A Home-Bound 65-Year-Old Woman Wi…


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CME/CE Released: 08/14/2009; Valid for credit through 08/14/2010 This activity has expired. The accredited provider can no longer issue certificates for this activity. Medscape cannot attest to the timeliness of expired CME activities. Target Audience This activity is intended for family medicine/primary care practitioners, internal medicine practitioners, gastroenterologists, geriatrics practitioners, nurses, and pharmacists involved in the care of patients with chronic constipation. Goal The goal of this activity is to increase clinicians’ recognition of the higher prevalence of chronic constipation in elderly patients as well as raise clinician awareness to the factors for the increased prevalence of CC in this population; allow clinicians to examine lifestyle measures often used by elderly patients to manage their constipation and evaluate their effectiveness; describe special considerations for targeting therapy in the elderly population; and review the evidence and provide a practical guide to the screening, diagnosis, and treatment of CC in the elderly population. Learning Objectives Upon completion of this activity, participants will be able to: 1. Recognize the higher prevalence of chronic constipation in elderly patients and the potential reasons for the increased prevalence in this population 2. Examine lifestyle measures often used by elderly patients to manage their constipation and evaluate their effectiveness 3. Describe special considerations for targeting therapy in the elderly population 4. Review the evidence and provide a practical guide to the screening, diagnosis, and treatment of chronic constipation in this population Credits Available Physicians - maximum of 1.50 AMA PRA Category 1 Credit(s)™ Nurses - 1.50 ANCC Contact Hour(s) (0.5 contact hours are in the area of pharmacology) Pharmacists - 1.50 k nowledge-based ACPE (0.150 CEUs) All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation. Physicians should only claim credit commensurate with the extent of their participation in the activity. Accreditation Statements
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A Home-Bound 65-Year-Old Woman Wi…

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MS. UCLA David Geffen School of Medicine. AstraZeneca Pharmaceuticals LP Editor Elizabeth Samander.. MedscapeCME requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. Author Brennan M. School of Nursing and Allied Health. Continuing Professional Education Department.. California Disclosure: Brennan M. Digestive Diseases. Scudder. Los Angeles. medscape. NP.. Baltimore City Public Schools. MedscapeCME. The ACCME defines "relevant financial relationships" as financial relationships in any amount. MSHS. that could create a conflict of interest. MedscapeCME Disclosure: Elizabeth Samander.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… Authors and Disclosures As an organization accredited by the ACCME. Baltimore. Spiegel. Spiegel. Bristol-Myers Squibb Company Served as an advisor or consultant to: Prometheus Laboratories Inc. Maryland Disclosure: Laurie E. including financial relationships of a spouse or life partner. Clinical Assistant Professor. has disclosed the following relevant financial relationships: Received grants for clinical research and educational activities from: Amgen Inc. Attending Physician. MedscapeCME encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration.org/viewarticle/707166_print 3/21 . Department of Gastroenterology. has disclosed no relevant financial relationships. MS. Nurse Practitioner. NP Accreditation Coordinator. George Washington University. MD. California. DC. occurring within the past 12 months. PhD.R. Los Angeles. Nurse Plannner Laurie E. Scudder.R. MD. PhD Scientific Director. School-Based Health Centers. at first mention and where appropriate in the content. MSHS Assistant Professor in Residence. Washington. Inc. Takeda Pharmaceuticals North America. has disclosed no relevant financial relationships.

MD. you will be able to see whether you answered correctly and will then read evidence-based information that supports the most appropriate answer choice. On physical examination she has a body mass index (BMI) of 31 kg/m2. there will be a short post-test assessment based on material covered in the activity. From MedscapeCME Gastroenterology A Home-Bound 65-Year-Old Woman With Chronic Constipation Brennan M. and a sense of incomplete evacuation with bowel movements. Defecation somewhat relieves the bloating and tightness. She says the symptoms are "devitalizing" and "draining. you provided her with a diary to track the frequency and quality of her bowel movements. She has never smoked tobacco and rarely drinks alcohol. presents with a major complaint of constipation. Digital rectal examination reveals 1 small external hemorrhoid. On the first clinic visit. is unremarkable. but has only recently developed progressive worsening of her symptoms over the past 2 years. She has difficulty with each bowel movement and is using over-the-counter laxatives. a 65-year-old woman. Spiegel. Her husband of 35 years recently died of metastatic colon cancer. while she was not taking any laxatives. Sue F. including abdominal examination. She now lives alone in her home and is intermittently visited by her older daughter. It is now severe enough that it affects her quality of life. lumpy stools. medscape. The patient reports straining with defecation.org/viewarticle/707166_print 4/21 .23/4/2011 A Home-Bound 65-Year-Old Woman Wi… MedscapeCME Staff involved in the planning and review of this activity have disclosed no relevant financial relationships. She often spends a prolonged period on the toilet to defecate.. She has had these symptoms for 2 years." and she reports that it has negatively affected her social life to the point where she stays at home and avoids social engagements due to embarrassment and worry about her bowel symptoms. who lives locally. After each question. She does not report any changes in her weight or appetite or any blood in her stool. She often cooks for herself and "tries to eat well. General physical examination. Please note that these questions are designed to challenge you. the severity of symptoms has been gradually increasing. She worked as a bank teller for over 40 years and just recently retired. She defecates 1 to 2 times per week on average." but admits that since her husband died it has become harder to prepare nutritious meals. There is no family history of gastrointestinal cancer. She reports intermittent lower abdominal "bloating" and "tightness" but no visual distention and no abdominal pain. is referred to you by her primary care provider for evaluation of chronic constipation. Valid for credit through 08/14/2010 The following test-and-teach case is an educational activity modeled on the interactive grand rounds approach. You notice that she had 4 bowel movements during the past week. hard. At the end of the case. but there are usually residual symptoms despite stool passage. However. MSHS CME/CE Released: 08/14/2009.R. Her medical history is unremarkable except for high blood pressure and high cholesterol. producing minimally hard stool. The questions within the activity are designed to test your current knowledge. usually without success. Patient History Sue F. and vital signs are stable. She recalls having constipation for most of her life. you will not be penalized for answering the questions incorrectly.

