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Practice Parameters for the Evaluationand Management of Constipation Charles A. Ternent, M.D., Amir L. Bastawrous, M.D., Nancy A. Morin, M.D.,C. Neal Ellis, M.D., Neil H. Hyman, M.D., W. Donald Buie, M.D., and The StandardsPractice Task Force of The American Society of Colon and Rectal Surgeons T he American Society of Colon and Rectal methods of care or exclusive of methods of care Surgeons is dedicated to ensuring high-quality reasonably directed to obtaining the same results.
patient care by advancing the science, prevention, The ultimate judgment regarding the propriety of any and management of disorders and diseases of the specific procedure must be made by the physician in colon, rectum, and anus. The Standards Committee is light of all of the circumstances presented by the composed of Society members who are chosen individual patient.
because they have demonstrated expertise in thespecialty of colon and rectal surgery. This Committee was created to lead international efforts in definingquality care for conditions related to the colon, An organized search of MEDLINE, PubMed, and rectum, and anus. This is accompanied by develop- the Cochrane Database of Collected Reviews was ing Clinical Practice Guidelines based on the best performed through October 2006. Key-word combi- available evidence. These guidelines are inclusive, nations included constipation, obstructed defecation, and not prescriptive. Their purpose is to provide slow transit, surgery, rectocele, rectal intussuception, information on which decisions can be made, rather pelvic dyssynergia, anismus, paradoxical puborecta- than dictate a specific form of treatment. These lis, and related articles. Directed searches of the guidelines are intended for the use of all practi- embedded references from the primary articles also tioners, health care workers, and patients who desire were accomplished in selected circumstances.
information about the management of the conditionsaddressed by the topics covered in these guidelines.
It should be recognized that these guidelines STATEMENT OF THE PROBLEM should not be deemed inclusive of all proper Constipation is a symptom-based disorder of unsat- isfactory defecation that may be associated withinfrequent stools, difficult stool passage, or both Reprints are not available.
The diagnostic criteria for functional constipation Correspondence to: Neil H. Hyman, M.D., Fletcher Allen Health according to the Rome III consensus include two or Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont05401.
more of the following symptoms: straining, lumpy or Dis Colon Rectum 2007; 50: 2013–2022 hard stools, sensation of incomplete evacuation, sen- sation of anorectal obstruction, and manual maneuvers * The American Society of Colon and Rectal SurgeonsPublished online: 31 July 2007 to facilitate defecation more than 25 percent of the Dis Colon Rectum, December 2007 time, and less than three unassisted defecations per hemochezia, weight loss of more than 10 pounds, week. These symptoms need to be present for at least family history of colon cancer or inflammatory bowel three days per month during the previous three months disease, anemia, change in bowel habits or blood in with symptom onset at least six months before the stool, which suggest the need for more aggres- diagnosis.Loose stools must be rarely present without sive endoscopic and/or radiologic evaluation.An the use of laxatives, and there must be insufficient adequate history may help to identify factors associ- criteria for irritable bowel syndrome The ated with constipation, such as immobility, psychiat- symptoms of chronic constipation frequently overlap ric illness, contributing medications, endocrine with constipation-predominant IBThe Rome III etiologies, such as diabetes and hypothyroidism, diagnostic criteria for IBS include abdominal pain or previous pelvic surgery, or symptoms consistent with discomfort at least three days per month in the constipation-predominant irritable bowel syndrome previous three months (symptom onset more than 3 (IBS)–The history may suggest the presence of months before diagnosis) with two or more features: obstructed defecation if there is straining with bowel improvement with defecation, onset associated with a movements, incomplete evacuation, sensation of change in frequency of stool and/or change in the obstructed defecation, and the use of manual maneu- form of stoSubclassification into constipation- vers to aid defecation.Nevertheless, symptoms predominant IBS (IBS-C) based on the Rome III alone may not reliably distinguish slow-transit con- criteria also requires the presence of Bristol Stool stipation from anorectal dysfunction.
