Constipation

Publication Date: January 1, 2013

Key Points

Key Points

Figure 1A. Bristol Stool Form Scale


Figure 1B. IBS Subtypes and Stool Form


Table 1. Symptom Criteria for Constipationa

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Irritable Bowel Syndrome (IBS)
Criteria fulfilled for the last 3 months with symptom onset ≥6 months prior to diagnosis.
Recurrent abdominal pain, on average, ≥1 day per week in the last 3 months, associated with ≥2 of the following criteria:
  1. Improved with defecation
  2. Associated with a change in frequency of stool
  3. Associated with a change in form (appearance) of stool
IBS with predominant constipation (IBS-C):
More than one-fourth (25%) of bowel movements with Bristol stool form types 1 or 2 and less than one-fourth (25%) of bowel movements with Bristol stool form types 6 or 7.
Alternative for epidemiology or clinical practice: Patient reports that abnormal bowel movements are usually constipation (like type 1 or 2 in the picture of Bristol Stool Form Scale (BSFS), see Figure 1A).
Functional Constipation (FC)b
FC is a functional bowel disorder in which symptoms of difficult, infrequent, or incomplete defecation predominate. Patients with FC should not meet IBS criteria. Although abdominal pain and/or bloating may be present, they are not predominant symptoms. Symptom onset should occur ≥6 months before diagnosis, and symptoms should be present during the last 3 months.
General Definition of Constipation
  • infrequent bowel movements, typically fewer than 3 per week and persistent
  • hard stools
  • a feeling of incomplete evacuation
  • abdominal discomfort, bloating, and distention
  • excessive straining
  • a sense of anorectal blockage during defecation
  • need for manual maneuvers during defecation
Defecatory disorders
Prolonged and excessive straining before elimination
  • When evacuatory defects are pronounced, soft stools and even enema fluid may be difficult to pass.
Need for perineal or vaginal pressure to allow stools to be passed or direct digital evacuation of stools
Diagnosis requires anorectal tests (manometry, rectal balloon expulsion, or defecography [barium or MRI]) suggestive of a defecatory disorder
Normal transit constipation (NTC)
Normal colonic transit and anorectal functions
Slow transit constipation (STC)
Slow colonic transit and normal anorectal functions
Combination Disorders
Some patients may have combination or overlap disorders (eg, STC with defecatory disorders), perhaps even associated with features of irritable bowel syndrome.
a Criteria fulfilled for the last 3 months with symptom onset ≥6 months before diagnosis.
b For research studies, patients meeting criteria for OIC should not be given a diagnosis of FC because it is difficult to distinguish between opioid side effects and other causes of constipation. However, clinicians recognize that these 2 conditions might overlap.

Figure 2. Conceptual Framework to Explain FBDs


Assessment

Assessment

...asible, discontinue medications that can...


A careful digital rectal examina...


...y components of the rectal examination incl...


...for Medical Causes...

In the absence of other symptoms and signs, on...

...r clinical features warrant otherwise, met...

A colonoscopy should not be performed in patients...

...ometry and a rectal balloon expulsion...

...aphy should not be performed before anorectal ma...

Defecography should be considered when...

...lonic transit should be evaluated if...


Treatment

...atment...

...fter discontinuing medications that can...


...l tests should be performed in patients who do no...


...or retraining by biofeedback therapy rather...


...ical Treatmen...

...bowel symptoms are refractory to simp...

...tests and colonic transit should be reevalua...

...ubtotal colectomy rather than continuing th...

...olonic intraluminal testing (manometry, ba...

...s or enemas rather than oral laxatives alone shou...


...reatment Algorithm for Chronic Constipation...


...gure 4. Treatment Algorithm for NTC and ST...


...ent Algorithm for Defecating Disorders...


...rapeutic Options for IBS-CHaving tro...


...peutic Options for Functional Constipatio...


...Common Drugs Causing ConstipationH...


...ary of Dietary Supplements and Medications U...