Chronic constipation

Abstract

Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of ‘alarm’ features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.

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Figure 1: Global prevalence of chronic constipation.
Figure 2: Motor patterns in a healthy adult colon.
Figure 3: Intrinsic reflex circuitry involved in peristalsis.
Figure 4: Electrolyte and fluid absorption and secretion in the intestine.
Figure 5: Diagnosis and management algorithm for chronic constipation.
Figure 6: Anorectal manometry patterns during attempted defecation.

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Acknowledgements

This study was supported in part by the US Public Health Service NIH Grant 5R21DK104127-02 and Grant 1 U34 DK109191-01 to S.S.R. The authors thank C. L. Stanislav (Mayo Clinic, USA) for her excellent administrative support.

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Contributions

Introduction (M.C.); Epidemiology (A.C.F.); Mechanisms/pathophysiology (M.C., G.M.M., P.G.D., S.S.R. and W.D.C.); Diagnosis, screening and prevention (W.D.C.); Management (M.S., A.L. and T.M.Y.-F.); Quality of life (L.C.); Outlook (M.C.); Overview of Primer (M.C.).

Corresponding author

Correspondence to Michael Camilleri.

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Competing interests

M.C. serves on an advisory board for Ironwood Pharmaceuticals and Shire Pharmaceuticals, with compensation to his employer and not to him personally, and has received grant and research support from NGM Pharmaceuticals. A.C.F. has received grant and research support from Almirall and has acted as a consultant and speaker for Almirall, Norgine and Shire Pharmaceuticals. S.S.R. serves on the advisory board for Forest Labs, Salix Pharmaceuticals, Takeda Pharmaceuticals and Synergy Pharmaceuticals and has received research grants from Forest Labs and Medtronic Corporation. M.S. has received grant and research support from Danone Nutricia Research and Ferring Pharmaceuticals and has acted as a consultant and speaker for Allergan, Almirall, Danone Nutricia Research, Menarini, Nestlé, Shire Pharmaceuticals, Takeda Pharmaceuticals and Tillotts. L.C. has served on advisory boards for BioAmerica, Cairn Diagnostics, IM Healthcare Science LLC, Napo Pharmaceuticals, Salix Pharmaceuticals, and Synergy Pharmaceuticals. All other authors have no relevant conflicts of interest related to the content of this Primer to declare.

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Camilleri, M., Ford, A., Mawe, G. et al. Chronic constipation. Nat Rev Dis Primers 3, 17095 (2017). https://doi.org/10.1038/nrdp.2017.95

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