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improved outcomes in colon and rectal surgery
(A) (B) (C)
Figure 33.11 Mercedes or triangular closure. A. Stoma site with fascia closed, B. Initial approximation of skin and subcutaneous fat, C. Completed closure with small
area in center left open for drainage and secondary healing.
stenosis or hernia. Experienced plastic surgeons can carefully use
liposuction techniques to remove subcutaneous fat around the
stoma. Obviously, care must be taken to not injure the stoma
during the procedure and to leave a flat smooth peristomal skin
surface for the ostomy faceplate. Once the fatty tissue is removed,
it will not be redeposited despite additional weight gain.
Ostomy Reversal
Reversal of temporary stomas should be undertaken as soon as
physiologically feasible to reestablish gastrointestinal continuity
and for psychological improvement. This of course implies that
the purposes of the stoma placement has been met and the patient
is capable and a candidate for another operative procedure. There
are two main operative approaches to ostomy reversal, local or via
a laparotomy. While both approaches are associated with inadvertent enterotomies, bleeding, wound infections, and anastomotic
complications, the biggest advantages of the laparotomy approach
is improved exposure and the ability to reexplore the abdomen.
Certainly, the type of ostomy is important to consider when planning the operative approach as loop ileostomies are technically
the least challenging to reverse and often amenable to local reversal. Although a local approach is preferred, patients with a prior
Hartmann’s procedure or those in which the distal remnant is not
available via a local approach are obviously forced to undergo a
repeat laparotomy. Surprisingly, there is a paucity of recent data
that highlights the potential perils of this seemingly benign operation. The most recent study, published in 2005, was a retrospective
review of 533 patients undergoing stoma closure at the University
Hospital of Vienna.(70) The majority of the patients (51%) underwent reversal of a colostomy, 44% had closure of an ileostomy, and
5% had combined reversals of both a colostomy and an ileostomy.
All patients underwent a laparotomy using the intraperitoneal
approach. Their 30-day mortality was 3% (15 patients) with rates
similar for either ileostomy or colostomy reversal. Causes of death
were multisystem organ failure after nonsurgical complications in
nine patients, and anastomotic leakage, missed small bowel injury,
and cecal perforation in the remaining six patients. Overall complications were 20%, with anastomotic leakage (5%), ileus (4%),
postoperative bleeding (2%), and wound infection (2%). When
analyzing patient related factors between survivor and nonsurvivors, only advanced patient age was found to be statistically
significant. This study, which highlights the potential morbidity
of stoma reversal, also emphasizes the importance of meticulous
surgical technique required in these challenging patients with
reoperative abdomens.
Our approach to ostomy reversal begins with a thorough preoperative evaluation which includes interrogation of the distal
colon with either a barium enema and/or endoscopy. The primary
reason for which sentinel procedure was performed is important
to consider since it may reveal if the purposes of the ostomy has
been met and potentially alter the decision on reversal. An obvious but sometimes overlooked step should also be the evaluation
of the patient’s sphincter tone and ability to control fecal stream
once continuity has been restored. This may require not only
clinical evaluation, but formal documentation through anorectal
physiology testing including manometry. Baseline poor sphincter
tone or incontinence should be considered a contraindication for
ostomy reversal in all but the rarest of cases. Finally, additional
patient factors which can be altered, such as nutritional status,
steroid use, and tobacco abuse, should be optimized before surgery. When planning the operative approach for end colostomy
reversals, additional factors to consider before embarking on the
operation should include the expected amount of adhesive disease
likely to be encountered or previously encountered (i.e., review
prior operative notes), whether there is a history of prior abdominal or pelvic radiation, concomitant pathology such as the presence of incisional hernias, and the type of ostomy. For instance,
patients with multiple prior surgeries and a history of radiation
will most likely benefit from a laparotomy approach that includes
preoperative ureteral stent placement, while those patients with
loop ostomies without any other comorbidities can be managed
with a local approach. Whether a stapled or hand-sewn anastomosis is performed is up to the surgeon’s discretion. Key technical
points in each method, however, is to ensure adequate mobilization and visualization of the distal colonic or rectal stump with
resection of both the exteriorized bowel or end stump back to
normal healthy bowel before the anastomosis. Finally, delayed
primary closure is performed for the area in which the stoma was
placed and drains are not routinely placed.
CONCLUSION
Beyond bringing a loop of bowel to the skin surface, there are a
wide variety of issues that a surgeon needs to consider when creating a stoma. Having a thorough understanding of the indications
ostomies
for stoma placement, the technical details for the various ostomies,
and the physical and psychological impact of living with an ostomy
will aid the surgeon in caring for these unique patients. Finally,
understanding the potential complications from ostomy placement and having the knowledge to correctly deal with them is an
essential tool for all providers and emphasizes the importance of a
multidisciplinary team of specialists.
