Chronic constipation: let symptom type and severity direct treatment: how various therapies fit into the scheme of things; what is unlikely to help

Practice recommendations

* Increased fiber intake end diet (C) or fiber continuations (B) is an appropriate initial therapy for chronic constipation.

* Osmotic and stimulant laxatives may be administered to patients who do not rejoin to more conservative measures if the limitations of these agents are explained (B)

* Tegaserod, a selective 5-hydroxytryptamine stamp 4 (5-[HT.sub.4]) receptor partial agonist, is more effective than placebo at relieving symptoms of chronic idiopathic constipation in patients younger than 65 years of age (A).

* Patients with suspected defecation disorders and those with treatment-refractory symptoms should be referr to a gastroenterologist for further evaluation (C)

by dint of the time a patient dioceses you with a complaint of constipation, chances are she has tried a counteractive or 2 and is now looking for something of recent origin However, the abandoned remedies may nevertheless prove useful, depending on the nature of her complaint and upon her understanding of how the counteractive was supposed to have worked. In this article, we discuss the benefits and limitations of several treatment options in managing a patient's distinct condition, as assessed in part 1 (page 580)

* Symptom-focused treatment

As by means of the ACG Task Force guidelines, initial treatment of chronic constipation (in the absence of alarm features and secondary causes) is empiric. (1) The patient's symptoms--specifically those greatest in quantity bothersome--should direct your decisions. A plan with equal reason guided will also help you manage the patient's expectations.

Address patients' prior disappointments

greatest in quantity patients will have self-treated before coming to diocese you, and some even will have tried prescribed regimens. Initial treatment of constipation has traditionally revolv lifestyle changes (eg diet, fluid, exercise modification), increased fiber retake, and laxatives. However, evidence supporting use of these modalities in this setting is sparse, and patient overlooks often show dissatisfaction with these approaches. For instance, a web-based overlook showed that 96% of patients with chronic constipation have tried a certain number of form of traditional medication (eg magnitude mg agents, stool softeners, laxatives). (2) Overall, 47% were not satisfied with their generally received treatment, primarily because of inadequate symptom relief and unwanted side effects

Furthermore, patient compliance with more [i]or[/i] less therapies is poor because of side events such as flatulence, distension, and bloating. sum of two units recently published systematic reviews evaluating treatment options for patients with chronic constipation came to similar conclusions. (13)

Below we discuss the ACG Chronic Constipation Task Force conclusions and recommendations. (1) Explicit communication with patients about what they can wait for will help ensure treatment success

Prescribe fiber, increase water intake

Just a scarcely any clinical trials have evaluated the events of lifestyle changes on constipation symptoms, and they have generally been poorly designed or involved small numbers of patients (TABLE). (4-7)

Educating patients about peculiar nutrition and designating a time for daily defecation are public initial approaches, but efficacy of these strategies in this patient population has not been established (SOR: C) (45)

Exercise has dubious value. Exercise is ofttimes recommended as a way to treat constipation because of its purported event on reducing gastrointestinal (GI) transit time (SOR: C) (6) However, uncontroll studies have ground that aerobic exercise does not necessarily decrease transit time and may actually continue lengthen in time it. (6)

Increasing water alone generally unhelpful Few data support the benefits of increased fluid consumption, do not include for dehydrated patients. In single study, increased intake (to 1 L/d) of water or isotonic fluid had no issue on the stool weight of healthy tenders (4)

... on the other hand fiber plus water works. However, in a application of mind involving patients with chronic constipation, a high-fiber diet and 2 L/d of water increased oftenness of bowel movements and reduc use of laxatives compared with the same diet and ad libitum fluid intake (P<001) by the agency of binding water, fiber increases stool weight, touchs stool, decreases colonic transit time, and increases GI motility. (4589)

You can praise that patients gradually increase fiber intake above several weeks to a total of 20 g/d to 25 g/d) (18) end fiber-rich foods (vegetables leg, carrots, broccoli, string beans], fruits [eg peaches, apples, oranges], whole-grain breads, pasta, cereal, etc) (SOR: C) or size supplements (eg, psyllium, methylcellulose, and polycarbophil) (SOR: B) In conjunction with other lifestyle modifications, this is a reasonable management decision. (11) Because failure to balance the ratio between fiber and fluid can worsen constipation, and level cause intestinal obstruction, tell patients who increase their fiber consumption to also increase their fluid intake (30 mL/kg material part weight daily). (5,12)

Caveats. not many data support the benefits of this approach. Epidemiologic studies display a low prevalence of constipation in countries in which fiber-rich diets are the norm, (8) on the contrary extrapolating data from healthy populations to constipated patients may not be justified. (13) In fact, small in number data from controlled trials support the use of fiber therapy in patients with constipation. In the uncontroll Nurses' Health inquiry subjects in the highest quintile of dietary fiber intake (median intake, 20 g/d) were les likely to have constipation than those in the lowest quintile (median intake, 7 g/d) (14) This general dearth of evidence l the ACG Chronic Constipation Task Force to bring to an end that psyllium increases stool oftenness in patients with chronic constipation (ACG grade: B) on the other hand that there are insufficient data to make a recommendation about the efficacy of calcium polycarbophil, methylcellulose and bran in this patient population (ACG grade: B) (1)