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AGA
The AGA Institute Medical Position Panel consisted of the lead technical review author (Adil E. Bharucha, MBBS, MD,
AGAF), a Clinical Practice and Quality Management Committee representative and content expert (Spencer D. Dorn, MD,
MPH), and two gastroenterologists and content experts (Anthony Lembo, MD, and Amanda Pressman, MD).
may emerge from lower-quality evidence. Abbreviations used in this paper: AGA, American Gastroenterological
Symptoms of constipation are extremely common; the prev- Association; GRADE, Grading of Recommendations Assessment, Devel-
alence is approximately 16% in adults overall and 33% in adults opment and Evaluation; NTC, normal transit constipation; STC, slow
transit constipation.
older than 60 years. Many people seek medical care for consti- © 2013 by the AGA Institute
pation, but fortunately most do not have a life-threatening or 0016-5085/$36.00
disabling disorder and the primary need is for control of symp- http://dx.doi.org/10.1053/j.gastro.2012.10.029
GASTROENTEROLOGY 2013;144:211–217
AGA
The AGA Institute Medical Position Panel consisted of the lead technical review author (Adil E. Bharucha, MBBS, MD,
AGAF), a Clinical Practice and Quality Management Committee representative and content expert (Spencer D. Dorn, MD,
MPH), and two gastroenterologists and content experts (Anthony Lembo, MD, and Amanda Pressman, MD).
may emerge from lower-quality evidence. Abbreviations used in this paper: AGA, American Gastroenterological
Symptoms of constipation are extremely common; the prev- Association; GRADE, Grading of Recommendations Assessment, Devel-
alence is approximately 16% in adults overall and 33% in adults opment and Evaluation; NTC, normal transit constipation; STC, slow
transit constipation.
older than 60 years. Many people seek medical care for consti- © 2013 by the AGA Institute
pation, but fortunately most do not have a life-threatening or 0016-5085/$36.00
disabling disorder and the primary need is for control of symp- http://dx.doi.org/10.1053/j.gastro.2012.10.029
212 AGA GASTROENTEROLOGY Vol. 144, No. 1
maneuvers during defecation), which suggest a defecatory a marked reduction in colonic intrinsic nerves and
disorder. Not infrequently, patients who have daily bowel interstitial cells of Cajal.
movements describe constipation. Reduced stool frequency Combination Disorders
is poorly correlated with delayed colonic transit. Although
Some patients may have combination or overlap
many people experience occasional constipation (eg, when
disorders (eg, STC with defecatory disorders), perhaps
they travel), this review is geared toward people who have
even associated with features of irritable bowel syndrome.
persistent symptoms (ie, chronic constipation).
Clinical Evaluation
Clinical Subgroups Historical features are key, and the questioning of
Symptoms of constipation may be secondary to the patient must be specific. What feature does the patient
diseases of the colon (stricture, cancer, anal fissure, rate as most distressing? Is it infrequency per se, straining,
proctitis), metabolic disturbances (hypercalcemia, hy- hard stools, unsatisfied defecation, or symptoms unre-
pothyroidism, diabetes mellitus), and neurologic disor- lated to bowel habits or defecation per se (eg, bloating,
ders (parkinsonism, spinal cord lesions). Some of these pain, malaise)? The presence of these last characteristics
will be amenable to specific therapies, but when they suggests underlying irritable bowel syndrome.
are not, the challenge remains one of symptomatic Defecatory disorders should be suspected strongly on
treatment of constipation. More frequently, constipa- the basis of a careful history and digital rectal examina-
tion is due to disordered colonic and/or pelvic floor/ tion. Prolonged and excessive straining before elimination
anorectal function. Assessments of colonic transit and are suggestive; when evacuatory defects are pronounced,
anorectal function allow patients to be categorized into soft stools and even enema fluid may be difficult to pass.
3 subgroups (ie, defecatory disorders, normal transit The need for perineal or vaginal pressure to allow stools
constipation [NTC], and slow transit constipation to be passed or direct digital evacuation of stools is an
[STC]), which facilitates management in refractory pa- even stronger clue. It is important to raise these questions
tients. early, because evacuatory disorders do not respond well to
standard laxative programs and failure to recognize this
Defecatory Disorders component is a frequent reason for therapeutic failure.
