II. Definition: Chronic Functional Constipation (Rome II)

  1. Timing Criteria
    1. Symptoms present 12 weeks in prior 12 months
    2. Less than 3 stools per week
  2. Symptoms affect >25% of stools (two or more present)
    1. Straining
    2. Lumpy or hard stools
    3. Sensation of incomplete evacuation
    4. Sensation of anorectal obstruction
    5. Attempts at self disimpaction (manual maneuvers)
  3. Excluding symptoms
    1. No signs Organic Constipation (Acute Constipation)
      1. See Constipation for red flag symptoms
    2. No loose stools present
    3. Irritable Bowel Syndrome

III. Causes

  1. See Constipation Causes
  2. Inadequate water intake
  3. Low fiber dietary intake
  4. Sedentary lifestyle
  5. Altered motility
    1. Irritable Bowel Syndrome
    2. Slow transit
    3. Failure to respond to urge to defecate

IV. Symptoms and Signs Suggestive of Functional Constipation

  1. No red flags suggestive of Organic Constipation
    1. See Constipation for list of red flag symptoms
  2. Chronic duration
  3. No Weight loss
  4. No systemic symptoms

V. Diagnostics

  1. Colorectal Transit Time
  2. Colonic Contrast Study (single/double contrast barium)
  3. Evacuation Proctography

VI. Management: Initial Symptomatic Treatment

  1. See Laxative
  2. Disimpact stool first if Fecal Impaction
  3. Precautions
    1. Avoid these protocols in Bowel Obstruction, persistent Fecal Impaction
    2. Ensure no preceding Electrolyte disturbance and maintain adequate hydration
  4. Consider bowel evacuation
    1. Evacuation Protocol 1
      1. First: Fleets Enema x1-2 (or pink lady or tap water enema in emergency department)
      2. Next: Magnesium Citrate 1.745 g/30 ml, 10 oz bottle (296 ml) once or divided dosing
    2. Evacuation Protocol 2 (similar to Colonoscopy preparation)
      1. Bisacodyl 10 mg (two 5 mg tablets) orally a couple hours before Miralax twice daily for one day
      2. Polyethylene glycol (Miralax)
        1. Mix 255 g (15 capfuls or 1.25 cups) combined with Gatorade 64 oz (2 quarts)
        2. Drink 8 ounce glass every 15 minutes for one hour (32 oz) twice daily for one day
    3. Evacuation Protocol 3
      1. Enemas (e.g. Fleet Enema) twice daily for 3 days
    4. Evacuation protocol 4
      1. Polyethylene glycol 4-8 Liters per day until clean
      2. Contraindicated in Bowel Obstruction, fecal impact
      3. Exercise caution with Electrolyte and fluid losses
  5. Protocol recommended by AGA
    1. Step 1
      1. Milk of Magnesia (Magnesium Hydroxide)
      2. Increase Dietary Fiber
      3. Review prevention as described below
    2. Step 2
      1. Add Bisacodyl to Step 1 regimen
    3. Step 3
      1. Add Polyethylene glycol (e.g. Miralax)
  6. Authors approach
    1. Confirm no Small Bowel Obstruction, Diverticulitis or other contraindication to evacuation
    2. Rectal exam to check for impaction
    3. Evacuation Protocol 1 (as above)
    4. Miralax 1 capful daily in 8 oz crystal light for 1-2 weeks
    5. Maintain fluids >64 ounces daily and avoid Caffeine
    6. When stooling regularly start Dietary Fiber >15 grams daily

VII. Management: Special Circumstances

  1. See Narcotic Related Constipation
  2. Women with refractory chronic Functional Constipation
    1. Colchicine 0.6 mg PO tid (4 weeks of use in trial)
    2. Verne (2003) Am J Gastroenterol 98:1112-6 [PubMed]

VIII. Prevention

  1. Eliminate all Laxative use
    1. Laxatives cause rebound Constipation
    2. Lactulose may be used infrequently prn
    3. Replace all Laxatives with Bulk-Forming agents
    4. Anticipate 1-2 week adjustment period
      1. Use Fleet Enema if no stool q3 days for 1-2 weeks
  2. Increase Dietary Fiber or Bulk-forming agent (Psyllium)
    1. Used with >1.5 L/day fluids to prevent worsening
    2. Increase to 20 grams of Dietary Fiber per day
    3. Anticipate initial bloating with fiber intake
      1. Increase fiber by 5 grams per day per week
    4. May exacerbate atonic colon or slow transit colon
      1. These patients may benefit from low fiber intake
  3. Increase hydration to at least 64 ounces per day
  4. Avoid Caffeine
  5. Participate in regular Exercise
  6. Bowel Retraining: Avoid stool retention
    1. Take the time to go to the bathroom regularly
    2. Make use of physiologic bowel cycles
      1. Plan Bowel Movement soon after waking
      2. Plan Bowel Movement 10-30 minutes after meal
    3. Consider initiating program with enema or suppository
      1. Lukewarm enema within one hour of meal
      2. Bisacodyl suppository immediately after meal
    4. Consider enema for no stool in 2 days

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Related Studies

Ontology: Constipation - functional (C0401146)

Concepts Disease or Syndrome (T047)
SnomedCT 266524003, 155782005, 197118003
Spanish constipación - funcional (trastorno), estreñimiento - funcional, estreñimiento - funcional (trastorno), constipación - funcional
English functional constipation, functional constipation (diagnosis), Constipation - functional, Constipation - functional (disorder), Constipation-functional, Functional constipation

Ontology: Chronic constipation (C0401149)

Concepts Sign or Symptom (T184)
SnomedCT 236069009
Dutch constipatie chronisch
French Constipation chronique
German chronische Konstipation
Italian Costipazione cronica
Portuguese Obstipação crónica
Spanish Estreñimiento crónico, constipación crónica, estreñimiento crónico, estreñimiento crónico (hallazgo), estreñimiento crónico (trastorno)
Japanese 慢性便秘, マンセイベンピ
English chronic constipation (symptom), chronic constipation (diagnosis), chronic constipation, constipation chronic, Constipation, chronic, Chronic constipation, Chronic constipation (disorder), Chronic constipation (finding), Constipation chronic
Czech Chronická zácpa
Hungarian Obstipatio chronikus

Ontology: Constipation care (C1300313)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 389082000
Spanish manejo del estreñimiento, atención del estreñimiento, atención del estreñimiento (régimen/tratamiento), atención de la constipación, tratamiento de constipación (régimen/tratamiento), tratamiento de constipación
English constipation management, care constipation, Constipation care (regime/therapy), Constipation care, Constipation management