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==Medical Therapy==
==Medical Therapy==
* General principles of medical therapy in patients with chronic constipation are as following:<ref name="pmid20801775">{{cite journal| author=Camilleri M, Bharucha AE| title=Behavioural and new pharmacological treatments for constipation: getting the balance right. | journal=Gut | year= 2010 | volume= 59 | issue= 9 | pages= 1288-96 | pmid=20801775 | doi=10.1136/gut.2009.199653 | pmc=3189401 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20801775  }}</ref>
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=== Chronic constipation management ===
* Chronic constipation treatment includes both behavioral and pharmacological interventions.
* Behavioral management mostly consists of life style and dietary modification, while pharmacological interventions are mostly based on laxatives.
==== Lifestyle modification ====
* Increasing physical activity is postulated to improve constipation and colonic transit time in patients with constipation.<ref name="pmid2604760">{{cite journal |vauthors=Meshkinpour H, Kemp C, Fairshter R |title=Effect of aerobic exercise on mouth-to-cecum transit time |journal=Gastroenterology |volume=96 |issue=3 |pages=938–41 |year=1989 |pmid=2604760 |doi= |url=}}</ref>
* Moderate physical exercise as much as 32 min per day showed significant improvement of quality of life but no significant decrease in laxative need for treatment.<ref name="pmid16875507">{{cite journal |vauthors=Chin A Paw MJ, van Poppel MN, van Mechelen W |title=Effects of resistance and functional-skills training on habitual activity and constipation among older adults living in long-term care facilities: a randomized controlled trial |journal=BMC Geriatr |volume=6 |issue= |pages=9 |year=2006 |pmid=16875507 |pmc=1562427 |doi=10.1186/1471-2318-6-9 |url=}}</ref>
* Moderate to vigorous training (20-60 min, 3-5 times per week) revealed significant improvement in constipation symptoms in patients with irritable bowel syndrome (IBS).<ref name="pmid21206488">{{cite journal |vauthors=Johannesson E, Simrén M, Strid H, Bajor A, Sadik R |title=Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial |journal=Am. J. Gastroenterol. |volume=106 |issue=5 |pages=915–22 |year=2011 |pmid=21206488 |doi=10.1038/ajg.2010.480 |url=}}</ref>
==== Dietary interventions ====
* Fiber supplementation is the main primary therapeutic intervention for every patients with constipation.
* The polysaccharide fibers are the agents that increase the weight of stool and and improve the stool consistency through absorbing and retaining water.<ref name="pmid19824937">{{cite journal |vauthors=Emmanuel AV, Tack J, Quigley EM, Talley NJ |title=Pharmacological management of constipation |journal=Neurogastroenterol. Motil. |volume=21 Suppl 2 |issue= |pages=41–54 |year=2009 |pmid=19824937 |doi=10.1111/j.1365-2982.2009.01403.x |url=}}</ref>
* The most common used bulking organic polysaccharide in Canada is [[Psyllium]]. Psyllium is found to significantly decrease colonic transit and improve stool consistency, as well as lactulose.<ref name="pmid8824651">{{cite journal |vauthors=Ashraf W, Park F, Lof J, Quigley EM |title=Effects of psyllium therapy on stool characteristics, colon transit and anorectal function in chronic idiopathic constipation |journal=Aliment. Pharmacol. Ther. |volume=9 |issue=6 |pages=639–47 |year=1995 |pmid=8824651 |doi= |url=}}</ref>
* <ref name="pmid9891195">{{cite journal |vauthors=Dettmar PW, Sykes J |title=A multi-centre, general practice comparison of ispaghula husk with lactulose and other laxatives in the treatment of simple constipation |journal=Curr Med Res Opin |volume=14 |issue=4 |pages=227–33 |year=1998 |pmid=9891195 |doi=10.1185/03007999809113363 |url=}}</ref>
==== Biofeedback treatment ====
* The most important behavioral treatment for constipation is biofeedback, consisting of teaching the patients how to use their abdominal and pelvic muscles during defecation.
* During the biofeedback patients receive feedback upon their abdominal and pelvic floor muscle contractions recording by means of surface electromyogrphy (EMG).
* Based on the biofeedback, patients are been taught how to increase intra-abdominal pressure and also relax their pelvic floor muscles to have a coordinated evacuation.<ref name="pmid20801775" />