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4
Operative and nonoperative therapy for chronic constipation
Harry T Papaconstantinou
CHALLENGING CASE
A 33-year-old women presents with constipation of 8 years duration. She goes 7–10 days between bowel movements, despite taking multiple laxatives. She tried extra dietary fiber, polyethylene
glycol, and lubiprostone, all without relief. Her lack of bowel
activity is significantly impacting on her life style.
CASE MANAGEMENT
A barium enema demonstrates normal anatomy. A colonic transit
study demonstrates 20 markers evenly distributed throughout
the colon on day 5. A balloon expulsion test and anal manometry
were normal. A diagnosis of colonic inertia is made and the
patient is offered a total abdominal colectomy with an ileorectal
anastomosis.
INTRODUCTION
Constipation is a common medical complaint resulting in over
2.5 million physician visits in the United States each year.(1)
Reports have indicated that constipation is a significant problem
with its prevalence ranging from 2 to 27%, and associated medication costs of over $500 million each year.(2) Stool weight, transit
time, and frequency of defecation correlate strongly with dietary
fiber intake. It is estimated that the average daily consumption of
fiber in the United States is <20 grams, therefore, the prevalence
of constipation should be no surprise.(3, 4) Furthermore, constipation adversely affects work-related productivity, educational
performance, and results in significantly lower quality of life and
higher psychological distress.(5, 6)
Constipation is not a specific disease, but rather a constellation
of symptoms. Physicians typically define constipation in objective
terms of bowel movement frequency, specifically fewer than three
bowel movements per week. However, constipation has different
meaning to individual patients, and may be described as the need
to strain to defecate, having hard stools, the inability to defecate
at will, incomplete evacuation, or the infrequent passage of stool.
Regardless of the ambiguity of defining constipation, patients frequently perceive the need for treatment due to advertising portraying “regularity” as the secret to health and well-being.(7, 8)
Therefore, it is important for the physicians to clarify patient’s
intended meaning, and to establish a more objective definition
for this subjective symptom. Recently, a consensus of parameters
has been created and updated to more clearly define constipation
and is known as the Rome III criteria (Table 34.1).(9) The establishment of these parameters has provided more uniform definition of constipation, and is a valuable tool to identify patients
that require treatment.
Successful treatment of constipation requires the accurate identification of the underlying etiology of the symptom. In most
patients, constipation is the direct result of specific medical conditions (Table 34.2) or side effect of medications (Table 34.3). These
Table 34.1 Rome III diagnostic criteria for constipation.
Criteria must be fulfilled for the last 3 months.
Symptom onset at least 6 months before diagnosis .
1) Must include 2 or more of the following.
a. Straining ≥25% of defecation.
b. Lumpy or hard bowel movements ≥25% of defecation.
c. Sensation of incomplete evacuation ≥25% of defecation.
d. Sensation of anorectal obstruction ≥25% of defecation.
e. Manual maneuvers to facilitate bowel movement ≥25% of defecation.
f. Fewer than 3 defecations per week.
2. Loose stools are rarely present without the use of laxatives.
3. Insufficient criteria for irritable bowel syndrome
Table 34.2 Medical conditions causing constipation.
Endocrine and Metabolic Neurogenic
Chronic renal failure Autonomic neuropathy Amyloidosis
Diabetes mellitus Cerebrovascular disease Dermatomyositis
Hypothyroidism Dementia Myotonic dystrophy
Hypercalcemia Depression Systemic sclerosis
Hypokalemia Multiple sclerosis Scleroderma
Pregnancy Muscular dystrophy
Milk-alkali syndrome Parkinson’s disease
Porphyria Spinal chord lesions
Carcinomatosis Hirschsprung’s disease
Chaga’s disease
Collagen Vascular and
Musculoskeletal
extracolonic causes can be easily identified in a careful and complete
history and physical examination. Constipation for these patients
is treated through medical management including alteration of
their medications, prescription of laxatives, or dietary and lifestyle
modifications. A small group of patients will have a functional disorder of the colon and anorectum resulting in constipation. It is
within this group of patients that colon and rectal surgeons can
make the greatest impact, and is the focus of this chapter.
Functional constipation can be divided into three groups:
1) slow-transit constipation, 2) pelvic floor dysfunction, and
3) combined slow-transit constipation and pelvic floor dysfunction. Slow-transit constipation, also known as colonic inertia,
is characterized by prolonged length of time for stool to pass
through the colon.(10) Delay in stool transit is thought to be a
primary dysfunction of the colonic smooth muscle (myopathy)
or innervation (neuropathy). Pelvic floor dysfunction results in
evacuation disorders, and is characterized by either difficulty or
inability to expel stool from the anorectum.(11) Common disorders of pelvic floor dysfunction include obstructive defecation,
pelvic floor dyssynergia, outlet obstruction, or anismus.(11–13)
improved outcomes in colon and rectal surgery
Table 34.3 Drugs associated with constipation.
