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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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