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Medication Induced Constipation And Diarrhea. Practical Gastroenterology. 32(5): 12-28. May 2008.

This article reviews the problems of constipation and diarrhea that occur as a side effect of medication use. The authors note that medication-induced constipation and diarrhea are frequent side effects that contribute to the costs of health care for evaluation and management and also contribute to patient morbidity. The diagnosis is often delayed due to poor association of symptom onset with the use of a medication. The authors define constipation; discuss its epidemiology, economic impact, and risk factors; consider diagnostic and treatment issues; and discuss the treatment of constipation in the setting of chronic opioid use. The next section covers the definition and mechanisms of medication-induced diarrhea, antibiotic-associated diarrhea, diarrhea associated with protease inhibitors, and chemotherapy-induced diarrhea. The authors conclude by encouraging health care providers to have a high index of suspicion when patients present with constipation or diarrhea and to obtain a detailed medication history of all medications taken in the past 2 months; this approach can avoid multiple diagnostic tests. High-risk patient populations for medication-induced diarrhea or constipation include the elderly, nursing home or long-term care residents, patients with chronic pain, those with prolonged hospitalization, and those being treated with broad spectrum antibiotics. 3 figures. 2 tables. 35 references.

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Constipation - Including Sigmoidocele and Rectocele. IN: Wexner, S.; Stollman, N., eds. Diseases of the Colon. . New York, NY: Informa Healthcare USA. 2007. pp 99-136.

This chapter about constipation is from a comprehensive text that offers chapters about each of the major colonic disorders. Most chapters are coauthored by at least one surgeon and one gastroenterologist to reflect the in-depth collaboration between these fields that is required for managing diseases of the colon. In this chapter, the author discusses constipation, including definition, prevalence and risk factors, history, physical examination, differential diagnosis, medical treatment, physiological investigation, pelvic flood dysfunction, biofeedback, rectocele, cul-de-sac hernias, enterocele and sigmoidocele, intussusception, perineal descent syndrome, combined colonic inertia with outlet obstruction, and normal evaluation. The author cautions that anorectal physiological testing does not reveal the cause in 25 to 50 percent of patients who complain of chronic constipation. Reasons for this include transient symptoms, misperceptions of the normal range of bowel patterns, or psychological causes of the symptoms. Treatment options include conservative therapy, laxatives, suppositories and enemas, prokinetic agents, and, in a small group of patients, surgery. The author concludes that a comprehensive physiologic investigation is crucial to successfully treat these challenging disorders. The chapter includes black-and-white photographs and illustrations and concludes with an extensive list of references. 8 figures. 3 tables. 249 references.

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Constipation, Diarrhea, Hemorrhoids and Fecal Incontinence. IN: Pregnancy in Gastrointestinal Disorders. 2nd ed. Bethesda, MD: American College of Gastroenterology. 2007. pp 4-9.

This chapter about constipation, diarrhea, hemorrhoids, and fecal incontinence is from a monograph that presents updated information about pregnancy in women with gastrointestinal disorders. The authors note that the pathophysiology of these common alterations in bowel patterns may be specific to hormonal and structural changes that occur during pregnancy and as a result of delivery. The chapter focuses on bringing readers up to date on the research in the area covered, the recommended treatments, and patient management concerns, notably issues of maternal and fetal safety. Specific topics include drug therapy, the use of dietary and behavioral modification to manage constipation, the etiology of diarrhea during pregnancy, oral rehydration for acute diarrhea, symptoms of hemorrhoids, the use of surgical hemorrhoidectomy, problems with diagnosing fecal incontinence, and treatment for fecal incontinence. The authors conclude that disturbances in bowel function are common in pregnancy and are often responsive to conservative medical therapy. 3 tables. 20 references.

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Constipation: Evaluation And Treatment of Colonic And Anorectal Motility Disorders. Gastroenterology Clinics of North America. 36(3): 687-712. September 2007.

This article on the evaluation and treatment of colonic and anorectal motility disorders characterized by constipation is from a special issue of Gastroenterology Clinics of North America that focuses on gastrointestinal (GI) motility. This article focuses on the colonic and anorectal motility disturbances that are associated with chronic constipation. Although many conditions such as metabolic problems, fiber deficiency, anorectal problems, and drugs can cause constipation, when these conditions are excluded, functional constipation can be diagnosed. The author categorizes functional chronic constipation into three overlapping subtypes: slow transit constipation, dyssynergic defecation, and irritable bowel syndrome (IBS) with constipation. The Rome III criteria may serve as a useful guide for making a clinical diagnosis of functional constipation. The author recommends an evidence-based approach to treat patients with chronic constipation. The availability of specific drugs for the treatment of chronic constipation, notably tegaserod and lubiprostone, has enhanced the therapeutic armamentarium for managing these patients. The author reports on the effectiveness of biofeedback therapy in the treatment of dyssynergic defecation. 4 figures. 3 tables. 118 references.

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Gastrointestinal Electrical Stimulation for Treatment of Gastrointestinal Disorders: Gastroparesis, Obesity, Fecal Incontinence, And Constipation. Gastroenterology Clinics of North America. 36(3): 713-734. September 2007.

This article on the use of electrical stimulation to treat gastroparesis, obesity, fecal incontinence, and constipation is from a special issue of Gastroenterology Clinics of North America that focuses on gastrointestinal (GI) motility. The authors note that because these organs have their own natural pacemakers the electrical signals they generate can be altered by externally delivering electric currents by intramuscular, serosal, or intraluminal electrodes to specific sites in the GI tract. They describe various methods of GI electrical stimulation and their peripheral and central effects and mechanisms; update the status of GI electrical stimulation in the clinical settings of gastroparesis, obesity, fecal incontinence, and constipation; and predict future directions and developments of GI electrical stimulation technology and their areas of possible clinical applications. The authors conclude that, although some of the research results are still equivocal, most studies indicate that electrical stimulation is able to alter certain GI functions. 9 figures. 1 table. 123 references.

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Managing Bowel Dysfunction. Bethesda, MD: National Institutes of Health Clinical Center. June 2007. 20 p.

This patient education fact sheet reviews the management of bowel dysfunction, defined as problems with the frequency, consistence, and/or ability to control the bowel movements. People may have trouble with their bowel movements due to many factors including medications, diseases or treatments for diseases, stress, or a change in eating or exercise patterns. The fact sheet reviews the physiology of the male and female digestive systems, normal bowel function, and the diagnosis of bowel problems with laboratory tests, radiologic or ultrasonic examination, special procedures, and fecal occult blood sampling. The fact sheet describes the causes, treatment, and prevention of bowel dysfunctions, including constipation, diarrhea, and fecal incontinence. A section considers specialized surgical procedures for bowel dysfunctions, including colostomy or ileostomy. Practical tips and strategies for everyday activities, meal planning, skin care, and exercise are provided; three sample menus are included. The fact sheet concludes with a brief glossary of relevant terms. 5 figures. 3 tables.

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Rifaximin as Acute Therapy and Maintenance Treatment for Functional Gastrointestinal Symptoms. Gastroenterology and Hepatology. 3(1): 9. January 2007.

This article is from a continuing education supplement that offers case studies that demonstrate the potential use of antibiotic therapy in the management of patients with functional gastrointestinal disorders. The cases provide examples of the pathogenic role of bacteria in irritable bowel syndrome (IBS) and suggest that treatment strategies that affect gut bacteria and the respective host responses to these pathogens might alleviate symptoms in patients with functional gastrointestinal symptoms. This article describes the case of a 55-year-old Caucasian woman who presented with a 10-year history of functional gastrointestinal symptoms, including mild diarrhea, severe constipation, abdominal pain, bloating, and gas. Symptoms were exacerbated by certain carbohydrates and alleviated only by not eating. A diagnosis of Rome II-positive, alternating-form irritable bowel syndrome (IBS) was determined. Based on clinical symptoms, the patient was administered oral rifaximin 400 milligrams twice daily for 10 days. Following completion of rifaximin treatment, probiotic therapy and tegaserod 2 milligrams daily were administered as maintenance therapy. At 3 months follow-up, the patient had not experienced symptom recurrence. The author briefly discusses the implications of this case study. 4 references.

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Understanding Constipation. Baltimore, MD: AGA Institute. 2007. 4 p.

This brochure from the American Gastroenterological Association (AGA) provides an overview of constipation, defined as the infrequent and difficult passage of stool. The brochure reviews common misconceptions about constipation and bowel habits and outlines the causes of constipation, which can include poor diet, imaginary constipation, irritable bowel syndrome (IBS), poor bowel habits, laxative abuse, travel, hormonal disturbances, pregnancy, fissures and hemorrhoids, specific diseases, loss of body salts, mechanical compression, nerve damage, medications, and colonic motility disorders. The brochure describes constipation in children, constipation in older adults, when to seek medical attention for constipation, diagnostic tests that may be used to confirm the condition, and treatment options. One section reviews the different types of laxatives, including bulk-forming, stimulants, osmotics, stool softeners, lubricants, saline laxatives, and chloride channel activators. A final section summarizes the basic information presented in the brochure. One illustration presents the organs of the digestive system labeled in a simple line drawing. Readers are referred to the AGA website at www.gastro.org/patient for more information about digestive health and to find a local AGA member physician. 2 figures.