Form Scale Types 1 and 2.The numerous possible A physical examination, including digital rectal disorders leading to constipation argue for individu- examination, plus the selective use of anoscopy and alized evaluation and management according to the proctosigmoidoscopy may identify the presence of nature, extent, and chronicity of this common fecal impaction, stricture, external or internal rectal prolapse, rectocele, paradoxical or nonrelaxing pubo-rectalis activity, or a rectal mas EVALUATION OF CONSTIPATION 2. The routine use of blood tests, x-ray studies, or endoscopy in patients with constipation withoutalarm symptoms is not indicated. Level of Evidence: 1. A problem-specific history and physical exam- Class V; Grade of Recommendation: D.
ination should be performed in patients with consti- Evidence to support the routine use of blood tests, pation. Level of Evidence: Class IV; Grade of radiography, or endoscopy in the routine evaluation Recommendation: B.
of patients with constipation without alarm features A history and physical examination may identify is lacking.Nevertheless, endoscopic evaluation of the presence of Balarm symptoms and signs, such as the colon is justified for patients who meet criteria for LEVELS OF EVIDENCE AND GRADE RECOMMENDATION Source of Evidence Meta-analysis of multiple well-designed, controlled studies, randomized trials with low-false positive and low-false negative errors (high power) At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (low power) Well-designed, quasi-experimental studies, such as nonrandomized, controlled, single-group, preoperative– postoperative comparison, cohort, time, or matched case-control series Well-designed, nonexperimental studies, such as comparative and correlational descriptive and case studies Case reports and clinical examples Grade of Recommendation Evidence of Type I or consistent findings from multiple studies of Type II, III, or IV Evidence of Type II, III, or IV and generally consistent findings Evidence of Type II, III, or IV but inconsistent findings Little or no systematic empirical evidence Adapted from Cook DJ, Guyatt GH, Laupacis A, Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 1992;102(4 Suppl):305S-311S. Sackett DL. Rules of evidence and clinicalrecommendations on the use of antithrombotic agents. Chest 1989;92(2 Suppl):2S-4S.
PRACTICE PARAMETERS FOR CONSTIPATION screening colonoscopy or those with alarm fea- small-bowel function and functional results after total tures.Furthermore, blood tests may be helpful to abdominal colectomy for colonic inertiaHowever, a rule out hypercalcemia and/or hypothyroidism.
long-term, prospective study did suggest that patients 3. Anorectal physiology and colon transit time with generalized gastrointestinal disorder (GID) have a investigations may help to identify the underlying diminished long-term success rate after colectomy (13 etiology and improve the outcome in patients with percent GID vs. 90 percent no GID)Similarly, a high refractory constipation. Level of Evidence: Class III; postoperative morbidity from recurrent small-bowel Grade of Recommendation: B.
obstructions (70 percent) exists in patients with GID A review of 31 studies of colectomy for constipation found that preoperative physiologic tests, including at NONOPERATIVE MANAGEMENT least anorectal manometry, defecography, and transit study, resulted in a median satisfaction rate of 89percent compared with 80 percent for an incompletephysiologic evaluatioStudies in which slow co- 1. The initial management of symptomatic consti- lonic transit had been documented before colectomy pation is typically dietary modification, including a for refractory constipation also reported an improved high-fiber diet and fluid supplementation. Level of rate of good outcomes (90 vs. 67 percent) Evidence: Class II; Grade of Recommendation: B.
The balloon expulsion test is a simple screening Conservative measures should be attempted before procedure to exclude pelvic floor dyssynergia (PFD), surgical intervention for Empiric treat- because symptoms alone may not be enough to ment for constipation with a high-fiber diet seems to distinguish between slow-transit constipation and be an inexpensive and effective therapeutic interven- outlet obstructioA prospective study of balloon tion for addressing constipation-related bowel dys- expulsion in patients with constipation found a spec- The daily intake of 25 g of fiber per day ificity and negative predictive value for excluding PFD has been shown to increase the stool frequency in of 89 and 97 percent, respectively. A nonpathologic patients with chronic constipation. Furthermore, in- balloon expulsion test may avoid the use of other creasing fluid intake to 1.5 to 2 liters per day has been pelvic floor investigations, such as anorectal manome- shown in a randomized, clinical trial of chronic try, surface EMG studies, and defecography constipation to increase stool frequency and decrease Anorectal manometry and surface anal electromyog- the need for laxative in individuals already consuming raphy may help to confirm pelvic floor dyssynergia or a high-fiber Increased physical activity also anismus.The presence of Hirschprung_s disease also seems to be helpful.
can be suggested by anorectal manometry when the 2. The use of polyethylene glycol, tegaserod, and rectoanal inhibitory reflex is absenDefecography is lubiprostone for the management of chronic consti- probably the most useful diagnostic technique for pation is appropriate when dietary management is identifying internal rectal intussuception. In the setting inadequate. Level of Evidence: Class II; Grade of of obstructed defecation, defecography may help to Recommendation: A.
detect structural causes, such as intussuception, rec- Polyethylene glycol (PEG) can be used to promote tocele with retained stool, pelvic dyssynergia, and bowel function in patients with chronic constipation.
