Treatment of Constipation

Constipation is persistent, difficult, infrequent, or seemingly incomplete defecation. It is very difficult to define constipation precisely due to the wide range of normal bowel habits. For treatment of constipation, the cause of constipation should be identified. Treatment of constipation is based on the cause of it.

Patients with slow-transit constipation are treated with laxatives. The examples of laxatives are bulk, osmotic, prokinetic, secretory, and stimulant laxatives including fiber, psyllium, milk of magnesia, lactulose, polyethylene glycol (colonic lavage solution), lubiprostone, and bisacodyl. There is also newer treatment modality aiming at enhancing motility and secretion and may have application in special circumstances such as constipation-predominant IBS (irritable bowel syndrome) in females or in severe constipation.

If a 3 to 6 months trial of medical therapy fails with above treatment regimes and patients continues to have documented slow-transit constipation which is not associated with obstructed defecation, the patients should be considered for laparoscopic colectomy (resection or part of colon) with ileorectostomy (joining of ileum and rectum surgically).  But these operations should not be done if there is continued evidence of an evacuation disorder or a generalized GI dysmotility. Referral to a specialized center for further tests of colonic motor function should be done in these cases.

The presence of megacolon and megarectum is indication for surgical intervention in constipation. But there may be unacceptable complications after surgery like small-bowel obstruction and fecal soiling, particularly at night during the first postoperative year. Frequency of defecation is 3–8 per day during the first year and 1–3 per day from the second postoperative year onwards.

Patients with severe slow-transit constipation require aggressive medical or surgical treatment. However, approximately only 60% of patients with severe constipation are found to have such a physiologic disorder (colonic transit delay and evacuation disorder). Patients with spinal cord injuries or other neurological disorders require a bowel regime that includes rectal stimulation, enema therapy, and carefully timed laxative therapy. 

Patients with evacuation and transit/motility disorder should pursue pelvic floor retraining (biofeedback and muscle relaxation), psychological counseling, and dietary modification first, and than colectomy and ileorectosomy (if colonic transit studies do not normalize and symptoms are intractable despite biofeedback and optimum medical therapy). If patient only has pelvic floor dysfunction, biofeedback training has a 70–80% success rate which is measured by regaining of comfortable stool habits.

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