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Understanding Irritable Bowel Syndrome. Baltimore, MD: AGA Institute. 2007. 4 p.

This brochure from the American Gastroenterological Association (AGA) provides an overview of irritable bowel syndrome (IBS), a common disorder of the intestine that leads to crampy pain, gassiness, bloating, and changes in bowel habits, including constipation and diarrhea. The brochure reviews the lifestyle impact of IBS and outlines the causes and triggers of the condition, which can include problems with colonic motility, an oversensitive gastrointestinal tract, certain foods, hormones associated with the menstrual cycle, and emotional conflict or stress. The brochure describes how IBS is diagnosed, the relationship between IBS and more serious problems, and treatment options, including the role of a healthy diet, dietary fiber, small meals, and the role of medicines in relieving IBS symptoms. Another section explores the interplay between diet, stress, and IBS. A final section summarizes the basic information presented in the brochure. One illustration presents the organs of the digestive system labeled in a simple line drawing. Readers are referred to the AGA website at www.gastro.org/patient for more information about digestive health and to find a local AGA member physician. 6 figures.

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Evaluation and Treatment of Constipation in Infants and Children. American Family Physician. 73(3): 479-480. February 1, 2006.

This article reviews the evaluation and treatment of constipation in infants and children, a problem that is usually functional and the result of stool retention. However, the authors encourage family physicians to be alert for indications of the presence of an uncommon but serious organic cause of constipation, such as Hirschsprung's disease, also called congenital aganglionic megacolon; pseudo-obstruction; spinal cord abnormality; hypothyroidism; diabetes insipidus; cystic fibrosis; gluten enteropathy; or congenital anorectal malformation. Functional constipation is treated with disimpaction using oral or rectal medication. Polyethylene glycol is effective and well-tolerated, but a number of alternatives are also available. After disimpaction, children may need to be on a maintenance program for months to years because relapse of functional constipation is common. Education of the family and, when possible, the child is important for improving functional constipation. Cow's milk may promote constipation in some children, so a trial period of withholding milk may be considered. Adding fiber to the diet is another recommended strategy. The authors conclude that, despite treatment, only 50 to 70 percent of children with functional constipation demonstrate long-term improvement. Two patient care algorithms are provided. 2 figures. 6 tables. 18 references.

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Functional Bowel Disorders. IN: Drossman, D.A., ed. Rome III: The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon Associates, Inc. 2006. pp. 487-555.

This chapter on functional bowel disorders is from a lengthy reference book that presents the Rome III criteria for functional gastrointestinal disorders (FGIDs), a classification system based on the assumption and premise that for each disorder there are identifiable symptom clusters that emerge across clinical and population groups. The authors of this chapter define functional bowel disorders as FGIDs with symptoms attributable to the middle or lower gastrointestinal tract. These disorders include irritable bowel syndrome (IBS), functional bloating, functional constipation, functional diarrhea, and unspecified functional bowel disorder. In each of these categories, the authors provide a definition and discuss epidemiology, symptoms, nomenclature and classification, clinical evaluation, physiological features, and treatment strategies. Specific topics include gastrointestinal motor disturbances, visceral hypersensitivity, postinfectious IBS, history of physical or sexual abuse, food intolerance, drug therapy, measurements of colonic transit, fiber supplementation and bulk laxatives, osmotic laxatives, and unspecified functional bowel disorder. The chapter concludes with a list of recommendations for future research in functional bowel disorders. 4 tables. 464 references.

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Chronic Constipation : From Evaluation to Treatment. Digestive Health Matters. 14(4): 4-9. Winter 2005.

This article brings readers up-to-date on the evaluation and treatment of chronic constipation. The author begins by defining constipation and differentiating chronic constipation from irritable bowel syndrome (IBS), a condition that can be characterized by constipation as one of its features. The term constipation includes a complex group of symptoms related to slow, impaired, difficult, or painful defecation. The article then addresses the major identifiable causes of constipation, when to consult a doctor for evaluation, the role of colonoscopy in diagnosis, the indications for specialized testing, including anorectal manometry and defecography, and treatment strategies, which are dependent upon diagnosis. The author discusses the use of drug therapies, biofeedback therapy, dietary fiber and fluids, and surgical options. The author concludes that most people with constipation can be successfully treated when a complete evaluation is performed and a rational treatment plan is pursued in partnership with their health care provider. 2 figures. 3 tables. 3 references.

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Common Questions About Constipation: Myths and Misconceptions. Digestive Health Matters. 14(2): 13-14. Summer 2005.

This article presents some common myths and misconceptions about constipation, along with the facts. The issues discussed include autointoxication (the release of toxins from stool kept in the colon for a long period of time), the interplay between hormones and constipation, the role of a high fiber diet in preventing or treating constipation, and the use of stimulant laxatives. The author recommends a diet that is high in fiber as a first-line therapy for constipation and also notes that overall, the available data indicates that laxatives are safe and effective treatments for constipation. 1 reference.

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Defecation Disorders After Surgery for Hirschsprung's Disease. Digestive Health Matters. 14(02): 10-12 p. Summer 2005.

This article describes Hirschsprung's disease, a congenital disorder characterized by the absence of nerve cells in the rectum or colon. Usually the problem involves only the bottom portion of the colon, but sometimes the entire colon or even part of the small intestine can be involved. The part of the bowel that lacks nerve cells cannot propel stool toward the anus, and the disorder results in obstruction, severe constipation, or inflammation (enterocolitis). The author outlines the defecation disorders that may be encountered after surgery for Hirschsprung's disease. Topics include constipation, functional fecal retention, dilation treatment, fecal incontinence, neuropathy (abnormal functioning of the nerves), hypertensive anal sphincter, the use of colon manometry, abdominal pain, and expected outcomes. The author concludes with a brief discussion of the psychosocial impact to a child of coping with Hirschsprung's disease. 5 references.

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Medication for Inflammatory Bowel Disease. Toronto, Canada: Crohn’s and Colitis Foundation of Canada. 8 p.

This brochure reviews some of the medications that may be used for inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis. After an introductory section that briefly summarizes these diseases, the booklet describes medications used to reduce inflammation in the gastrointestinal tract; medications used to reduce symptoms of the disease, such as diarrhea and cramps; and medications used to treat complications. Specific drugs discussed include sulfasalazine; 5-aminosalicylate, also known as mesalamine, mesalazine, and olsalazine; glucocorticosteroids, including prednisone, hydrocortisone, betamethasone, tixocortol, and budensonide; immunosuppressive agents, including azathioprine, 6-mercaptopurine, methotrexate, and cyclosporine A; antibiotics, including metronidazole, ciprofloxacin, ampicillin, cefazolin, gentamicin, and tobramycin; new biological therapies, including infliximab; antidiarrheal drugs, including Loperamide, codeine, diphenoxylate, tincture of opium, and paregoric; bulk-formers, primarily natural fiber sources; bile salt binders, i.e., cholestyramine, used for Crohn’s disease only; and nicotine, which is sometimes used for ulcerative colitis. For each drug, the brochure notes synonyms, how the drug is prescribed, how it works, possible side effects, and the different forms, if any, the drug comes in. The remainder of the article considers medications for other symptoms and problems, complications of IBD that may require therapy, alternative therapies, and conventional therapies. The contact information and mission of the Crohn’s and Colitis Foundation of Canada are noted. A form to join the organization or contribute money to its causes is included. 1 figure.

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Your Guide to High Fiber Diet. Cincinnati, OH: Procter & Gamble Company. 2005. 8 p.

Fiber is the part of a plant that humans cannot digest and that does not provide the body with any nutrients, vitamins, or minerals. Instead, fiber adds bulk to the foods that are eaten, to help them move more easily through the digestive system. This brochure describes the use of dietary fiber to promote good health. The brochure reviews the latest information about dietary fiber, describes why fiber is important, outlines daily fiber recommendations, describes easy ways to increase fiber, and explains the use of a fiber supplement. Fiber helps maintain regularity and helps reduce constipation and its discomfort. A blank chart is provided for readers to track the fiber they ingest in one week. One section shows a sample menu of increased-fiber foods; another chart offers a list of common foods and their fiber amount. The brochure is produced by the maker of Metamucil, a popular fiber supplement, and readers are encouraged to consider the use of Metamucil in their efforts to increase fiber intake. 4 figures. 3 tables.

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Colonic Motor Disorders: Constipation. In: Kelly, K.A.; Sarr, M.G.; Hinder, R.A., eds. Mayo Clinic Gastrointestinal Surgery. St. Louis, MO: Elsevier Science. 2004. p. 475-487.

Constipation is a very common complaint, however its definition is complex. There are two fundamental causes of functional constipation: anorectal dysfunction and slow colonic transit. This chapter on constipation is from a book that focuses on the major diseases treated by gastrointestinal surgeons, from the esophagus to the anal canal. The presentation has a definite clinical orientation and a major emphasis on practical applications as they are applied at the Mayo Clinic. The authors of this chapter review pathogenesis and etiology, diagnosis and imaging, psychologic evaluation, indications for operation, conduct of operation, surgical outcomes, and long term follow up. The authors stress that few patients presenting with constipation are surgical candidates. Selection of operative candidates is based on evaluation of colonic transit with either radiopaque markers or scintigraphy. Patients with anorectal dysfunction should be treated with pelvic floor retraining. The chapter is illustrated with line drawings and full-color photographs. 6 figures. 3 tables. 91 references.

