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EnhancedPrimaryCarePathway:CONSTIPATION

1.FocusedsummaryofconstipationrelevanttoprimarycareDefinition.Chronicconstipationisafunctionalboweldisorderdefinedasabnormalcolonictransit(fewerthan3bowelmovementsperweekthataremostlyhardorlumpyi.e.Bristolstoolscaletype1-2)and/ordefecatorydysfunction(difficultstoolpassagei.e.straining,sensationofincompleteevacuation/obstruction/blockage,digitalevacuation/supportoftheperineum).Painorbloatingmaybepresentinpatientswithconstipation,butitisnotadominantsymptom;patientswithconstipation-predominantirritablebowelsyndrome(IBS-C)haveabdominaldiscomfortorbloatingasamajorsymptom,accompaniedbyconstipation.ThereissignificantoverlapbetweenchronicconstipationandIBS-Cintermsofclinicalpresentationandtreatment.ForadditionaladviceaboutIBS-C,pleaserefertotheEnhancedPrimaryCarePathwayforIBShttp://www.specialistlink.ca/pages/referral-pathways.cfm.Pathophysiology.Constipationmaybeduetoaprimaryfunctionaldisorderofcolonicmotility(slowtransit)and/ordyssynergicdefecation(incoordinationofrectalpropulsionandanalsphincterrelaxation).Intheprimarycaresetting,constipationisveryoftencausedorcompoundedbysecondaryeffectsofmedicationsortheirunderlyingdiseases.Mechanicalorstructuralcausesofconstipation(e.g.massorstricture)arerelativelyrareinpracticeandcanusuallybediscernedbyclinicalredflagsorphysicalfindingsonabdominalandanorectalexam.Thereisnoincreaseinprevalenceofcolorectalcancerinpatientswithconstipationand,therefore,constipationisgenerallynotanindicationfordiagnosticcolonoscopy;however,colorectalcancerscreeningshouldbeundertakeninpatientswithconstipationaccordingtoageandfamilyhistory.Constipationinolderadultsisaspecialcategory,whichcanbeparticularlychallengingtoassessandtreat.Secondarycausesaremostoftenatplayintheelderlyduetomultiplemedicalconditionsandmedicationsthatpredisposetoconstipation,limitedphysicalactivity,lesscontrolorattentiontodietandfluidintake,andfailuretomaintainabowelregimenorrecognizethecalltostool.Evaluation.Routinelaboratorytestingisgenerallynotrecommendedinpatientswithchronicconstipation.Instead,athoroughanddetailedhistory,medicationreview,andphysicalexaminationisofparamountimportanceandmaythenguideuseofselectedlaboratorytestssuchasCBC,glucose,creatinine,calcium,andTSHtoassessforanemiaasaredflagorcommoncontributorymetabolicdisturbances.Thereisnoliteraturetosupportroutineuseofplainabdominalx-ray,radiopaquemarkertransitstudy,bariumenema,ordefecographyforassessmentofconstipationinprimarycare.Anabdominalradiographmaybeusefulinsomeelderlypatientswithepisodicdiarrheaandfecalincontinencetoevaluatethepossibilityofsevereconstipationwithoverflowinordertoavoiderroneousprescriptionofantidiarrheals.Anorectalmanometry,barostat,andballoonexpulsionstudiesarereservedforpatientswithsuspectedforanorectaldyssynergyunderevaluationbyaGastroenterologist.Overviewofmanagement.Acompleteandthoroughmedicalassessment,patientreassuranceandeducation,dietarychanges,andincreasedphysicalactivityandfluidintakealongwithbulk-forminglaxativesprovidesignificantandpromptbenefitinmostpatients.Polyethyleneglycolandstimulantlaxativesareusedinthosewhofailtorespondtoinitialconservativeapproaches.Additionoflinaclotideorprucaloprideshouldbeconsideredforthosewithrefractoryconstipationorforepisodicuse.Gastroenterologyreferralisappropriateiffailedresponsetotheabovefoundationaltreatments,presenceofredflags,orstrongsuspicionofdyssynergicdefecationatinitialassessment.

