Functional constipation

Last updated
Functional constipation
Other namesChronic idiopathic constipation
Specialty Gastroenterology
Symptoms Hard or lumpy stools, decreased frequency of bowel movements, a feeling of incomplete evacuation or obstruction, straining, stomach pain and bloating.
Diagnostic method Rome criteria, history and physical examination.
TreatmentEducation, lifestyle modification, faecal disimpaction, and maintenance therapy.
Medication polyethylene glycol (PEG), milk of magnesia, senna, bisacodyl, plecanatide, linaclotide, and lubiprostone.

Functional constipation, also known as chronic idiopathic constipation (CIC), is defined by less than three bowel movements per week, hard stools, severe straining, the sensation of anorectal blockage, the feeling of incomplete evacuation, and the need for manual maneuvers during feces, without organic abnormalities. Many illnesses, including endocrine, metabolic, neurological, mental, and gastrointestinal obstructions, can cause constipation as a secondary symptom. When there is no such cause, functional constipation is diagnosed. [1]

Contents

Functional constipation requires symptoms to be present at least a fourth of the time. Causes include anismus, descending perineum syndrome, inability to control the external anal sphincter, poor diet, unwillingness to defecate, nervous reactions, and deep psychosomatic disorders. Comorbid symptoms like headache may also be present, especially in children.

Functional constipation is diagnosed using the Rome criteria, a consensus of experts. The criteria include over 25% of defecations involving straining, 25% resulting in lumpy or hard stools, 25% requiring partial evacuation, 25% experiencing anorectal blockage or obstruction, and 25% using manual techniques. Less than three weekly spontaneous bowel movements are also considered. A thorough history and physical examination, including a digital rectal exam, is crucial for diagnosing constipation. Additional laboratory testing is typically used in cases of uncertainty or to rule out underlying medical conditions.

Functional constipation is a condition that requires nonpharmacological management, including education and lifestyle modifications. It begins with dietary guidelines, focusing on regular fiber and fluid intake. Children with functional constipation should consume a normal intake of fiber, as per ESPGHAN/NASPGHAN criteria. Parents and children should receive counseling about overflow incontinence and withholding behavior. An organized toilet-training program with a reward system can help reduce faecal impaction.

Pharmacological treatment for children with functional constipation consists of maintenance therapy and faecal disimpaction. High-dose oral polyethylene glycol (PEG) or enemas containing active substances can induce fecal disimpaction, while maintenance therapy is recommended after successful disimpaction to avoid reoccurring stool buildup. Glycerine or bisacodyl suppositories are also used for both adults and children. Maintenance treatment for functional constipation includes osmotic laxatives, milk of magnesia, and mineral oil. Stimulant laxatives like senna or bisacodyl are recommended for those with persistent symptoms.

Signs and symptoms

Individuals suffering from functional constipation often exhibit hard or lumpy stools, decreased frequency of bowel movements, a feeling of incomplete evacuation or obstruction, straining, and in some cases, stomach pain and bloating. [2] Generally speaking, symptoms are considered chronic if they have persisted for three months or more. [3]

Faecal incontinence, which is the involuntary loss of stools in the underwear during toilet training and is brought on by an overflow of soft stools passing around a solid faecal mass in the rectum (faecal impaction), is a common symptom in children. [4] Urinary symptoms, including urine incontinence and urinary tract infections, are frequently observed in children who suffer from functional constipation. [5]

Causes

To be considered functional constipation, symptoms must be present at least a fourth of the time. [6] Possible causes are:

There is also possibility of presentation with other comorbid symptoms such as headache, especially in children. [7]

Diagnosis

Functional constipation cannot be diagnosed with particular testing; instead, the Rome criteria, a consensus of experts, is used to make this diagnosis. [8] The Rome IV criteria define functional constipation as meeting at least two of the six requirements given below: [9]

  1. Over ¼ (25%) of defecations involve straining. [9]
  2. More than ¼ (25%) of defecations result in lumpy or hard stools (Bristol Stool Form Scale 1-2). [9]
  3. Sensation of partial evacuation for over ¼ (25%) of the defecations. [9]
  4. Sensation of anorectal blockage or obstruction during more than ¼ (25%) of bowel movements. [9]
  5. Manual techniques (such as pelvic floor support and digital evacuation) to assist in more than ¼ (25%) of defecations. [9]
  6. Less than three weekly spontaneous bowel movements. [9]
  7. Loose stools are rarely seen without the use of laxatives. [9]
  8. Not enough criteria met to diagnose irritable bowel syndrome. [9]

