Algorithm Treatment of Constipation

Algorithm Treatment of Constipation - The patient should be asked about the frequency of bowel movements and the chronicity of constipation. Constipation occurring recently in an adult may indicate significant colon pathology such as malignancy; constipation present since early infancy may be indicative of neurologic disorders. The patient also should be carefully questioned about usual diet and laxative regimens. Does the patient have a diet consistently deficient in high-fiber items and containing mainly highly refined foods? What laxatives or cathartics has the patient used to attempt relief of constipation? The patient should be questioned about other concurrent medications, with interest focused on agents that might cause constipation.

For most patients who complain of constipation, a thorough physical examination is not required after it is established that constipation (a) is not a chronic problem, (b) is not accompanied by signs of significant GI disease (e.g., rectal bleeding or anemia), and (c) does not cause severe discomfort. In these circumstances, the patient may be referred directly to the first-line therapies for constipation described in the next section (mainly bulk-forming laxatives and dietary fiber with occasional use of saline or stimulant laxatives). Table bellow presents a general treatment algorithm for the management of constipation.

Constipation Treatment Algorithm
Constipation Treatment Algorithm
The proper management of constipation requires a number of different modalities; however, the basis for therapy should be dietary modification. The major dietary change should be an increase in the amount of fiber consumed daily. In addition to dietary management, patients should be encouraged to alter other aspects of their lifestyles if necessary. Important considerations are to encourage patients to exercise (achieved even by brisk walking after dinner) and to adjust bowel habits so that a regular and adequate time is made to respond to the urge to defecate. Another general measure is to increase fluid intake. This is generally recommended and believed beneficial, although there is little objective evidence to support this measure.

If an underlying disease is recognized as the cause of constipation, attempts should be made to correct it. GI malignancies may be removed via surgical resection. Endocrine and metabolic derangements should be corrected by the appropriate methods. For example, when hypothyroidism is the cause of constipation, cautious institution of thyroid-replacement therapy is the most important treatment measure. As discussed earlier, many drug substances may cause constipation.

If a patient is consuming medications well known to cause constipation, consideration should be given to alternative agents. For some medications (e.g., antacids), nonconstipating alternatives exist. If no reasonable alternatives exist to the medication thought to be responsible for constipation, consideration should be given to lowering the dose.

Nonpharmacologic Therapy

Dietary Modification and Bulk-Forming Agents
The most important aspect of therapy for constipation for the majority of patients is dietary modification to increase the amount of fiber consumed. Fiber, the portion of vegetable matter not digested in the human GI tract, increases stool bulk, retention of stool water, and rate of transit of stool through the intestine. The result of fiber therapy is an increased frequency of defecation. Also, fiber decreases intraluminal pressures in the colon and rectum, which is thought to be beneficial for diverticular disease and for irritable bowel syndrome.
The specific physiologic effects of fiber are not well understood. Patients should be advised to include at least 10 g of crude fiber in their daily diets.26 Fruits, vegetables, and cereals have the highest fiber content. 

Bran, a by-product of milling of wheat, is often added to foods to increase fiber content and contains a high amount of soluble fiber, which may be extremely constipating in larger doses. Raw bran is generally 40% fiber. Medicinal products, often called “bulk-forming agents,” such as psyllium hydrophilic colloids, methylcellulose, or polycarbophil, have properties similar to those of dietary fiber and may be taken as tablets, powders, or granules (Table bellow). A trial of dietary modification with high-fiber content should be
continued for at least 1 month before effects on bowel function are determined. Most patients begin to notice effects on bowel function 3 to 5 days after beginning a high-fiber diet, but some patients may require a considerably longer period of time. Patients should be cautioned that abdominal distension and flatus may be particularly troublesome in the first few weeks of fiber therapy, particularly with high bran consumption. In most cases these problems resolve with continued use.
laxatives and Cathartics
Dosage Recommendations for Laxatives and Cathartics
Bulk-forming laxatives have few adverse effects. The only major caution in the use of bulk-forming laxatives is that obstruction of the esophagus, stomach, small intestine, and colon has been reported when the agents have been consumed without sufficient fluid and in patients with intestinal stenosis.


In a small percentage of patients who present with complaints of constipation, surgical procedures are necessary because of the presence of colonic malignancies or GI obstruction from a number of other causes. In each case, the involved segment of intestine may be resected or revised. Surgery may be required in some endocrine disorders that cause constipation, such as pheochromocytoma, which requires removal of a tumor.

The majority of patients with constipation related to pelvic floor dysfunction can benefit from electromyogram-guided biofeedback therapy. The value of biofeedback in children with chronic constipation has not been well demonstrated.


by Umaee
Source: Pharmacotherapy 7th
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