EPIDEMIOLOGY

Prevalence

The exact number of people who experience chronic costipation is not known. The prevalence varies according to the demographic features and the definition used. Studies of prevalence have estimated the rate to be as high as 27%, but 15% is the more commonly accepted number.

Demographic patterns from several studies suggest that chronic constipation is more prevalent in certain popula­tions such as women and people older than 65 years of age. For every man who experiences chronic constipation, it is thought that two to three women have the same disorder. The rate of chronic constipation for patients over 65 years of age has been reported to be as high as 40%, signaling that this group of patients is particularly at risk.

Quality of Life

Patients with chronic constipation report lower levels of general well-being. Constipation has been associated with depression. Subjects with self-reported constipation also have significantly lower quality-of-life scores in all domains of the Short-Form Health Survey (SF-36) (Figure 2).

FIGURE 2 Chronic constipation and its effect on quality of life

FIGURE 2 Chronic constipation and its effect on quality of life. The Short-Form Survey (SF-36) is used to capture scientif¬ically valid patient-reported health outcomes. A change in the SF-36 subscale score of five points is considered clinically significant. GI = gastrointestinal.

Economic Impact

In 2001, there were more than 5.7 million outpatient visits made for the diagnosis and management of constipation, with an estimated cost of $29 million (in 1985 dollars) for ambulatory physician visits. In one study, a diagnostic evaluation for chronic constipation alone cost, on average, an estimated $2,752 per patient. The annual cost of care related to constipation for nursing-home patients, including expenses for labor and supplies, has been estimated at $2,253. Although serious complications are still somewhat rare, when they do occur, they can easily translate into substantial costs in the hospital setting. For example, in 2003, volvulus related to constipation cost Medicare just over $48,000 per patient. During that same time period, constipation-related hemorrhoids, intestinal impaction, and ulcers cost Medicare in the range of $9,000 to $21,000 per patient (Table 2). canadian antibiotics

Table 2   Hospital Cost Per Patient in 2003: Complications and Comorbidities of Constipation

Medicare

Commercial

Length of Stay

ICD-9

(Mean Charge)

(Mean Days)

(Mean Days)

Intestinal impaction

560.30

$11,307 $7,844 3.7
Anal fissures

565.0

$13,949 $11,923 3.0
Hemorrhoids

455.6

$9,757 $9,049 2.3
Volvulus

560.2

$48,812 $35,034 9.8
Intestinal obstruction

560.9

$17,141 $13,598 4.8
Ulcers (stercoral/rectal)

569.41

$21,495 $20,547 5.7

Indirect costs can also take a significant toll. In one study, patients with functional constipation missed 21.9 days of work or school in the previous year (an adjusted mean number), compared with 4.9 days for patients without a functional gastrointestinal diagnosis.

A survey of slightly more than 550 patients who met the Rome II criteria found that 12% of the employed patients reported missing days from work or school during the previous month, and 60% reported impairment at work (a 21% reduction in productivity). An estimated 13.7 million days of restricted activity and 3.4 million days of disability associated with time spent in bed are reported annually as a result of constipation.

MEDICAL COMPLICATIONS OF CHRONIC CONSTIPATION

If left untreated, chronic constipation can have serious consequences. It has been suggested that it can lead to pudendal nerve damage, resulting in fecal incontinence and rectal prolapse. Chronic constipation has also been associated with urological abnormalities; urinary tract infections and hemorrhoids may also be associated with constipation.
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Table 3   Constipation-Related Medical Complications

Cases

Controls

Relative Risk 95% Confidence Interval

P Value

Intestinal impaction

703.8 ± 12.1

109.1 ± 1.8

5.95

5.7-6.2

<.000l
Anal fissure

254.5 ± 7.3

54.1 ± 1.3

4.80

4.5-5.2

<.000l
Irritable bowel syndrome (IBS)

1,394 ± 17.3

288.2 ±3.0

4.72

4.6-L9

<.000l
Hemorrhoids

3,136.9 ± 26.9

718.8 ± 4.8

4.10

4.0-L2

<.000l
Volvulus

84.58 ± 4.2

20.7 ± 0.8

3.67

3.3-L2

<.000l
Intestinal obstruction

811.3 ± 13.1

215.1 ± 2.6

3.38

3.3-3.5

<.000l
Ulcers (stercoral/rectal)

113.98 ± 4.8

31.7 ± 1.0

3.23

2.9-3.6

<.000l

An analysis of more than 100,000 Medicaid patients who made at least one physician visit for constipation was performed. These patients, when compared with controls, experienced a significantly higher risk of comorbidities such as intestinal impaction, anal fissure, hemorrhoids, and volvulus (Table 3). One limitation of this study was that because chronic constipation is so common, the control group probably included patients who had the disorder but who had not been assigned an International Classification of Diseases (ICD-9) code or who had not sought care for the condition. This would have reduced the magnitude of the relative risks.