These disorders are primarily characterized by im- The current regimen and bowel pattern should be re-
paired rectal evacuation from inadequate rectal propulsive corded. How often is a “call to stool” noted? Is the call
forces and/or increased resistance to evacuation; the latter always answered? What laxatives are being used, how
may result from high anal resting pressure (“anismus”) often, and at what dosage? Are suppositories or enemas
and/or incomplete relaxation or paradoxical contraction of used in addition? How often are the bowels moved, and
the pelvic floor and external anal sphincters (“dyssynergia”) what is the consistency of the stools? Physicians and
during defecation. Structural disturbances (eg, rectocele, in- patients need to be aware that after a complete purge it
tussusception) and reduced rectal sensation may coexist. will take several days for residue to accumulate such that
Other terms for these conditions include outlet obstruction, a normal fecal mass will be formed. Importantly, many
obstructed defecation, dyschezia, anismus, and pelvic floor commonly used medications have constipation as a nota-
dyssynergia. Patients with defecatory disorders may have ble side effect (eg, opiates, anticholinergics, calcium chan-
slow colonic transit that may improve once the defecatory nel blockers). A full record of prescription and over-the-
disorder is treated. counter medications must be obtained.
The physical examination and screening tests, if deemed
NTC and STC
appropriate, should also eliminate diseases to which consti-
In addition to normal anorectal function, pa-
pation is secondary (see technical review). The key compo-
tients with NTC and STC have normal or slow colonic
nents of the rectal examination include the following:
transit, respectively. Some patients with STC have co-
lonic motor disturbances (ie, reduced colonic propul- ● In the left lateral position, with the buttocks sepa-
sive activity or increased uncoordinated motor activity rated, observe the descent of the perineum during
in the distal colon) that may impede colonic transit. simulated evacuation and the elevation during a
However, others do not. Indeed, a similar proportion of squeeze aimed at retention. The perianal skin can be
patients with NTC, STC, and even defecatory disorders observed for evidence of fecal soiling and the anal
have colonic motor disturbances as measured by in- reflex tested by a light pinprick or scratch.
traluminal techniques (ie, manometry and a barostat).
● During simulated defecation, the anal verge should
Hence, the relationship between colonic motor distur-
AGA
puborectalis muscle, which should also contract dur- This algorithm starts by recommending anorectal test-
ing squeeze. Acute localized tenderness to palpation ing for patients who do not respond to a trial of laxatives
along the puborectalis is a feature of the levator ani and/or fiber. Anorectal testing is simple and safe and can
syndrome. Finally, the patient should be instructed potentially modify management; a rectal balloon expul-
to integrate the expulsionary forces by requesting sion test is also inexpensive. There is evidence that pelvic
that she or he “expel my finger.” floor retraining is superior to laxatives for defecatory
disorders. Hence, anorectal testing may be considered
● An examination should then be conducted to evalu-
earlier when symptoms or signs strongly suggest pelvic
ate for a rectocele or consideration be given to gyne-
floor dysfunction. Interpretation of any single test must
cologic consultation.
be guarded, because it must be recognized that patient
Although a careful digital rectal examination is useful cooperation and understanding comprise an important
for identifying pelvic floor dysfunction, a normal exam- voluntary component of most tests of anorectal function.
ination does not exclude this diagnosis. After the initial The tests themselves must be in a setting as private as
history and physical examination, a set of focused tests possible to reduce embarrassment and facilitate coopera-
should be considered to exclude disorders that are tion. Ideal conditions are often not possible. Although
either treatable (eg, hypothyroidism) or important to anorectal manometry and a rectal balloon expulsion test
diagnose early (eg, colon cancer). However, data do not generally suffice to diagnose or exclude a defecatory dis-
exist to strictly evaluate and define the tests that need order, defecography, which is generally performed with
to be performed. A complete blood cell count should be barium, or at some centers with magnetic resonance im-
performed. Although metabolic tests (thyroid-stimulat- aging, is useful if results are inconclusive.