Anticholinergics
Cation-containing agents
Neurally active agents
Others
Antidepressants
Antipsychotics
Aluminum (antacids, sucralfate)
Bismuth
Calcium (antacids, supplements)
Iron supplements
Opiates
Antihypertensives
Ganglionic blockers
Vinca alkaloids
Calcium channel blockers
Antihistamines
Antiparkinsonian drugs
Diuretics
Nonsteroidal anti-inflammatory drugs
Recent advances in the analysis of colonic motility and pelvic floor
physiology have allowed for the identification and classification of
these two subtypes. This is important as treatment modalities are
different. Surgery is indicated for patients with slow-transit constipation, while nonoperative treatment modalities, such as biofeedback therapy, are effective in patients with pelvic floor dysfunction.
Patients with mixed conditions require correction of the pelvic
floor abnormality before undergoing an operation for slow-transit
constipation. Patient selection is critical for treatment success.
EVALUATION AND DIAGNOSTIC STUDIES
Initial evaluation of patients with constipation is a complex task
and starts with a careful history and physical examination. Most
patients are reluctant to discuss these issues, and establishing a
trustworthy relationship is important to define the nature of bowel
dysfunction. Constipated patients present with a constellation of
symptoms that include excessive straining to defecate, passage of
hard stools, the inability to defecate at will, digital disimpaction,
vaginal splinting, feeling of blockage at the anal opening, incomplete evacuation, and/or the infrequent passage of stool. Details
of defecatory characteristics and habits are helpful and should
include stool frequency, stool consistency, stool size, and degree of
straining during defecation. These patients should be asked about
precipitating events and the duration and severity of the problem.
A dietary history should be obtained to assess of the amount of
daily fiber ingested and fluids consumed, as stool transit time and
frequency of defecation correlate strongly with dietary fiber intake.
(3, 4) If the patient has already been treated by a referring physician it is important to know the number and types of laxatives
used, patient compliance, and whether there was any improvement
in symptoms. A long history of constipation refractory to dietary
measures and laxative use is suggestive of functional constipation,
while a history of recent onset should alert the physician to seek
and exclude an organic cause such as neoplastic disease or stricture.
A complete medical history will provide evidence of extracolonic
causes of constipation such as diabetes, hypothyroidism, or cerebrovascular disease (Table 34.2). Detailed review of the patient’s
medication list will identify specific medications that are known to
cause constipation (Table 34.3).
A complete physical exam with specific emphasis on the abdomen and perineum are important. A normal physical exam is
not uncommon. A detailed anorectal exam starts with inspection of the perianal skin. Perineal sensation and the anocutaneous reflex are assessed by gently stroking the perineal skin with a
cotton-tipped applicator stick. Absence of a reflex contraction of
the external anal sphincter indicates the presence of neuropathy.
A digital rectal examination is performed to identify the presence
of an anorectal stricture, distal rectal mass, and the presence of
stool or blood within the rectal vault. Positive findings require
further aggressive evaluation including colonoscopy. During digital examination, sphincter tone is assessed at rest and voluntary
squeeze. It is important to ask the patient to bear down as if to
defecate. This maneuver allows the examiner to determine relaxation of the external anal sphincter and the presence of perineal
descent. Absence of these features is suggestive of pelvic floor
dysfunction or dyssynergic defecation.(11) Vaginal and bimanual examination should be performed to rule out rectocoele as a
cause of outlet obstruction constipation.
Routine evaluation of the colon is performed when there is a
lack of identifiable causes of constipation. This can be performed
by colonoscopy, barium enema, or CT colonography. Although it
has been reported that there is no increased incidence of colon or
rectal neoplasia in patients with chronic constipation (14), routine anatomic evaluation of the colon is performed to exclude
tumors, strictures, and large bowel disease. Endoscopic evaluation of the colon may reveal evidence of chronic laxative abuse
(melanosis coli), diverticular disease with stricture, malignancy,
or colitis cystica profunda (internal rectal prolapse). Further
work-up and treatment is dependent on the findings. However, in
the absence of anatomic causes of constipation, patients should
be initially treated with dietary and lifestyle modifications with
or without medications. If initial treatment of constipation fails
to improve the patient’s symptoms, further investigational studies are required to differentiate between functional constipation
types. It may seem intuitive that patients with slow-transit constipation would complain of infrequent bowel movements, while
patients with pelvic floor dysfunction would report feelings of
incomplete evacuation and excessive straining. However, recent
reports show that symptoms alone do not differentiate between
the subgroups of functional constipation.(6, 15, 16) In fact, up
to 62% of patients with pelvic floor dysfunction report stool
frequency of less than three bowel movements per week.(6) For
this reason symptom assessment should be combined with objective testing to better assess the nature of a patient’s complaint.
Physiologic studies of the colon (colonic transit study) and pelvic
floor (anorectal manometry, balloon expulsion test, defecogram,
and electromyography) are required to differentiate between
slow-transit constipation, pelvic floor dysfunction, and patients
with mixed features, and accurate diagnosis is critical for treatment success.