* Regarding the outcomes, the biofeedback behavioral therapy is the choice treatment for functional defecation disorder.<ref name="pmid16012938">{{cite journal |vauthors=Chiarioni G, Salandini L, Whitehead WE |title=Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation |journal=Gastroenterology |volume=129 |issue=1 |pages=86–97 |year=2005 |pmid=16012938 |doi= |url=}}</ref>
==== Pharmacological intervention ====
===Constipation===
* '''1 Adult'''
** '''1.1 Over the counter medicines'''
*** 1.1.1 '''''Bulk forming agents'''''
****Preferred regimen (1): Citrucel 500 mg PO q8-12h
****Preferred regimen (2): FiberCon 625 mg PO q6-12h
****Preferred regimen (3): Konsyl 5 g (1 tablespoon) dissolved in 250 mL water PO q8-24h
****Alternative regimen (1): Metamucil 1000 mg PO q8-12h
***1.1.2 '''''Osmotic agents'''''
****Preferred regimen (1): Cephulac 5 g (1 tablespoon) dissolved in 250 mL water PO q6-8h
****Preferred regimen (2): Fleet Phospho-Soda 15 mL dissolved in 250 mL water PO q6-8h
****Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
****Alternative regimen (1): Miralax 34 g dissolved in 250 mL water PO daily
****Alternative regimen (1): Sorbitol 30-150 mL (70% solution) once
***1.1.3 '''''Stool softeners'''''
****Preferred regimen (1): Colace 100-300 mg PO daily
****Preferred regimen (2): Docusate
*****Docusate sodium: 50-300 mg PO daily
*****Docusate calcium: 240 mg PO daily
****Alternative regimen (1): Surfak 240 mg PO daily
***1.1.4 '''''Lubricants'''''
****Preferred regimen (1): Fleet 19 g dissolved in 118-197 mL water PO daily
****Preferred regimen (2): Zymenol
***1.1.5 '''''Stimulants'''''
****Preferred regimen (1): Correctol 
****Preferred regimen (2): Dulcolax
****Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
****Alternative regimen (1): Purge
****Alternative regimen (1): Senokot 
*'''1.2 Prescription medicines'''
**1.2.1 '''''Chloride channel activators'''''
***
**1.2.2 '''''Guanylate cyclase-C agonists'''''
* '''2 Pediatrics'''
** '''2.1 Over the counter medicines'''
*** 2.1.1 '''''Bulk forming agents'''''
**** Preferred regimen (1): Citrucel 500 mg PO daily
**** Preferred regimen (2): FiberCon 625 mg PO daily
****Preferred regimen (3): Konsyl 2.5 g (1/2 tablespoon) dissolved in 250 mL water PO q8-24h
****Alternative regimen (1): Metamucil 500 mg PO q8-12h
***1.1.2 '''''Osmotic agents'''''
****Preferred regimen (1): Cephulac 2.5 g (1/2 tablespoon) dissolved in 250 mL water PO q6-8h
****Preferred regimen (2): Fleet Phospho-Soda 5-10 mL dissolved in 250 mL water PO q6-8h (not for < 5 years of age)
****Preferred regimen (3): Milk of Magnesia 5-15 mL PO daily
****Alternative regimen (1): Miralax 17 g dissolved in 250 mL water PO daily 
****Alternative regimen (1): Sorbitol 2 mL/kg (as 70% solution) once
***1.1.3 '''''Stool softeners'''''
****Preferred regimen (1): Colace 100 mg PO daily
****Preferred regimen (2): Docusate
*****Docusate sodium
******< 2 years: Not recommended
******2-12 years: 50-150 mg PO daily
******>12 years: 50-300 mg PO daily
*****Docusate calcium
******< 12 years: Not recommended
******>12 years: 240 mg PO daily
****Alternative regimen (1): Surfak 50 mg PO q12h
***1.1.4 '''''Lubricants'''''
****Preferred regimen (1): Fleet 19 g dissolved in 118-197 mL water PO daily
****Preferred regimen (2): Zymenol
***1.1.5 '''''Stimulants'''''
****Preferred regimen (1): Correctol 
****Preferred regimen (2): Dulcolax
****Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
****Alternative regimen (1): Purge
****Alternative regimen (1): Senokot 
==== Laxatives ====
==== Prokinetics ====
==== Probiotics ====
==== 5-HT receptor agonists ====
==== Other agents ====
===Physical Intervention===
===Physical Intervention===
Constipation that resists all other measures requires physical intervention. ''Manual disimpaction'' (the physical removal of impacted stool) is done by patients who have lost control of their bowels secondary to spinal injuries. Manual disimpaction is also used by physicians and nurses to relieve rectal impactions. Finally, manual disimpaction can occasionally be done under [[sedation]] or a [[General anaesthetic|general anesthetic]]—this avoids pain and loosens the anal sphincter.  
Constipation that resists all other measures requires physical intervention. ''Manual disimpaction'' (the physical removal of impacted stool) is done by patients who have lost control of their bowels secondary to spinal injuries. Manual disimpaction is also used by physicians and nurses to relieve rectal impactions. Finally, manual disimpaction can occasionally be done under [[sedation]] or a [[General anaesthetic|general anesthetic]]—this avoids pain and loosens the anal sphincter.  