straining. or even resorting to manual maneuvers to aid stool passage.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… What would be your next step in managing this patient? Explain that she does not have constipation and that her bowel habits could be considered normal on the basis of the frequency of her bowel habits Explain that most likely she has irritable bowel syndrome and that she may benefit from stress management and fiber Send her for further evaluation for her symptoms Ask her to continue the over-the-counter laxatives Save and Proceed Defining Chronic Constipation "Constipation" means different things to different people. [2-4] The scale provides 7 prototypical stool forms ranging from hard. Constipation often includes abnormalities of both frequency and form -. although potentially obvious. However. constipation can be correctly diagnosed in the absence of infrequent defecation. Therefore. What is constipation? Historically constipation has been defined as infrequent defecation. Patients with constipation typically point to type 1 and type 2 bowel movements as their predominant stool form.[1] Moreover. and traditionally cite a frequency of fewer than 3 bowel movements per week as evidence of clinically important constipation. and because these different symptoms may require widely disparate therapies. rounds "nuts" (type 1) to watery without formed elements (type 7). a nagging sense of incomplete evacuation. round stools. and a sense of incomplete evacuation may have constipation even if she passes multiple bowel movements daily. it is instructive to use the Bristol Stool Scale (Figure 1) when asking patients to classify their bowel movements. prolonged bouts of defecation often resulting in unsuccessful evacuation.org/viewarticle/707166_print 5/21 . stool frequency alone is only part of the story. is important to help guide diagnostic and therapeutic decision-making. it is vital for treating clinicians to fully understand and explore each patient's individual illness experience and to tailor therapy accordingly. Because patients cite a variety of symptoms to describe constipation. Certainly a patient with hard. patients do not uniformly report infrequent defecation as their defining symptom. They may also experience straining with defecation. Because most patients understandably lack a working knowledge of normative stool consistency.namely. infrequent bowel movements or alterations in the consistency of the bowel movements. This insight. medscape.

many patients do not comply with this tidy dichotomy. however. Acute constipation has a shorter time course and a different differential diagnosis than CC. It is important to emphasize the difference between acute constipation and CC. These variations in patient assessment of abdominal discomfort make it difficult to clearly distinguish IBS-C from CC.org/viewarticle/707166_print 6/21 . Those principally concerned with improving stool frequency or form independent of abdominal pain probably have CC. It is common to encounter patients who have mild or moderate abdominal discomfort in CC but who do not report discomfort as a predominant symptom.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… Figure 1.[5] Table I. Patients who acknowledge that abdominal pain is a major factor are more likely to have IBS-C than CC. The Rome III criteria define CC as the presence of cardinal symptoms for at least 12 weeks in the previous 12 months. patients with CC do not report pain as a predominant feature of their illness experience. The Bristol Stool Scale. Whereas the hallmark symptom of IBS-C is abdominal pain in association with constipation. patients with IBS-C may have abdominal pain on some occasions but not consistently. it is useful to note the difference between CC and irritable bowel syndrome (IBS) with constipation (IBS-C). Finally. The Rome III criteria (Table 1) provide a working definition of chronic constipation (CC). ask the patient whether pain or discomfort is a predominant feature or whether the "main problem" is limited to the constipation itself. Similarly. [3. Rome III Diagnostic Criteria* for Constipation Chronic constipation must include 2 or more of the following in > 25% of defecations: Straining Lumpy or hard stools Sensation of incomplete evacuation medscape. If in doubt.5] Practically. [3] The criteria highlight the difference between stool frequency and stool form and emphasize that infrequent bowel movements alone do not necessarily define constipation.

You recommended that she get a colonoscopy. Fecal occult blood testing was negative on 3 occasions over the past year. Sue F. All but 1500 mL of this volume is subsequently reabsorbed before exiting the ileum. Her primary care provider ordered a complete blood count. From Longstreth et al. Patient History (cont'd) She does not report alarm features. like it's been for years. 2006. and pancreas.org/viewarticle/707166_print 7/21 . all of which were normal. Typically around 1500 mL of dietary fluid is delivered to the small intestine daily. She had a colonoscopy 5 years ago that revealed sigmoid diverticula and melanosis coli. but says she's "almost getting to that point. "like pebbles. and hypercholesterolemia for which she takes simvastatin. Gastroenterology. or sweats. liver. and serum electrolytes. She has a history of 2 normal spontaneous vaginal deliveries without complications." Her only abdominal surgery was an appendectomy when she was 30 years old." She has not had to use manual disimpaction to assist stool passage. liver chemistries. no nausea or vomiting. Thus. Her medical history includes osteoarthritis for which she takes intermittent ibuprofen as needed. and no blood in her bowel movements. had a colonoscopy 5 years ago and asks whether she needs to have this test done again. it is useful to first review key aspects of normal intestinal physiology. where it joins with nearly 7 L of additional secretions intrinsically produced from the parotids.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… Sensation of anorectal obstruction/blockage Manual maneuvers < 3 defecations a week Loose stools are rarely present without the use of laxatives Insufficient criteria for irritable bowel syndrome (IBS) *Criteria fulfilled for at least 3 months with symptom onset at least 6 months before diagnosis. where it is stored and admixed with feces. it is usually round. No polyps were documented. The colon ultimately medscape. no fevers. She has been receiving all of these medications for over 5 years without a change in dose. between 8 and 9 L of fluid enters the jejunum. hypertension for which she receives lisinopril. The colon receives the remaining 1500 mL of fluid. What would be your next step in managing this patient? Explain that she does not have constipation and that her bowel habits could be considered normal on the basis of the frequency of her bowel habits Explain that most likely she has irritable bowel syndrome and that she may benefit from stress management and fiber Send her for further evaluation for her symptoms Ask her to continue the over-the-counter laxatives Save and Proceed Pathophysiology and Differential Diagnosis of CC To understand the pathophysiology of CC. stomach. Specifically. chills.140:1480. Her stool caliber has not changed over time. there is no unintended weight loss.

