Diagnosis and treatment of chronic constipation--a European perspective

Abstract

Background: Although constipation can be a chronic and severe problem, it is largely treated empirically. Evidence for the efficacy of some of the older laxatives from well-designed trials is limited. Patients often report high levels of dissatisfaction with their treatment, which is attributed to a lack of efficacy or unpleasant side-effects. Management guidelines and recommendations are limited and are not sufficiently current to include treatments that became available more recently, such as prokinetic agents in Europe.

Purpose: We present an overview of the pathophysiology, diagnosis, current management and available guidelines for the treatment of chronic constipation, and include recent data on the efficacy and potential clinical use of the more newly available therapeutic agents. Based on published algorithms and guidelines on the management of chronic constipation, secondary pathologies and causes are first excluded and then diet, lifestyle, and, if available, behavioral measures adopted. If these fail, bulk-forming, osmotic, and stimulant laxatives can be used. If symptoms are not satisfactorily resolved, a prokinetic agent such as prucalopride can be prescribed. Biofeedback is recommended as a treatment for chronic constipation in patients with disordered defecation. Surgery should only be considered once all other treatment options have been exhausted.

Figure 1

Types of constipation.Primary (idiopathic) constipation can be conceptually categorized into three main types: normal-transit, slow-transit and pelvic floor dysfunction. IBS-C, constipation predominant irritable bowel syndrome; STC, slow-transit constipation.

Figure 2

Enterokinetic treatment algorithm. Once idiopathic chronic constipation has been identified (Rome III); and education, lifestyle and dietary measures; and treatment with laxatives (response evaluable after 2–4 weeks) have failed to provide adequate relief, an enterokinetic agent can be commenced (response to prucalopride evaluable after 4–12 weeks). If constipation symptoms are still refractory to pharmacological treatment, patients should be referred for physiological testing as outlined in the published Rome algorithm for refractive constipation and difficult defecation. ^†2 or 1 mg day⁻¹ if the patient is >65 years.

Figure 3

Refractory constipation and difficult defecation. (1) Patients who fulfill the criteria for functional constipation and those who have not improved with an increase in dietary fiber and the use of simple laxatives, and with no alarm features, often warrant further physiological assessment. (2) The three key physiological investigations are anorectal manometry, the balloon expulsion test, and a colonic transit study. (3, 4) If both anorectal manometry and balloon expulsion are normal, the results of colonic transit testing enable characterization of the disorder as functional constipation with slow (5) or normal transit (6). (7, 8) If both manometry and the rectal balloon expulsion test are abnormal, this is sufficient to diagnose a functional defecation disorder. (9) If only one of the anorectal manometry and balloon expulsion is abnormal, further testing using barium or magnetic resonance defecography may be used to confirm or exclude the diagnosis. (10) If defecography reveals features of disordered defecation, a diagnosis of a functional defecation disorder can be made. (8) If defecography is not abnormal, then the patient does not fulfill criteria for the diagnosis of a functional defecation disorder; further diagnosis then depends on the presence or absence of colonic transit delay (see above 4–6). (11–13) Treatment of choice for disordered defecation is biofeedback. If there is no adequate response to therapy, further investigation may be considered at this point. The presence of a functional defecation disorder does not exclude the diagnosis of slow colonic transit. Thus, depending on the results of the colonic transit study, the patient can be characterized as suffering from a functional defecation disorder with slow (12) or normal colonic transit. (13, 14) Slow colonic transit may result from a defecation disorder. If it is felt appropriate to distinguish between the two possibilities, the colonic transit evaluation may be repeated after correction of the defecation disorder. If transit normalizes, the presumption is that the delay was secondary to the defecation disorder; if not, the delayed colonic transit is presumed to be a comorbid condition, which may require therapy if there is no clinical improvement with the treatment of functional defecation disorder. This figure has been adapted by permission from Macmillan Publishers Ltd: The American Journal of Gastroenterology, copyright (2010).