Chapter 040. Diarrhea and Constipation (Part 17) ppsx

Chapter 040. Diarrhea and
Constipation
(Part 17)

Constipation: Treatment
After the cause of constipation is characterized, a treatment decision can be
made. Slow-transit constipation requires aggressive medical or surgical treatment;
anismus or pelvic floor dysfunction usually responds to biofeedback management
(Fig. 40-4). However, only ~60% of patients with severe constipation are found to
have such a physiologic disorder (half with colonic transit delay and half with
evacuation disorder). Patients with spinal cord injuries or other neurologic
disorders require a dedicated bowel regime that often includes rectal stimulation,
enema therapy, and carefully timed laxative therapy.
Patients with slow-transit constipation are treated with bulk, osmotic,
prokinetic, secretory, and stimulant laxatives including fiber, psyllium, milk of
magnesia, lactulose, polyethylene glycol (colonic lavage solution), lubiprostone,
and bisacodyl. Newer treatment aimed at enhancing motility and secretion may
have application in circumstances such as constipation-predominant IBS in
females or severe constipation. If a 3- to 6-month trial of medical therapy fails and
patients continue to have documented slow-transit constipation unassociated with
obstructed defecation, the patients should be considered for laparoscopic
colectomy with ileorectostomy; however, this should not be undertaken 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 is
warranted. The decision to resort to surgery is facilitated in the presence of
megacolon and megarectum. The complications after surgery include small-bowel
obstruction (11%) and fecal soiling, particularly at night during the first
postoperative year. Frequency of defecation is 3–8 per day during the first year,
dropping to 1–3 per day from the second year after surgery.
Patients who have a combined (evacuation and transit/motility) disorder
should pursue pelvic floor retraining (biofeedback and muscle relaxation),

psychological counseling, and dietetic advice first, followed by colectomy and
ileorectosomy if colonic transit studies do not normalize and symptoms are
intractable despite biofeedback and optimized medical therapy. In patients with
pelvic floor dysfunction alone, biofeedback training has a 70–80% success rate,
measured by the acquisition of comfortable stool habits. Attempts to manage
pelvic floor dysfunction with operations (internal anal sphincter or puborectalis
muscle division) have achieved only mediocre success and have been largely
abandoned.
FURTHER READINGS
Bartlett JG: Narrative review: The new epidemic of Clostridium difficile-
associated enteric disease. Ann Intern Med 145:758, 2006 [PMID: 17116920]
Camilleri M: Chronic diarrhea: A review on pathophysiology and
management for the clinical gastroenterologist. Clin Gastroenterol Hepatol 2:198,
2004 [PMID: 15017602]
Farrell RJ, Kelly CP: Celiac sprue. N Engl J Med 346:180, 2002 [PMID:
11796853]
Gadewar S, Fasano A: Current concepts in the evaluation, diagnosis and
management of acute infectious diarrhea. Curr Opin Pharmacol 5:559, 2005
[PMID: 16207535]
Lembo A, Camilleri M: Chronic constipation. N Engl J Med 349:1360,
2003 [PMID: 14523145]
Musher DM, Musher BL: Contagious acute gastrointestinal infections. N
Engl J Med 351:2417, 2004 [PMID: 15575058]
Wald A: Constipation in the primary care setting: Current concepts and
misconceptions. Am J Med 119:736, 2006 [PMID: 16945605]
Wald A: Clinical practice. Fecal incontinence in adults. N Engl J Med
356:1648, 2007 [PMID: 17442907]
BIBLIOGRAPHY
American Gastroenterological Association: Medical Position Statement:
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Brandt LJ et al: Systematic review on the management of irritable bowel
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