extent of rectal emptying. Defecography has been A randomized, clinical trial found that daily therapy shown to have good interobserver agreement for with 17 g of PEG laxative for 14 days resulted in enterocele and rectocele and fair-to-moderate inter- significant improvement of bowel movement fre- observer agreement for intussuception and anismus quency in patients with constipation compared with The measurement of colon transit time using radi- placebo at two weeksProkinetic agents, such as opaque markers in patients with suspected slow-transit the 5-HT4 receptor partial agonist tegaserod maleate, constipation is inexpensive, simple, and safe. There are can be used for treatment of constipation-predominant different methodologies that produce similar IBS. Seven short-term, placebo-controlled studies ful- results,–including the use of radioisotope filled the inclusion criteria for the Cochrane review in markers.The interpretation of colon transit stud- patients with constipation-predominant IBS. Tegaserod ies may be facilitated by knowledge of the status of improved the number of bowel movements and days the pelvic floor in the patient with constipation.
without bowel movements compared with placebo.
Some studies have not found a relationship between Another systematic review found good evidence to Dis Colon Rectum, December 2007 support the use of PEG and tegaserod for the treatment taking laxatives and 174 patients taking placebo. The of constipation.Furthermore, clinical outcome anal- treatment group was noted to have a mean increase ysis of a single-blind, randomized, multicenter trial of of 0.9 stools per week and a mean increase in stool the treatment of idiopathic constipation during three weight of 42 g, but these findings were not different months with PEG or lactulose showed that signifi- than the placebo effect at a four-week duration.
cantly more patients were successfully treated with Furthermore, long-term laxative usage can result in PEG than lactulose (53 vs. 24 percent) with overall the development of cathartic colon.
decreased total management costs Lubiprostone (Amitiza) is an oral bicyclic fatty acid that selectively activates Type 2 chloride channels in the INDICATIONS FOR SURGERY apical membrane of the gastrointestinal epithelium, resulting in increased fluid secretion. Two randomized,double-blind, multicenter, Phase III studies in patientswith chronic idiopathic constipation have shown that 1. Patients with refractory slow-transit constipation the frequency of spontaneous bowel movements may benefit from total abdominal colectomy with (SBMs) was significantly greater in patients receiving ileorectal anastomosis (TAC-IRA). Level of Evidence: lubiprostone 24 mg twice per day than in those receiving Class III; Grade of Recommendation: B.
placebo at each weekly time point throughout both Clinical improvement with total abdominal colectomy four-week studies (P < 0.05). One study found that the with ileorectal anastomosis (TAC-IRA) is reported in 50 mean frequency of SBMs in the lubiprostone group to 100 percent of patients with slow-transit constipation was five per week compared with four per week in the The results of segmental colon resection for placebo group after seven days (P < 0.0001). Signifi- colonic inertia have been disappointing with some small cantly greater improvements occurred with lubipro- series reporting up to a 100 percent failure rate stone than placebo in the degree of straining, stool Similarly, the antegrade colonic enema (ACE) proce- consistency, and constipation severity in both studies dure has been described for treatment of intractable at all time intervals up to four weeks (P < 0.05) constipation. Nevertheless, studies have shown a 33 3. The use of psyllium supplements and lactulose percent conversion rate to TAC-IRA with associated for the treatment of chronic constipation is appropri- stoma complications, wound infection, pain, and ate. Level of Evidence: Class II; Grade of Recommen- psychologic problems in aduTAC-IRA has been reported to have an 8 to 33 percent morbidity from A systematic review of the literature found that recurrent bowel obstruction and can be associated with psyllium and lactulose improved symptoms of consti- diarrhea, incontinence, and recurrence of constipa- pation.A prospective, nonrandomized trial studied Patients should be counseled that the abdominal 224 patients with simple constipation who were treated pain and bloating may persist postoperatively even after with ispaghula husk and 170 patients who were treated normalization of bowel frequency.A retrospective with other laxatives, mostly lactulose, for up to four study of 55 patients after TAC-IRA for colonic inertia with weeks. The husk-treated group produced a higher normal anal manometry identified prolonged postoper- percentage of normal, well-formed stools and fewer ative ileus in 24 percent of cases. Good to excellent hard stools than other laxatives. The husk was found to results were reported in 89 percent of patients and poor be an effective treatment for simple constipation with results in 11 percent. Postoperative stool frequency was 5, better stool consistency and lower adverse events 4, and 3 per day at 1, 2, and 12 months, respectiv compared with lactulose or other laxatives TAC-IRA is recommended for carefully selected 4. The use of common agents, such as milk of patients with severe documented colonic inertia and no magnesia, senna, bisacodyl, and stool softeners, for evidence of severe or correctable pelvic floor dysfunction chronic constipation is reasonable. Level of Evi- after nonoperative treatments have failed.
dence: Class III; Grade of Recommendation: C.
