CLINICAL REVIEW

Chronic Constipation
An Evidence-Based Review
Lawrence Leung, MBBChir, FRACGP,
FRCGP, Taylor Riutta, MD, Jyoti
Kotecha, MPA, MRSC, and Walter
Rosser MD, MRCGP, FCFP
JABFM July-August 2011 Vol. 24
No. 4
http://www.jabfm.org

Introduction
Medical personnel define constipation
as 3 bowel movements per week,
patients often equate constipation
with stool consistency, feelings of
incomplete emptying, straining, and
urge for defecation.
The normalcy of bowel habit ranges
widely from 3 bowel movements per
day to 3 per week

Introduction
The Rome III criteria in 2006 for constipation
as having at least 2 of the following:
(1)Straining during 25% defecation;
(2)Lumpy or hard stools in 25% of defecation;
(3)Sensation of incomplete evacuation in
25% of defecation;
(4)Sensation of anorectal
obstruction/blockage in 25% of defecation;
(5) Need for manual maneuvers to facilitate
in 25% of defecation;
(6) Fewer than 3 defecations per week

Introduction
Also, patients should rarely have loose stools
without laxatives and be distinct from
having irritable bowel syndrome
For constipation to be defined as chronic, a
patient must be symptomatic for at least 6
months with applicable criteria for the
previous 3 months
Risk Factor for chronic constipation :
1.Female
2.Advanced age (>70 yo)

Extrinsic Etiology of Chronic

Constipation

Low fiber intake

Neurological disorders
Psychological
Inadequate
comorbidities
hydration
Concurrent
Reduced mobility
medications (eg,
Reduced sensation
anticholinergics,
diuretics, b-blockers,
of thirst,
opiates, iron
Electrolyte
supplements, calcium
disturbances
channel blockers,
Endocrine and
antidepressants,
acetaminophen,
metabolic disorders
aspirin and NSAIDs)

Intrinsic Etiology of Chronic

Constipation

Pelvic floor dysfunction (PFD) 37%

Laxity of the pelvic floor muscles

Impaired rectal sensation
Decreased luminal pressure in the anal canal

Slow colon transit time (STC) 23%

Reduced cholinergic
enhanced adrenergic responses
mitigated gastrocolic reflex
dysynergy of rectosigmoid colonic activities
enteric neurodegeneration of both the myenteric plexus
ganglia and the interstitial cells of Cajal
abnormalities of enteric neurotransmitters such as
substance P
vasoactive intestinal peptides and nitric oxide

Overlap of up to 55%

Complications of Chronic
Constipation

Fecal incontinence
Hemorrhoids
Anal fissure
Organ prolapse
Fecal impaction and bowel
obstruction
Bowel perforation and stercoral
peritonitis

Evidence-Based
Management of Chronic
Constipation

Metode

Sebuah pencarian literatur dari laporan medis yang diterbitkan dalam

semua bahasa dilakukan dari PubMed, EMBASE, dan Cochrane Database of
Systematic Review dari awal sampai Oktober 2010 menggunakan the Ovid
Portal dari Queen University, Kingston, Ontario.

Kata-kata kunci abstrak awal: "konstipasi kronis," "pengobatan," dan uji

coba.

Pencarian manual referensi dan review artikel dilengkapi pencarian

komputerisasi, hanya artikel full-length yang dianggap.

Dua pengulas (L.L. dan T.R.) bekerja secara independen dan memeriksa
ulang mencari abstrak yang sesuai dengan kata-kata kunci seperti yang
disebutkan.

mengadopsi bentuk sederhana untuk memilih studi yang sesuai 2 kriteria

inklusi berikut:
(1) yang melibatkan manusia, subyek yang berusia lebih dari 18 tahun
dan (2) mendeskripsikan setidaknya 1 bentuk pengobatan untuk
konstipasi kronis

 Evaluasi studi yang dipilih dilakukan oleh

masing-masing reviewer (LL dan TR) tentang
kualitas dan bukti sesuai Strength of
Recommendations Taxonomy (SORT), dengan
tingkat bukti dari I hingga III dan rekomendasi
dari A ke C.
Setiap ketidaksepakatan dibahas dan
diselesaikan antara pemeriksa untuk mencapai
konsensus bersama.

Hasil
145 abstrak diidentifikasi dengan menggunakan katakata kunci "konstipasi kronis" DAN "Pengobatan" DAN
uji coba."
Duplikat telah dihapus, dan,setelah memaksakan kriteria
seleksi, hanya 62 artikel yang merupakan teks lengkap
relevan dan diambil; dianggap memenuhi syarat dimana
konsensus yang sama dicapai antara kedua pengulas (LL
dan TR). Konsultasi tambahan dengan dua rekan penulis
lainnya (WR dan JK) dianggap sesuai kebutuhan.
Penelitian tersebut kemudian dinilai menurut SORT

Non Farmakologi
Modifikasi Gaya Hidup
Konsumsi serat makanan
Cairan
Olahraga

Biofeedback
Bacteriotherapy (Probiotics)
Surgery
total colectomy
Partial colectomy
division of puborectalis

Pengobatan Farmakologi
Obat untuk konstipasi kronis dapat dikategorikan
menjadi:

Agen pembentuk bulk

Pelunak feses dan emolien
Agen osmotik
Stimulan
Aktivator channel klorida
Agonis reseptor 5-HT4
Agonis reseptor guanylate cyclase-c

Conclusions
a common condition was found in at
least one quarter of patients, chronic
constipation is treated in a wide
variety of ways, with relatively little
evidence-based data, especially
regarding dietary fiber, fluids and
exercise.

Physical examination
(1) previous surgical scars
(2) abdominal distension and bowel sounds
(3) palpable mass (fecoliths)
(4) inspection of anus for skin tags, hemorrhoids,
fissures, hematomas, and prolapse
(5) rectal examination to assess anal reflex, sphincter
tone, tenderness, out-pouching (rectocele), or mass in
the rectum
(6) Gynecological examination to exclude cystoceles or
vaginal/uterine prolapse
(7) full neurological examination to exclude neurological
causes.

Investigations include
(1)Blood tests such as complete blood
count, serum glucose, and thyroid and
renal functions
(2)Colon transit time: Radiograph study with
the Sitz, Scintigraphy with radioisotope
(3) Anorectal manometry
(4) Balloon expulsion test
(5) Defecography
(6) Dynamic pelvic MRI

A. If 5 or fewer
markers remain,
patient has grossly
normal colonic
transit.

B. Most rings are

scattered about
the colon. Patient
most likely has
hypomotility or
colonic inertia.

C. Most rings are

gathered in the
rectosigmoid.
Patient has
functional outlet
obstruction.

 Increasing daily dietary fiber intake may

help constipation caused by fiber
deficiency.
Exercise decreases constipation.
Higher fluid intake improved chronic
constipation in the presence of a highfiber diet.
The latest evidence does not support a
role of senna in causing colon cancer in
rats and humans