Colonic Transit Studies
Self-reported stool frequencies correlate poorly with colonic
transit, and patient’s recall of stool habits is often inaccurate indicating that subjective complaints are not sufficient to determine
diagnosis. Colonic transit studies provide objective assessment of
operative and nonoperative therapy for chronic constipation
(A) (B)
Figure 34.1 Colonic transit study using single capsule radiopaque markers. Abdominal radiographs shown were taken 5 days after capsule ingestion. The presence of
>6 marks scattered throughout the colon is diagnostic for slow colonic transit (A). Retention of markers within the rectum and rectosigmoid region suggests pelvic
outlet obstruction (B).
stool movement through the colon, and are critical tests to identify patients that will benefit from colectomy. Two methods are
commonly used to measure colonic transit time and include radiopaque marker methods and scintigraphic techniques. Studies
have shown that that these two tests correlate well to each other
and are sensitive for identifying colonic transit delays in patients
with slow-transit constipation.(17, 18) Objective documentation
of slow-transit constipation is critical for patient selection for
surgery, and has been shown to significantly improve outcomes
after colectomy (90% vs. 67%).(19, 20)
Radiopaque Marker Test. The most common and widely used
study of colonic transit time is the radiopaque marker method.
This test was first described by Hinton et al. in 1969, and since that
time several modifications have been described including single
and multiple capsule techniques.(21–23) This study is performed
by having the patient swallow a single capsule (Stizmarks; Konsyl®
Pharmaceuticles, Ft. Worth, Texas) containing 24 radiopaque markers, and then tracking the markers by abdominal radiographs at
3 days and 5 days. Patients are instructed to stop laxatives, cathartics,
and enemas for 2–7 days before ingestion of the capsule, and during the test period to prevent false results. In patients with normal
Although this test has been shown to be highly reproducible, when
considering total abdominal colectomy for colonic inertia, it has
been shown that patients have more favorable results if two marker
studies have demonstrated slow-colonic transit times to confirm
the diagnosis.(24)
Scintigraphic technique. Scintigraphic defecography is another
modality available to study colonic transit. Delayed-release capsules containing charcoal or polystyrene pellets radiolabeled with
technetium-99m or indium-111 are coated with a pH-sensitive
polymer methacrylate. The coating dissolves in an alkaline pH
within the terminal ileum and cecum. Colonic distribution of the
radioisotope is determined on scans taken 24 and 48 hours after
capsule ingestion, and is highly sensitive and specific for identifying slow colon transit.(25, 26) Colon transit measurements by
radiopaque markers and scintigraphic techniques correlate well
with each other, and are sensitive for identifying colonic transit
delays in patients with slow transit constipation.(18)
When a diagnosis of slow-transit constipation is made, the
physician must be aware of specific conditions that may be associated with this functional disorder and adversely affect surgical
treatment with colectomy. First, slow-colonic transit constipation
ers will have passed through the colon and are either completely
evacuated or found in the rectum. Patients with slow colonic transit
show the presence of 6 or more markers scattered throughout the
colon (Figure 34.1A). Patients with pelvic floor dysfunction such as
functional obstructive or dyssynergic defecation, exhibit retention
of 6 or more markers in the rectum or rectosigmoid region with a
near normal transit of markers through the colon (Figure 34.1B).
such as panenteric intertia. A recent review has suggested that
patients with this generalized gastrointestinal motility disorder
have significantly diminished long-term success rate after colectomy for slow-transit constipation.(27) This is supported by the
high rate of recurrent small-bowel obstruction (70%) in patients
with panenteric intertia.(28) Collectively, these data suggest that
whole gut transit studies should be considered before colectomy
improved outcomes in colon and rectal surgery
for slow-transit constipation, and include gastric emptying,
upper gastrointestinal small bowel follow-trough, and cholycystokinnin hepatic dimethyliminodiacetic acid (CCK-HIDA)
scan. Colectomy in patients with a global gastrointestinal motility
disorder is not likely to improve their symptoms and is discouraged. Second, in patients with findings suggestive of pelvic floor
dysfunction, up to two-thirds will exhibit mixed pattern constipation with both slow transit and obstructive delay.(29) Further
pelvic floor physiology testing and treatment of the pelvic floor
dysfunction is required before colectomy to improve outcomes
and avoid treatment failure.
Pelvic Floor Physiology Tests
Patients with functional constipation due to pelvic floor dysfunction and obstructive defecation have difficulty with evacuation
of rectal contents. Normal evacuation requires the involuntary
relaxation of the internal anal sphincter as well as the voluntary
relaxation of the external anal sphincter and pelvic floor muscles. Failure of this coordinated effort results in outlet obstructive
symptoms. Pelvic floor physiology testing can identify specific
disorders such as blunting of the rectal anal inhibitory reflex
(RAIR), paradoxical puborectalis contraction, and anatomic
abnormalities that cause outlet obstruction. Common tests used
to identify these disorders include anorectal manometry, balloon
expulsion test, defecography, and electromyography.