8] The timing of these effects is partly coordinated by the interstitial cells of Cajal (ICCs) found in the myenteric plexus. distal relaxation. propagation is inefficient. This may occur through anatomic or functional barriers to proper evacuation. and secretion. The segment may be long. But this advice does not necessarily comport with physiology. The disease is characterized by a lack of reflex inhibition of the internal anal sphincter due to lack of enteric inhibitory neurons. some patients develop constipation from rectal outlet obstruction or delay. as occurs in "colonic inertia" -. There is no organomegaly or palpable mass. She has thick pasty brown stool in the vault. [9.org/viewarticle/707166_print 8/21 . Digital rectal examination reveals perianal dried brown stool. The main learning point here is that the intestines have a remarkable ability to absorb fluid. which coordinates proximal contraction. in fact. or ClC-2) serve as a key regulator of intestinal secretory function by promoting water and sodium transport into the lumen. The ICCs are thought to play a vital role in organizing colonic motility. and feces become firm and desiccated. to help with her incontinence.a severe and recalcitrant form of constipation -. it is not easy to overwhelm the system with oral hydration.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… absorbs nearly 90% of the remaining fluid load. In addition to slow-transit constipation. Although staying well hydrated is good general advice.[9] as discussed further below. this is a very uncommon cause of CC in adults. it does not follow that increasing oral hydration will alter stool consistency or frequency. Her blood pressure is 130/85 mm Hg and pulse rate is 75 beats/min. in which case the disease is typically detected shortly after birth in neonates who are unable to pass meconium.colonic motility slows. or change in appetite. This occurs through a variety of signals. Whereas CC is generally unrelated to the amount of oral hydration. This results in an aganglionic segment of bowel that is dysfunctional. blood in her stool. 1 tablet twice a day. Normally the colon is a well-coordinated organ that intermittently propels feces through synchronized contractions of the smooth muscle apparatus investing its walls. leaving only 100-150 mL to be excreted with the feces. General physical examination is unremarkable and her abdomen is mildly distended with normal bowel sound. Sue F.10] Loss of ICCs over time is one possible explanation for why CC is more prevalent with increasing age. But short segments of Hirschsprung's disease may evade detection for years and only present with longstanding constipation in adults. [9] If ICCs are diminished. Which of these tests is the first that you would obtain to provide you with more useful information about this patient? Balloon expulsion test Anorectal manometry for evaluation of rectal tone and compliance Abdominal radiography Defecography for evaluation of pelvic floor function Save and Proceed medscape. [11] Nonetheless. [6] In addition. it may be precipitated by alterations in intestinal transit. reports no abdominal pain. not the bowels. Anal sensation is intact and the tone of the rectum is normal. Excess fluid is excreted by the kidneys. The intestines will readily reabsorb the excess fluid before it could provide a substantive effect on feces stored in the colon. The classic example of a functional obstruction is Hirschsprung's disease. On review of her medications you notice that she is taking an antidiarrheal medicine. This is clinically relevant because patients often attempt to "treat" constipation by drinking large volumes of water and. which arises from failure of the neural crest cells to migrate to the end of the bowel during normal embryogenesis. chloride channels (namely chloride channel-2. and is especially uncommon in elderly patients with CC. [7. including serotonin (namely 5HT-4). many well-intentioned clinicians advise their constipated patients to stay well hydrated.

not increase -.[12] The increase in rectal pressure is a normal consequence of the Valsalva maneuver and is the initiating event for defecation." They keep their external anal sphincter paradoxically "tight" at the very moment when they should be relaxing.[12] If the balloon cannot be expelled within 2 minutes. [12] To understand pelvic dyssynergia. including the elderly. During a normal bowel movement. This is accompanied by a relaxation of the puborectalis sling. medscape. it provides further evidence for possible anorectal outlet obstruction. potential dyssynergic defecation is suggested. The tip-off on anorectal manometry is a paradoxical increase in the anal pressure that correlates with the increase in rectal pressure (Figure 2). which is normally detected with a decrease -. in which a patient has a rectal balloon instilled with 50-60 mL of water and then has 2 minutes to expel the balloon while on a commode (easier said than done. the anal sphincter should relax to reduce the physical barrier to expulsion.[14] Traditional laxative therapy is not very effective in this condition because the problem is not one of motility but of outlet delay. The final part of a normal reflex is the relaxation of the anal sphincter. The definitive treatment for pelvic dyssynergia is biofeedback therapy.in the anal pressure. pelvic dyssynergia is a highly prevalent cause of functional outlet delay in adults. To easily evacuate a stool. Anorectal manometry in pelvic dyssynergia. the pressure in the anal canal is rising. Another approach to diagnosis is to use a radiopaque marker study (Sitzmark TM study). even for nondyssynergic patients). the pressure profile in Figure 2 is akin to squeezing toothpaste out of the tube while keeping the cap on. In the case depicted in Figure 2. The anal sphincters are striated muscles under voluntary control.a process that typically requires several sessions with active coaching and real-time feedback regarding sphincter tone. it is important to first understand normal anorectal function. Stool is no different. pressure in the rectum increases while pressure in the anal canal decreases. [12] Figure 2. As a crude analogy. not falling.org/viewarticle/707166_print 9/21 .[13] described further below. The cap needs to come off first so that the toothpaste can be squeezed out.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… In contrast to Hirschsprung's disease. If the markers collect in the rectum without being expelled. Pelvic dyssynergia can be detected by a standard balloon expulsion test. which allows a straightening of the anorectal angle. But some people are literally "anal retentive. in which patients learn to literally relax their external anal sphincter during defecation -.

