A biopsychosocial
approach to
constipation
Kyle Staller, MD, MPH
Director, GI Motility Laboratory, MGH
Center for Neurointestinal Health
Clinical and Translational Epidemiology Unit
NESGNA Fall Conference, October 12, 2017
Disclosures
• Research support from Astra-Zeneca, Gelesis, and
Pathway Genomics
2
What is normal?
Am J Gastroenterol. 2017 Aug 1.
• Overall the “3 by 3” metric
most understood by lay public:
– Normal is from 3 bowel
movements/day to 3 bowel
movements/week)
What is constipation: Rome criteria
4
Gastroenterology. 2016; Feb 15; 150:1393-1407.
• Requires ≥2 of the following symptoms with
chronicity:
– Hard stools
– Straining
– Incomplete evacuation
– Sensation of blocked evacuation
– Vaginal or perianal pressure needed to facilitate
defecation
– <3 bowel movements per week
• No loose stools without laxatives
• No secondary cause of constipation (i.e.
opioids)
Background: burden of constipation
5
Am J Gastroenterol. 2011 Sep;106(9):1582-91
• Affects 55 million Americans (Women: 16%, Men 12%,
Elderly 40%)
Background
• Our current understanding of constipation based
on physiology with 3 subtypes:
– Slow-transit constipation
– Pelvic floor dysfunction
– Normal-transit constipation
Secondary causes of constipation
7Ann Intern Med. 2015 Apr 7;162(7):ITC1.
Measuring colonic transit: using a Sitz marker study
• MGH protocol:
– Patient ingests a pill containing 24 radio-opaque markers
(Day 0)
– Abdominal plain film (Day 5)
Why not treat everyone with laxatives?
• Chronic constipation is more than stool frequency
Constipation is likely a spectrum of disease
Normal-transit constipation
Isolated slow-transit
constipation
Mixed physiology
Obstructed defecation
Irritable bowel syndrome? (IBS-C)
Visceral hypersensitivity
Pelvic floor physiology
N Engl J Med. 2003 Oct 2;349(14):1360-8.
Testing for pelvic floor dysfunction:
anorectal manometry
Gastroenterology 2013 144, 211-217.
When to order anorectal manometry
• Retained markers frequently seen in patients w/
pelvic floor dysfunction undergoing transit testing
• Presumed symptoms of dyssynergic defecation:
– Painful defecation
– Straining
– Incomplete evacuation
– Sensation of blocked evacuation
– Vaginal or perianal pressure needed to facilitate
defecation
• Multiple studies have shown that the positive and
negative predictive value of symptoms alone is
inadequate for the diagnosis of dyssynergic
defecation
Am J Gastroenterol. 2014 Aug;109(8):1141-57.
Staller K et al. Am J Gastroenterol. 2015 Jul;110(7):1049-55.
Evolution of anorectal manometry technology
Water perfusion
Anorectal manometry
High resolution
Anorectal manometry
High definition (3D)
Balloon expulsion testing
Role of physical therapy in refractory constipation
Am J Gastroenterol. 2014 Aug;109(8):1141-57.
When all else fails: surgery for constipation
• Could consider diverting loop
ileostomy followed by
colectomy with ileorectal
anastomosis
• Number of colectomies for
chronic constipation is
increasing
Aliment Pharmacol Ther. 2015 Dec;42(11-12):1281-93.
Refractory constipation: colectomy
Aliment Pharmacol Ther. 2015 Dec;42(11-12):1281-93.
Refractory constipation: colectomy
Aliment Pharmacol Ther. 2015 Dec;42(11-12):1281-93.
• Growing acceptance of surgical treatment of constipation
– 14.4% of colectomies for
constipation
• High complication rate:
– ED visits or hospitalizations in 1/3 of
patients undergoing colectomy for
chronic constipation
• High healthcare resource utilization: surrogate for well-being?
Surgery for constipation: an alternative approach
Lancet. 1990 Nov 17;336(8725):1217-8.