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Epidemiology and Quality of Life in Functional Gastrointestinal Disorders. Alimentary Pharmacology and Therapeutics. 20: 31-39. November 2004.

This article reviews the epidemiology and quality of life in patients with functional gastrointestinal disorders, particularly irritable bowel syndrome (IBS), functional dyspepsia, and chronic constipation. Data shows that the prevalence of functional gastrointestinal disorders is statistically significant across the world, with a higher rate seen in woman with IBS and chronic constipation, but not those with functional dyspepsia. The author cautions, however, that differences between global and gender prevalence rates may be due to cultural factors and study methodology. IBS was found to be associated with a significant health care burden, including increased outpatient service, abdominal and pelvic surgeries, physician visits, and health care costs. Impaired health-related quality of life (HRQoL) was shown in patients with IBS, particularly in those with moderate to severe disease seen in referral settings. The HRQoL appears to improve in treatment responders, or correlates with symptom improvement. Predictors of HRQoL in patients with functional gastrointestinal disorders include psychosocial factors, such as early adverse life events, and symptoms related to visceral perception (e.g., pain and chronic stress). The author concludes that although gastrointestinal-related symptoms are obviously important, non-gastrointestinal symptoms appear to have a major, if not greater, effect on health care visits, health care costs, and HRQoL in patients with IBS. 1 figure. 1 table. 67 references.

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Approach to the Patient with Constipation. In: Textbook of Gastroenterology. 4th ed. [2-volume set]. Hagerstown, MD: Lippincott Williams and Wilkins. 2003. p. 894-910.

Although constipation is a common gastrointestinal complaint in clinical practice, some uncertainty exists as to the precise definition of the term. This lack of objectivity has contributed to the controversy concerning the incidence, pathogenesis, and treatment of constipation and defecation disorders. Furthermore, the availability of over-the-counter laxatives and their long-term and often inappropriate use may result in laxative dependence, may damage the bowel, and may lead to problems where none previously existed. This chapter on the approach to patients with constipation is from a lengthy, two-volume textbook that integrates the various demands of science, technology, expanding information, good judgment, and common sense into the diagnosis and management of gastrointestinal patients. Topics include definitions, the socioeconomic and medical consequences of constipation, pathophysiological considerations, evaluation of constipation, diagnostic strategies, and treatment options. The author notes that there is general agreement that selecting treatment strategies requires understanding of the whole patient, fiber supplements should be added to the diet, establishing proper toileting arrangements can help certain patients, and long-term use of stimulant laxatives should be judicious. Surgery has a role in selected patients with severe constipation in whom abnormal bowel function can be ameliorated by operative intervention. 2 figures. 5 tables. 185 references.

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Constipation in Children. Flourtown, PA: American Society for Pediatric Gastroenterology, Hepatology and Nutrition. 2003. 1 p.

Constipation is defined as either a decrease in the frequency of bowel movements, or the painful passage of bowel movements. This brief fact sheet considers the problem of constipation in children. The fact sheet defines the condition, outlines etiology (causes), the symptoms that can accompany the constipation (including stomach pain, poor appetite, crankiness) and epidemiology (how common the condition is), then discusses treatment options. Constipation can begin when there are changes in the diet, the time of toilet training, following travel, or after a viral illness. In most cases, there is no need for diagnostic testing prior to treatment for constipation. Treatment of constipation varies according to the source of the problem and the child's age and personality. Some children may only require changes in diet such as an increase in fiber, fresh fruits, or in the amount of water they drink each day. For more information, readers are encouraged to visit www.naspghan.org (the web site of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition).

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Constipation. In: Bonci, L. American Dietetic Association Guide to Better Digestion. Hoboken, NJ: John Wiley and Sons, Inc. 2003. p. 184-200.

Coping with a gastrointestinal disorder, whether it is irritable bowel syndrome (IBS), gas (flatulence), constipation, heartburn, or another condition, can be embarrassing and debilitating. While medical treatments and prescriptions can offer relief, one of the most important ways patients can help themselves is in their dietary choices. This chapter on constipation is from a book that describes how patients can self-manage their digestive disorders through dietary choices. In this chapter, the author first defines constipation and considers the various causes for constipation, then discusses the symptoms of the condition, diagnostic considerations, treatment goals and strategies, the impact of diet on constipation, using diet to help prevent or treat constipation, strategies for boosting dietary fiber intake, the importance of fluids, the use of fiber supplements, dietary or herbal supplements that can worsen symptoms of constipation, and the role of physical activity. A chart of the fiber content of common foods and a menu plan for a 5 week fiber-increasing diet are provided. 4 figures.

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Constipation. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2003. 8 p.

This fact sheet describes constipation, defined as small amounts of hard, dry bowel movements, usually fewer than three times a week. People who are constipated may find it difficult and painful to have a bowel movement. Other symptoms of constipation include feeling bloated, uncomfortable, and sluggish. Written in a question-and-answer format, the fact sheet covers a definition of constipation, the incidence of constipation, causes of the condition, the diagnostic tests to confirm problems of constipation, treatment options, and complications. Common causes of constipation are not enough fiber in the diet, not enough liquids, lack of exercise, medications, irritable bowel syndrome (IBS), lifestyle changes (pregnancy, older age, travel), abuse of laxatives, ignoring the urge to have a bowel movement, specific diseases such as stroke, problems with the colon and rectum, and problems with intestinal function (chronic idiopathic constipation). Diagnostic tests include colorectal transit study, anorectal function tests, barium enema x ray, and sigmoidoscopy or colonoscopy. A final section describes the goals and work of the National Digestive Diseases Information Clearinghouse. 1 figure.

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Three Steps to Better Management of Constipation. Patient Care. 37(6): 37-40. June 2003.

This article presents a patient management plan that helps health care providers sort out the many treatment options for constipation, the main complaint in more than several million primary care visits each year. In addition to questions about the medical history and the symptoms and duration of constipation, caregivers are advised to obtain a complete list of the patient's prescription and over-the-counter (OTC) medications. The physical examination should focus on abdominal size and tenderness, organomegaly, masses, a perianal inspection, an internal rectal exam, and appropriate examinations for concomitant medical problems. The minimum laboratory assessment should consist of a CBC count; levels of serum calcium, potassium, glucose, creatinine, and thyroid-stimulating hormone; and a test for fecal occult (hidden) blood. The goal of treatment is to restore and maintain adequate stool frequency and consistency with as few artificial aids as possible. Obstructive problems need to be addressed, and concomitant diseases or disorders should be treated. Three-step management includes hydration and fiber, laxatives and stool softeners, and, in refractory cases, prescription stimulants and colonic irritants. 1 table. 7 references.

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What I Need to Know About Constipation. Bethesda, MD: National Digestive Diseases Information Clearinghouse. 2003. 13 p.

This brochure provides basic information about constipation, defined as three bowel movements or fewer in a week. In addition, the stool is hard and dry and can be painful to pass. Written in a question-and-answer format and using nontechnical language, the brochure reviews the causes of constipation and offers suggestions for preventing the problem. Recommendations include eating more fiber, drinking plenty of water and other liquids, getting enough exercise, allowing enough time for bowel movements, using laxatives only with the advice of a health care provider, and checking with the physician about medications that can cause constipation. Simple line drawings supplement and reinforce the textual material. A table of high-fiber foods is provided. The brochure includes a list of resource organizations where readers can get more information, a list of other titles in the series, and an acknowledgements page. A final page describes the goals and activities of the National Digestive Diseases Information Clearinghouse. The brochure is also available in Spanish. 3 figures. 1 table.

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Compliance, Tone and Sensitivity of the Rectum in Different Subtypes of Irritable Bowel Syndrome. Neurogastroenterology and Motility. 14(3): 241-247. June 2002.

Irritable bowel syndrome (IBS) consists of various subtypes; it is unknown whether these subtypes share a common pathophysiology. Evaluation of motor and sensory function of the rectum using a barostat may help to explore a common pathophysiological background or differences in pathophysiology in subtypes of BIS. This article reports on a study in which authors evaluated compliance, tone, and sensitivity of the rectum, in both fasting state and postprandially (after a meal), using a computerized barostat in 15 patients with diarrhea-predominant IBS (IBSD), 14 patients with constipation-predominant IBS (IBSC), and 12 healthy controls. Rectal compliance was decreased in both IBS groups compared with controls. The perception of urge was increased only in IBSD patients, whereas pain perception was significantly increased in both IBS groups. Spontaneous adaptive relaxation was decreased in IBSD patients. Postprandially, rectal volume decreased significantly in the controls and in IBSD patients, but not in IBSC patients. In conclusion, both rectal motor and sensory characteristics are different between IBSD and IBSC patients. Therefore, testing of rectal visceroperception, adaptive relaxation, and the rectal response to a meal may help distinguish groups of patients with different subtypes of IBS. 5 figures. 2 tables. 23 references.

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Constipation. In: Feldman, M.; Friedman, L.S.; Sleisenger, M.H. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 7th ed. [2-volume set]. St. Louis, MO: Saunders. 2002. p. 181-210.