A thorough history and physical examination should be performed while evaluating constipation. [10] Along with push and squeeze maneuvers, a comprehensive digital rectal exam (DRE) is a crucial component of the clinical examination. [11]

Generally speaking, additional laboratory testing should be carried out only in cases of uncertainty or to rule out underlying medical conditions such as hypothyroidism or celiac disease. Abdominal radiography, with or without the introduction of radio-opaque markers to determine colonic transit time, and abdominal ultrasonography are frequently employed supplementary tests in the diagnosis of constipation. [12]

Chronic idiopathic constipation is similar to constipation-predominant irritable bowel syndrome (IBS-C); however, people with CIC do not have other symptoms of IBS, such as abdominal pain. [6]

Treatment

Treatment for functional constipation begins with nonpharmacological management. This includes education and lifestyle modifications, such as diet changes, consistent exercise, and guidance on proper body position and behavior when using the restroom. [13]

The first treatments for constipation are dietary guidelines, which include the requirement for a regular consumption of fiber and fluids. A normal intake of fiber is advocated for children with functional constipation, as per the criteria of ESPGHAN/NASPGHAN. It is not recommended to increase the consumption of fiber above what is considered normal. [14]

In order to effectively treat childhood constipation, it is imperative that parents and children receive counseling. This includes teaching them about the concept of overflow incontinence and the significance of withholding behavior. [13] One way to reduce faecal impaction and lower the risk of faecal incontinence is to use an organized toilet-training program with a reward system that instructs the kid to try to defaecate at least twice or three times a day (after each meal). [15]

Children with functional constipation can be treated pharmacologically in two stages: maintenance therapy and faecal disimpaction. High-dose oral polyethylene glycol (PEG) or enemas containing active substances such sodium phosphate, sodium lauryl sulfoacetate, or sodium docusate can be used to induce fecal disimpaction. Maintenance therapy is suggested following successful disimpaction in order to avoid reoccurring stool buildup. Adults rarely need faecal disimpaction, although the methods are comparable, and substantial doses of PEG or magnesium citrate are popular oral therapies. For both adults and children, glycerine or bisacodyl suppositories provide an alternative to enemas. [13]

The first-choice maintenance treatment advised for functional constipation is osmotic laxatives. [14] [16] Other often used laxatives include milk of magnesia (magnesium hydroxide) and mineral oil, a lubricant. [13] Clinical recommendations advocate using stimulant laxatives, such as senna or bisacodyl, in both adults and children if symptoms are still present. [14] [16]

A number of novel therapeutic treatments have been suggested and licensed in recent years for the treatment of functional constipation. [13] Prosecretory drugs including plecanatide, linaclotide, and lubiprostone alter gut epithelial channels, encouraging intestinal fluid secretion and increasing stool volume, which improves GI transit. [17] Functional constipation has been treated with a variety of 5-hydroxytryptamine 4 (5-HT4) agonists. [13] Serotonin (5-HT) is an enteric and central neurotransmitter that binds to the gut's 5-HT4 receptors to boost acetylcholine release, which in turn increases secretion and motility of the gut. [18] Additionally, serotonin promotes motility by stimulating the mucosa's afferent neurons, which in turn triggers the gastrocolic reflex. [19]

Research

A 2014 meta-analysis of three small trials evaluating probiotics showed a slight improvement in management of chronic idiopathic constipation, but well-designed studies are necessary to know the true efficacy of probiotics in treating this condition. [20]

Children with functional constipation often claim to lack the sensation of the urge to defecate, and may be conditioned to avoid doing so due to a previous painful experience. [21] One retrospective study showed that these children did indeed have the urge to defecate using colonic manometry, and suggested behavioral modification as a treatment for functional constipation. [22]

See also

Related Research Articles

<span class="mw-page-title-main">Defecation</span> Expulsion of feces from the digestive tract

Defecation follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus or cloaca. The act has a variety of names ranging from the common, like pooping or crapping, to the technical, e.g. bowel movement, to the obscene (shitting), to the euphemistic, to the juvenile. The topic, usually avoided in polite company, can become the basis for some potty humor.

<span class="mw-page-title-main">Constipation</span> Infrequent or difficult bowel movements

Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.

<span class="mw-page-title-main">Laxative</span> Agents that relax and loosen the bowels and stools

Laxatives, purgatives, or aperients are substances that loosen stools and increase bowel movements. They are used to treat and prevent constipation.