many medications are known to precipitate or at least contribute to constipation (Table 2). Hepatogastroenterology. a long list of underlying disorders may present with CC. [5] Figure 3 provides a comprehensive list of potential underlying secondary causes of CC. Because older patients tend to medscape. up to 27% of individuals report symptoms consistent with CC. 2001. it is prevalent among all age groups. but she reported that it caused bloating and did not improve her constipation. In fact. including amyloidosis. Secondary causes of chronic constipation.org/viewarticle/707166_print 10/21 . and a variety of systemic disorders. [5] Finally. such as hypothyroidism and advanced diabetes. both highly prevalent diseases in their own right. Figure 3. the population prevalence of CC is nearly twice that of diabetes or asthma. et al. such as hypercalcemia and hypokalemia. [16] There are a variety of potential reasons why older patients have a higher prevalence of CC. [16] Nonetheless. making CC the second most common outpatient gastrointestinal tract diagnosis behind acid reflux disease. These include endocrinopathies. In fact. [16] Although CC is especially common among the elderly. the rate of consultation for CC is higher in children younger than 15 years of age than in adults older than 65 years of age. physician visits for CC among adults rise in lockstep with increasing age. She now seeks additional treatment options and wonders why nothing has worked to date. It is rare for rectal cancer to present with CC. and myopathies. degenerative neurologic conditions. systemic sclerosis. Patient History (cont'd) She has used bisacodyl tablets for the past 15 years to help normalize her bowel movements. As the symptoms became worse 2 years ago she began to use psyllium powder on the advice of her primary care provider. [5] Recent data indicate that over 3 million physician visits annually are the principal reason for consultation. as detailed further below.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… Other causes of anatomic outlet obstruction include rectoceles and rectal prolapse.48:1050. In particular. although presence of alarm features. Burden of Illness and Epidemiology CC is an extraordinarily common healthcare problem. Adapted from: Candelli M.[15] Although there is some variability in the estimated prevalence of CC among studies. metabolic abnormalities. should always raise awareness for underlying malignancy. including Parkinson's disease and spinal lesions.

patients with chronic constipation are most likely to report: Impairment of daily activities Inability to afford treatment Absenteeism from work or school Decrease in productivity Save and Proceed The burden of illness of CC is more than an epidemiologic phenomenon --it can also severely affect the health-related quality of life (HRQOL) of patients themselves. Just as the function of the central nervous system can decrease over time. a possible consequence of being sedentary and immobile (although it remains unclear whether immobility itself can cause constipation). [18] Pelvic floor laxity can also promote constipation through dyssynergic defecation. medication use alone probably explains much of the increased prevalence in the elderly population. as occurs with Alzheimer's disease and other progressive forms of dementia. [17] These patients are also commonly prescribed narcotics for chronic pain. [9. especially nursing home residents.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… use more medications than younger patients. [10] Although the analogy between colonic inertia and Alzheimer's dementia is imperfect.10] Patients with "colonic inertia.[12] Older or sedentary patients (especially women) may develop weakness and laxity of the pelvic floor musculature." a severe form of CC marked by diminished or absent colonic transit. ultimately.org/viewarticle/707166_print 11/21 . codeine Alosetron Without relief of symptoms. promotes constipation through discoordinated fecal expulsion. both conditions have in common an age-related abatement in neural function with resulting functional impairment. have a dramatically lower density of ICCs on intestinal biopsy compared with healthy controls. dicyclomine Amitriptyline Verapamil NA Aluminum-containing products Aluminum hydroxide. some forms of constipation may represent a sort of "dementia" of the gut. play a vital role as the "gut pacemaker" for intestinal transit and. are especially prone to developing CC. Table 2. Decrements in HRQOL are medscape. in particular. the function of the enteric nervous system can also decrease as patients age. [19] Data indicate that patients with CC score lower on all 8 scales of the Short Form-36 HRQOL questionnaire compared with "normal" cohorts without CC. sucralfate Opiates 5-HT3 Antagonists NA = not applicable Morphine. which diminishes the bolstering effect of perirectal structures and. may fall in numbers. meperidine. Common Medication Classes Associated With Chronic Constipation Medication Class Anticholinergic medications Antihistamines Antispasmodics Antidepressants Calcium-channel blockers Iron supplements Example NA Diphenhydramine Hyoscyamine. [12] In addition. Narcotic-related CC can be severe and difficult to treat. [9] The ICCs. Bed-bound patients. with time.