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2.Checklisttoguideyourin-clinicreviewofthispatientwithconstipation

o Atleasttwosymptomsofconstipation:fewerthan3bowelmovementsperweek,stoolformthatismostlyhardorlumpy(Bristol1-2),difficultstoolpassageleadingtostraining,incompleteevacuation,sensationofobstruction,orrequirementfordigitalevacuation

o Absenceofredflags:suddenorprogressivechangeinbowelhabit,bloodinstool,irondeficiencyanemia,unintendedweightloss,familyhistoryofcolorectalcancerinafirstdegreerelative

o Fullreviewofprescribed(Netcare)andover-the-countermedicationsthatmaycauseconstipationandtimingwithitsonsetorworsening;assessdietaryfibre/fluidintakeandphysicalactivity

o Detailedabdominalandanorectalexamination

o Assessforclinicalandphysicalfeaturesofanorectaldyssynergy

3.ReferencesandlinkstoadditionalresourcesforpatientsCanadianDigestiveHealthFoundationUnderstandingConstipationhttp://www.cdhf.ca/bank/document_en/5understanding-constipation-.pdf-zoom=100

UpToDate®–BeyondtheBasicsPatientInformationaboutConstipationinAdults(freelyaccessible)http://www.uptodate.com/contents/constipation-in-adults-beyond-the-basics?source=search_result&search=constipation&selectedTitle=4%7E150

UpToDate®–BeyondtheBasicsPatientInformationaboutHighFibreDiet(freelyaccessible)http://www.uptodate.com/contents/high-fiber-diet-beyond-the-basics?source=see_link

“Fibre101”https://www.pdx.edu/sites/www.pdx.edu.shac/files/Fiber101.pdf

4.Clinicalflowdiagramwithexpandeddetail

This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofconstipationfrombothGastroenterologyandPrimaryCareliterature:DrossmanDAandHaslerWL.RomeIV—FunctionalGIdisorders:Disordersofgut-braininteractionGastroenterology2016;150:1257-61http://www.gastrojournal.org/issue/S0016-5085(15)X0019-9WaldA.Constipation:Advancesindiagnosisandtreatment.JAMA2016;315:185-191http://jama.jamanetwork.com/article.aspx?articleid=2481010SchusterBG,KosarL,KamrulR.Constipationinolderadults:Astepwiseapproachtokeepingthingsmoving.CanadianFamilyPhysician2015;61:152-158Fullarticlehttp://www.cfp.ca/content/61/2/152.full.pdf+htmlCFPlusAdditionalInfohttp://www.cfp.ca/content/suppl/2015/02/10/61.2.152.DC1/Constipation_in_older_adults.pdfBharuchaAE,DornSD,LemboA,PressmanA.AmericanGastroenterologicalAssociationpositionstatementonconstipation.Gastroenterology.2013;144:211-7.http://www.gastrojournal.org/article/S0016-5085(12)01545-4/pdfJamshedN,LeeZE,OldenKW.Diagnosticapproachtochronicconstipationinadults.AmericanFamilyPhysician2011;84:299-306.http://www.aafp.org/afp/2011/0801/p299.html

Thefollowingisabest-practiceclinicalpathwayformanagementofconstipationintheprimarycaremedicalhome,whichincludesaflowdiagramandexpandedexplanationoftreatmentoptions:

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FlowDiagram:CONSTIPATIONDiagnosisandManagement-ExpandedDetail1. ApresumptivediagnosisoffunctionalconstipationcanbemadebasedonRomeIVcriteria(2016).Inordertoapply

thesecriteria,itisessentialtocollectadetailedhistoryofstoolfrequencyandform(seeBristolStoolScaleonpage6)andfeaturesofdefecatorydysfunction.It iswellrecognizedthatpatientswhomeetthesecriteriafordiagnosisoffunctionalconstipation commonly will also meet criteria for IBS-C and therefore additional approaches should be considered ifsignificant abdominalbloatingordiscomfort co-existwith constipation (seeEnhancedPrimaryCarePathway for IBS-Chttp://www.specialistlink.ca/pages/referral-pathways.cfm. Important additional history includes: (1) duration andprogressionofsymptoms(problemsincechildhoodormorerecentonsetandworsening),(2)precipitatingevents(changesindiet, fluid intake,physicalactivity,medications introducedaroundsymptomonset), (3) laxatives triedalready (mostproductsareaccessibleover-the-counter,notingtype,duration,andcombinationofagentshelpsdiscernundertreatedfromtreatmentresistantcases),(4)alarmfeatures.

