World Gastroenterology Organisation Global Guideline:... : Journal of Clinical Gastroenterology (original) (raw)

WGO GUIDELINE

Constipation—A Global Perspective

Lindberg, Greger MD, PhD*; Hamid, Saeed S. MD†; Malfertheiner, Peter MD‡; Thomsen, Ole Ostergaard MD, PhD§; Fernandez, Luis Bustos MD∥; Garisch, James MD¶; Thomson, Alan MD♯; Goh, Khean-Lee MD**; Tandon, Rakesh MD††; Fedail, Suliman MD‡‡; Wong, Benjamin C.Y. MD§§; Khan, Aamir Ghafoor MD∥∥; Krabshuis, Justus H.¶¶; LeMair, Anton MD♯♯

*Karolinska Institutet, Stockholm, Sweden

†Aga Khan University, Karachi, Pakistan

‡Otto von Guericke University, Magdeburg, Germany

§University of Copenhagen, Herlev Hospital, Herlev, Denmark

∥Hospital Bonorino Udaondo, Buenos Aires, Argentina

¶St Georges Hospital, Port Elizabeth, South Africa

♯University of Western Ontario, London, Ontario, Canada

**University of Malaya, Kuala Lumpur, Malaysia

††All India Institute of Medical Sciences, New Delhi, India

‡‡University of Khartoum, Khartoum, Sudan

§§Department of Medicine, University of Hong Kong, Hong Kong

∥∥Lady Reading Hospital, Peshawar, Pakistan

¶¶Highland Data, Tourtoirac, France

♯♯Highland Data, Amsterdam, The Netherlands

This guideline is written and reviewed by a committee of the WGO chaired by Dr Lindberg

Supported by none.

Conflict of interest: None.

Erratum

The article on page 483 of the July 2011 issue has been replaced at www.jcge.com. In the original article, the author listing was omitted. The correct author list and the author affiliations are below. In addition, a number of corrections have been made to the text. We apologize for these errors.

Greger Lindberg, MD, PhD,* Saeed S. Hamid, MD,† Peter Malfertheiner, MD,‡ Ole Ostergaard Thomsen, MD, PhD,§ Luis Bustos Fernandez, MD,‖ James Garisch, MD,¶ Alan Thomson, MD,# Khean-Lee Goh, MD,** Rakesh Tandon, MD,†† Suliman Fedail, MD,‡‡ Benjamin C.Y. Wong, MD,§§ Aamir Ghafoor Khan, MD,‖‖ Justus H. Krabshuis,¶¶ and Anton LeMair, MD##

From the *Karolinska Institutet, Stockholm, Sweden; †Aga Khan University, Karachi, Pakistan; ‡Otto von Guericke University, Magdeburg, Germany; §University of Copenhagen, Herlev Hospital, Herlev, Denmark; ‖Hospital Bonorino Udaondo, Buenos Aires, Argentina; ¶St Georges Hospital, Port Elizabeth, South Africa; #University of Western Ontario, London, Ontario, Canada; **University of Malaya, Kuala Lumpur, Malaysia; ††All India Institute of Medical Sciences, New Delhi, India; ‡‡University of Khartoum, Khartoum, Sudan; §§Department of Medicine, University of Hong Kong, Hong Kong; ‖‖Lady Reading Hospital, Peshawar, Pakistan; ¶¶Highland Data, Tourtoirac, France; and ##Highland Data, Amsterdam, The Netherlands.

This guideline is written and reviewed by a committee of the WGO chaired by Dr Lindberg.

Journal of Clinical Gastroenterology. 46(1):90, January 2012.

INTRODUCTION

Constipation is a chronic problem in many patients all over the world. In some groups of patients such as the elderly, constipation is a significant health care problem, but in the majority of cases chronic constipation is an aggravating, but not life threatening or debilitating, complaint that can be managed in primary care with cost-effective control of symptoms.

The terminology associated with constipation is problematic. There are 2 pathophysiologies, which differ in principle but overlap: disorders of transit and evacuation disorders. The first can arise secondary to the second, and the second can sometimes follow from the first.

This guideline focuses on adult patients and does not specifically discuss children or special groups of patients (such as those with spinal cord injury).

Cascades: A Resource-sensitive Approach

A gold standard approach is feasible for regions and countries in which the full range of diagnostic tests and medical treatment options are available for the management of all types and subtypes of constipation.

A cascade is a hierarchical set of diagnostic, therapeutic, and management options for dealing with risk and disease, ranked according to the resources available.

DEFINITION AND PATHOGENESIS

The word “constipation” has several meanings, and the way it is used may differ not only between patients but also between different cultures and regions. In a Swedish population study, it was found that a need to take laxatives was the most common conception of constipation (57% of respondents). In the same study, women (41%) were twice as likely as men (21%) to regard infrequent bowel motions as representing constipation, whereas equal proportions of men and women regarded hard stools (43%), straining during bowel movements (24%), and pain when passing a motion (23%) as representing constipation. Depending on various factors—the diagnostic definition, demographic factors, and group sampling—constipation surveys show a prevalence of between 1% and >20% in western populations. In studies of the elderly population, up to 20% of community-dwelling individuals and 50% of institutionalized elderly persons reported symptoms.