Constipation is a common reason for consultation in primary care, in which its management is often simple and successful without the need for investigation or long term use of drugs. Only a small proportion of all patients with constipation are referred to a gastroenterologist when there has been no response to dietary or other measures. This chapter on constipation is from a comprehensive and authoritative textbook that covers disorders of the gastrointestinal tract, biliary tree, pancreas, and liver, as well as the related topics of nutrition and peritoneal disorders. Topics include presenting symptoms, epidemiology, clinical definition and classification, pathophysiology, constipation as a manifestation of systemic disorders, constipation as a manifestation of central nervous system or extrinsic nerve supply to the gut, constipation secondary to structural disorders of the colon, rectum, anus and pelvic floor, drug treatment that may cause of aggravate constipation, psychological disorders as causes of or aggravating factors in constipation, clinical assessment, diagnostic tests, medical treatment, behavioral treatments (including defecation training and biofeedback), surgical treatment, and particular clinical problems (including those in children, difficult defecation, pregnancy, laxative dependence, laxative abuse, and elderly patients with overflow incontinence). The chapter includes a mini-outline with page citations, full-color illustrations, and extensive references. 11 figures. 9 tables. 200 references.

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Constipation. In: Edmundowicz, S.A., ed. 20 Common Problems in Gastroenterology. New York, NY: McGraw-Hill, Inc. 2002. p. 179-187.

Constipation is the most common digestive complaint in the United States, accounting for 2.5 million physician visits annually. This chapter on constipation is from a book that focuses on the most common gastroenterological problems encountered in a primary practice setting. The chapter is organized to support rapid access to the information necessary to evaluate and treat most patients with this problems. Topics include incidence and definitions of constipation, principal diagnoses, key history and physical examination, specialized testing of colonic and anorectal function, treatment options, patient education, common errors, and emerging concepts. Treatments discussed include exercise and fiber; pharmacology, including nonabsorbable disaccharides, saline cathartics, lubricants, stool softeners, oral stimulants, enemas, prokinetic agents, and other pharmacologic treatments; biofeedback therapy; and surgical treatment. The chapter includes an outline for quick reference and selected references. 5 tables. 22 references.

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Constipation: Getting Relief. San Bruno, CA: StayWell Company. 2002. [2 p.].

This patient education brochure describes constipation and its treatment. Written in nontechnical language, the brochure first defines constipation as bowel movements that occur less often than usual or the need to strain to pass hard, dry stool. Symptoms of constipation include a feeling of fullness in the rectum, bloating and gas, feeling the urge but being unable to pass stool, abdominal pain and cramping, and nausea. One of the main causes of constipation is a diet that is too low in dietary fiber and water. Other causes can include travel (and changes in diet and bowel habits), pregnancy, too little exercise, misuse of laxatives, side effects of certain medications, systemic diseases (diabetes or hyperthyroidism, for example), and ignoring the urge to have a bowel movement. Diagnosis will include the patient's medical history and some diagnostic tests such as sigmoidoscopy and barium enema. Most treatment plans focus on increasing dietary fiber, getting regular exercise, and avoiding chronic laxative use. One section of the brochure illustrates and describes the physiology of normal bowel movements and what happens in constipation. The last page of the brochure summarizes the recommendations for increasing dietary fiber. The brochure is illustrated with full color line drawings. 7 figures.

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Disorders of Defecation. In: Corman, M.L.; Allison, S.I.; Kuehne, J.P. Handbook of Colon and Rectal Surgery. Philadelphia, PA: Lippincott Williams and Wilkins. 2002. p.225-245.

Chronic idiopathic constipation and abdominal pain are among the most common reasons for patients to solicit medical advice. This chapter addresses a number of conditions associated with bowel evacuation problems, the presenting complaint of which is often constipation. The chapter is from a handbook that addresses the entire range of diseases affecting the colon, rectum, and anus. Topics include physiology of the colon (absorption and propulsion), etiology of chronic constipation, clinical presentations, evaluation of the constipated patient, medical management (diet, exercise, laxatives, enemas, and suppositories), spastic pelvic floor syndrome, obstructed defecation, anismus, Hirschprung's disease, surgery in the management of constipation, intestinal pseudo-obstruction, proctalgia fugax, and coccygodynia. 1 figure. 1 table.

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Long-term Safety of Tegaserod in Patients with Constipation-Predominant Irritable Bowel Syndrome. Alimentary Pharmacology and Therapeutics. 16(10): 1701-1708. October 2002.

The oral administration of the drug tegaserod causes gastrointestinal (GI) effects resulting in increased gastrointestinal motility (movement of contents through the GI tract) and attenuation of visceral sensation. This article reports on a study undertaken to determine the long term safety and tolerability of tegaserod in patients with irritable bowel syndrome (IBS) with constipation as the predominant symptom of altered bowel habits. The multicenter, open label study included 579 patients. Of these, 304 (53 percent) completed the trial. The most common adverse events, classified as related to tegaserod for any dose, were mild and transient diarrhea (10.1 percent), headache (8.3 percent), abdominal pain (7.4 percent), and flatulence (5.5 percent). Forty serious adverse events were reported in 25 patients (4.4 percent of patients) leading to discontinuation in 6 patients. There was one serious adverse event, acute abdominal pain, classified as possibly related to tegaserod. There were no consistent differences in adverse events between patients previously exposed to tegaserod and those treated for the first time in this study. The authors conclude that tegaserod appears to be well tolerated in the treatment of patients with constipation-predominant IBS. The adverse event profile, clinical laboratory evaluations, vital signs, and electrocardiogram recordings revealed no evidence of any unexpected adverse events, and suggest that treatment is safe over a 12 month period. 1 figure. 4 tables. 23 references.

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Naloxone Treatment for Irritable Bowel Syndrome: A Randomized Controlled Trial with an Oral Formulation. Alimentary Pharmacology and Therapeutics. 16(9): 1649-1654. September 2002.

Opioids change gut motility and secretion, causing delayed intestinal transit and constipation. Endorphins play a role in the constipation troubling some patients with irritable bowel syndrome (IBS); hence naloxone, an opioid antagonist, may have a therapeutic role. This article reports on a study undertaken to assess the efficacy and safety of an oral formulation of naloxone in IBS patients with constipation. The randomized, double-blind, placebo-controlled trial included 25 patients with IBS (constipation-predominant and alternating types) who received 8 weeks of treatment with naloxone capsules, 10 milligrams twice daily, or identical placebo. Adequate symptomatic relief was recorded in six of 14 on naloxone and three of 11 on placebo. Whilst the differences were not significant, improvements in severity gradings and mean symptom scores for pain, bloating, straining and urgency to defecate were greater with naloxone than placebo for all parameters. In addition, quality of life assessments improved to a greater extent in patients taking naloxone. The authors conclude that preliminary results suggest that naloxone is well tolerated and beneficial in patients with irritable bowel syndrome and constipation. A larger clinical trial is needed to provide sufficient statistical power to assess efficacy. 4 figures. 2 tables. 29 references.

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Prucalopride, a Systemic Enterokinetic, for the Treatment of Constipation. Alimentary Pharmacology and Therapeutics. 16(7):1347-1356. July 2002.

Laxatives are frequently ineffective in treating constipation. An alternative therapeutic approach is to target serotonin 4 receptors, which are involved in initiating peristalsis. This article reports on a study undertaken to assess the effectiveness and safety of a systemically active serotonin 4 agonist, prucalopride. In the study, 74 women with constipation were stratified into slow or normal transit groups, and each group was randomized to receive either placebo or 1 milligram prucalopride daily for 4 weeks. Prucalopride, not placebo, increased spontaneous stool frequency and reduced time to first stool. Prucalopride reduced the number of retained markers in all patients compared to placebo. Prucalopride reduced the mean number of retained markers in slow transit, but did not alter the marker count in normal transit. Orocecal transit was accelerated by prucalopride, not placebo. Prucalopride, not placebo, increased rectal sensitivity to distension and electrical stimulation. Prucalopride significantly improved several domains of the Short Form Health Status Survey and the disease specific quality of life. Adverse effects were similar for prucalopride and placebo. 1 figure. 3 tables. 39 references.

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Randomized, Double-blind, Placebo-Controlled Trial of Tegaserod in Female Patients Suffering from Irritable Bowel Syndrome With Constipation. Alimentary Pharmacology and Therapeutics. 16(11): 1877-1888. November 2002.

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder which affects up to 20 percent of the population, with a predominance in females. This article reports on a study undertaken to evaluated the effectiveness and safety of the drug tegaserod in female patients with IBS characterized by symptoms of abdominal pain or discomfort and constipation. In the randomized, double-blind, multicenter study, 1519 women received either tegaserod, 6 milligrams twice a day (n = 767), or placebo (n = 752) for 12 weeks, preceded by a 4 week baseline period without treatment and followed by a 4 week open withdrawal period. The primary effectiveness evaluation was the patient's symptomatic response as measured by the Subject's Global Assessment of Relief. Other efficacy variables included abdominal pain or discomfort, bowel habits, and bloating. Results showed that tegaserod produced significant improvements in the Subject's Global Assessment of Relief and other efficacy variables. These improvements were seen within the first week, and were maintained throughout the treatment period. After withdrawal of treatment, the symptoms rapidly returned. Overall, tegaserod was well tolerated. Diarrhea was the most frequent adverse event; however, this led to discontinuation in only 1.6 percent of tegaserod-treated patients. The authors conclude that tegaserod produced rapid and sustained improvement of symptoms in female irritable bowel syndrome patients and was well tolerated. 4 figures. 2 tables. 31 references.

