clinical characteristics of these patients, including the results of biofeedback therapy, were analyzed. RESULTS: The delivery group showed higher rates of pelvic floor dyssynergia than the control group (14/27, 52% vs. 6/27, 22%; p<0.05). The prevalence of slow transit constipation was lower in the radical hysterectomy group and delivery group than in the control group (7/35, 20% and 5/27, 19% vs. 12/27, 44%; p<0.05). The prevalence of anatomical abnormalities was not different between the groups. The radical hysterectomy group showed higher rate of obstructive sensation and the delivery group showed higher rate of hard stool and digital maneuvers. The biofeedback therapy was effective in 10 out of 12 patients (91%) among the radical hysterectomy and delivery group. CONCLUSIONS: Radical hysterectomy and delivery seem to induce functional constipation, which may be caused by anorectal dysfunction such as pelvic floor dyssynergia. The biofeedback treatment was effective in functional constipation after radical hysterectomy or delivery.

Adult↗
PubMedDate not supplied

Gastrointestinal motility in constipation.

This study included ten subjects with normal intestinal habits and 25 with constipation. Data were collected from X-rays of gastrointestinal transit times and from intraluminal pressures in the sigmoid and rectum using electromanometry. A comparison of the results led to the following conclusions: a) transit times to the cecum were essentially similar in both the control group and patients with constipation; b) the barium contrast arrived faster in the proximal sigmoid of patients with constipation compared to the control group; c) the mean of the total time of gastrointestinal emptying was slower in constipation; d) under unstimulated conditions, the electromanometry study of the sigmoid and rectum showed a higher motility index in constipation than in the control group; e) the high values of the percent activity was the most important element in the elevation of the motility index in constipation; f) the propulsion and retention activities of the colon were higher in constipation than in normals, as was demonstrated by radiologic and electromanometric studies.

Adult↗
PubMed1984

Physiologic investigation of primary chronic constipation in children: comparison with the barium enema study.

Rectoanal manometry and a rectometrographic study were carried out on 31 control subjects and 63 constipated children. A single contrast barium enema was performed on all constipated children and on 20 children for whom this x-ray study (made for a reason other than constipation) was considered normal. This study allowed the determining of four manometric parameters (rectoanal inhibitory reflex threshold, rectorectal reflex threshold, conscious rectal sensitivity threshold, maximal anal resting closure pressure), of three rectometrographic parameters (maximal rectal tolerable pressure, maximal rectal tolerable volume, maximal rectal compliance), and of one radiologic parameter (rectopelvic ratio). It appeared that the barium enema study was not meaningful. The threshold of the inhibitory reflex and of the rectoanal reflex did not allow for a specific definition of abnormality in constipation. Anal closure pressure was higher in 38% of the constipated patients. The sensitivity threshold was significantly higher in the constipated group. In 79% of the patients an increase in rectal compliance was observed. Finally, in this series of constipated patients who did not have Hirschsprung's disease, organic abnormalities were demonstrated in 97% of the children.

Adolescent↗
PubMed1995

[Surgical therapy of rectal prolapse using rectopexy and resection. Effect of resection treatment on postoperative constipation and sphincter muscle function--a follow-up study of 112 patients].

Between 1985 and 1991, 112 patients underwent posterior abdominal rectopexy (n = 59 Ivalon sponge, n = 53 Vicryl-rectopexy) for complete rectal prolapse. The follow-up period was 3 months to 9 1/2 years. 25 patients with severe constipation and rectal prolapse were treated by rectopexy combined with colectomy (left colectomy n = 18, sigmoidectomy n = 3, ileo-sigmoidostomy n = 4). Left colectomy combined with Ivalon or Vicryl-rectopexy does not seem to increase operative and postoperative morbidity but tends to diminish constipation in 84% of patients. There were no complications attributable to bowel resection or anastomosis. Following abdominal rectopexy without resection constipation was reduced 7.5% only, the bowel function was unchanged in 69% and obstipation was improved after the operation in 23%. In the group of patients without evident constipation (n = 74) treated with synchrone resection has no benefit with regard to the new occurred constipation, recurrence prolapse and continence ability. Infection around the prosthesis developed in 1.5% in the resection group, and in 2.1% in the rectopexy alone group. The prolapse recurrence rate was 2.6%. Conclusion. Resection in conjunction with abdominal rectopexy tends to diminish postoperative constipation does not seem to increase operative morbidity, and is indicated in patients with constipation only.

Adult↗
PubMed1998

Constipation in elderly patients attending a polyclinic.

OBJECTIVE: To determine the prevalence of and risk factors for constipation in the elderly. Differences between the white and black elderly populations in this regard were examined. DESIGN: Cross-section hospital-based study. SETTING: The family medicine clinics at National and Pelonomi hospitals in greater Bloemfontein. PARTICIPANTS: 179 white and 188 black patients, born before 1930, visiting the clinics during December and January 1994/95 and seen by one doctor. MAIN OUTCOME MEASURES: Constipation. RESULTS: In both the black and white population groups 29% of the participants were constipated according to the definition used in this study. Depression was a risk factor for constipation in both population groups. Age over 80 years was a risk factor in the black participants. The fibre and fluid contents of participants' diets were not found to be associated with constipation. Pain during defaecation was positively associated with constipation. Forty-three per cent of the white and 76.6% of the black participants used laxatives. Of the white and black laxative users 14.3% and 21.5%, respectively, used more than one laxative at a time. CONCLUSION: The prevalence of constipation was high in both groups. Laxative use and abuse are very common in the black elderly population.

Age Factors↗
PubMed2002

Treatment Options for Refractory Childhood Constipation.

Constipation in children is very common. Childhood constipation responds successfully to medical therapies, behavioral modifications, or a combination of both in approximately 70% of children within 2 years of diagnosis. Persistence of constipation is associated with fecal incontinence, recurrent fecal impactions, and significant emotional problems. Refractory constipation that interferes with both the child's function and the family's life requires extensive evaluations in order to uncover its cause and devise appropriate therapeutic strategies. Children with persistent constipation can be divided into three broad categories: 1) those who have functional constipation, 2) those affected by enteric neuromuscular disorders, and 3) those whose constipation is associated with neurologic handicaps. Treatment options vary widely. The majority of patients require more aggressive medical and more intense behavioral interventions. Others benefit from novel approaches, including surgical intervention.

Journal Article↗