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Treatment# General Measures
Initial management includes patient education and an explanation of normal bowel habits. Medications known to cause constipation should be discontinued or minimized,and metabolic abnormalities (eg,hypothyroidism) should be corrected. Regular exercise and increases in fiber and oral fluids are encouraged. Patients are informed that their constipation developed over time and that correction is not likely to occur overnight. Alternative measures will often need to be tried until the symptoms are resolved. Recent major developments have significantly improved treatment options: re-evaluation and reduction in the number of stimulant laxatives,newer osmotic agents,introduction of intestinal secretory agents,availability of biofeedback for defecatory disorders,and appreciation of the highly selective but important role of surgery. A stepwise approach as described in [Table 4](https://ncbi.nlm.nih.gov/pmc/articles/PMC3096424/table/i1524-5012-8-1-25-t04/) will usually lead to success.
# Table 4
Pharmacologic Management of Constipation
[Open in a separate window](https://ncbi.nlm.nih.gov/pmc/articles/PMC3096424/table/i1524-5012-8-1-25-t04/?report=objectonly)
# Bulking (Fiber) Agents
Dietary fiber increases stool bulk,water content,and bacterial proliferation. This increased fecal mass reduces colonic transit time in most patients. The goal is to increase total fiber intake to 20 to 30 g daily,which can often be achieved through diet and fiber supplements,as documented in multiple studies.,Patients are encouraged to increase their intake of fruits,vegetables,and high-fiber breakfast cereals or raw bran. High-fiber cereals contain 8 to 10 g of fiber per serving. Patients with lactose intolerance or poor dietary compliance are better managed with dietary supplements such as psyllium or methylcellulose. Patient compliance with fiber recommendations is often poor because of the side effects of bloating,flatulence,and distension. Different types and amounts of fiber will affect patients differently. For this reason,patients are encouraged to start at lower doses and slowly increase their intake. If one type of fiber does not improve symptoms,other types should be tried. Varying the amounts or frequency of ingested fiber might also be necessary. Patients are advised to continue a regimen for 3 or 4 days before making any change to identify what is hindering or improving the patients functioning.
# Pharmacologic
Osmotic laxatives,such as polyethylene glycol (Miralax) or lactulose (Chronulac),can be used in patients with continuing symptoms who do not respond to fiber. These agents are safe to use long term and do not promote dependency. The lay and medical belief that these agents harm the colon (“cathartic colon”) and promote dependency,habituation,or abuse is not supported by objective data.,These osmotic agents (unabsorbed agents,sugars,or salts) work by retaining or pulling fluid into the intestinal lumen. The dose should be titrated over several days to produce a semisolid stool. Excessive doses of these agents can produce fluid overload or electrolyte abnormalities,so they must be used with care in patients with renal insufficiency or cardiac dysfunction. Nonabsorbed sugars may also produce flatulence.
Emollient laxatives soften stool by reducing surface tension,thereby allowing intestinal fluids to penetrate the fecal mass. Mineral oil requires caution in elderly and neurologically impaired patients and in those with impaired swallowing because it carries the risk of aspiration and the potential for interference with absorption of fat-soluble vitamins.
Stimulant laxatives are used in patients with significant constipation who do not respond to fiber or osmotic laxatives. These agents increase intestinal motility and stimulate fluid secretion into the bowel lumen. Despite folklore,there is little evidence that chronic use of stimulants causes “cathartic colon.” Chronic use of laxatives that contain anthraquinones can cause melanosis coli,a brown-black pigmentation of the colonic mucosa. This condition has no clinical consequence and will regress if the patient stops taking the laxative. Although anthraquinones were a common component of laxatives in the past,currently they are rarely seen except in “natural” over-the-counter preparations. When stimulants are being used,it is important to find the least expensive product that can adequately relieve the patients symptoms. Different agents or combinations may be required.
Secretory agents constitute a new option for managing constipation. Lubiprostone (Amitiza,Sucampo Pharmaceuticals,Bethesda,Md) is a chloride-channel activator that acts locally on the apical membrane of the gastrointestinal tract to increase intestinal fluid secretion. It is indicated for treatment of idiopathic constipation.