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents — including flatus (gas), liquid stool elements and mucus, or solid feces. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<span class="mw-page-title-main">Irritable bowel syndrome</span> Functional gastrointestinal disorder

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by a group of symptoms that commonly include abdominal pain, abdominal bloating and changes in the consistency of bowel movements. These symptoms may occur over a long time, sometimes for years. IBS can negatively affect quality of life and may result in missed school or work or reduced productivity at work. Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.

Encopresis is voluntary or involuntary passage of feces outside of toilet-trained contexts in children who are four years or older and after an organic cause has been excluded. Children with encopresis often leak stool into their undergarments.

Functional abdominal pain syndrome (FAPS), chronic functional abdominal pain (CFAP), or centrally mediated abdominal pain syndrome (CMAP) is a pain syndrome of the abdomen, that has been present for at least six months, is not well connected to gastrointestinal function, and is accompanied by some loss of everyday activities. The discomfort is persistent, near-constant, or regularly reoccurring. The absence of symptom association with food intake or defecation distinguishes functional abdominal pain syndrome from other functional gastrointestinal illnesses, such as irritable bowel syndrome (IBS) and functional dyspepsia.

Functional gastrointestinal disorders (FGID), also known as disorders of gut–brain interaction, include a number of separate idiopathic disorders which affect different parts of the gastrointestinal tract and involve visceral hypersensitivity and motility disturbances.

<span class="mw-page-title-main">Fecal impaction</span> Solid buildup of feces in the rectum due to chronic constipation

A fecal impaction or an impacted bowel is a solid, immobile bulk of feces that can develop in the rectum as a result of chronic constipation. Fecal impaction is a common result of neurogenic bowel dysfunction and causes immense discomfort and pain. Its treatment includes laxatives, enemas, and pulsed irrigation evacuation (PIE) as well as digital removal. It is not a condition that resolves without direct treatment.

The Bristol stool scale is a diagnostic medical tool designed to classify the form of human faeces into seven categories. It is used in both clinical and experimental fields.

The Rome process and Rome criteria are an international effort to create scientific data to help in the diagnosis and treatment of functional gastrointestinal disorders, such as irritable bowel syndrome, functional dyspepsia and rumination syndrome. The Rome diagnostic criteria are set forth by Rome Foundation, a not for profit 501(c)(3) organization based in Raleigh, North Carolina, United States.

<span class="mw-page-title-main">Lubiprostone</span> Medication used for constipation

Lubiprostone, sold under the brand name Amitiza among others, is a medication used in the management of chronic idiopathic constipation, predominantly irritable bowel syndrome-associated constipation in women and opioid-induced constipation. The drug is owned by Mallinckrodt and is marketed by Takeda Pharmaceutical Company.

<span class="mw-page-title-main">Anorectal manometry</span> Medical functional test of the anus and rectum

Anorectal manometry (ARM) is a medical test used to measure pressures in the anus and rectum and to assess their function. The test is performed by inserting a catheter, that contains a probe embedded with pressure sensors, through the anus and into the rectum. Patients may be asked to perform certain maneuvers, such as coughing or attempting to defecate, to assess for pressure changes. Anorectal manometry is a safe and low risk procedure.

Bile acid malabsorption (BAM), known also as bile acid diarrhea, is a cause of several gut-related problems, the main one being chronic diarrhea. It has also been called bile acid-induced diarrhea, cholerheic or choleretic enteropathy, bile salt diarrhea or bile salt malabsorption. It can result from malabsorption secondary to gastrointestinal disease, or be a primary disorder, associated with excessive bile acid production. Treatment with bile acid sequestrants is often effective. Depending on the severity of symptoms, it may be recognised as a disability in the United Kingdom under the Equality Act 2010.

<span class="mw-page-title-main">Anismus</span> Failure to relax the pelvic floor muscles during defecation

Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women. It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with parcopresis, or psychogenic fecal retention.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

Transanal irrigation is medical procedure in which water is used to evacuate feces from the rectum and descending colon via the anus.

Plecanatide, sold under the brand name Trulance, is a medication for the treatment of chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation. It is available in India under the brand name "Plectide". Plecanatide is an agonist of guanylate cyclase-C. Plecanatide increases intestinal transit and fluid through a buildup of cGMP.

Constipation in children refers to the medical condition of constipation in children. It is a functional gastrointestinal disorder.