2. Focused physical examination provides information about mass or structural lesions and clues about dysfunctionaldefecation, whichwould require specialist consultation.Abdomen: noting distention, focal discomfort, palpablemass,inguinallymphadenopathy.Inspectionofperineum:notingskinconditions,analwinkreflexandsensorydeficits,strainmaneuvers to assess degree of perineal descent and elicit hemorrhoidal or rectal prolapse, seepage; apply traction toexaminetheanalcanalforpresenceandlocationoffissurewhichusuallyevokessharplocalizedpain.Digitalanorectalexamination:notingstricture,highrestinganalsphinctertoneandvoluntarysqueezepressure,massorirregularityofanalcanalanddistalrectumoncircumferentialfingersweep,andpresenceandformofstoolorblood.Arectocoeleisprolapseoftheanteriorrectalwallintothevaginaandisassociatedwithobstructivedefecation.WhenthepatientbearsdownduringDRE,theanalsphincterandpuborectalissling(feltposteriorly)shouldrelaxandtheperineumshoulddescend.DuringDRE,highrestinganalsphinctertoneor,onbeardownmanoeuver,paradoxicalcontractionofthepuborectalisandfailureoftheperineumtodescendarecluestoanorectaldyssynergy.

3. Consider secondary causesof constipation.ForPrimaryCarephysicians, it is important to do a thorough reviewofmedications.Netcareisavaluabletooltoidentifymedicationsthatcouldcontributetoconstipation.ChoosingMedicationProfile>All>SummaryReportinNetcarewillgenerateachronologicallistwhichprovidesfocusonmedicationsassociatedwithtimeofonsetofconstipation.Therearemanymedicalconditionsandtheirdrugtreatmentsthatareassociatedwithconstipationandrecognitionofthismayallowdisease-specificintervention(e.g.hypothyroidism,diabetes).Seepage6forfurtherdetails.

4. Generalapproachtotreatingfunctionalconstipation.Thereisawiderangeofwhatisconsiderednormalbowelfunction

in adults. Education, reassurance, management of expectations: some patients believe they must have a bowelmovementeverydayinordertobehealthy.Remindingpatientsthatabowelmovementevery2-3daysisconsideredwithinnormallimitsandsomevariabilityofstoolformisexpectedandnormal.ItisoftenhelpfultoshowpatientstheBristolStoolScaletobetterquantifystoolformand,inmanypatients,revealsnormaloridealstoolformmuchofthetime.Patientsgainreassuranceandhopeinknowingthatbowelfunctionusuallyimproveswithverysimpleinterventions,thatthemedicalliteratureconsistentlyshowsthatmostpatientswithconstipationdonotrequireextensiveinitialinvestigation,andthatcolonoscopy almost never reveals relevant abnormalities. Fibre, fluid, physical activity: There is a dose-responserelationshipbetweenfibreandfluidintakeandstooloutput,anditisimportanttoquantifyatinitialvisit,aspatientswithconstipationwhosefibreandfluidintakesareinadequatearemostlikelytobenefitfromthisintervention.MostCanadiansconsumeonly10-20gof fibreperday,which is far less than the recommended30g/d target. It is challenging formostpatientstoachievethisamountofdailyfibreintakeduetopalatability,adverseeffects(intestinalgasandcramps),andlackofknowledgeaboutwhat30g/doffibrelookslikeinpracticalterms.Althoughthereisverylittleevidenceofclinicaleffect,increasedexercisemayhavefavorableeffectsonintestinalfluidhandlingandmotilityandseemssensibleintermsofoverallpatientwell-being.Patientadherencetotheseprinciplesoftherapyforconstipationtendstobepoorandneedsfrequentmonitoring, reinforcement, andenablementbyPrimaryCarephysicians.Laxatives:Bulk-formingagents arenatural orsyntheticpolysaccharidesthatbindfluidintheguttoincreasestoolvolumeandmass.Osmoticagentsarepoorlyabsorbedsugarsthatdrawwaterintotheboweltoloosenstool.Stimulantlaxativesincreasesecretoryandpropulsiveactivityintheintestine.Surfactantssoftenstoolbybreakingsurfacetensiononformedstoolallowingwatertopenetrate.

5. Specificadditionalapproaches.Failureto improveaftertheabovegeneralapproachesareexhaustedisdiagnostically

useful,suggestingspecificadditionalordominantmechanismsunderlyingconstipation inaparticularpatient.ThismaybolsterclinicalimpressionofIBS-Cordefecatorydysfunction,ormayindicateasubtypeofconstipationknownas“slowtransit”whichguidesnextstepsinhelpingthesepatients.

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TheBristolStoolScale:Anindexofcolonictransittime

LewisSJ,HeatonKW.Stoolformscaleasausefulguidetointestinaltransittime.ScandJGastroenterol.1997;32:920-4.