[5] Although the predictive validity of these features for malignancy is somewhat unreliable. Deep palpation in her left lower quadrant elicits mild discomfort. Patient History (cont'd) On physical examination she is noted to be obese. In particular. lead to dissatisfaction with care." "devitalized. Alarm Features in Chronic Constipation Family history of colon cancer/organic gastrointestinal disease Overt rectal bleeding Iron deficiency anemia Positivity on fecal occult blood test Significant unintended weight loss (>10 pounds of weight in 2-3 months) Severe. or unexplained iron deficiency anemia. and a normal expulsion effort with a normal amount of perineal descent. Any of these symptoms or signs should mandate a structural examination of the colon." "worn down. Patients with alarm features should be evaluated for possible gastrointestinal malignancy. their presence should never be ignored. However. There is solid stool in her rectal vault that is guaiac negative. and even affect work productivity. it is important to ask patients about how CC affects their HRQOL. outlet obstruction.21] In short. unintended weight loss. it is vital to screen for "alarm features" when evaluating any patient with CC. regardless of age. One study found that patients report an average of 2. recent decrease in stool caliber (not just frequency or consistency).23/4/2011 A Home-Bound 65-Year-Old Woman Wi… especially large in the "vitality" subscale of the SF-36. Digital rectal examination reveals 1 small external hemorrhoid. especially if there is rectal bleeding. the HRQOL burden of CC leads to diminished work productivity and higher rates of work absenteeism compared with controls. If the latter." as with the current case. failure to recognize and address the HRQOL effect of CC could undermine the provider-patient relationship. normal-transit constipation. Visual inspection of her abdomen reveals protuberance consistent with her body habitus and an old scar from a right-lower-quadrant appendectomy. Table 3." or "drained. preferably colonoscopy. She has a blunt affect and appears dispirited. Table 3 lists alarm symptoms and signs that should be elicited in any patient presenting with CC. which is consistent with the common clinical report of feeling "tired.4 days per month of productivity from CC and that there are over 13 millions days of restricted work activity annually from CC. no evidence of a rectocele or rectal prolapse. this is especially important in the elderly because the prevalence of underlying gastrointestinal malignancy is higher in this age group. occult blood-positive stools. Clinical Clues From the Patient History and Physical Examination in CC The patient history and physical examination provide important clinical clues in CC. persistent constipation Recent narrowing of stool caliber Lack of response to traditional treatments medscape.[20. Bowel sounds are present and unremarkable. Through a careful and directed history and examination. She has normal sphincter tone. with a BMI of 31 kg/m2. There is no conjunctival pallor.org/viewarticle/707166_print 12/21 . or a combination thereof as discussed further below. Data indicate that HRQOL decrements in patients with CC are directly related to the frequency of physician visits. the history and examination should focus on whether the patient has an underlying medical condition leading to CC ("secondary" CC) or primary CC. [19] In addition. First and foremost. Her vital signs are normal. the astute clinician can often predict underlying disorders even in the absence of diagnostic testing. the clinician should estimate whether the underlying cause of primary CC is slow-transit constipation. The remainder of her general examination is unremarkable.

This raises the possibility of normal-transit constipation with an underlying functional gastrointestinal disorder. suggests underlying and progressive slow-transit constipation. Anecdotally. True slow-transit constipation. The larger point is that clinicians must remember outlet obstruction early on because traditional therapies for CC. 2005. Elevated psychosocial distress. or need for manual maneuvers may have a functional outlet obstruction. [23] Instead." she has no abdominal pain and her abdominal symptoms do not fully resolve with defecation. particularly in the absence of typical IBS-C characteristics or outlet delay. she has not resorted (yet) to manual maneuvers. has a normal expulsion effort without paradoxical external anal sphincter. Patients without evidence of secondary CC or primary outlet obstruction may have slow-transit or so-called normaltransit CC. incomplete evacuation. The longstanding nature of her symptoms is also relevant because the symptoms predate the recent death of her husband by many years. Assuming the patient does not have alarm features. although she reports straining and incomplete evacuation. [5] Both forms of CC may also coexist with outlet delay but by definition cannot coexist with each other. this sort of longstanding CC. Many of these patients have concurrent abdominal pain and either meet criteria for IBS-Cor fluctuate between CC and IBS-C. she reports recent HRQOL decrements related to the death of her husband. Second. Third. First. this variable is nonetheless worth evaluating because extremes in either direction might help direct additional diagnostic testing. [12. [5. [22] Although estimating the degree of perineal descent can be an unreliable exercise. Am J Gastroenterol. although not necessarily etiologic. and unnecessary extension of HRQOL decrements. although she reports some bloating and "tightness. and is devitalized and possibly depressed. several historical and physical clues help narrow the diagnostic decision making. Failure to detect outlet obstruction early in the diagnostic course can lead to delays in providing effective treatment. again suggesting that her symptoms have been troubling her for a long time. has normal perineal descent on rectal examination. In these patients it is helpful to perform a careful digital rectal examination to estimate rectal tone. In one series of 277 Patients with CC undergoing colon transit studies. the next step is to estimate whether the patient has a functional outlet obstruction. This is especially important in elderly women. such as balloon expulsion or anorectal manometry. who are at highest risk for outlet obstruction from rectoceles or prolapse. and measure the degree of perineal descent. the data from the history and examination suggest that primary CC is more likely than secondary CC. [12] Patients reporting excessive straining. lack of any perineal descent might indicate pelvic dyssynergia with "tenting" of the perineum from forced contraction of the external anal sphincter. is commonly observed in patients with normal transit constipation. screen for paradoxical contraction of the external anal sphincter during forced expulsion. Excessive perineal descent may indicate a rectocele. dissatisfaction with care. making up over 70% of cases.100(suppl 1):S5. such as laxatives. medication history. This suggests that CC is more likely than underlying IBS-C because the latter is marked by predominant abdominal pain that typically improves with defecation. described previously. may not be effective at all if the underlying problem is pelvic dyssynergy. These findings suggest that outlet delay may not be a predominant mechanism for her constipation. such as dyssynergic defecation. only 11% were found to have slow-transit constipation. her medical history. normal-transit constipation is the most common subgroup within primary CC.23] These patients may have underlying visceral hypersensitivity and misperceive normal peristalsis as pathologic. Fourth. and general physical examination do not point to obvious secondary causes of CC. has no recent change in stool caliber. as outlined below. The finding of melanosis coli on a previous colonoscopy indicates longstanding use of stimulant laxatives. Fifth. [5] In reviewing the current case. and had no polyps or masses found on colonoscopy 5 years ago. and true slow-transit constipation is still possible. prolonged defecation with minimal success.22] Normally the perineum remains within 2 to 3 cm of the ischial tuberosities both at rest and with straining. the patient does not report alarm features. All of this makes underlying colon cancer unlikely. is actually quite rare. However. and does not have an obstetrical history that would raise suspicion for pelvic floor disruptions. Cost-Effective Diagnostic Testing in CC medscape.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… New-onset constipation in an elderly patient From Brandt et al. [19] In contrast. Although further diagnostic testing is warranted. it is important to emphasize that the relationship between psychological distress and CC is not necessarily causal.org/viewarticle/707166_print 13/21 .