<span class="mw-page-title-main">Neurogenic bowel dysfunction</span> Human disease involving inability to control defecation

Neurogenic bowel dysfunction (NBD) is the inability to control defecation due to a deterioration of or injury to the nervous system, resulting in faecal incontinence or constipation. It is common in people with spinal cord injury (SCI), multiple sclerosis (MS) or spina bifida.

References

  1. ↑ Shin, Jeong Eun (2022). "Functional Constipation". Sex/Gender-Specific Medicine in the Gastrointestinal Diseases. Singapore: Springer Nature Singapore. pp. 259–272. doi:10.1007/978-981-19-0120-1_17. ISBN   978-981-19-0119-5.
  2. ↑ Lacy, Brian E.; Mearin, Fermín; Chang, Lin; Chey, William D.; Lembo, Anthony J.; Simren, Magnus; Spiller, Robin (2016). "Bowel Disorders". Gastroenterology. 150 (6). Elsevier BV: 1393–1407.e5. doi:10.1053/j.gastro.2016.02.031. ISSN   0016-5085. PMID   27144627. Archived from the original on 2022-11-14. Retrieved 2024-06-30.
  3. ↑ Black, Christopher J; Ford, Alexander C (2018). "Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management" (PDF). Medical Journal of Australia. 209 (2): 86–91. doi:10.5694/mja18.00241. ISSN   0025-729X. PMID   29996755. Archived (PDF) from the original on 2020-05-05. Retrieved 2024-06-30.
  4. ↑ Wald, Ellen R; Di Lorenzo, Carlo; Cipriani, Lynne; Colborn, D Kathleen; Burgers, Rosa; Wald, Arnold (2009). "Bowel Habits and Toilet Training in a Diverse Population of Children". Journal of Pediatric Gastroenterology and Nutrition. 48 (3). Wiley: 294–298. doi:10.1097/mpg.0b013e31817efbf7. ISSN   0277-2116. PMID   19274784.
  5. ↑ Burgers, Rosa E.; Mugie, Suzanne M.; Chase, Janet; Cooper, Christopher S.; von Gontard, Alexander; Rittig, Charlotte Siggaard; Homsy, Yves; Bauer, Stuart B.; Benninga, Marc A. (2013). "Management of Functional Constipation in Children with Lower Urinary Tract Symptoms: Report from the Standardization Committee of the International Children's Continence Society". Journal of Urology. 190 (1). Ovid Technologies (Wolters Kluwer Health): 29–36. doi:10.1016/j.juro.2013.01.001. ISSN   0022-5347. PMID   23313210.
  6. 1 2 "Americal College of Gastroenterology: Fuinctional Bowel Disorders" (PDF). Archived from the original (PDF) on 2011-09-27. Retrieved 2010-06-26.
  7. ↑ Inaloo S, Dehghani SM, Hashemi SM, Heydari M, Heydari ST (2014). "Comorbidity of headache and functional constipation in children: a cross-sectional survey". Turk J Gastroenterol. 25 (5): 508–11. doi:10.5152/tjg.2014.6183. PMID   25417610.
  8. ↑ Drossman, Douglas A. (2016). "Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV". Gastroenterology. 150 (6). Elsevier BV: 1262–1279.e2. doi:10.1053/j.gastro.2016.02.032. ISSN   0016-5085. PMID   27144617. Archived from the original on 2023-10-18. Retrieved 2024-06-30.
  9. 1 2 3 4 5 6 7 8 9 "Rome IV Criteria". Rome Foundation. 2023-03-06. Archived from the original on 2022-01-19. Retrieved 2024-06-10.
  10. ↑ Jani, Bhairvi; Marsicano, Elizabeth (2024-03-14). "Constipation: Evaluation and Management". Missouri Medicine. 115 (3). Missouri State Medical Association: 236–240. PMC   6140151 . PMID   30228729.
  11. ↑ Tantiphlachiva, Kasaya; Rao, Priyanka; Attaluri, Ashok; Rao, Satish S.C. (2010). "Digital Rectal Examination Is a Useful Tool for Identifying Patients With Dyssynergia". Clinical Gastroenterology and Hepatology. 8 (11). Elsevier BV: 955–960. doi:10.1016/j.cgh.2010.06.031. ISSN   1542-3565. PMID   20656061.
