Name:

DOB:

PHN/ULI:

RHRN:

RefMD: Dr.

RefMDFax:

RefDate:

DateToday: CONFIRMATION: ReferralReceived

CONSTIPATIONTRIAGECATEGORY: EnhancedPrimaryCarePathway

REFERRALSTATUS: CLOSEDDearDr.,Theclinicalanddiagnosticinformationyouhaveprovidedfortheabove-namedpatientisconsistentwithadiagnosisofchronicconstipation.Basedonfullreviewofyourreferral,ithasbeendeterminedthatmanagementofthispatientwithintheEnhancedPrimaryCarePathwayisappropriate,withoutneedforspecialistconsultationatthistime.ThisclinicalpathwayhasbeendevelopedbytheCalgaryZonePrimaryCareNetworkinpartnershipwiththeSectionofGastroenterologyandAlbertaHealthServices.Theselocalguidelinesarebasedonbestavailableclinicalevidence,andarepracticalintheprimarycaresetting.Thispackageincludes:

1. Focusedsummaryofconstipationrelevanttoprimarycare2. Checklisttoguideyourin-clinicpatientreview3. Linkstoadditionalresourcesforthisspecificcondition4. Clinicalflowdiagramwithexpandeddetail

ThisreferralisCLOSED.IfyouwouldliketodiscussthisreferralwithaGastroenterologist,callSpecialistLINK,adedicatedGIphoneconsultationservice,available08:00-17:00weekdaysat403-910-2551ortoll-free1-855-387-3151.IfyourpatientcompletestheEnhancedPrimaryCarePathwayandremainssymptomaticorifyourpatient’sstatusorsymptomschange,anewreferralindicating‘completedcarepathway’or‘newinformation’shouldbefaxedto403-944-6540.Thankyou.

KevinRioux,MDPhDFRCPCMedicalLead,CentralAccessandTriageSectionofGastroenterology

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EnhancedPrimaryCarePathway:CONSTIPATION

1.Focusedsummaryofconstipationrelevanttoprimarycare

Definition.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

The following is a best-practice clinical pathway formanagement of constipation in the primarycaremedicalhome,whichincludesaflowdiagramandexpandedexplanationoftreatmentoptions:

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FlowDiagram:CONSTIPATIONDiagnosisandManagement-ExpandedDetail1. Apresumptivediagnosisof functionalconstipationcanbemadebasedonRomeIVcriteria(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 andprogression of symptoms (problem since childhood or more recent onset and worsening), (2) precipitating events(changesindiet,fluidintake,physicalactivity,medicationsintroducedaroundsymptomonset),(3)laxativestriedalready(most products are accessible over-the-counter, noting type, duration, and combination of agents helps discernundertreatedfromtreatmentresistantcases),(4)alarmfeatures.

2. Focused physical examination provides information aboutmass 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,highrestinganalsphincter toneandvoluntarysqueezepressure,massor irregularityofanal canal anddistal rectumon circumferential finger sweep, andpresence and formof stool or blood.A rectocoele isprolapseoftheanteriorrectalwallintothevaginaandisassociatedwithobstructivedefecation.Whenthepatientbearsdown during DRE, the anal sphincter and puborectalis sling (felt posteriorly) should relax and the perineum shoulddescend. During DRE, high resting anal sphincter tone or, on bear down manoeuver, paradoxical contraction of thepuborectalisandfailureoftheperineumtodescendarecluestoanorectaldyssynergy.

3. Consider secondary causes of constipation. ForPrimaryCarephysicians, it is important todoa thorough reviewofmedications.Netcareisavaluabletooltoidentifymedicationsthatcouldcontributetoconstipation.ChoosingMedicationProfile > All > Summary Report in Netcare will generate a chronological list which provides focus on medicationsassociated with time of onset of constipation. There are manymedical conditions and their drug treatments that areassociated with constipation and recognition of this may allow disease-specific intervention (e.g. hypothyroidism,diabetes).Seepage6forfurtherdetails.

4. General approach to treating functional constipation. There is a wide range of what is considered normal bowel

function in adults. Education, reassurance, management of expectations: some patients believe they must have abowel movement every day in order to be healthy. Reminding patients that a bowel movement every 2-3 days isconsideredwithin normal limits and some variability of stool form is expected andnormal. It is often helpful to showpatientstheBristolStoolScaletobetterquantifystoolformand,inmanypatients,revealsnormaloridealstoolformmuchof the time. Patients gain reassurance and hope in knowing that bowel function usually improves with very simpleinterventions,thatthemedicalliteratureconsistentlyshowsthatmostpatientswithconstipationdonotrequireextensiveinitial investigation, and that colonoscopy almostnever reveals relevant abnormalities.Fibre, fluid, physical activity:Thereisadose-responserelationshipbetweenfibreandfluidintakeandstooloutput,andit is importanttoquantifyatinitialvisit,aspatientswithconstipationwhosefibreandfluidintakesareinadequatearemostlikelytobenefitfromthisintervention.MostCanadiansconsumeonly10-20goffibreperday,whichisfarlessthantherecommended30g/dtarget.Itischallengingformostpatientstoachievethisamountofdailyfibreintakeduetopalatability,adverseeffects(intestinalgasandcramps),and lackofknowledgeaboutwhat30g/dof fibre looks like inpractical terms.Although there isverylittleevidenceofclinicaleffect,increasedexercisemayhavefavorableeffectsonintestinalfluidhandlingandmotilityandseems sensible in termsof overall patientwell-being.Patient adherence to theseprinciplesof therapy for constipationtendstobepoorandneedsfrequentmonitoring,reinforcement,andenablementbyPrimaryCarephysicians.Laxatives:Bulk-formingagentsarenaturalorsyntheticpolysaccharidesthatbindfluidintheguttoincreasestoolvolumeandmass.Osmoticagentsarepoorlyabsorbedsugarsthatdrawwater intothebowelto loosenstool.Stimulant laxatives increasesecretory andpropulsive activity in the intestine. Surfactants soften stool by breaking surface tension on formed stoolallowingwatertopenetrate.

5. Specific additional approaches.Failuretoimproveaftertheabovegeneralapproachesareexhausted isdiagnostically

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.

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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