Revision as of 21:39, 18 December 2017

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Overview

In people without medical problems, the main intervention is to increase the intake of fluids (preferably water) and dietary fiber. The latter may be achieved by consuming more vegetables and fruit and whole meal bread, and by adding linseeds to one's diet. The routine non-medical use of laxatives is to be discouraged as this may result in bowel action becoming dependent upon their use. Enemas can be used to provide a form of mechanical stimulation.

In alternative and traditional medicine, colonic irrigation, enemas, exercise, diet and herbs are used to treat constipation.

Medical Therapy

  • General principles of medical therapy in patients with chronic constipation are as following:[1]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic Constipation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EXCLUDE:
• Inadeqate fiber intake
• Medication
• Cancer
• Stricture
• Systemic or neurologic disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No clinical response
 
 
Fiber supplement, Simple laxatives
 
 
Clinical response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
• Anorectal manometry
• Balloon expulsion test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Colonic transit time
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unclear diagnosis
 
Evacuation disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Delayed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Barium enema
• MR proctography
 
• Pelvic floor retraining
• Psychology
• Diet
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Fiber supplement
• Osmotic laxatives
• Secretagogues
• Prokinetics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinically significant structural disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical response
 
No clinical response
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rectal surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Colonic manometry
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Colonic inertia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider colectomy plus ileorectostomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Chronic constipation management

  • Chronic constipation treatment includes both behavioral and pharmacological interventions.
  • Behavioral management mostly consists of life style and dietary modification, while pharmacological interventions are mostly based on laxatives.

Lifestyle modification

  • Increasing physical activity is postulated to improve constipation and colonic transit time in patients with constipation.[2]
  • Moderate physical exercise as much as 32 min per day showed significant improvement of quality of life but no significant decrease in laxative need for treatment.[3]
  • Moderate to vigorous training (20-60 min, 3-5 times per week) revealed significant improvement in constipation symptoms in patients with irritable bowel syndrome (IBS).[4]

Dietary interventions

  • Fiber supplementation is the main primary therapeutic intervention for every patients with constipation.
  • The polysaccharide fibers are the agents that increase the weight of stool and and improve the stool consistency through absorbing and retaining water.[5]
  • The most common used bulking organic polysaccharide in Canada is Psyllium. Psyllium is found to significantly decrease colonic transit and improve stool consistency, as well as lactulose.[6]
  • [7]

