Chronic Constipation

INTRODUCTION

Chronic constipation, widely prevalent and commonly seen in clinical practice, can have a significant impact on patients’ quality of life. It also has a major impact on the U.S. economy in terms of both health care costs and lost productivity.

Commonly accepted treatments vary in terms of their efficacy and safety—and both physicians and their patients have expressed a strong desire for improved therapeutic options. This article provides a brief overview of chronic constipation, including its definition, potential impact, and treatment. The objective is to give managed care decision makers and prescribing physicians the means to make informed choices about this all-too-prevalent condition.

WHAT IS CHRONIC CONSTIPATION?

Although chronic constipation is a common digestive complaint in North America, the definition of constipation varies widely. Physicians tend to think of constipation as strictly a matter of frequency, namely, defecation every three to four days or less. Patients, however, usually define constipation more by its symptoms, such as straining and hard stools, rather than by the actual frequency of defecation.
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Table 1   Rome III Criteria

1. The Rome III guidelines define patients with chronic constipation as having two or more of the following symptoms for the last three months, with symptom onset at least six
months prior to diagnosis:

  • straining in at least 25% of defecations
  • lumpy or hard stools in at least 25% of defecations
    • sensation of incomplete evacuation in at least 25% of defecations
    • sensation of anorectal obstruction or blockage for at least 25% of defecations
    • manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation or support of the pelvic floor)
  • Fewer than three defecations per week

2.  Loose stools are rarely present without the use of laxatives.

3.  There are insufficient criteria for irritable bowel syndrome.

In order to devise a uniform standard, the Rome Committee defined functional constipation as a unique category separate from chronic constipation. The consensus-based Rome III criteria of functional constipation are shown in Table 1. These criteria have been revised from the Rome II criteria. The main difference between Rome II and Rome III criteria lies in the less restrictive time frame for symptoms. Whereas Rome II criteria require symptoms to be present for at least 12 weeks (not necessarily consecutive) in the previous 12 months, Rome III criteria require symptoms to originate from six months prior to diagnosis, and to be currently active (i.e., the patient meets the criteria) for three months.

FIGURE 1 Commonly reported symptoms

FIGURE 1 Commonly reported symptoms in chronic constipation.

A SYMPTOM-ORIENTED DISORDER

There is a widespread misconception that the most common symptom of chronic constipation is infrequent bowel movements (i.e., fewer than three bowel movements a week). In fact, one study of patients who met the Rome II criteria for chronic constipation found that most reported more than three bowel movements per week. Much more commonly reported was straining during a bowel movement, hard or lumpy stools, a feeling of incomplete evacuation, sensations that the stool could not be passed, and abdominal fullness or bloating (Figure 1). Apcalis Oral Jelly