• Malone in 1990 describes an alternative approach using the
appendix as a conduit for antegrade colonic enemas (ACE)
Dis Colon Rectum. 2007 Jan;50(1):22-8.
Surgery for constipation: an alternative approach
Lancet. 1990 Nov 17;336(8725):1217-8.
• Newer techniques using
specially-designed catheters
have significantly decreased
the complication rate
• Placement:
– Endoscopic
– Percutaneous (IR)
– Laparoscopic (surgery)
Laparoscopic Percutaneous Endoscopic Cecostomy (LAPEC)
• Technique originally described in children by Allan Goldstein
from MGH
• Uses colonoscopy in conjunction with laparoscopic approach
to secure cecum to abdominal wall and decrease risk of
peritoneal contamination and peritonitis
Making the jump: LAPEC in adults
• LAPEC follow-up study of mostly children and young adults:
– Few tube removals
– Overall success rate of 95%
• Now regularly performing in adults
– Joint venture with Allan Goldstein, MD and Hiroko Kunitake, MD
– Stay tuned for more data about which patients derive the most benefit
Koyfman S…Staller K. J Gastrointest Surg. 2017 Apr;21(4):676-683.
Breakdown of constipation at MGH
Staller K et al. Neurogastroenterol Motil. 2015 Oct;27(10):1378-88.
Pathophysiology of constipation
32
Gastroenterology. 2016 Feb 19. pii: S0016-5085(16)00223-7
What about IBS?
33
Gastroenterology. 2016; Feb 15; 150:1393-1407.
Recurrent abdominal pain
Related to defecation
Associated with change in
frequency of stool
Associated with change in form of
stool
>1 day/week in last 3 weeks
+ 2 or more of
IBS subtypes
Gastroenterology. 2016; Feb 15; 150:1393-1407.
Impact of IBS on quality of life varies by stool form
35
Am J Gastroenterol. 2012 Feb;107(2):286-95.
Impact of IBS on quality of life varies by subtype
36
Am J Gastroenterol. 2012 Feb;107(2):286-95.
Psychosocial factors in constipation
• Prevalence of comorbid psychiatric
disease rages from 40-90% among
IBS patients at a tertiary care center
• Women with IBS are more likely to
have experienced childhood verbal,
sexual, or physical abuse
– Leads to persistent changes in
the brain-gut axisresults in
perception of otherwise
unconscious input from GI tract
37
JAMA. 2015 Mar 3;313(9):949-58.
Non-laxative medications
for constipation/IBS
38
Use of neuromodulators in IBS with constipation
• Neuromodulators reduce
global IBS symptoms and
abdominal pain in IBS
patients1.
• Benefits:2.
1. Reduction in pain
2. Treatment of psychological
distress
3. Treatment of comorbid
psychiatric disease
4. Leverage motility effects
5. Long-term treatment may
reverse maladaptive brain
changes
Potential actions of
antidepressants in IBS
Antidepressant
action
Visceral
analgesia
Changes in
motility
Smooth muscle
relaxation
1. Am J Gastroenterol. 2014;109:1350-1365.
2.Am J Gastroenterol. 2017 May;112(5):693-702
Dietary treatments for
constipation symptoms
40
Patient demand for dietary advice in constipation
outstrips the supply of available evidence for providers
• More than 70% of IBS patients
believe that food plays a role in
their symptoms1.
• Self-reported food intolerance in
IBS is associated with more
severe symptom severity2.
• Evolution of concept of non-
celiac gluten (wheat) sensitivity
41
1. Clin Gastroenterol Hepatol 2015.
2. Clin Gastroenterol Hepatol. 2015 Nov;13(11):1899-906.
Worsening of symptoms in IBS patients with blinded
re-introduction of gluten
42
Am J Gastroenterol. 2011 Mar;106(3):508-14
Lentils, cabbage, brussels sprouts,
asparagus, green beans, legumes
Sorbitol
Raffinose
Honey, apples, pears, peaches,
mangos, fruit juice, dried fruit
Apricots, peaches, artificial sweeteners,
artificially sweetened gums
Wheat (large amounts), rye (large
amounts), onions, leeks, zucchini
Excess
Fructose
Fructans
Fermentable oligo-, di-, monosaccharides and polyols
What are FODMAPs?