Biofeedback treatment

  • The most important behavioral treatment for constipation is biofeedback, consisting of teaching the patients how to use their abdominal and pelvic muscles during defecation.
  • During the biofeedback patients receive feedback upon their abdominal and pelvic floor muscle contractions recording by means of surface electromyogrphy (EMG).
  • Based on the biofeedback, patients are been taught how to increase intra-abdominal pressure and also relax their pelvic floor muscles to have a coordinated evacuation.[1]
  • Regarding the outcomes, the biofeedback behavioral therapy is the choice treatment for functional defecation disorder.[8]

Pharmacological intervention

Constipation

  • 1 Adult
    • 1.1 Over the counter medicines
      • 1.1.1 Bulk forming agents
        • Preferred regimen (1): Citrucel 500 mg PO q8-12h
        • Preferred regimen (2): FiberCon 625 mg PO q6-12h
        • Preferred regimen (3): Konsyl 5 g (1 tablespoon) dissolved in 250 mL water PO q8-24h
        • Alternative regimen (1): Metamucil 1000 mg PO q8-12h
      • 1.1.2 Osmotic agents
        • Preferred regimen (1): Cephulac 5 g (1 tablespoon) dissolved in 250 mL water PO q6-8h
        • Preferred regimen (2): Fleet Phospho-Soda 15 mL dissolved in 250 mL water PO q6-8h
        • Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
        • Alternative regimen (1): Miralax 34 g dissolved in 250 mL water PO daily
        • Alternative regimen (1): Sorbitol 30-150 mL (70% solution) once
      • 1.1.3 Stool softeners
        • Preferred regimen (1): Colace 100-300 mg PO daily
        • Preferred regimen (2): Docusate
          • Docusate sodium: 50-300 mg PO daily
          • Docusate calcium: 240 mg PO daily
        • Alternative regimen (1): Surfak 240 mg PO daily
      • 1.1.4 Lubricants
        • Preferred regimen (1): Fleet 19 g dissolved in 118-197 mL water PO daily
        • Preferred regimen (2): Zymenol
      • 1.1.5 Stimulants
        • Preferred regimen (1): Correctol 
        • Preferred regimen (2): Dulcolax
        • Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
        • Alternative regimen (1): Purge
        • Alternative regimen (1): Senokot 
  • 1.2 Prescription medicines
    • 1.2.1 Chloride channel activators
    • 1.2.2 Guanylate cyclase-C agonists
  • 2 Pediatrics
    • 2.1 Over the counter medicines
      • 2.1.1 Bulk forming agents
        • Preferred regimen (1): Citrucel 500 mg PO daily
        • Preferred regimen (2): FiberCon 625 mg PO daily
        • Preferred regimen (3): Konsyl 2.5 g (1/2 tablespoon) dissolved in 250 mL water PO q8-24h
        • Alternative regimen (1): Metamucil 500 mg PO q8-12h
      • 1.1.2 Osmotic agents
        • Preferred regimen (1): Cephulac 2.5 g (1/2 tablespoon) dissolved in 250 mL water PO q6-8h
        • Preferred regimen (2): Fleet Phospho-Soda 5-10 mL dissolved in 250 mL water PO q6-8h (not for < 5 years of age)
        • Preferred regimen (3): Milk of Magnesia 5-15 mL PO daily
        • Alternative regimen (1): Miralax 17 g dissolved in 250 mL water PO daily
        • Alternative regimen (1): Sorbitol 2 mL/kg (as 70% solution) once
      • 1.1.3 Stool softeners
        • Preferred regimen (1): Colace 100 mg PO daily
        • Preferred regimen (2): Docusate
          • Docusate sodium
            • < 2 years: Not recommended
            • 2-12 years: 50-150 mg PO daily
            • >12 years: 50-300 mg PO daily
          • Docusate calcium
            • < 12 years: Not recommended
            • >12 years: 240 mg PO daily
        • Alternative regimen (1): Surfak 50 mg PO q12h
      • 1.1.4 Lubricants
        • Preferred regimen (1): Fleet 19 g dissolved in 118-197 mL water PO daily
        • Preferred regimen (2): Zymenol
      • 1.1.5 Stimulants
        • Preferred regimen (1): Correctol 
        • Preferred regimen (2): Dulcolax
        • Preferred regimen (3): Milk of Magnesia 30-60 mL PO daily
        • Alternative regimen (1): Purge
        • Alternative regimen (1): Senokot 