including a complete blood count. regardless of age. Finally.org/viewarticle/707166_print 14/21 . In addition. as reviewed above. regardless of CC. or barium enema but that patients older than age 50 years should undergo routine colorectal cancer screening independent of their CC diagnosis. latex glove. as described above. biofeedback therapy vs medical therapy). then it is useful to perform an objective test before starting therapy because the treatment for pelvic dyssynergia in particular is very different from that for other forms of constipation (ie. and 60-mL syringe. This can be estimated in advance of testing from a careful history and examination. many providers opt to treat patients empirically before conducting additional tests. provide minimal data in patients with CC. respectively). colonoscopy. routine laboratory tests have low yield in CC and should be ordered on the basis of pretest likelihood of underlying disease determined from a careful and detailed history and physical examination. or outlet delay as the basis of their symptoms. I typically begin with empirical treatment unless I suspect underlying outlet delay. Clinicians should bear this in mind when performing diagnostic testing but should also recognize that most testing strategies have low yield in the absence of alarm signs or symptoms. and thyroid function testing. Once secondary constipation has been ruled out on the basis of the history and physical examination and judicious diagnostic testing. However. The first step is to cut the index finger off the glove and fit it over the end of the nasogastric tube while ensuring the outlet ports are covered by the latex.values that were statistically similar to the yield in control patients undergoing routine colorectal cancer screening (20% and 1% for adenomas and cancer. medscape. This is especially relevant in the elderly population. it is important to recognize that many underlying organic conditions can lead to CC. colonoscopy in young patients without alarm features is an exercise in diminishing returns and is probably not cost-effective. serum electrolytes. The ACG further emphasizes that there are inadequate data to recommend the routine use of flexible sigmoidoscopy. However.26] An inexpensive rig can be created with a nasogastric tube. the result is an oblong "balloon" at the end of the tube (Figure 4).[25. [5] Data from a study by Pepin and Ladabaum[24] revealed that colonoscopy identified adenomas and cancer in 19% and 2% of patients with CC. the ACG points out that high-quality data regarding diagnostic test yield in CC are generally lacking and that patients should be approached in an individualized manner depending on the pretest likelihood for underlying organic disease. the next step is to evaluate whether the patient has normal-transit. Moreover. which harbors more diseases. In short. If outlet delay is being considered. slow-transit. the American College of Gastroenterology (ACG) conducted a systematic review of the literature to identify data supporting diagnostic testing strategies in CC. suture. on average.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… As outlined above. than younger patients. patients eligible for colorectal cancer screening should be screened. respectively -. presence of alarm features should generally prompt colonoscopy. In 2005. [5] The ACG concluded that almost all the standard laboratory tests. Balloon expulsion is a simple test that can be easily completed in the office setting. A suture (or even a string) is then tied tightly at the bottom of the latex to form a seal.

This is an important step because surgery. as described further below. [26] Of note. In contrast. [25] I tend to use defecography -. a radio-opaque marker study may be warranted. The patient is then asked to sit on a commode or toilet and spontaneously evacuate the balloon.especially in the elderly -. then slow-transit constipation is likely. I typically do not discriminate but treat empirically. Thus. If fewer than 20% of the capsules remain. Copyright 2009 Brennan M. they are often elusive. then outlet obstruction is highly unlikely. [25] Thus. If slow-transit constipation is suspected.[26] If more than 20% of the markers remain distributed throughout the colon at day 5.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… Figure 4. but the most common is to administer a capsule with 24 markers and obtain an abdominal radiograph 5 days later. defecography may help confirm the suspicion. the tube is inserted into the rectum digitally. [25] Its negative predictive value is 97%. and 50-60 mL of fluid is instilled through the tube with the syringe. then outlet obstruction may still be present despite the normal balloon expulsion test result. may be the treatment of choice if there is a clinically important rectocele or prolapse. Patients with a normal balloon expulsion test result usually have normal-transit constipation but may have slow-transit constipation. [26] medscape. not medical therapy alone or biofeedback therapy.R. Spiegel. MSHS. the positive predictive value of the balloon expulsion test is only 64%. Balloon expulsion test rig. After leak testing is performed. MD.org/viewarticle/707166_print 15/21 . If the balloon cannot be expelled after 2 minutes of effort. the diagnosis is normal-transit constipation. indicating that additional confirmatory testing with anorectal manometry or defecography may be required if the balloon expulsion result is positive but the diagnosis remains in question. There are a variety of techniques for interpreting the marker study results.because it can screen for anatomic barriers such as a rectocele or prolapse. [26]Although these diagnoses can often be found on digital rectal examination. this relatively simple office examination has an 88% sensitivity and 89% specificity when compared with the gold standard of specialized anorectal manometry. then the test result is considered to be positive. if a patient can spontaneously evacuate the balloon within 2 minutes. Patients with an incomplete response may require further diagnostic testing. [26] If the markers remain but are co-located in the rectum.