Although constipation is generally relieved after TAC- Various laxatives may be used for chronic consti- IRA, studies have shown that, postoperatively, 41 percent pation but there are inconsistent results in the of patients are affected with abdominal pain, 65 percent literature. A meta-analysisfound 11 large, well- with bloating, 29 percent require assistance with bowel controlled, published studies regarding the efficacy movements, 47 percent have some incontinence to gas of laxatives in constipation. There were 375 patients or liquid stooand 46 percent may be affected with PRACTICE PARAMETERS FOR CONSTIPATION Postoperative quality of life assessment after with laxatives. These results of biofeedback were TAC-IRA showed significantly decreased scores com- sustained at 12 and 24 months along with reductions pared with those of the general Neverthe- in straining, sensations of incomplete evacuations, less, 93 percent of carefully selected patients with TAC blockage, use of enemas and suppositories, and would undergo colectomy again for STC given the abdominal pain. Biofeedback patients reporting the chanceAn ileostomy is an alternative consideration major improvement in symptomatology were able to in many of these patients.
relax the pelvic floor and evacuate a 50-ml balloon at 2. Refractory slow-transit constipation associated 6-month and 12-month follow-up. Therefore, biofeed- with concomitant pelvic outlet obstruction may benefit back seems to be the treatment of choice for PFD from correction of the pelvic floor dysfunction and totalabdominal colectomy with ileorectal anastomosis. Levelof Evidence: Class III; Grade of Recommendation: B.
SURGICAL MANAGEMENT Studies of colectomy for refractory constipation have OF OBSTRUCTED DEFECATION demonstrated successful outcomes for TAC-IRA in 89 to Surgical Procedures 100 percent after preoperative workup, including colontransit study, defecography, and anorectal physiology Indications for rectocele repair vary but generally investigation.A thorough preoperative workup may include relief of the outlet obstruction symptoms help to exclude patients with constipation-predominant with manual support of the vaginal wall or rectum IBS or normal-transit constipation who will be unlikely to and lack of rectocele emptying on defecography.
benefit from surgical intervention. Furthermore, patients Although controversial, some propose that rectoceles with combined STC and outlet obstruction pathology should be > 4 cm in size to warrant repa may be offered individualized management.– 1. Surgical repair of a rectocele may appropriately STC and associated pelvic floor dyssynergia can be be performed via a transvaginal approach. Level of treated with biofeedback and TAC-IRA, although this Evidence: Class III; Grade of Recommendation: C.
group has been shown to have a higher rate of recurrent The traditional technique for transvaginal rectocele defecatory problems and lower satisfaction rates after repair is a nonanatomic, longitudinal plication of the colectSTC with rectal intussuception and/or non- rectovaginal fascia with the repair continuing onto the emptying rectocele/enterocele can be treated with TAC- perineal body in which any injuries to the puborectalis IRA after repair of the anatomic cause of the outlet and perineal muscles also are addressed.This technique is reported to be successful in preventingvaginal bulging in 80 percent and corrects the need for MANAGEMENT OF PELVIC FLOOR digital assistance of defecation in 67 percent of patientsLess favorable clinical results have beenreported with a failure to relieve evacuatory difficultyor lower rectal symptoms in 33 percent of patients.
1. Biofeedback therapy is appropriately recom- Postoperative dyspareunia will occur in 25 percent of mended for treatment of symptomatic pelvic floor patients and at least 10 percent may recur and require dyssynergia. Level of Evidence: Class II; Grade of reoperation; 36 percent will report a problem with fecal Recommendation: B.