Milk (cow, goat, or sheep), custard,
ice cream, yogurt, soft unripened
cheeses (eg, cottage cheese, ricotta)
Lactose
1. Clin Gastroenterol Hepatol. 2008;6:765-771.
2. J Am Diet Assoc. 2006;106:1631-1639.
3. Ther Adv Gastroenterol. 2012;5:261-268
Gastroenterology. 2013;145:320-328.
Which diet to choose? Gluten-free or low-FODMAP?
Low FODMAP run-in Blinded re-introduction
of high FODMAP foods
Low FODMAP diet has a differential effect on IBS
patients compared to healthy controls
45
Gastroenterology. 2014 Jan;146(1):67-75.e5.
Other non-pharmacologic
treatments for
constipation/IBS
46
Questions about probiotics are a reality of taking
care of patients with IBS
• Probiotics likely provide some benefit
to patients with IBS
• On the whole, products containing
Bifidobacterium (either alone or in a
cocktail) are effective in IBS
• Best quality data is for
Bifidobacterium infantis 35624
• Recent data suggests a benefit of B.
lactis DN-173-010A in patients with
IBS-C and bloating
• Any advice to patients limited by
poor quality of existing data
47
J Clin Gastroenterol 2015; 49: Supp. 1.
Psychological therapies improve IBS symptoms
• Psychosocial therapies have
been shown to be effective in
improving IBS symptoms
– Cognitive behavioral therapy
(CBT)
– Hypnotherapy
– Multi-component psychological
therapy
– Multi-component psychological
therapy administered by phone
– Dynamic psychotherapy
• Use limited by lack of skilled
therapists in managing IBS
Am J Gastroenterol. 2014;109(Suppl 1):S2-S26.
What type of constipation patient am I seeing today?
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Clinical feature Mild (40%) Moderate (35%) Severe (25%)
Physiological factors Primarily bowel dysfunctionBowel dysfunction and CNS
pain dysregulation
Primarily CNS pain
dysregulation
PsychosocialNone or mild psychosocial
distressModerate psychosocial distress
Severe–high psychosocial
distress, catastrophizing, abuse
history
Sex Men = women Women > men Women >>> men
Age Older > younger Older = younger Younger > older
Abdominal pain Mild/intermittent Moderate, frequentSevere/very frequent or
constant
Number of other
symptomsLow (1–3) Medium (4–6) High (≥7)
Health-related
quality of lifeGood Fair Poor
Health care use 0–1/y 2–4/y ≥5/y
Activity restriction Occasional (0–15 days) More often (15–50 days) Frequent/constant (>50 days)
Work disability <5% 6%–10% ≥11%
Adapted from Gastroenterology. 2016 Feb 19. pii: S0016-5085(16)00223-7.
Explaining the biopsychosocial model of constipation
to patients
• Start with transit description
– Most intuitive how most people
(including MDs) think about
constipation
• Describe pelvic floor
dysfunction using physiologic
explanation
• Visceral hypersensitivity
– Artificial to think about gut motility
in isolation
– Normal gut sensations improperly
amplified in PNS and CNS
– Abnormal sensory response to
colonic stool burden
Treatment of constipation is a “3-legged stool”
1. Address underlying colonic transit disturbances
– Motility agents (laxatives)
– Don’t be surprised if:
normalization of bowel movements ≠ resolution of symptoms
– Surgery utilized very cautiously
2. Treat visceral hypersensitivity and IBS overlay
– Neuromodulators with an eye toward gut transit and coexisting
motility disturbances (i.e. gastroparesis, small bowel dysfunction)
3. Consider effects of psychiatric overlay, trauma
– Introduce cognitive behavioral therapy after establishing
therapeutic relationship
Investing time up front can pay dividends later on
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Thank you
Acknowledgements:• Center for Neurointestinal Health
• Braden Kuo, MD
• Andrew Chan, MD, MPH
• Grant support from the American
Gastroenterological Association