  12. ↑ Tabbers, Merit M.; Boluyt, Nicole; Berger, Marjolein Y.; Benninga, Marc A. (2011-06-24). "Clinical practice". European Journal of Pediatrics. 170 (8). Springer Science and Business Media LLC: 955–963. doi:10.1007/s00431-011-1515-5. ISSN   0340-6199. PMID   21701812.
  13. 1 2 3 4 5 6 Vriesman, Mana H.; Koppen, Ilan J. N.; Camilleri, Michael; Di Lorenzo, Carlo; Benninga, Marc A. (2019-11-05). "Management of functional constipation in children and adults". Nature Reviews Gastroenterology & Hepatology. 17 (1). Springer Science and Business Media LLC: 21–39. doi:10.1038/s41575-019-0222-y. ISSN   1759-5045. PMID   31690829.
  14. 1 2 3 Tabbers, M.M.; DiLorenzo, C.; Berger, M.Y.; Faure, C.; Langendam, M.W.; Nurko, S.; Staiano, A.; Vandenplas, Y.; Benninga, M.A. (2014). "Evaluation and Treatment of Functional Constipation in Infants and Children". Journal of Pediatric Gastroenterology and Nutrition. 58 (2). Wiley: 258–274. doi:10.1097/mpg.0000000000000266. ISSN   0277-2116. PMID   24345831.
  15. ↑ van der Plas, R. N.; Benninga, M. A.; Taminiau, J. A. J. M.; Büller, H. A. (1997-08-20). "Treatment of defaecation problems in children: the role of education, demystification and toilet training". European Journal of Pediatrics. 156 (9). Springer Science and Business Media LLC: 689–692. doi:10.1007/s004310050691. ISSN   0340-6199. PMID   9296531.
  16. 1 2 Bharucha, Adil E.; Pemberton, John H.; Locke, G. Richard (2013). "American Gastroenterological Association Technical Review on Constipation". Gastroenterology. 144 (1). Elsevier BV: 218–238. doi:10.1053/j.gastro.2012.10.028. ISSN   0016-5085. PMC   3531555 . PMID   23261065.
  17. ↑ Simrén, Magnus; Tack, Jan (2018-06-21). "New treatments and therapeutic targets for IBS and other functional bowel disorders". Nature Reviews Gastroenterology & Hepatology. 15 (10). Springer Science and Business Media LLC: 589–605. doi:10.1038/s41575-018-0034-5. ISSN   1759-5045. PMID   29930260.
  18. ↑ Thomas, Rachel H.; Luthin, David R. (2015-05-27). "Current and Emerging Treatments for Irritable Bowel Syndrome with Constipation and Chronic Idiopathic Constipation: Focus on Prosecretory Agents". Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 35 (6). Wiley: 613–630. doi:10.1002/phar.1594. ISSN   0277-0008. PMID   26016701.
  19. ↑ Coss-Adame, Enrique; Rao, Satish S. C. (2014). "Brain and Gut Interactions in Irritable Bowel Syndrome: New Paradigms and New Understandings". Current Gastroenterology Reports. 16 (4): 379. doi:10.1007/s11894-014-0379-z. ISSN   1522-8037. PMC   4083372 . PMID   24595616.
  20. ↑ Ford, Alexander C; Quigley, Eamonn M M; Lacy, Brian E; Lembo, Anthony J; Saito, Yuri A; Schiller, Lawrence R; Soffer, Edy E; Spiegel, Brennan M R; Moayyedi, Paul (2014). "Efficacy of Prebiotics, Probiotics, and Synbiotics in Irritable Bowel Syndrome and Chronic Idiopathic Constipation: Systematic Review and Meta-analysis". The American Journal of Gastroenterology. 109 (10): 1547–1561. doi:10.1038/ajg.2014.202. ISSN   0002-9270. PMID   25070051. S2CID   205100508.
  21. ↑ Fleisher, DR (November 1976). "Diagnosis and treatment of disorders of defecation in children". Pediatric Annals . 5 (11): 71–101. doi:10.3928/0090-4481-19761101-07. hdl: 10355/5155 . PMID   980548.
  22. ↑ Firestone Baum, C; John A; Srinivasan K; Harrison P; Kolomensky A; Monagas J; Cocjin J; Hyman PE (January 2013). "Colon manometry proves that perception of the urge to defecate is present in children with functional constipation who deny sensation". Journal of Pediatric Gastroenterology and Nutrition . 56 (1): 19–22. doi: 10.1097/MPG.0b013e31826f2740 . PMID   22922371. S2CID   46075633.

Further reading

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.