Anorectal Manometry. Anorectal manometry provides a
comprehensive assessment of anal sphincter muscle tone and
the anorectal sensory response to different stimuli. This test is
useful in the evaluation of patients with obstructive defecation,
and helps to detect abnormalities during attempted defecation
such as pelvic floor dyssynergia or anismus.(30) The complete
manometric evaluation of the anorectum includes determination
of the resting pressure, squeeze pressure, length of the high-pressure zone, rectal compliance, RAIR, and the ability of the internal
anal sphincter to relax with straining. In normal defecation, as
rectal pressure rises there is a synchronized fall in the internal
anal sphincter pressure. A blunted rectal sensation is a common
finding in patients with functional obstructive defecation.(31)
Absence of the RAIR suggests secondary causes of constipation
such as Hirschsprung’s disease, Chagas disease, or previous surgery.(32–34) External sphincter muscle relaxation for the elimination of stool is a learned response that is under voluntary control.
Inability to perform this coordinated movement represents the
chief pathophysiologic abnormality in patients with dyssynergic
defecation and anismus, and may be due to impaired rectal contraction, paradoxical puborectalis contraction, or impaired anal
relaxation.(11, 35) Anorectal manometry has been shown to be
inaccurate in the diagnosis of paradoxical puborectalis and dyssynergic defecation, and further testing with balloon expulsion
test and electromyography should be performed to assist in diagnosis.(36)
Balloon Expulsion Test. The balloon expulsion test is a functional evaluation of the patient’s ability to defecate. In this test,
a latex balloon is filled with 60 ml of warm water or air within
the rectum. The patient is asked to expel the balloon in a private bathroom while sitting on the toilet. The physiologic position and privacy allow this method to more closely approximate
normal evacuation. Normal subjects can expel the balloon within
1 minute.(37) While seeming trivial, it is important that patients
do not flush the balloon as it can severely damage the plumbing.
Inability to expel the balloon is suggestive of functional outlet
obstruction such as paradoxical puborectalis contraction and
dyssynergic defecation. The balloon expulsion test is a simple and
accurate test that has been shown to have a high specificity (89%)
and negative predictive value (97%) for excluding pelvic floor
dyssynergia as a cause of constipation.(36, 38, 39)
Defecography. Defecography is the real time imaging of
patient defecation, and provides dynamic characterization of the
interaction between the anal sphincter complex and the rectum
in an attempt to define abnormalities in the pelvic floor. It provides information on the anatomic and functional changes of the
anorectum during defecation, and is effective in differentiating
between anatomic and functional causes of obstructive defecation. Before the test is performed, the patient is cleansed of stool
using an enema. Barium paste is placed into the rectum, and with
the aid of fluoroscopy the process of defecation is video-recorded.
Static and real-time dynamic radiographic images are obtained
during the process of defecation. Specific measurements such
as the anorectal angle, perineal descent, and puborectalis length
during stages of squeeze and push are calculated.(40) Patients
with paradoxical puborectalis contraction and dyssynergic defecation will exhibit failure of the anorectal angle to open, persistence of the puborectalis impression on the rectum, and poor
rectal emptying of the barium paste.(41–43) It has been shown
that patients with a diagnosis of paradoxical puborectalis on
defecography have a high frequency of constipation symptoms.
(44) Defecography is reported to be too sensitive for paradoxical
puborectalis contraction and dyssynergic defecation leading to a
high false-positive diagnosis, but this test does have the advantage
of evaluating any coexistent pelvic floor pathology.(45) Anatomic
causes of obstructive defecation are readily identifiable during
defecography and include internal intussusception of the rectum, rectocoele, enterocoele, and sigmoidocoele. The physiologic
importance of these findings is often unclear, and the surgeon
must determine their significance to individual patient symptoms and complaints to determine need for surgical repair.
Electromyography. Surface electromyography (EMG) can be
performed by anal plug, intraanal sponge, or concentric needle
technique to diagnose patterns of anal sphincter and pelvic floor
muscle dysfunction. Electrodes are used to record action potentials
derived from motor units within contracting muscles. Recordings
are taken at rest, squeeze, and push. In normal patients, the act
of defecation and push is accompanied by a decrease in motor
unit activity signifying relaxation of the anal sphincter complex
(Figure 34.2A). Patients with dyssynergic defecation and paradoxical puborectalis contraction exhibit increased motor unit
activity during push indicating an increase in anal sphincter
complex contraction during defecation (Figure 34.2B). Studies
have shown that the negative predictive value for this test is high
(91%) indicating EMG can accurately rule out paradoxical puborectalis contraction; however, the positive predictive value is
quite low when compared with defecography.(46–48) This suggests the need for comprehensive physiologic testing to accurately
diagnose paradoxical puborectalis contraction.