ing hormone, serum glucose, creatinine, and calcium) Up to 50% of patients with defecatory disorders also
are often performed, their diagnostic utility and cost- have slow colonic transit. Therefore, slow colonic transit
effectiveness have not been rigorously evaluated and are does not exclude a defecatory disorder. In addition, coex-
probably low. A structural evaluation of the colon may istent slow colonic transit does not alter the management
be appropriate in certain circumstances, especially if of defecatory disorders. In contrast to the previous version
the patient has alarm symptoms or has abrupt onset of of this guideline, assessment of colonic transit is recom-
constipation or is older than 50 years and has not mended only after excluding a defecatory disorder or as
undergone previous screenings for colorectal cancer. shown later during management in Figures 2 and 3. After
Depending on the circumstances, colonoscopy, com- excluding a defecatory disorder, consideration should be
puted tomographic colonography, or flexible sigmoid- given to assessing colonic transit by radiopaque markers,
oscopy and barium enema will effectively exclude le- scintigraphy, or a wireless motility capsule in patients
sions that could cause constipation. with persistent symptoms while being treated with laxa-
If this evaluation uncovers a secondary cause for con- tives. Identifying slow colonic transit may reassure pa-
stipation, the appropriate treatment can be offered. The tients about the pathophysiology of their symptoms, serve
patient’s medications can be adjusted when possible to as an objective marker for documenting the response to
avoid those with constipating effects. A trial of fiber therapy, and also provide the physician with the rationale
and/or over-the-counter laxatives can be instituted. for treating patients with newer, often more expensive
treatments. At present, the medical approaches used for
Clinical Assessment of Constipation managing NTC and STC are similar. However, the major
pharmacologic trials in chronic constipation did not as-
sess if the response to therapy is influenced by colonic
If feasible, discontinue medications that can cause con- transit. Although newer agents may also be considered
stipation before further testing (strong recommenda- without assessing colonic transit, the long-term side ef-
tion, low-quality evidence). fects, if any, of these agents are unknown and exposure to
A careful digital rectal examination that includes assess- such potential risks might be more appropriate in pa-
ment of pelvic floor motion during simulated evacuation tients with more severe forms of constipation associated
is preferable to a cursory examination without these ma- with slow transit. Hence, we empirically recommend as-
neuvers and should be performed before referral for ano- sessing colonic transit in patients with chronic constipa-
rectal manometry. However, a normal digital rectal exam- tion whose symptoms do not respond to laxatives or
ination does not exclude defecatory disorders (strong first-line pharmacologic therapy.
recommendation, moderate-quality evidence). At the conclusion of this initial evaluation, the patient
with constipation can be tentatively diagnosed as having
AGA
(1) NTC or, in patients who also have pain and other
features of the disorder, irritable bowel syndrome; (2)
Diagnostic Tests STC; (3) defecatory disorder, (4) a combination of STC
Patients who do not respond to these measures and defecatory disorder; or (5) secondary constipation (ie,
may benefit from special testing and treatments; these can secondary to an organic disease such as mechanical ob-
be presented most simply as an algorithm (Figure 1). struction, systemic disease, or side effect of a drug).
214 AGA GASTROENTEROLOGY Vol. 144, No. 1
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Medical Management not respond to laxatives. Two such drugs are lubipro-
Figures 2 and 3 show treatments for the clinical stone and linaclotide whose daily costs at the time this
subgroups. guideline was developed were $7-$9. Another agent,
We suggest a gradual increase in fiber intake, as both prucalopride, is not available in the United States but
foods included in the diet and as supplements and/or has been approved in other countries.
Biofeedback therapy improves symptoms in more than
an inexpensive osmotic agent, such as milk of magnesia
70% of patients with defecatory disorders. The motivation
or polyethylene glycol. Depending on stool consistency,
of the patient and therapist, the frequency and intensity
the next step may be to supplement the osmotic agent
of the retraining program, and the involvement of behav-
with a stimulant laxative (eg, bisacodyl or glycerol sup-
ioral psychologists and dietitians as necessary all likely
positories), which is preferably administered 30 min- contribute to the chances of success. The schedule of
AGA
utes after a meal to synergize the pharmacologic agent therapy can be tailored to patients’ symptoms and varies
with the gastrocolonic response. For all of these agents among centers.
(polyethylene glycol 17 g daily, milk of magnesia 1 oz Patients who do not respond to standard approaches
twice daily, psyllium 15 g daily, glycerin or bisacodyl may require colonic manometry and barostat testing,
suppositories), the approximate daily cost is $1 or less. which is only available at selected centers. Figure 3 shows
A newer agent should be considered when symptoms do the algorithm for defecatory disorder.
216 AGA GASTROENTEROLOGY Vol. 144, No. 1
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