CONSTIPATION CAUSES AND MANAGEMENT

Introduction: Chronic constipation is considered a common, persistent problem that affect several patients globally. In the US, it is estimated that the prevalence of constipation is about fifteen percent in the general population. This number is similar to the estimated global prevalence of about fourteen percent. Risk factors include but not limited to old age, female, and lower socioeconomic status. Almost fifty percent of people complaining of constipation report symptoms for more than five years. Chronic constipation affects the quality of life and the psychological well-being. Chronic constipation has a major economic burden and leads to significant healthcare utilization for patients. It is estimated that more than US$800 million dollars were spent on laxatives by constipated patients in 2007. Moreover, constipation-related emergency room visits and inpatient admissions are increasing as well, particularly in a young age population. The definition of chronic constipation has changed over time to include more than a decreased number of stools per week. It involves a pattern of symptoms like excessive straining, a sense of incomplete evacuation, failed or lengthy attempts to defecate, use of digital manoeuvres for evacuation of stool, abdominal bloating, and hard consistency of stools.  The wider definition of constipation has led to a more expansive therapeutic approach. Constipation is categorized into two types: primary and secondary types. Primary constipation is due to disturbed regulation of the neuromuscular components within the colon and anorectum as well as disruption in their corresponding ascending and descending pathways in the brain-gut axis. With the help of a symptom-based criteria and diagnostic testing, primary constipation can be additionally categorized into functional defecation disorder, slow-transit constipation (STC), and constipation-predominant irritable bowel syndrome (IBS-C). Functional defecation disorders include dyssynergic defecation and illnesses that may obstruct defecation such as rectal prolapse, rectocele, and descending perineum syndrome. Dyssynergic defecation is defined as paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defecation. STC is recognized as inadequate propulsive forces in the colon in the absence of dyssynergic defecation. Multiple underlying factors have been suggested for IBS-C, including genetic, environmental, social, biological, and psychological factors. It is important to consider that there is huge overlap between dyssynergic defecation, STC, and IBS-C. Greater than half of dyssynergic patients will exhibit delayed colonic transit. The opposite also holds true with greater than two-thirds of STC patients having concurrent dyssynergia. Secondary constipation could result from a variety of factors such as metabolic disturbances (hypercalcaemia, hypothyroidism), drugs (e.g. opiates, calcium channel blockers, antipsychotics), neurologic disorders (parkinsonism, spinal cord lesions, diabetes mellitus), and primary diseases of the colon (stricture, cancer, anal fissure, proctitis).Aim of work: In this review, we will discuss constipation causes and managementMethodology: We did a systematic search for constipation causes and management using PubMed search engine (http://www.ncbi.nlm.nih.gov/) and Google Scholar search engine (https://scholar.google.com). All relevant studies were retrieved and discussed. We only included full articles.Conclusions: Constipation is a very common and complicated disorder, symptoms of which include more than decreased frequency of bowel movements. Over a detailed history and prospective stool diary, it is important to determine the severity and chronicity of symptoms and identify the presence of underlying secondary causes. Chronic idiopathic constipation, refractory to dietary and lifestyle changes and laxatives, should be assessed with proper testing to recognize underlying pathophysiology. Suspicion of dyssynergic defecation on a proper digital rectal examination should be verified with anorectal manometry and/or defecography and referred to centres with expertise in manometry-based biofeedback therapy. Colectomy should be reserved for patients with underlying colonic neuropathy identified on colonic manometry. Drugs for chronic idiopathic constipation in the pipeline, whether secretagogues, serotonergic agonists, or bile acid transporter inhibitors, are considered safe and effective, promising to give doctors more therapeutic alternatives in their arsenal. It continues to be seen where these newer agents will fit in the management guideline.

Key words: Constipation, pathophysiology, causes, management