Functional constipation is generally defined as a disorder characterized by persistent difficult or seemingly incomplete defecation, and/or infrequent bowel movements (once every 3 to 4 d or less) in the absence of alarm symptoms or secondary causes. Differences in the medical definition and variations in the reported symptoms make it difficult to provide reliable epidemiologic data.

Pathogenesis and Risk Factors

Functional constipation can have many different causes, ranging from changes in diet, physical activity, or lifestyle to primary motor dysfunctions due to colonic myopathy or neuropathy. Constipation can also be secondary to evacuation disorder. Evacuation disorder may be associated with a paradoxical anal contraction or involuntary anal spasm, which may be an acquired behavioral disorder of defecation in two thirds of patients (Table 1).

T1-4

TABLE 1:

Pathophysiology of Functional Constipation

Although physical exercise and a high-fiber diet may be protective, the following factors increase the risk of constipation (the association may not be causative):

Associated Conditions and Medications

(Tables 2 and 3)

T2-4

TABLE 2:

Possible Causes and Constipation-associated Conditions

T3-4

TABLE 3:

Medications Associated With Constipation

DIAGNOSIS

Constipation is a common condition, and although a minority of patients seek medical care, in the United States alone this accounts for several million physician visits per year, whereas in the United Kingdom more than 13 million general practitioner prescriptions were written for laxatives in 2006. Gastrointestinal specialist help should focus on efficiently applying health care resources by identifying those patients who are likely to benefit from specialized diagnostic evaluation and treatment.

Diagnostic Criteria for Functional Constipation

An international panel of experts developed uniform criteria for the diagnosis of constipation—the Rome III criteria (Table 4).

T4-4

TABLE 4:

Rome III Criteria for Functional Constipation

Patient Evaluation

The medical history and physical examination in constipation patients should focus on identifying possible causative conditions and alarm symptoms.

F1-4

FIGURE 1:

The Bristol Stool Form Scale: A measure to assist patients in reporting on stool consistency. Reproduced from http://commons.wikimedia.org/wiki/File:Bristol_Stool_Chart.png. © 1997 Informa Healthcare.

Alarm Symptoms (Table 5)

T5-4

TABLE 5:

Alarm Symptoms in Constipation

Indications for Screening Tests

Laboratory studies, imaging or endoscopy, and function tests are only indicated in patients with severe chronic constipation or alarm symptoms (Table 6).

T6-4

TABLE 6:

Physiologic Tests for Chronic Constipation

Transit Measurement

The 5-day marker retention study is a simple method for measuring colonic transit. Markers are ingested on one occasion and the remaining markers are counted on a plain abdominal radiograph 120 hours later. If >20% of the markers remain in the colon, transit is delayed. Distal accumulation of markers may indicate an evacuation disorder, and in typical cases of slow-transit constipation almost all markers remain and markers are seen in both the right and the left colon.

Several companies produce markers, but markers can also be made from a patient-safe radiopaque tube by cutting it into small pieces (2 to 3 mm in length). A suitable number of markers (20 to 24) can be placed in gelatin capsules to facilitate ingestion.

Clinical Evaluation

Classification of the patient's constipation should be possible on the basis of the medical history and appropriate examination and testing (Table 7).

T7-4

TABLE 7:

Constipation Categories Based on Clinical Evaluation

Cascade Options for Investigating Severe and Treatment-refractory Constipation

Cascade: a hierarchical set of diagnostic, therapeutic, and management options for dealing with risk and disease, ranked according to the resources available.

Level 1: Limited resources

Level 2: Medium resources

Level 3: Extensive resources

TREATMENT

Scheme for General Management of Constipation (Table 8)

T8-4

TABLE 8:

General Management of Constipation

Symptomatic Approach

If organic and secondary constipation have been evaluated and excluded, most cases can be managed adequately with a symptomatic approach.

Diet and Supplements

Medication

Surgery

Evidence-based Summary (Table 9)

T9-4

TABLE 9:

Summary: Evidence Base for the Treatment of Constipation*

Cascade Options for Treatment of Chronic Constipation

The following cascade is intended for patients with chronic constipation without alarm symptoms and with little or no suspicion of an evacuation disorder. The main symptoms would be hard stools and/or infrequent bowel movements.

Level 1: Limited resources

Level 2: Medium resources

Level 3: Extensive resources

Cascade Options for Treatment of Evacuation Disorders

This cascade is for patients with chronic constipation without alarm symptoms, but with suspicion of an evacuation disorder. The main symptoms would be prolonged straining, a feeling of incomplete evacuation, thin stools, a feeling of blockage, or failure of treatment for constipation with hard stools.

Level 1: Limited resources

Level 2: Medium resources

Level 3: Extensive resources

© 2011 Lippincott Williams & Wilkins, Inc.