FigureadaptedfromCanadianDigestiveHealthFoundation

ImportantsecondarycausesofconstipationtoconsiderMedications MedicalConditionsCommon Common

Ironandcalciumsupplements CerebrovasculardiseaseAntihypertensives CognitiveimpairmentAntidepressants RenaldysfunctionAntacids DiabetesmellitusNSAIDs HypothyroidismOpioids Depression

Lesscommon LesscommonAntiparkinsonianagents HypomagnesemiaandhypokalemiaBileacidsequestrants HypercalcemiaandhypocalcemiaBisphosphonates HyperparathyroidismAnticonvulsants AnorexianervosaAntispasmodics AutonomicneuropathyAntihistamine MusculardystrophiesAntipsychotics ParkinsondiseaseAntiemetics Multiplesclerosis

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GeneralPrinciples

DietaryFibre

Counselpatientstotargetof30g/doffibreperdayfromvariousfoodsources.Fibreiscategorizedbysolubilityinwaterandfermentabilitybyintestinalbacteria.Thereislimitedevidencetoguidechoiceofbestdietaryfibreformanagementofconstipation.InsolublefibremechanicallystimulatestheGImucosathuspromotingsecretionandperistalsis.Solublefibreincreasesstoolbulkbyosmoticandgel-formingeffectsandbyselectivelyincreasingbacterialbiomass,whichprobablyhasadditionalbeneficialeffectsongutfunction.However,someformsofsolublefibrealsocontainhighlyfermentablesubstratesthatleadtogasproduction,pain,andbloating.Nonetheless,itisworthwhilemakingageneralrecommendationtopatientssimultaneouslyincreasedietaryfibreandfluidintakeinagradedmanner,buildinginsomeexpectationthatsomefoodsmaycausebloating,pain,orflatulence.Prunescontaininsolublefibreaswellassorbitolandfructansandhavebeenshowntobeeffectiveinmanagementofconstipationthroughbothbulk-formingandosmoticeffectsatadoseof12medium-sizedprunesperday.Providepatienthandout:“Fibre101”

FluidIntake Consumptionof1.5-2.0Loffluidperdaysignificantlyenhancestheeffectivenessoffibre.

PhysicalActivityModeratetovigorousexercisefor20-60minutes3-5xperweek,aspergeneralhealthguidelines.Althoughexercisespeedsupintestinaltransit,thereisnoevidencetoinformspecificrecommendationsoffrequency,duration,orintensityofexerciseinmanagementofconstipation.ItisreasonabletotalktopatientsaboutpossiblebeneficialeffectsofexerciseonGIfunctionandthewell-establishedbenefitstooverallphysicalhealthandwell-being.

Self-Management AlbertaHealthyLivingProgram(ahs.ca/info/cdmcalgaryzone.asp)

Bulk-FormingAgents

PsylliumMetamucil®1tablespoonOD-TID($5-10/mo.)Intermediatesolubleandfermentablefibrewhichhasgoodlaxativeeffectbutsomeriskofbloatingandflatus.Startwithlowdoseandtitratetoeffect.

Methylcellulose Citrucel®2capletsOD-QID($10-40/mo.)Goodlaxativeeffect,onsetofaction12-72h.Insoluble,non-fermentablefibreproducinglessbloatingandflatulence.

CalciumPolycarbophil Prodiem®2capletsOD-QID($5-20/mo.)Goodlaxativeeffect,onsetofaction12-72h.Lessriskofflatulenceandbloatingcomparedwithotherbulk-formingagents.

Inulin Benefibre®1-2teaspoonOD-TID($10-20/mo.)Mildlaxativeeffect,onsetofaction24-48h.Non-absorbedfermentablesugarmaycausebloating,pain,orflatulence.

OsmoticLaxatives

PolyethyleneglycolPEG3350(Lax-A-Day®RestoraLAX®PEGalax®Relaxa®)17-34g/d($25-50/mo.)Startwith17gatnightdissolvedin250mLofwater,juice,orsoda;titrateuptoeffectormaximumof34g/d.Onsetofaction48-96h.Studiessuggestsuperiortolactulose.

Lactulose Lactulose15-30mLODtoTID($10-20/mo.)Onsetofaction24-48h.Non-absorbedfermentablesugar,whichmaycausebloating,pain,orflatulence.

StimulantLaxatives

Bisacodyl Bisacodyl(Dulcolax®)5-10mgPOQHS($0.20-0.40/dose)Bisacodyl(Dulcolax®TheMagicBullet®)10mgsuppositoryPRNmax.30mg/d($1.00/dose)

Sennosides Sennosides8.6mgtab(Senokot®)2-4tabOD-BIDmax.4tabBID($0.40-0.80/dose)

Prokinetics

Linaclotide Constella®145µg/d,30minutesbeforebreakfast($100/mo.)

Prucalopride Resotran®2mg/d,4weektrial($120/mo.)

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