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Sorting out the most Common GI Complaints. Patient Care. 36(3): 21-22, 25-26, 28, 31. February 15, 2002.

Millions of patients have gastrointestinal (GI) symptoms including belching (burping), intestinal gas (flatulence), abdominal distension, and indigestion, among others. Most of these do not signal the presence of a serious illness, but the practitioner's advice on preventing and treating nuisance symptoms can be enormously valuable to patients. This article helps primary care providers sort out the most common GI complaints. The authors stress that even trivial GI complaints deserve careful attention in the history and physical. Ominous symptoms include anemia, dysphagia (swallowing difficulties), bleeding, and weight loss. Once a potentially serious GI disorder has been ruled out, prevention and treatment efforts against the patient's most troublesome complaints can be initiated. Alpha-D-galactosidase may reduce gas associated with bean consumption; patients should be encouraged to incorporate these valuable foods in their diets. Sorbitol containing products may cause excessive gas production, even diarrhea. Patients should not increase their fiber consumption without increasing their fluid intake. Heartburn is usually well managed with H2 receptor antagonists and proton pump inhibitors. The authors caution that testing for gallstones is not indicated, unless the patient has the characteristic severe pain associated with this condition. And eradicating Helicobacter pylori in a patient with nonulcer dyspepsia usually does not reduce the symptoms. 1 figure. 1 table. 6 references.

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What is Constipation Anyway?. Participate. 11(3): 1-3. Fall 2002.

This newsletter article notes that constipation is one of the most difficult gut symptoms to define. The difficulty lies in the many features of constipation. Since more than 98 percent of people have at least 3 bowel movements per week, less is often invoked as abnormal. Many people happily manage will fewer, while others within that range are decidedly uncomfortable with what they believe is constipation. The author stresses that frequency of defecation cannot be considered in isolation. Other factors of equal importance are the consistency or form of the stool, the effort required to expel it, and the accompany abdominal discomfort and distension. The author also discusses acute versus chronic constipation, and different perspectives of constipation, including those of patients, physicians, and physiologists. 1 figure. 2 tables. 8 references.

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Childhood Constipation: Evaluation and Treatment. Journal of Clinical Gastroenterology. 33(3): 199-205. 2001.

This article reviews the evaluation and treatment of childhood constipation, a common condition. The authors estimate that between 5 and 10 percent of pediatric patients have constipation or encopresis (fecal soiling). Constipation is the second most referred condition in pediatric gastroenterology practices, accounting for up to 25 percent of all visits. The authors lay out a practical approach for those physicians not familiar with constipation in children. The diagnosis of constipation requires careful history taking and interpretation. Diagnostic tests are not often needed and are reserved for those who are severely affected. The daily bowel habits of children are extremely susceptible to any changes in routine environment. Constipation and subsequent fecal retention behavior often begins soon after a child has experienced a painful evacuation. Childhood constipation can be difficult to treat and often requires prolonged support by physicians and parents, explanation, medical treatment, and most importantly, the child's cooperation. 1 figure. 5 tables. 31 references.

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Chronic Constipation in Children: Rational Management. Consultant. 42(12): 1723-1732. November 2001.

This article reviews a strategy of rational management of chronic constipation in children. The authors note that irregular bowel habits are a common cause of chronic constipation in children; illness and travel are among the disruptions in daily routine that can result in stool withholding. Medical conditions, such as diabetes and Hirschsprung disease, and medications, including methylphenidate, analgesics, and cough syrups, can also cause constipation. Encopresis (fecal incontinence, or involuntary loss of stool), anal outlet bleeding, and rectal pain caused by anal fissures are associated with chronic constipation; hemorrhoids rarely develop in children. Barium enemas, survey films, and colonic transit studies can detect and define functional or structural obstruction. Physicians should recommend regular postprandial (after a meal) toilet visits; moderate exercise; and increased fluid and fiber intake, using a 'medicinal' fiber product if necessary. Parents should be discouraged from excessive use of laxatives and cathartics. Options for long term therapy include mineral oil and osmotic laxatives. 3 tables. 69 references.

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Chronic Idiopathic Constipation: A Psychological Enquiry. European Journal of Gastroenterology and Hepatology. 13(1): 39-44. January 2001.

Intractable idiopathic (of undetermined cause) constipation in women is often associated with psychosocial problems. This article reports on a study undertaken to determine the past and current psychological factors associated with slow and normal transit constipation. Consecutive female patients (n = 28) referred for biofeedback treatment were interviewed before the procedure. Transit studies revealed that 12 had slow transit constipation (STC) and 16 had normal transit constipation (NTC). Patients were assessed for evidence of previous and current psychiatric diagnoses; family and social history was noted; and self-rating scales were used to measure psychological distress, abnormal attitudes to eating, and current psychosocial functioning. The mean age of the 28 patients was 38.2 years (plus or minus 10.8 years) with a mean duration of symptoms of 17.6 years (plus or minus 16.9 years). Seventeen (61 percent) had a current psychiatric disorder and 18 (64 percent) a previous episode of psychiatric illness. The mean age of the 16 NTC patients was 38.4 years (plus or minus 10.1 years) with a mean duration of symptoms of 12.4 years (plus or minus 15.9 years). By contrast, the 12 STC patients had a much longer mean duration of constipation (24.3 years; plus of minus 16.4 years), a mean age of 37.9 years (plus of minus 12.1 years), with half having an onset in childhood. The STC patients reported more psychosocial distress on the rating scales than those with NTC, and only one did not experience some form of adverse life event or gynecological procedure in the 6 months before the onset of constipation. Eleven (39 percent) of the 28 women had had a hysterectomy at a mean age of 36 years, but only four (14 percent) reported a history of sexual abuse. Of the nine (32 percent) patients who reported markedly distorted attitudes to food, six had NTC and three had STC. The authors conclude that although STC is a chronic disorder accompanied by high rates of psychological distress, it does not appear to be associated with gross functional impairment. The authors suggest that patients who present to surgical departments with chronic intractable constipation should routinely have a psychological assessment. 2 figures. 3 tables. 31 references.

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Colectomy for Slow-Transit Constipation: Preoperative Functional Evaluation Is Important but Not a Guarantee for a Successful Outcome. Diseases of the Colon and Rectum. 44(4): 577-580. April 2001.

This article reports on a study designed to assess the results of preoperative functional evaluation of patients with severe slow transit constipation in relation to functional outcome. The study included 439 patients with chronic intractable constipation who were evaluated by marker studies. Of these patients, 21 underwent colectomy (removal of a portion of the colon) and ileorectal anastomosis (reconnection of the ileum portion of the small intestine to the rectum) for slow transit constipation. Mean colorectal transit time was 156 hours (normal time is usually less than 45 hours). Small bowel transit time was normal in 10 patients and delayed in 5 patients. Six patients were nonresponders. Morbidity (illness or complications) was 33 percent. Small bowel obstruction occurred in 6 patients; relaparotomy was done in 4 patients. Follow up varied from 14 to 153 months. After three months, defecation frequency was increased in all patients. mean stool frequency improved from one bowel movement per 5.9 days to 2.8 times per day. Sixteen patients felt improved after surgery. Seventeen patients continued to experience abdominal pain, and 13 still used laxatives and enemas. Satisfaction rate was 76 percent (16 patients). After one year, defecation frequency was back at the preoperative level in 5 patients. An ileostomy was created in two more patients because of incontinence and persistent diarrhea. Eleven patients (52 percent) still felt improved. A relation between small bowel function and functional results could not be demonstrated. The authors conclude that preoperative evaluation is important but not a guarantee for successful outcome. Colectomy remains an ultimate option for patients with disabling slow transit constipation, but patients should be informed that, despite an increased defecation frequency, abdominal symptoms might persist. Any common use of colectomy to treat constipation should be discouraged. 1 table. 16 references.

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Constipation and Fecal Incontinence in the Elderly. Gastroenterology Clinics of North America. 30(2): 497-515. June 2001.

Continence and defecation are complex functions that require the interaction of visceral and pelvic muscles and the nerves that regulate their activity. These activities may be abnormal in elderly patients and can produce symptoms, such as chronic constipation or fecal incontinence (involuntary loss of stool). This article, from a special issue on gastrointestinal (GI) disorders in the elderly, addresses constipation and fecal incontinence in this population. The author emphasizes that, contrary to widespread opinion, much can be done to improve constipation and incontinence in the elderly and relieve a considerable burden in these patients. Relatively little research has been done to differentiate physiologic changes in rectoanal function resulting from aging and pathologic changes resulting from diseases occurring as patients age. Treatment includes identification and treatment of the underlying disease, if possible, protective skin care, continence aids, psychologic support, drug therapy (for stimulation of defecation at intervals, antidiarrheal drugs), biofeedback, and surgical therapy. Results of therapy often can be good, leading to alleviation of suffering and the ability to lead a fuller life. 1 figure. 4 tables. 92 references.

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Constipation in Infants and Children: Evaluation and Treatment. In: American Academy of Pediatric. Pediatric Clinical Practice Guidelines and Policies: A Compendium of Evidence-based Research for Pediatric Practice. Elk Grove Village, IL: American Academy of Pediatrics. 2001. p. 95-128.