Enemas can be self-administered to assist evacuation. Tap water is preferred for small-volume stimulation,and oil-retention enemas are useful for hard or impacted stool. Small volumes and near-normal osmolity are preferred to prevent injury to the mucosa and fluid absorption.
[Table 4](https://ncbi.nlm.nih.gov/pmc/articles/PMC3096424/table/i1524-5012-8-1-25-t04/) summarizes the pharmacologic options available to manage constipation and lists the average monthly costs for each option. The therapeutic goal for all agents is to use the least expensive agents that relieve the patients symptoms. Over time,some medications may become less effective and might need to be altered or combined with other agents. Patients who remain refractory to maximal medical therapy may benefit from a surgical referral.
# Surgical
A small group of patients who are refractory to these regimens might be considered for surgical treatment. Improvements in physiologic evaluations and experience have helped to optimize patient selection for surgery.,The two groups of patients who benefit from surgery are those with either an anatomic abnormality or a specific functional aberration,such as colonic inertia. Surgery has a limited role in treating outlet obstruction.
Several operations are used to treat colonic inertia. All involve a colonic resection and have varied from a segmental resection (left or right colectomy),to a subtotal colectomy with cecorectal or ileosigmoid anastomosis,to a total colectomy. The best results have been obtained with colectomy and ileorectal anastomosis (ileoproctostomy). Doing a lesser operation has led to a high incidence of recurrent constipation. Overall,the more colon removed,the lower the incidence of constipation and the greater the number of bowel movements. As a compromise,most surgeons currently perform a total colectomy with an ileorectal anastomosis with the anastomosis at the level of the sacral promitory. This leaves 12 to 18 cm of rectum and allows a patient to average 2 to 4 bowel movements per day. The stool is looser than normal but becomes formed after a short period of adaptation. Patients have good control,and the incidence of recurrent constipation is very low. More than 95% of properly selected patients can be expected to be satisfied with their surgical treatment,and the results will last long term. About 5 to 7 patients a year are offered surgical therapy of colonic inertia at the Ochsner Clinic. No mortalities have occurred to date,and the vast majority of patients have been pleased with their results.
Several reports have documented patients quality of life after surgical management. – FitzHarris and colleagues surveyed 75 patients who had undergone total abdominal colectomy and ileorectal anastomosis a mean of 3.9 years (range,0.5–9.6) before the survey. Using a 54-item validated questionnaire (Gastrointestinal Quality-of-life Index),these investigators found that 81% of the patients were at least somewhat pleased with their bowel frequency,but 41% cited abdominal pain,21% incontinence,and 46% diarrhea at least some of the time. However,93% stated that they would undergo subtotal colectomy again if given a second chance. Long-term studies have confirmed that initial success is maintained in most appropriately selected patients. The most common long-term complication has been bowel obstructions.
Correctable outlet problems such as rectal prolapse respond well to perineal procedures such as an Altemeier or Delorme,whereas a symptomatic rectocele can be corrected with a transanal or transvaginal repair. Patients with normal colonic motility and outlet obstruction from a nonrelaxing puborectalis muscle should initially be offered biofeedback. This therapy is available from the Ochsner Clinic physical therapy department. The few patients who are not helped by this therapy may be considered for a botulinum A toxin injection into the puborectalis muscle.
Patients with colonic inertia and rectal dysmotility may be offered an ileostomy or a restorative proctocolectomy. The potential benefits of these procedures must be balanced against the functional limitations and the associated morbidity.
# Table 5
Recommendations
[Open in a separate window](https://ncbi.nlm.nih.gov/pmc/articles/PMC3096424/table/i1524-5012-8-1-25-t05/?report=objectonly)
# Fecal Impaction
Patients with fecal impactions can be managed by several maneuvers. Low impactions often require digital disimpaction,which can be assisted by the administration of an oil-retention enema (Fleet Mineral Oil). An effective alternative in patients without an intestinal obstruction is the administration of an oral osmotic laxative. A polyethylene glycol solution (Miralax,Braintree Laboratories,Braintree,Mass) can be administered at a rate of 1 capful in 4 oz of water every 15 minutes until stool evacuation occurs. After resolution of the impaction,patients who have not had a recent colon evaluation (eg,barium enema or colonoscopy) should have one,and a maintenance bowel program (daily fiber or laxative) should be initiated.","department":"
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