incontinence–A prospective study of rectocele The success rates of biofeedback for the treatment repair using xenograft has been reported.Although of PFD are reported to be 35 to 90 percentA significant decreases in rectal emptying difficulties recent, randomized, clinical trial of individuals with were noted, cure of the rectal emptying difficulties chronic severe PFD who had failed management was reported by less than half of the patients at the with 20 g per day of fiber plus enemas or suppos- three-year follow-u itories up to twice per week were randomized into Recently, the concept of an anatomic Bdefect five weekly biofeedback sessions (n = 54) or PEG specific transvaginal rectocele repair has been de- 14.6 to 29.2 g per day plus five weekly sessions in scribed. In this technique, the defect in the rectovagi- constipation prevention. Stool frequency increased in nal fascial defect is closed transversely. During the both groups. However, at six months major improve- short-term, results with this technique seem encour- ment was reported in the biofeedback group in 80 aging with the symptom of constipation improved in percent compared with 22 percent of patients treated more than 80 percent of patients and a low incidence Dis Colon Rectum, December 2007 of recurrent clinical rectocele or postoperative need recommended in combination with a conventional for digital assistance of defecation.A pilot study sphincteroplasty and/or levatorplasty for the man- of 30 randomized patients comparing transvaginal to agement of patients with a symptomatic rectocele transrectal rectocele repair found that symptoms of and incontinence secondary to a sphincter defect.
outlet obstruction were significantly alleviated by both Short-term results of this combined procedure show approaches (93 percent in the vaginal group and 73 an improvement in evacuation and continence in 75 percent in the transrectal group), but the transvaginal percent of patients.The transperineal insertion of a technique had less recurrent rectoceles than the prosthetic mesh has been described with a significant transrectal approach (7 vs. 40 percent)None of the reduction in the need for digital assistance of patients developed postoperative de novo dyspareunia defecation and in the size and amount of barium in this study; however, the sample size was smal retained in rectoceles.Controlled clinical trials of 2. Surgical repair of a rectocele may appropriately this technique need to be performed before the role be performed via a transrectal approach. Level of of this procedure in the management of rectoceles Evidence: Class II; Grade of Recommendation: B.
can be determined.
Although transrectal repairs of rectoceles were 4. The role of transrectal stapled repair of recto- described in the mid 1960s, the suboptimal results celes and rectal intussuception is uncertain. Level of in terms of bowel and sexual function of the trans- Evidence: Class III; Grade of Recommendation: D.
vaginal repairs led to the rediscovery and popularity The repair of rectoceles and internal intussucep- of these techniques in the 1980s.Another benefit tion using endoanal staplers has been reported and of transanal repair is the ability to address the continues to be investigated. Initial results with the coexistent anorectal pathology that will be present stapled rectocele repair are encouraging in terms of in up to 80 percent of patients.
evacuatory improvement, but currently there are no The transrectal, anatomic, defect-specific rectocele studies comparing it to other methods, nor are long- repair involves the transverse closure of the rectocele term outcomes kno–There are reports of by an interrupted plication of the muscularis anteri- postoperative bleeding, pain, incontinence, consti- orly as in a Delorme procedure for rectal prolapse.
pation, and rectovaginal fistula using this tech- This method results in a relative foreshortening of the anal canal with diminished internal sphincter func- 5. Surgical repair for rectal intussusception associ- tion and resting anal pressures leading some to ated with severe, intractable symptoms of obstructed conclude that this procedure is contraindicated in defecation may be considered as a last resort. Level patients with combined fecal incontinence and of Evidence: Class III; Grade of Recommendation: C.
A study evaluating the Ivalon rectopexy for An alternative is a nonanatomic technique in treatment of rectal intussuception and outlet obstruc- which the defect is repaired longitudinally by tion failed to cure defecatory difficulties. Rectopexy approximating the musculofascial edges of the was recommended for intussuception associated defect. This repair tends to be under tension but with ulcer and bleeding but not for those with does lengthen the anal canal, which may address the obstructed defecation symptoms.The Delorme potential for worsening of fecal incontinence with repair has been reported in 21 patients with intussu- the anatomic repair.
ception and outlet obstruction with improvement of The results with either of these techniques are symptoms in 71 percent and no recurrent intussu- comparable with evacuatory difficulty improved in 47 ception.The Wells rectopexy has been reported to to 84 percent, correction of the need for digital result in defecographic resolution of the intussucep- assistance of defecation in 54 to 100 percent, and tion in 92 percent, but complete symptomatic relief decreased constipation in 48 to 71 percent. Most of was rareA study of rectopexy for treatment of the variations in results seem to be related to internal intussuception resulted in 70 percent resolu- differences in patient selection and criteria for tion of symptoms and healing of all rectal ulcers evaluating the outcomes.
The Ripstein procedure was shown to achieve 3. The role of transperineal techniques or the use of complete resolution of symptoms in 20 percent, prosthetic mesh for rectocele repair is uncertain. Level partial resolution of outlet obstruction symptoms in of Evidence: Class III; Grade of Recommendation: D.
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