Chapter 040. Diarrhea and Constipation (Part 17)

Constipation: Treatment After the cause of constipation is characterized, a treatment decision can be made. Slow-transit constipation requires aggressive medical or surgical treatment; anismus or pelvic floor dysfunction usually responds to biofeedback management (Fig. 40-4). However, only ~60% of patients with severe constipation are found to have such a physiologic disorder (half with colonic transit delay and half with evacuation disorder). Patients with spinal cord injuries or other neurologic disorders require a dedicated bowel regime that often includes rectal stimulation, enema therapy, and carefully timed laxative therapy.Patients with slow-transit constipation are treated with bulk, osmotic, prokinetic, secretory, and stimulant...
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Chapter 040. Diarrhea and Constipation (Part 17) Chapter 040. Diarrhea and Constipation (Part 17) Constipation: Treatment After the cause of constipation is characterized, a treatment decision can bemade. Slow-transit constipation requires aggressive medical or surgical treatment;anismus or pelvic floor dysfunction usually responds to biofeedback management(Fig. 40-4). However, only ~60% of patients with severe constipation are found tohave such a physiologic disorder (half with colonic transit delay and half withevacuation disorder). Patients with spinal cord injuries or other neurologicdisorders require a dedicated bowel regime that often includes rectal stimulation,enema therapy, and carefully timed laxative therapy. Patients with slow-transit constipation are treated with bulk, osmotic,prokinetic, secretory, and stimulant laxatives including fiber, psyllium, milk ofmagnesia, lactulose, polyethylene glycol (colonic lavage solution), lubiprostone,and bisacodyl. Newer treatment aimed at enhancing motility and secretion mayhave application in circumstances such as constipation-predominant IBS infemales or severe constipation. If a 3- to 6-month trial of medical therapy fails andpatients continue to have documented slow-transit constipation unassociated withobstructed defecation, the patients should be considered for laparoscopiccolectomy with ileorectostomy; however, this should not be undertaken if there iscontinued evidence of an evacuation disorder or a generalized GI dysmotility.Referral to a specialized center for further tests of colonic motor function iswarranted. The decision to resort to surgery is facilitated in the presence ofmegacolon and megarectum. The complications after surgery include small-bowelobstruction (11%) and fecal soiling, particularly at night during the firstpostoperative year. Frequency of defecation is 3–8 per day during the first year,dropping to 1–3 per day from the second year after surgery. Patients who have a combined (evacuation and transit/motility) disordershould pursue pelvic floor retraining (biofeedback and muscle relaxation),psychological counseling, and dietetic advice first, followed by colectomy andileorectosomy if colonic transit studies do not normalize and symptoms areintractable despite biofeedback and optimized medical therapy. In patients withpelvic floor dysfunction alone, biofeedback training has a 70–80% success rate,measured by the acquisition of comfortable stool habits. Attempts to managepelvic floor dysfunction with operations (internal anal sphincter or puborectalismuscle division) have achieved only mediocre success and have been largelyabandoned. FURTHER READINGS Bartlett JG: Narrative review: The new epidemic of Clostridium difficile-associated enteric disease. Ann Intern Med 145:758, 2006 [PMID: 17116920] Camilleri M: Chronic diarrhea: A review on pathophysiology andmanagement for the clinical gastroenterologist. Clin Gastroenterol Hepatol 2:198,2004 [PMID: 15017602] Farrell RJ, Kelly CP: Celiac sprue. N Engl J Med 346:180, 2002 [PMID:11796853] Gadewar S, Fasano A: Current concepts in the evaluation, diagnosis andmanagement of acute infectious diarrhea. Curr Opin Pharmacol 5:559, 2005[PMID: 16207535] Lembo A, Camilleri M: Chronic constipation. N Engl J Med 349:1360,2003 [PMID: 14523145] Musher DM, Musher BL: Contagious acute gastrointestinal infections. NEngl J Med 351:2417, 2004 [PMID: 15575058] Wald A: Constipation in the primary care setting: Current concepts andmisconceptions. Am J Med 119:736, 2006 [PMID: 16945605] Wald A: Clinical practice. Fecal incontinence in adults. N Engl J Med356:1648, 2007 [PMID: 17442907] BIBLIOGRAPHY American Gastroenterological Association: Medical Position Statement:Guidelines for the evaluation and management of chronic diarrhea.Gastroenterology 116:1461, 1991 Brandt LJ et al: Systematic review on the management of irritable bowelsyndrome in North America. Am J Gastroenterol 97(Suppl):S1, 2002 DuPont HL and Practice Parameters Committee of the American College ofGastroenterology: Guidelines on acute infectious diarrhea in adults. Am JGastroenterol 92:1962, 1997 [PMID: 9362174] Enck P: Biofeedback training in disordered defecation. A critical review.Dig Dis Sci 38:1953, 1993 [PMID: 8223066] Fine KD, Schiller LR: AGA technical review on the evaluation andmanagement of chronic diarrhea. Gastroenterology 116:1461, 1999 Higgins PD, Johanson JF: Epidemiology of constipation in North America:A systematic review. Am J Gastroenterol 99:750, 2004 [PMID: 15089911] Lembo A, Camilleri M: Chronic constipation. Current Concepts ...