psyllium should be discouraged. ultimately improving CC symptoms. both inorganic bulking agents that are not fermentable. and exercising. methylcellulose.[27-31] Most of these studies indicate that psyllium. at doses of 7 to 24 g daily. Dietary fiber may help. this study showed equivalency between medscape. [32] Similarly. [5] Five randomized controlled trials have compared psyllium with placebo. particularly with the advice to "start low and go slow" with dosing. the quality of these studies is generally poor. and the data are not entirely consistent. it is reasonable to counsel patients about healthy living practices. However. but it can be difficult to consume enough fiber (20 to 30 g per day) from dietary sources alone to alter intestinal transit. In short. Bulking Agents Bulking agents include organic and inorganic polymers that work by retaining water in the stool. but this alone is unlikely to improve CC. psyllium undergoes bacterial fermentation in the colon and can generate gas and bloating. In theory. this helps to emulsify stools and speed transit time. but over time this may decrease. In patients without bloating psyllium may be well tolerated. As discussed above. osmotic laxatives. [5] However.[5. Furthermore. may be less motivated to change longstanding and habituated diets to achieve sufficient levels of fiber intake. There is often an initial discomfort and bloating upon initiation of therapy. Finally. In patients with preexisting bloating. staying well hydrated. concurrent therapies should be used. and chloride channel activators. stool softeners. improves stool frequency and consistency compared with placebo. Patients with substantial bloating might benefit from calcium polycarbophil or methylcellulose. Elderly patients. there is only one low-quality study supporting methylcellulose. only one uncontrolled. Common bulking agents include psyllium. low-quality study to date has evaluated this calcium polycarbophil. such as the current case.org/viewarticle/707166_print 16/21 . calcium polycarbophil. in frail or debilitated elderly patients it may be hard to initiate an exercise routine. Moreover. exercise is important for all sorts of reasons.17] This typically includes increasing intake of dietary fiber. including lifestyle modifications. oral hydration does not substantially alter stool frequency or form because the small bowel and colon are highly efficient at absorbing excess water. among others. psyllium has the highest-quality data supporting its efficacy in CC. but probably not for initiating or aiding colonic motility. stimulant laxatives. However. minimal data support the effectiveness of these interventions. Lifestyle Modifications Lifestyle modifications are often recommended to help treat CC symptoms. Of these.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… On the basis of your experience. in particular. bulking agents. which of the following options is most effective in managing constipation in elderly patients? Bulking agents Stool softeners Enemas Stimulants/irritants Osmotic agents Lubricants Chloride channel activator Serotonergic agents Save and Proceed Treatment Options in CC There are a variety of approaches for treating CC. and bran.

along with nausea and. PEG has a lower incidence of adverse effects than lactulose but is more expensive. discontinuation of PEG because of adverse events is rare. less frequent straining. PEG yields looser stools. Stimulant Laxatives The most commonly available stimulant laxatives are senna and bisacodyl. [34. [42] However. stool softeners are relatively inexpensive and well tolerated. including fermentable carbohydrates (such as sorbitol and lactulose). or in patients in whom other forms of therapy have failed.[5] Stool softeners are though to work as surfaceacting agents that "soften" stool by acting as a detergent. [40. the ACG concluded that it is not possible to make a recommendation about the efficacy of stool softeners as a treatment for CC symptoms. and flatulence. [8. These agents are thought to treat CC by triggering high-amplitude propagating contractions (HAPCs) that promote motility and also by inhibiting water absorption. Yet despite their popularity. many patients report clinically relevant benefits from these agents and symptom recurrence upon discontinuation. [33] The ACG concluded that it is "not possible to make any recommendation" about use of calcium polycarbophil or methylcellulose. electrolyte imbalances. However. [36-39] Compared with lactulose. medscape. much less their specific mode of action. so they are not entirely benign. the data supporting stool softeners are sparse and weak. In randomized controlled trials.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… methylcellulose and psyllium. there are surprisingly few data supporting the effectiveness of stimulant laxatives. Data from 5 randomized trials reveal that PEG is superior to placebo. Stool Softeners Stool softeners available in the United States include docusate sodium and docusate calcium. it is unlikely that stool softeners alone will be adequate. These medications are widely used in both the ambulatory and inpatient setting.[5] The ACG systematic review identified 3 randomized. [5] Practically speaking. placebo-controlled trials of lactulose in CC. and there are historical concerns that they may cause a "cathartic colon" marked by diminished motility from a "burned out" myenteric plexus. nausea. It actually remains unclear whether docusate actually works this way or whether its mode of action is altogether different -. and even hepatotoxicity. both lactulose and PEG have received grade A evidence from the ACG.[43-48] The agent is a gastrointestinal-targeted bicyclic functional fatty acid that increases intestinal fluid secretion by selectively activating ClC-2 chloride channels. initial dosing of lactulose may produce transient flatulence and intestinal cramping. and better overall effectiveness. Long-term use of stimulant laxatives is common. Chloride Channel Activators Lubiprostone is a first-in-class locally acting chloride channel activator that has shown benefits in CC. vomiting. A wide variety of osmotic laxatives are available.org/viewarticle/707166_print 17/21 . [42] Stimulant laxatives may cause abdominal discomfort. Still. [5] As with stool softeners. and polyethylene glycol (PEG). The existing studies are of variable quality and reveal inconsistent results. Of these. stimulant laxatives represent an important rung in the therapeutic ladder.49] Clinically.[5] Osmotic Laxatives Osmotic laxatives entrain fluid in the intestinal lumen and act to break up and liquefy stool. bloating. rarely. Mechanism aside. In patients with severe symptoms.41] PEG is well tolerated and flavorless. [5] Nonetheless. however. Data in animals suggest that this agent may also restore mucosal barrier function. there are few data in humans showing that this occurs. However. cramping. which is appealing to many patients. indicating that both have been proven effective in randomized controlled trials. lubiprostone produced significantly more spontaneous bowel movements per week compared with placebo.[5] The effectiveness of docusate from the existing data is inconsistent. there are surprisingly few data supporting their efficacy. The ACG was unable to make any recommendation about the efficacy of stimulant laxatives. lubiprostone reveals important benefits vs placebo in patients with longstanding CC. In its guidance document. along with improvements in abdominal bloating.possibly even acting as a stimulant in the colon. excessive stool frequency. milk of magnesia.35] All the trials revealed that lactulose significantly improves stool consistency and increases the mean number of daily bowel movements compared with placebo. although the significance of this finding remains unclear. High doses may produce diarrhea.