4
operative and nonoperative therapy for chronic constipation
(A) (B)
Figure 34.2 Electromyographic tracings in a patient with normal defecation (A)
and paradoxical puborectalis contraction (B). Black arrows indicate push phase
that normally corresponds with muscle relaxation and lower amplitude waves. (R
rest; S strain; P push).
MEDICAL TREATMENT OF CONSTIPATION
Initial treatment of functional constipation regardless of type
is patient education, dietary and lifestyle modifications, and a
trial of medical management. Education of the patient is critical and should include explanation of normal physiologic bowel
patterns.(49) It is important to communicate to the patient that
their symptoms will not be corrected overnight, and modifications of the treatment regimen may be required. In many patients
a dietary and medication log can be helpful to accurately identify fiber and water consumption, and medication compliance.
A daily diary to record bowel movements, stool characteristics,
and associated abdominal symptoms is useful when assessing
responses to treatment. Patients should be encouraged to recognize and respond to the urge to defecate. Most patients who have
a normal bowel pattern usually empty stools at approximately
the same time every day suggesting this is in part a conditioned
reflex.(50) Ritualizing bowel habits may be useful to establish a
regular pattern of bowel movement and should be coordinated
with physiologic events that stimulate colonic motility (walking
and postprandial gastrocolic response).(11) General measures
such as adequate hydration and regular exercise has overall health
benefit; however, there is no evidence to support success in the
treatment of chronic constipation, except in situations of dehydration.(51, 52) Indirect evidence exists, as epidemiologic studies suggest that sedentary people are three times more likely to
report constipation.(53)
A diet high in fiber content increases stool weight and accelerates
colonic transit time.(54) In contrast, a diet that is deficient in fiber
may lead to constipation.(54, 55) Consensus exists that empiric
treatment for constipation with a high-fiber diet is inexpensive
and effective therapeutic intervention for addressing constipationrelated bowel dysfunction.(56, 57) There is a clear dose response
between daily fiber intake and fecal output that is enhanced by
increased fluid intake. Dietary supplements such as bran may cause
significant amounts of abdominal bloating and discomfort, which
may decrease patient compliance. Gradual increase in dose may
minimize these symptoms. Psyllium seed, methylcellulose, and calcium polycarbophil are bulk-forming laxatives that absorb water
into the colonic lumen and increases fecal mass, which in turn
stimulates motility and reduces colon transit time.(58) A literature
review of articles dealing with 18 double-blind studies related to
constipation found that dietary fiber supplements or bulk laxatives resulted in an average increase of 1.4 (95% CI, 0.6–2.2) bowel
movements per week, while laxative agents other than bulk showed
an increase of 1.5 (95% CI, 1.1–1.8) bowel movements per week.
(59) Others have shown that fiber has limited value in patients with
slow-transit constipation and pelvic floor dysfunction as patients
with these conditions did not respond effectively to dietary supplementation with 30 grams of fiber per day.(56) Conversely,
patients without an underlying motility disorder either improved
or became asymptomatic with fiber therapy. Collectively, these
data suggest that therapeutic trial of dietary fiber should be considered as initial treatment for patients with constipation, although
fiber supplements administered alone are probably more effective
in normal transit or fiber deficiency constipation than slow transit
constipation or pelvic floor dysfunction.(27)
Failure of fiber therapy requires alternative choices of laxative
medications. A list of common medications used to treat constipation is shown in Table 34.4. With so many potential options
available, the choice of laxative therapy is subject to patient preference, and physician opinion and consensus.(60, 61) Although
there are a variety of preparations available, the laxatives that are
frequently recommended include milk of magnesia, lactulose,
sorbitol, senna compounds, bisacodyl, and polyethylene glycol
preparations.
Milk of magnesia, magnesium citrate, and sodium phosphate
are saline laxatives that are poorly absorbed or nonabsorbed
osmotic preparations that result in secretion of water in the
intestines to maintain isotonicity with plasma.(62) Use of these
agents is not recommended in patients with cardiac and renal
dysfunction because excessive absorption may lead to electrolyte
abnormalities and volume overload. When ingested as hypertonic
improved outcomes in colon and rectal surgery
Table 34.4 Medications commonly used for constipation.
