Clinical Management of Constipation

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Abstract
First, it is important to find out whether the patient is complaining of infrequent defaecation, excessive straining at defaecation, abdominal pain or bloating, a general sense of malaise attributed to constipation, soiling, or a combination of more than one symptom. Second, one must decide if there is a definable abnormality as a cause of the symptom(s). Is the colon apparently normal or is its lumen widened (megacolon)? Is the upper gut normal or is there evidence of neuropathy or myopathy? Is the anorectum normal or is there evidence of a weak pelvic floor, mucosal prolapse, major rectocele, an internal intussusception or solitary rectal ulcer? Is there any systemic component such as hypothyroidism, hypercalcaemia, neurological or psychiatric disorder or relevant drug therapy? Choice of treatment will depend on this clinical evaluation. The range of treatments available is: Reassurance and stop current treatment: Patients with a bowel obsession may take laxatives or rectal preparations regularly without need. Increase dietary fibre: Most cases of ‘simple’ constipation respond to increased dietary fibre, possibly with an added supplement of natural bran. Toilet training and altered routine of life: Young people particularly may need to recognise the call to stool and alter their daily routine to permit and encourage regular defaecation. Medicinal bulking agent: Ispaghula, methyl cellulose, concentrated wheat germ or bran, and similar preparations are useful when patients with a normal colon find it difficult to take adequate dietary fibre. These preparations increase the bulk of stool and soften its consistency. They may be useful for those patients with the constipated form of irritable bowel syndrome. Additional bulk does not help patients with megacolon or severe idiopathic slow transit constipation. Osmotic laxatives or saline perfusion: Preparations of magnesium hydroxide or sulphate, sodium sulphate, or mannitol soften the stool and if taken in sufficient quantity produce a liquid stool. Magnesium hydroxide is a useful mild laxative for use in childhood. Patients with idiopathic megacolon need to keep the stools liquid with an osmotic laxative. Stimulant laxatives: Anthranoid preparations, bisacodyl and its derivatives are used occasionally by many patients and regularly by some patients with severe idiopathic slow transit constipation. Prokinetic drugs: Can be helpful as a supplement to laxatives. Rectal preparations: Useful particularly for emptying the rectum in childhood and elderly patients with rectal impaction and soiling. Biofeedback: Biofeedback training to increase rectal sensitivity to distension, relax the pelvic floor and increase the effectiveness of straining is proving beneficial for some patients with slow transit constipation and many of those with marked paradoxical contraction of the pelvic floor including children with soiling. Psychological: Certain patients, for example those with ‘denied bowel actions’ or eating disorders need primary psychiatric treatment. Other patients, for example those with a history of sexual abuse, may need it as a supportive measure. Surgery: Surgery is needed for aganglionosis, a few patients with idiopathic megacolon or idiopathic slow transit constipation or pseudoobstruction, and for those with severe rectal mucosal prolapse.

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