Constipation, defined as a delay or difficulty in defecation, present for two or more weeks, is a common pediatric problem encountered by both primary and specialty medical providers. This publication offers clinical practice guidelines for the management of pediatric constipation. The guidelines were formulated by the Constipation Subcommittee of the Clinical Guidelines Committee of the North American Society for Pediatric Gastroenterology and Nutrition. The Constipation Subcommittee, consisting of two primary care pediatricians, a clinical epidemiologist, and pediatric gastroenterologists, based its recommendations on an integration of a comprehensive and systematic review of the medical literature combined with expert opinion. The Subcommittee developed two algorithms to assist with medical management, one for older infants and children, and the second for infants less than one year of age. The guidelines provide recommendations for management by the primary care provider, including evaluation, initial treatment, follow up management, and indications for consultation by a specialist. The report is designed as a general guideline to assist providers of medical care in the evaluation and treatment of constipation in children. 77 references.

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Constipation. Postgraduate Medicine. 109(3): 193-194. March 2001.

This patient education handout reviews the current recommendations for managing problems with constipation. Constipation is defined as passage of hard stool fewer than three times a week, or difficulty passing stool. Constipation is not a disease, but a symptom of slow movement of food through the large intestine. The problem can be caused by inadequate fluid intake, lack of fiber in the diet, inactivity, medications, bowel obstruction, surgery, prolonged laxative use, stress, or not paying attention to the urge to move one's bowels. Changing one's diet and fluid habits and getting more exercise often solve any problems with constipation. Readers are encouraged to increase their levels of dietary fiber slowly in order to avoid bloating and gas problems. Readers are also encouraged to try a natural vegetable fiber supplement (e.g., Citrucel, Fiberall, Metamucil) instead of using a laxative. Stool softeners (docusate sodium or Colace, or docusate calcium or Surfak) are gentle and may be helpful. Osmotic laxatives can increase the water content in the stool; these agents are safe to use a few times a month. Stimulant laxatives are the most powerful and should be used only with great caution. In severe cases, constipation can result in fecal impaction, which occurs when the hardened stool cannot be eliminated through the rectum. One sidebar lists medications that may cause constipation as an unintended side effect; another sidebar lists foods that are good sources of fiber. 2 figures.

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Dealing with Irregularity: Constipation, Diarrhea, Excessive Gas and Foul-Smelling Gas. Digestive Health and Nutrition. 3(1): 16-20. January-February 2001.

This article offers strategies for dealing with problems of bowel irregularity, including constipation, diarrhea, excessive gas, and foul-smelling gas. The author notes that bowel habits vary greatly among individuals, so each person's perception of whether there even is a problem and how to deal with it best is different. The author stresses that too little fiber and liquid in the diet are by far the most common reasons for constipation among people living in western cultures. The fiber found in foods such as fruits, grains, and vegetables adds bulk to the stool, making it easier to move through the colon (large intestine). Liquids add both bulk and fluid to the stool. Exercise helps prevent constipation by maintaining energy levels and promoting intestinal activity. A number of pain medications; antidepressants; antacids that contain aluminum; diuretics; and antiinflammatory and antiseizure medications are some of the many medications that can contribute to constipation. Changes in routines can also cause irregularity. The author explores the role of aging as a cause of constipation. Laxatives are an effective remedy for constipation, but they should be used with caution. As with constipation, diarrhea means different things to different people. Bacterial and viral infections are the most common causes of acute diarrhea; food intolerance is another frequent cause of both diarrhea and gas. Regardless of the cause, diarrhea usually lasts only a few days and ends on its own without the need for medical attention. The author reviews the concerns regarding dehydration, which can be a consequence of diarrhea, particularly in children and in the elderly. Gas comes from two sources: swallowed air and the breakdown of certain undigested foods in the large intestine. Simple ways of reducing the gas from swallowed air include eating and drinking more slowly, not chewing gum, and having dentures properly fitted. For episodes of excessive or smelly intestinal gas, the use of a food diary may help identify the offending items. The author concludes by reiterating the importance of adequate fiber and fluid intake. The websites of four information resource organizations are listed.

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Dyssynergic Defecation. Gastroenterology Clinics of North America. 30(1): 97-114. March 2001.

Studies have shown that most patients with difficult defecation show a failure of rectoanal coordination that consists of impaired abdominal and rectal pushing forces or paradoxical anal contraction or inadequate anal relaxation. This article reviews this condition, termed dyssynergic defecation. A lack of coordination or dyssynergia of the abdominal and pelvic floor muscles that are involved in defecation appears to be the primary underlying mechanism. The authors discuss epidemiology, etiology (including psychosocial factors and pathophysiology), clinical features, diagnostic tests (digital rectal examination, anorectal manometry, balloon expulsion test, defecography), diagnostic criteria, and treatment options. Patients with dyssynergic defecation may present with a variety of symptoms, including feeling of incomplete evacuation, excessive straining, hard stools, digital disimpaction and vaginal splinting, anorectal pain, lumplike sensation or perianal heaviness, and tenesmus (ineffective spasms of the rectum). Treatment consists of standard treatment for constipation; specific treatment (i.e., neuromuscular conditioning or biofeedback therapy); and other measures, including botulinum toxin injection, myectomy, and ileostomy. 62 references.

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Hirschsprung's Disease: An Overview. Milwaukee, WI: International Foundation for Functional Gastrointestinal Disorders (IFFGD). 2001. [2 p.].

This fact sheet offers an overview of Hirschsprung's disease, a genetic disorder that results in the absence of nerve cells in the wall of the bowel. Collections of nerve cells (ganglia) control the coordinate contraction and relaxation of the bowel wall, called peristalsis, that is necessary for bowel contents to advance. Without this action, the bowel remains collapsed and stools cannot pass. Bowel contents build up behind the obstruction, resulting in constipation. The fact sheet describes the condition in infants and very young children, the emergency conditions that can accompany Hirschsprung's disease, diagnostic strategies, and treatment options. To diagnose Hirschsprung's disease, a barium enema x ray tests is used to identify the narrow collapsed segment of bowel as well as the dilated bowel in front of the affected regions. Treating Hirschsprung's disease requires surgery to remove the affected bowel and then to join the healthy bowel segments. There are several different surgical approaches, each with a high rate of success. The fact sheet includes the contact information for the International Foundation for Functional Gastrointestinal Disorders (IFFGD, www.iffgd.org).

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Pediatric Anorectal Disorders. Gastroenterology Clinics of North America. 30(1): 269-287. March 2001.

Anorectal disorders are common in children; it is estimated that 10 percent of children are brought to medical attention because of a defecation disorder, and constipation is the chief complaint in 3 to 5 percent of all visits to pediatricians. This article explores pediatric anorectal disorders, emphasizing the differences between children and adults in terms of clinical presentations, pathophysiology, diagnosis, and treatment. Topics include constipation, functional nonretentive fecal soiling, Hirschsprung's disease, other colonic neuromuscular disorders, children with neurologic handicap (including cerebral palsy and spinal dysraphism), and imperforated anus. The author stresses that the child's developmental stage; the interaction between patient, family, and peers; and the presence of behavioral and psychological comorbidity need to be assessed carefully in any diagnosis of pediatric anorectal disorders. There are three periods when a child is particularly vulnerable to developing constipation: the introduction of cereals and solid food in the diet of an infant, toilet training, and the start of school. Childhood functional constipation is a clinical diagnosis that can be made in most cases on the basis of a typical history and an essentially normal physical examination. The most successful approach to a child with functional constipation includes a combination of parental education, behavioral modification, and medial intervention. 3 figures. 2 tables. 58 references.

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Slow Transit Constipation. Gastroenterology Clinics of North America. 30(1): 77-95. March 2001.

This article reviews slow transit constipation, a clinical syndrome characterized by intractable constipation poorly responsive to dietary fiber and laxatives. Other gastrointestinal manifestations include abdominal pain, bloating, malaise, nausea, anorectal symptoms suggestive of difficult fecal expulsion, and delayed colonic transit without megacolon. Extragastrointestinal symptoms in this syndrome include painful or irregular menses, hesitancy in initiating micturition (urination), and somatic symptoms such as cold hands or blackout. The authors briefly discuss terminology and stress that slow transit constipation is the term used to define a disorder of colonic motor function, and is generally used for patients with delayed colonic transit but no underlying systemic disorder or pelvic floor dysfunction that explains their symptoms. The authors discuss epidemiology, pathophysiology, histology, clinical features, differential diagnosis, radiopaque marker diagnostic methods, scintigraphic techniques, medical treatments, surgical treatment, and the special situation of colonic dysfunction after spinal cord injury. The authors note that the disorder spans a spectrum of variable severity, ranging from patients who have relatively mild delays in transit but who are otherwise indistinguishable from irritable bowel syndrome patients at one extreme, to patients with colonic inertia or chronic megacolon at the other extreme. Potential mechanisms for impaired colonic propulsion include fewer colonic HAPCs (high amplitude propagated contractions) or a reduced colonic contractile response to a meal. The treatment is primarily medical; surgery is reserved for patients with severe disease or colonic inertia. 3 figures. 1 table. 85 references.

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Slow Transit Constipation: A Disorder of Pelvic Autonomic Nerves?. Digestive Diseases and Sciences. 46(2): 389-401. February 2001.