Ty pe Generic Name Trade Name Dosage Mechanism of action
Bran – 1 cup/day
Fiber
Stool Softener Docusate Sodium Colace 100 mg bid Ineffective for constipation
Osmotic
agents
Suppository
Stimulants
Saline
laxatives
Lubricant Mineral oil 15–45 mL Stool lubricantn
Enemas
Secretory agents Lubiprostone Amitiza 24 mg bid Stimulation of Chloride channels
Psyllium Metamucil 1 tsp up to tid
Methylcellulose Citrucel 1–2 tsp up to tid
Calcium polycarbophil Fibercon 2–4 tabs qd
Sorbitol 15–30 mL qd or bid Nonabsorbable disaccharides
Lactulose Chronulac 15–30 mL qd or bid Accelerate colonic transit
Polyethylene glycol Miralax 17 g/d Osmotic increase in intraluminal fluid
Glycerine Up to daily
Bisacodyl Dulcolax 10 mg daily
Bisacodyl Dulcolax 10 mg po up to 3x/wk Increase intraluminal fluid
Antraquinones Senokot 2 tabs qd to 4 tabs bid Stimulation myenteric plexus
Peri-colace 1–2 tabs qd Increase motility
Milk of Magnesia 15–30 mL qd or bidn Osmotic increase fluid small bowel
Magnesium
Mineral oil retention 100–250 mL qd Stool softened and lubricated
Tap water 500 mL
Phosphate Fleet 1 unit
Soapsuds 1500 mL
Haley’s M-O 15–30 mL qd or bid
Magnesium citrate 1 bottle
Increase stool bulk
Decrease colonic transit
Increase gastrointestinal motility
Rectal stimulation
Stimulate CCK
Decrease colon transit time
Evacuation induced by distended
colon; mechanical lavage
tid = three times a day; qd = daily; bid = twice a day.
solutions, there is a rapid osmotic equilibration that occurs, and
overuse may result in significant dehydration.(62)
Lactulose and sorbitol are nonabsorbable disaccharides that are
effective osmotic laxative agents. Lactulose is a known substrate
for colonic bacterial fermentation with resultant production of
hydrogen, methane, carbon dioxide, water, acid and short-chain
or volatile fatty acids.(63) These products act as osmotic agents
and also stimulate intestinal motility and secretion. Lactulose has
been shown to increase stool frequency in chronically constipated
patients (64); however, abdominal bloating, discomfort, and
flatulence are common side effects of this medication and may
decrease patient compliance. Sorbitol is a poorly absorbed sugar
alcohol that produces similar effects. In a trial of constipated men
over the age of 65, sorbitol administered as a 70% syrup (10.5 g/15
mL; 15 to 60 mL daily) was equivalent to lactulose in improving
symptoms.(65) Furthermore, it was cheaper and better tolerated
during a 4-week trial.
High-molecular-weight polyethylene glycol (PEG) is a large polymer with substantial osmotic activity that obligates intraluminal
water.(66) It is routinely used with a balanced electrolyte solution
for colon cleansing as polyethylene glycol electrolyte lavage solution
(PEG-ELS). These solutions are safe and effective, and are routinely
used for bowel preparations for colonoscopy and bowel surgery.
(67) Other forms have been effectively used as laxatives for the treatment of constipation. PEG 3350 (MiraLax, Braintree Laboratories,
Braintree, MA) is a large chemically inert polymer that also functions
as an osmotic laxative. It does not contain salts that can be absorbed,
and has been shown not to change measured electrolytes, calcium,
glucose, blood urea nitrogen (BUN), creatinine, or serum osmolality.(68) A recent randomized controlled multicenter trial has shown
effectiveness of 17g of PEG 3350 laxative over a dextrose placebo,
with greatest efficacy during the second week of the therapy.(69) An
8-week, double blind, placebo-controlled study showed that PEG
3350 administered to patients with chronic constipation increased
stool frequency and accelerated left colonic transit, without inducing abdominal cramps or bloating. In a long-term multicenter study
of PEG 4000, 14.6 g twice a day improved stool frequency, reduced
straining effort, softened stools, and decreased the need for oral laxatives and enemas when compared with placebo (70); however, there
was a high dropout rate (30% PEG 4000 and 60% placebo) which
raises concerns about efficacy and tolerance.
Stimulant laxatives. The stimulant laxatives have effects on
mucosal electrolyte transport and gut motility. Commonly used
laxatives in this category include bisacodyl and senna. Abdominal
discomfort and cramping are common side effects of these agents.
Bisacodyl produces defecation within 6 to 8 hours of taking the
operative and nonoperative therapy for chronic constipation
tablet, or 15 to 30 minutes after the suppository. It is believed
to exert its effect by inducing high amplitude propagated contractions of the bowel, and is an effective rescue medication for
chronic constipation.(27) Senna is member of the anthraquinone
family of laxatives that are common constituents of herbal and
over-the-counter laxatives. They are metabolized in the colon by
bacteria into their active forms. In a trial of elderly nursing home
residents (n = 77), a senna and fiber combination was reported
to be better than lactulose in improving stool frequency, stool
consistency, and ease of passage.(71) Furthermore, the senna and
fiber combination was 40% cheaper than lactulose therapy.
Side effects of these laxatives include allergic reactions, electrolyte imbalance, melanosis coli, and “cathartic colon”. Melanosis
coli is a result of chronic ingestion of anthraquinone-containing
laxatives. This condition is an abnormal pigmentation of the
colonic mucosa that is caused by the accumulation of apoptotic epithelial cells that are phagocytosed by macrophages.(72)
“Cathartic colon” is an alteration of colon anatomy that was
believed to be associated with chronic stimulant laxative use.
