Constipation
Publication Date: January 1, 2013
Last Updated: September 2, 2022
Assessment
- If feasible, discontinue medications that can cause constipation before further testing.
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- A careful digital rectal examination that includes assessment of pelvic floor motion during simulated evacuation is preferable to a cursory examination without these maneuvers and should be performed before referral for anorectal manometry. However, a normal digital rectal examination does not exclude defecatory disorders.
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The key components of the rectal examination include:
- In the left lateral position, with the buttocks separated, observe the descent of the perineum during simulated evacuation and the elevation during a squeeze aimed at retention. The perianal skin can be observed for evidence of fecal soiling and the anal reflex tested by a light pinprick or scratch.
- During simulated defecation, the anal verge should be observed for any patulous opening (suspect neurogenic constipation with or without incontinence) or prolapse of anorectal mucosa.
- The digital examination should evaluate resting tone of the sphincter segment and its augmentation by a squeezing effort. Above the internal sphincter is the puborectalis muscle, which should also contract during squeeze. Acute localized tenderness to palpation along the puborectalis is a feature of the levator ani syndrome. Finally, the patient should be instructed to integrate the expulsionary forces by requesting that she or he "expel my finger."
- An examination should then be conducted to evaluate for a rectocele or consideration be given to gynecologic consultation.
Testing for Medical Causes
In the absence of other symptoms and signs, only a complete blood cell count is necessary. ( Low , Strong )
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Unless other clinical features warrant otherwise, metabolic tests (glucose, calcium, sensitive thyroid-stimulating hormone) are not recommended for chronic constipation. ( Moderate , Strong )
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A colonoscopy should not be performed in patients without alarm features (eg, blood in stools, anemia, weight loss) unless age-appropriate colon cancer screening has not been performed. ( Moderate , Strong )
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Anorectal manometry and a rectal balloon expulsion should be performed in patients who fail to respond to laxatives. ( Moderate , Strong )
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Defecography should not be performed before anorectal manometry and a rectal balloon expulsion test. ( Low , Strong )
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Defecography should be considered when results of anorectal manometry and rectal balloon expulsion are inconclusive for defecatory disorders. ( Low , Strong )
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Colonic transit should be evaluated if anorectal test results do not show a defecatory disorder or if symptoms persist despite treatment of a defecatory disorder. ( Low , Strong )
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Treatment
After discontinuing medications that can cause constipation and performing blood and other tests as guided by clinical features, a therapeutic trial (ie, fiber supplementation and/or osmotic or stimulant laxatives) is recommended before anorectal testing. ( Moderate , Strong )
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Anorectal tests should be performed in patients who do not respond to these measures. ( High , Strong )
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Pelvic floor retraining by biofeedback therapy rather than laxatives is recommended for defecatory disorders. ( High , Strong )
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Surgical Treatment
Anorectal tests and colonic transit should be reevaluated when symptoms persist despite an adequate trial of biofeedback therapy. ( Low , Strong )
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A subtotal colectomy rather than continuing therapy with chronic laxatives should be considered for patients with symptomatic STC without a defecatory disorder. ( Moderate , Conditional (weak) )
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Colonic intraluminal testing (manometry, barostat) should be considered to document colonic motor dysfunction before colectomy. ( Moderate , Conditional (weak) )
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Suppositories or enemas rather than oral laxatives alone should be considered in patients with refractory pelvic floor dysfunction. ( Low , Conditional (weak) )
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Recommendation Grading
Overview
Title
Constipation
Authoring Organization
American Gastroenterological Association
Publication Month/Year
January 1, 2013
Last Updated Month/Year
October 3, 2024
Supplemental Implementation Tools
Document Type
Consensus
External Publication Status
Published
Country of Publication
US
Document Objectives
This document presents the official recommendations of the American Gastroenterological Association (AGA) on constipation.
Target Patient Population
Adults with constipation
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D003248 - Constipation
Keywords
constipation
Source Citation
American Gastroenterological Association, Bharucha AE, Dorn SD, Lembo A, Pressman A. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144(1):211-7. doi: 10.1053/j.gastro.2012.10.029. PMID: 23261064.