Slow transit constipation (STC) is a severe motility disorder, which in the majority of cases is of unknown etiology. In some patients, symptoms arise in childhood, but a proportion of patients present in later life, including after pelvic surgery or childbirth. In this article, the authors describe the current knowledge of the anatomy and function of the pelvic autonomic nerves with respect to colonic motility (experimental and observational studies); discuss evidence for pelvic nerve injury in STC arising after pelvic surgery or childbirth; and, on the basis that such patients are clinically indistinguishable from patients with chronic idiopathic (of unknown cause) STC, to evaluate whether there is evidence that pelvic autonomic neuropathy (nerve damage or disease) has an etiologic role in patients with chronic idiopathic STC. The authors document the clear importance of the pelvic autonomic nerves in colonic motor function. While there is an association between pelvic surgery and childbirth, and the onset of STC, there is little direct anatomical evidence that pelvic denervation occurs in these patients. However, the phenotype of these patients is similar to results of experimental and observational studies. The authors present evidence for possible pathogenetic mechanisms underlying the pelvic autonomic neuropathy in chronic idiopathic STC. 1 figure. 3 tables. 162 references.

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Surgical Treatment of Constipation and Fecal Incontinence. Gastroenterology Clinics of North America. 30(1): 131-166. March 2001.

This lengthy article reviews the surgical treatment of constipation and fecal incontinence. The authors emphasize that success in the management of constipation depends on an accurate determination of the cause. Because there are many extracolonic causes that can produce constipation, a detailed clinical history should be taken. Before physiologic investigation, patients must discontinue the use of medications that may cause or exacerbate their symptoms. A proper diet should be maintained, and patients must be supervised by a dietitian or a physician for a minimum of 3 to 6 months before any extensive physiologic evaluation is undertaken and before any surgery is considered. Diagnostic tests may include anorectal examination, colonic transit study, proctography and cinedefecography, electromyography, manometry, small bowel transit study, Minnesota Multiphasic Personality Inventory, and rectal biopsy. Surgery for constipation is reserved for a highly select group of patients; the authors review the indications for patients with pelvic outlet obstruction, with colonic inertia (slow transit throughout the colon), and with combined outlet obstruction and colonic inertia. The authors then discuss fecal incontinence, noting that obstetric injury (during childbirth) is a major cause and one amenable to surgical correction. Diagnostic tests can include physical examination, manometry, electromyography, pudendal nerve terminal motor latency, anal ultrasonography, and magnetic resonance imaging (MRI). The treatment of fecal incontinence should always be directed to the cause; many individuals can be managed adequately by noninvasive means. Surgical treatment can include sphincter repair, muscle transplant, the use of synthetic material, and diversion (the creation of a stoma). 4 figures. 9 tables. 297 references.

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Therapy of Constipation. Alimentary Pharmacology and Therapeutics. 15(6): 749-763. June 2001.

Constipation is a common symptom that may be idiopathic (of unknown cause) or due to various identifiable disease processes. This article reviews the current recommendations for treating constipation. Laxatives are agents that add bulk to intestinal contents, that retain water within the bowel lumen by virtue of osmotic effects, or that stimulate intestinal secretion or motility, thereby increasing the frequency and ease of defecation. Drugs which improve constipation by stimulating gastrointestinal motility (movement) by direct actions on the enteric nervous system are under development. Mineral oil is a lubricating agent that facilitates defecation by altering stool consistency and by forming a slippery layer around fecal pellets. Other modalities used to treat constipation include biofeedback and surgery. Laxatives and lavage (cleaning) solutions are also used for colon preparation and evaluation of the bowels after toxic ingestions. Most patients with constipation will try to treat this condition themselves before seeking medical attention. Therefore, it is important for the health care provider to obtain a good history of the treatments that have been tried previously in addition to trying to develop a good understanding of exactly what problems the patient is having with defecation. A detailed physical examination, including a thorough rectal examination is also important. 3 tables. 133 references.

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What You Can Do to Prevent and Treat Constipation. Guide to Women's Health. 12, 14. April 2001.

This fact sheet reviews strategies that readers can follow to prevent and treat constipation. Most cases of constipation are temporary and not serious. Poor diet and lack of exercise are usually to blame, and in most cases, simple dietary and lifestyle changes will relieve symptoms and help prevent constipation from recurring. A diet with enough fiber (20 to 35 grams each day) helps form soft, bulky stool. Good sources of fiber include beans, whole grains and bran cereals, fresh fruits, and vegetables such as asparagus, brussels sprouts, cabbage, and carrots. Other changes that can help treat and prevent constipation include: drinking enough water and other liquids; engaging in daily exercise; reserving enough time to have a bowel movement; and not ignoring the urge to have a bowel movement. Health care providers may recommend laxatives or enemas for a limited time in patients who have a slow response to these lifestyle changes. The fact sheet outlines different types of laxatives, including bulk forming laxatives, stimulants, stool softeners, and saline laxatives. For chronic constipation or constipation caused by problems such as rectal prolapse, anorectal dysfunction, or colonic inertia, surgical options may be recommended by the health care provider. One sidebar lists the common causes of constipation.

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AGA Technical Review on Constipation. Gastroenterology. 119(6): 1766-1778. December 2000.

This technical review identifies a rational, effective, and cost effective approach to the patient presenting with constipation. The authors review the epidemiology of constipation, risk factors, the economic impact of constipation, the clinical features and pathophysiology, clinical evaluation, secondary encounters and referral consultations, diagnostic tests (balloon expulsion test, defecography, colonic transit, and anorectal manometry), medical management, and the role of surgery in treating constipation. Constipation is associated with inactivity, low caloric intake, the number of medications being taken, low income, and a low education level. Constipation is also associated with depression as well as with physical and sexual abuse. These are noted as risk factors, not necessarily as causative agents. The review summarizes three patient care algorithms. After the initial history and physical examination, patients can be classified into one of several subgroups. Standard blood tests and a colonic structural evaluation should be performed to rule out organic causes of the constipation. If the initial evaluation is normal or negative, an empiric trial of fiber (and or dietary changes) can be followed by simple osmotic laxatives. Most patients will obtain symptom relief with these measures. Patients who fail to respond to this initial approach are appropriate candidates for more specialized testing. 5 tables. 95 references.

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American Gastroenterological Association Medical Position Statement: Guidelines on Constipation. Gastroenterology. 119(6): 1761-1766. December 2000.

Symptoms of constipation are extremely common; the prevalence has been reported to be as high as 20 percent. Many people seek medical care for constipation, but fortunately, most do not have a life threatening or disabling disorder, and the primary need is for control of symptoms. This document presents the official recommendations of the American Gastroenterological Association (AGA, May 2000) on managing patients with constipation. Recommendations focus on more rational and less invasive diagnostic approaches, and more rational and effective therapies that will improve the patient's quality of life; both of these approaches should have beneficial fiscal and logistic impacts on the health care system. The document first defines constipation and its clinical subgroups, including slow transit constipation (colonic inertia), pelvic floor dysfunction, and combination syndromes, then reviews the recommended clinical evaluation of the patient who presents with constipation. The remainder of the document briefly reviews the diagnostic tests, medical management, and the place of surgery and pelvic floor retraining programs for this patient population. 3 figures. 1 reference.

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Childhood Constipation: Finally Some Hard Data About Hard Stools! (editorial). Journal of Pediatrics. 136(1): 4-7. January 2000.

It is estimated that 55 million adults in the United States (approximately 28 percent of the population) are constipated. Similar data are not available on the prevalence in children, although it has been reported that 34 percent of toddlers in the United Kingdom and 37 percent of Brazilian children younger than 12 were considered by their parents to be constipated. This editorial offers a review of the literature on childhood constipation, focusing on research studies that quantified the prevalence of the problem. The editorial also serves as an introduction to two related articles in the same issue of Journal of Pediatrics. The author notes that the most common cause of constipation in pediatrics is a decision made by the child to delay defecation after experiencing a painful or frightening evacuation. Treatment is based on addressing all the factors that have contributed to its development. The evacuations are made more pleasant by stool softeners. The fear of defecation is overcome by avoiding anally invasive procedures (such as enemas) and by using positive reinforcement to make the process less intimidating. Key to successful treatment is a thorough understanding by the family of the pathophysiology of childhood constipation. The author applauds the authors of the other articles for addressing this poorly studied subject. Progress in the understanding of colonic motility disorders and the pathophysiologic mechanisms responsible for treatment failures will help in the selection of patients who may benefit from the use of cisapride and dietary changes. Development of safe prokinetics with a more selective action on colonic motility will undoubtedly facilitate their use in the treatment of childhood constipation. 12 references.

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Childhood Defecation Disorders: Constipation and Soiling. Participate. 9(3): 4-6. Fall 2000.