Barium enema findings included colonic dilation, loss of haustral folds, strictures, colonic redundancy, and wide gaping of the
ileocecal valve.(73) Initially, it was attributed to the destruction of
myenteric plexus neurons by laxatives (74); however, more recent
studies do not confirm those findings.(75) Current evidence supports the safety of currently available laxatives at recommended
doses for long-term use. Finally, anthraquinones have been proposed to have mutagenic effects and produce tumors in animal
models. Several cohort studies and one case-control study failed
to find an association between anthraquinones and colorectal
adenomas or carcinoma.(76)
Other drugs. Patients with severe slow-transit constipation
may not respond to medical therapies described above. Ideally,
slow-transit constipation should be treated with an agent that
restores normal colonic function. Medications such as secretagogues (lobiprostone, cholchicine, and misoprostol) and prokinetic
agents (tegaserod, alvimopan, linaclotide) are currently under
clinical trials for the treatment of constipation, and show promise
for patients with slow-transit constipation.
Lubiprostone is an oral bicyclic fatty acid that activates the type
2 chloride channels that are located on the intestinal epithelial
cell leading to an active secretion of chloride in the intestinal
lumen.(77) In healthy humans, this drug has been shown to slow
gastric emptying, but accelerated small bowel and colonic transit
time at 24 hours.(78) In a randomized control study with intent
to treat analysis, lubiprostone significantly increased the number
of spontaneous bowel movements per week, improved straining
effort, improved overall satisfaction with bowel habits, and produced softer stools when compared with placebo.(79)
Colchicine is a microtubule formation inhibitor that is commonly used to treat gouty arthritis. A significant side effect of
colchicine is diarrhea. In an open labeled study of 7 patients with
normal transit constipation, colchicine (0.6 mg orally 3 times
per day) increased stool frequency and accelerated colon transit time.(80) Furthermore, patients reported reduced symptoms
of abdominal pain, nausea, and bloating. However, long-term
use may be associated with neuromyopathy, and its use for
chronic constipation is not supported. The prostaglandin E1
analog misoprostol (1200 µg/d) has been shown to increase stool
frequency and accelerate colonic transit (81); however, the drug is
expensive and its beneficial effects appear to decline over time.
Tegaserod is a serotonin 5-HT4 receptor partial agonist that
has been shown to increase gastic emptying and colonic transit
time.(82) Large randomized controlled trials in the United States
and Europe have reported that tegaserod increases the number
of complete spontaneous bowel movements per week, relieves
constipation-related symptoms, and improves overall bowel satisfaction.(79, 83) However, recent reports of 0.01% incidence
of coronary and cerebrovascular events have suspended sales
of tegaserod. Another drug, alvimopan, is a peripherally acting
µ-opioid receptor antagonist. This drug does not cross the bloodbrain barrier, and therefore, does not inhibit the analgesic effect
of opioids. A physiologic study of alvimopan has shown that this
drug reverses opioid-induced delayed colonic transit in healthy
subjects.(84) These data were verified in another randomized
trial of opioid-induced bowel dysfunction, and has been shown
to be effective in the treatment of acute postoperative ileus.(85,
86) Further studies are necessary to determine efficacy of alvimopan on chronic constipation.
BIOFEEDBACK THERAPY
In patients with constipation due to pelvic floor dyssynergia, biofeedback therapy is frequently recommended after failure of conservative management described above.(87) Biofeedback therapy
uses electronically amplified recordings of pelvic floor muscle contractions (EMG) or anorectal pressure tracings to teach
patients how to relax pelvic floor muscles and to strain more
effectively when they defecate.(12) The purpose of this therapeutic modality is to restore a normal pattern of defecation by using
an instrument-based education program. The primary goals are
to correct the underlying dyssynergy that affects the abdominal,
rectal, and anal sphincter muscles, and to improve the rectal sensory perception. A series of training sessions are used to teach
diaphragmatic breathing techniques to improve abdominal pushing effort and to synchronize this with anal relaxation. Visual or
auditory feedback is used to provide the patent input regarding
performance during attempted defecation maneuvers.
Studies on biofeedback therapy for the treatment of pelvic
floor dyssynergia have been reviewed extensively.(88, 89) These
reviews suggest that two-thirds of these patients benefit from
biofeedback training, with individual studies reporting a 30 to
100% success rate; however, attempts to draw definitive conclusions about the usefulness and effectiveness of biofeedback for
the treatment of pelvic floor dyssynergia-type constipation are
difficult due to the lack of adequately controlled trials of sufficient sample size.(87) In a recent review of biofeedback therapy
for pelvic floor dyssynergia, 4 of 27 (<15%) studies in the adult
population were controlled, and only one well-controlled study
had a sample size that was sufficient to provide meaningful statistical conclusions.(87)
Biofeedback therapy for dyssynergic-type constipation is directed
at coordinating pelvic floor muscle relaxation with intraabdominal
pressure to generate an effective propulsive force. Instrumentation
protocols in these patients require either EMG monitoring of
muscle tone or anorectal pressures for biofeedback training. To
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