Laxatives

Prokinetics

Probiotics

5-HT receptor agonists

Other agents

Physical Intervention

Constipation that resists all other measures requires physical intervention. Manual disimpaction (the physical removal of impacted stool) is done by patients who have lost control of their bowels secondary to spinal injuries. Manual disimpaction is also used by physicians and nurses to relieve rectal impactions. Finally, manual disimpaction can occasionally be done under sedation or a general anesthetic—this avoids pain and loosens the anal sphincter.

Many of the products are widely available over-the-counter. Enemas and clysters are a remedy occasionally used for hospitalized patients in whom the constipation has proven to be severe, dangerous in other ways, or resistant to laxatives. Sorbitol, glycerin and arachis oil suppositories can be used. Severe cases may require phosphate solutions introduced as enemas

Pharmacotherapy

Laxatives

Main article: laxative

Laxatives may be necessary in people in whom dietary intervention is not effective or is inappropriate. Most laxatives can be safely used long-term, although some are associated with cramping and bloatedness and can cause the phenomenon of melanosis coli.

Contraindicated medications

Constipation medical therapy is considered an absolute contraindication to the use of the following medications:

References

  1. ↑ 1.0 1.1 Camilleri M, Bharucha AE (2010). "Behavioural and new pharmacological treatments for constipation: getting the balance right". Gut. 59 (9): 1288–96. doi:10.1136/gut.2009.199653. PMC 3189401. PMID 20801775.
  2. ↑ Meshkinpour H, Kemp C, Fairshter R (1989). "Effect of aerobic exercise on mouth-to-cecum transit time". Gastroenterology. 96 (3): 938–41. PMID 2604760.
  3. ↑ Chin A Paw MJ, van Poppel MN, van Mechelen W (2006). "Effects of resistance and functional-skills training on habitual activity and constipation among older adults living in long-term care facilities: a randomized controlled trial". BMC Geriatr. 6: 9. doi:10.1186/1471-2318-6-9. PMC 1562427. PMID 16875507. Vancouver style error: missing comma (help)
  4. ↑ Johannesson E, Simrén M, Strid H, Bajor A, Sadik R (2011). "Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial". Am. J. Gastroenterol. 106 (5): 915–22. doi:10.1038/ajg.2010.480. PMID 21206488.
  5. ↑ Emmanuel AV, Tack J, Quigley EM, Talley NJ (2009). "Pharmacological management of constipation". Neurogastroenterol. Motil. 21 Suppl 2: 41–54. doi:10.1111/j.1365-2982.2009.01403.x. PMID 19824937.
  6. ↑ Ashraf W, Park F, Lof J, Quigley EM (1995). "Effects of psyllium therapy on stool characteristics, colon transit and anorectal function in chronic idiopathic constipation". Aliment. Pharmacol. Ther. 9 (6): 639–47. PMID 8824651.
  7. ↑ Dettmar PW, Sykes J (1998). "A multi-centre, general practice comparison of ispaghula husk with lactulose and other laxatives in the treatment of simple constipation". Curr Med Res Opin. 14 (4): 227–33. doi:10.1185/03007999809113363. PMID 9891195.
  8. ↑ Chiarioni G, Salandini L, Whitehead WE (2005). "Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation". Gastroenterology. 129 (1): 86–97. PMID 16012938.


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