This article is the second in a two part series on pediatric functional gastrointestinal (GI) disorders that may prompt parents to bring their child to the doctor for constipation or fecal soiling. In this article, the author focuses on non retentive fecal soiling and functional fecal retention. Functional refers to a disorder where the primary problem is not due to disease or visible tissue damage or inflammation; in this article, the author uses functional to refer to symptoms that occur within the expected range of the body's behavior. Functional fecal retention is defined in children by the passage of large or enormous bowel movements at intervals less than twice per week, and the attempt to avoid having bowel movements on purpose. Accompanying symptoms include soiling of the underclothes, irritability, abdominal cramps, and decreased appetite. Functional fecal retention begins when there is a painful bowel movement and the child learns to fear the urge to have a bowel movement. After diagnosis, treatment goals include family and patient education, medication as necessary to assure painless defecation, and the provision of continued availability and interest in the child's problem. Fecal soiling refers to passage of bowel movements into the underclothing, or other inappropriate places. Fecal soiling commonly accompanies functional fecal retention, or after a chronic problem with diarrhea. Functional non retentive (not associated with fecal retention) fecal soiling is diagnosed in children older than 4, who have bowel movements in places and at times that are inappropriate, at least once a week for 3 months, in the absence of a disease to explain it. Treatment goals are to help the parent to understand that there is no medical disease, and to accept a referral to a mental health professional. Parents need guidance to understand that soiling is a symptom of emotional upset, not simply bad behavior. 1 table.

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Cisapride for the Treatment of Constipation in Children: A Double-Blind Study. Journal of Pediatrics. 136(1): 35-40. January 2000.

This article reports on a study undertaken to determine whether cisapride is effective in treating children with constipation. The double blind, placebo controlled study included children with chronic constipation who were randomly assigned to treatment with cisapride or placebo for 12 weeks. Forty children were enrolled, and 36 completed the therapy. Treatment successes occurred in 13 of 17 subjects in the cisapride group (76 percent) and 8 of 19 subjects in the placebo group (37 percent). The odds ratio for response after cisapride administration was 8.2 times higher. During cisapride therapy, there was a significant improvement in the number of spontaneous bowel movements per week and a significant decrease in the number of fecal soiling episodes per day, percentage with encopresis, number of laxative doses per week, percentage using laxatives, and total gastrointestinal transit time. With placebo, there were no significant changes in the number of spontaneous bowel movements, percentage with encopresis, or total gastrointestinal time; but there was a significant decrease in the number of fecal soiling episodes per day and the number of laxative doses per week. The authors conclude that cisapride was effective in treating children with constipation. The authors note, however, that cisapride is not recommended as the first line drug for children with constipation. Dietary fiber and other behavior changes are recommended first. 1 figure. 2 tables. 27 references.

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Constipation Management: An In-Service. Journal of Nurse Assistants. p. 28-29, 32. July 2000.

Constipation is a very common problem among the elderly. This article helps nurse assistants to understand the causes of constipation and the current recommendations for managing constipation in the elderly population, particularly those living in long term care facilities. The author first discusses the impact of aging on the gastrointestinal system, the problems associated with less exercise and activity, the continued need for adequate hydration (consumption of fluids), the use of medications that may cause or worsen constipation, changes in nutrition and food habits, and the impact of alcohol abuse. The author defines constipation as a delay in the routine of defecation, or the elimination of hard dry stool. Nursing facilities often cite a three day limit without stools as the guideline for intervention. The author describes three general types of constipation: atonic (weakness of the muscles of the colon and rectum), obstructive (blockage of the intestines), and spastic (contraction of the muscles of the intestinal wall). The goal for any treatment of the patient with constipation is to develop a regular pattern of bowel elimination and develop methods to prevent constipation. The nurse assistant and home health assistant should learn the patient's bowel pattern and help the patient keep to the pattern. In addition, patients should be encouraged to eat foods that contain fiber, such as fruits and vegetables, grains and cereals. It is essential to provide for privacy and time to defecate. Bedpan use should be avoided if possible. Appropriate hygiene for hands and perineal skin after bowel movements is essential. The author concludes that there are many things that the nurse assistant can do to promote successful elimination. Attention to routines, documentation of results, and reporting to the charge nurse are vital to maintaining normal bowel habits for the residents. Appended to the article is an inservice quiz for readers to test the knowledge gained from reading the article.

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Constipation, Colonic Inertia, and Colonic Marker Studies. Milwaukee, WI: International Foundation for Functional Gastrointestinal Disorders (IFFGD). 2000. [4 p.].

Treatment for the common condition of constipation often includes lifestyle modifications such as increasing fluid intake, consuming more fiber, and exercising regularly. At times, the symptom of constipation can represent serious illness. This fact sheet discusses constipation, colonic inertia, and the colonic marker studies used to diagnose the causes (epidemiology) of constipation. The symptoms of colonic inertia include long delays in the passage of stool accompanied by lack of urgency to move the bowels. Because there are a large number of potential causes for the symptoms of constipation, the physician may perform blood tests looking for systemic disease, as well as a colonoscopy or barium enema to look for intrinsic abnormalities of the colon. A review of medications will help determine if the patient is taking medicines that are affecting the functioning of the colon. In addition, testing of the anorectal function may be performed, including defecography (a radiographic test to identify anatomical defects during defecation) and electromyogram (EMG) to determine if a disorder of this region is present. One sidebar discusses the interplay between functional constipation (the symptoms of constipation present without a known cause) and irritable bowel syndrome (IBS). Another sidebar reviews pelvic floor dyssynergia, the failure of pelvic floor muscles to relax with defecation. The role of biofeedback therapy in the treatment of chronic constipation is emerging. Biofeedback therapy involves training the patient by using special equipment to relax pelvic floor and anal sphincter muscles. Surgical techniques have now been found to be effective in some patients who have colonic inertia. If organic disease is ruled out as the cause, then changes in diet, increased intake of fiber and liquids, and regular exercise can often help. 1 figure. 1 table.

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Keys to Bowel Success. Rehabilitation Nursing. 25(2): 66-69. March-April 2000.

Although many rehabilitation clients have neurogenic bowels requiring special bowel protocols, a review of the literature affirmed the authors' assumptions and experiences as professional nurses that any bowel program must begin with a good nursing assessment, a clean bowel, and eight keys to success. Once these criteria are met, bowel care can be individualized to meet the needs of the specific patient. This article presents a review of the relevant literature and a list of references for nurses seeking additional information on bowel programs. The authors stress that, if not assessed, addressed, and respected as part of the patient's comprehensive rehabilitation program, bowel dysfunction can interfere with a patient's self esteem and progress toward independent living. The eight keys to success include physical exercise, fiber intake, fluid intake, consistent time for defecation, position, privacy, medication management, and patient and family education. 1 table. 38 references.

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Methylnaltrexone for Reversal of Constipation Due to Chronic Methadone Use: A Randomized Controlled Trial. JAMA. Journal of American Medical Association. 283(3): 367-372. January 19, 2000.

Constipation is the most common chronic adverse effect of opioid pain medications in patients who require long term opioid administration, such as patients with advanced cancer, but conventional measures for ameliorating constipation often are insufficient. This article reports on a study undertaken to evaluate the efficacy of methylnaltrexone, the first peripheral opioid receptor antagonist, in treating chronic methadone induced constipation. The double blind, randomized placebo controlled trial was conducted between May 1997 and December 1998 at the clinical research center of a university hospital. The subjects (n = 22, 9 men and 13 women) had a mean age of 43.2 years and were enrolled in a methadone maintenance program and had methadone induced constipation. The 11 subjects in the placebo group showed no laxation response, and all 11 subjects in the intervention group had laxation response after intravenous methylnaltrexone administration. The oral cecal transit times at baseline for subjects in the treatment and placebo groups averaged 132.3 and 126.8 minutes, respectively. The average (standard deviation) change in the treatment group was minus 77.7 minutes, significantly greater than the average change in the placebo group of minus 1.4 minutes. No opioid withdrawal was observed in any subject, and no significant adverse effects were reported by the subjects during the study. The authors conclude that intravenous methylnaltrexone can induce laxation and reverse slowing of oral cecal transit time in subjects taking high opioid dosages. Low dosage methylnaltrexone may have clinical utility in managing opioid induced constipation. 3 figures. 1 table. 37 references.

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Prescription Medications That Can Be Harmful to the Digestive System. Digestive Health and Nutrition. p. 26-29. September-October 2000.

This article reviews the possible negative impact of prescription medications on the digestive system. Drugs that are swallowed enter the body through the gastrointestinal (GI) tract, making it an easy target for side effects. However, injected or infused drugs can also upset the GI tract. Sometimes taking the drug with food will decrease GI side effects; however, food can interfere with the actions of some medications. Nonsteroidal antiinflammatory drugs (NSAIDs) are very effective in helping to reduce the inflammation and pain caused by arthritis and other conditions, however, they increase the risk of ulcers when taking long term. Damage also can occur in the small and large intestine due to the prolonged use of NSAIDs. The drugs can bring about a relapse of inflammatory bowel disease (IBD) and they may cause a rare condition called collagenous colitis or cause diverticula pouches in the colon wall to bleed or perforate. Diarrhea is another common and potentially serious side effect of some prescription drugs; antibiotics, in particular, often cause diarrhea. Other drugs that cause diarrhea, include chemotherapy cancer drugs, magnesium-containing antacids, the antiobesity drug Xenical, and some diabetes drugs. In addition, some drugs can slow the motility of the GI tract or can limit activities, resulting in constipation. Other GI problems can include esophageal irritation (from oral pills getting stuck in the esophagus), liver toxicity, and pancreatitis (inflammation of the pancreas). The author concludes by reminding readers that most drugs have the potential for causing GI upset and that patients should work closely with their physicians to monitor side effects. 1 table.

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