because lubiprostone shows benefits for bloating. Kamm and colleagues found that 66% of patients responded to an initial SNS trial. underlying CC symptoms often improve. and subcutaneous methylnaltrexone for patients with opioid-related CC. and because the patient also exhibited recent psychosocial distress. urologists have found that in patients receiving SNS for urinary incontinence. She tolerated the medicine poorly and reported the medication's unappealing taste and its effect in worsening her bloating. a variety of new pharmacologic approaches are being developing. making outlet delay unlikely. Because normal-transit CC is more prevalent than slow-transit CC. The lack of alarm symptoms and signs. as with the current patient. In a prospective. However. Conclusion medscape. The patient was able to easily expel the 60-mL balloon in under 2 minutes. straining. time per bowel movement. uncontrolled European trial of SNS in 66 patients with recalcitrant CC. multicenter. normaltransit CC was presumed. She was then prescribed a course of 17 g of PEG powder mixed in water daily. Currently available approaches include botulinum therapy for outlet dysfunction. and even abdominal pain when measured before vs after the SNS trial. coupled with the history of a previously normal colonoscopy and normal complete blood count. Although a sham-controlled trial is lacking. an increasingly common and difficult-to-treat form of CC that is especially prevalent among nursing home patients. Of note. In addition. she was prescribed a course of lactulose. She developed transient nausea during the first week of therapy that subsided in time. Repeated colonoscopy reconfirmed melanosis coli but found no polyps or masses. Diarrhea occurs in 13% of patients. argued against an underlying organic disease." Moreover. These include subcutaneous neostigmine (which can promote utility through anticholinesterase inhibition). SNS provides an appealing alternative that is less invasive. She continued the medication for several months but slowly found that it lost its effect.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… discomfort.a rate that was nearly 6 times higher than that in patients receiving placebo in the clinical trials. straining with defecation. She initially responded well and had more frequent bowel movements and less straining. The US Food and Drug Administration-approved dose is 24 µg twice daily with meals.org/viewarticle/707166_print 18/21 . but discontinuation from diarrhea is rare. along with a reduction in her bloating symptoms. [50-53] SNS involves implantation of a stimulator device into the sacral nerve plexus. Because total colectomy is sometimes required in the most severe cases of CC (particularly those with colonic inertia). and she did not stop the therapy. As with most medications for CC. which occurred in nearly 30% of patients -. future research is needed before SNS will become more widely accepted and practices. and stool frequency. It is a common treatment for urinary and fecal incontinence. after several weeks the PEG became less effective and her straining returned. She began receiving lubiprostone. and acupuncture. sacral nerve stimulation (SNS). Of these. Novel Therapies Several novel therapeutic approaches for CC are currently available or will soon become available. it makes sense to consider the agent in the subset of patients with CC with comorbid bloating or tightness. prucalopride (a high-affinity 5-HT4 agonist). SNS requires special attention because it has shown benefit for the most difficult-to-treat forms of recalcitrant constipation. She was then referred for a radio-opaque marker study that confirmed slow-transit constipation (18 of the 24 markers remained scattered throughout her colon after 5 days). she still reported "bloating and tightness. lubiprostone has not been specifically tested in the elderly population. Because she had already received bisacodyl and psyllium with limited success. The patient was treated empirically without further testing. In addition to nonpharmacologic approaches such as SNS. Although the mechanism of action remains unclear. 24 µg twice daily. the SNS data are intriguing. bloating. SNS is thought to work through modulating afferent pathways and rectal sensation in patients with CC. Most clinicians currently reserve lubiprostone for patients with severe symptoms who have not responded to less expensive therapies. Patient History (cont'd) A balloon expulsion test was performed in the office. [45. However. Nonetheless.46] Side effects include nausea. which resulted in substantially improved stool frequency and form. Nausea with lubiprostone appears dose dependent and often improves with continued use. [53] The SNS improved stool frequency. lubiprostone fills an important void in patients with HRQOL decrements in whom multiple therapies have failed.

before colectomy. however. Spiller RC. Abstract 5. Chiarioni G.292:G647-G656. Scand J Gastroenterol. Camilleri M. Serotonin in the gastrointestinal tract. Coran AG.52:313-316. and predictors of health care seeking. J Clin Gastroenterol. Grunkemeier DM. Health-related quality of life in functional GI disorders: medscape. Gastroenterology. The narcotic bowel syndrome: clinical features. Clin Gastroenterol Hepatol. might provide some relief through as yet poorly understood mechanisms. Leung FW. 2009. Whitehead WE. This activity is supported by an independent educational grant from Sucampo Pharmaceuticals Inc.32:920-924.16:53-59. Lewis SJ.5:1126-1139. Am J Gastroenterol. Enck P. Dis Colon Rectum. Bassotti G. Abstract 12. Best Pract Res Clin Gastroenterol.130:657-664. 2007. and Tak eda Pharmaceuticals North America Inc. 2001. References 1. Kamm MA. Thompson WG. such as SNS. colonic inertia was ultimately diagnosed in the patient. Ferrazzi S. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases. Polley TZ Jr. Camilleri M. She is being evaluated for SNS vs colectomy because traditional medical therapies have been ineffective. Am J Gastroenterol.96:31303137. Heaton KW. 2006. Moeser AJ. Mearin F. et al. Abstract 18. 2009. Her HRQOL is poor and she is depressed. 1997. Systematic review on the management of chronic constipation in North America. Gastroenterology. 1994. Gastroenterology. 2004. Irvine EJ. 2006. Ruhl CE. Dalton CB. Prather CM. Curr Opin Endocrinol Diabetes Obes. Shifflett DE. Brandt LJ. O'Donnell LJ. Whitehead WE. et al. Quigley EM. Patients' recollection of their stool form. An office guide to whole-gut transit time. Ferrazzi S. Diamant NE. 2006. Koch TR. Rao S. Engelke KJ.130:1480-1491.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… Given the progressive nature of the symptoms. Definition and epidemiology of functional gastrointestinal disorders. 2007. Corazziari E. Cassara JE. Rance L.136:741-754. Abstract 19. pathophysiology. and the slow transit documented with the marker study. demographics. Abstract 4.127:802-815. Pare P. 1990. Hirschsprung's disease in adolescents and adults. Gastroenterology. Morelli A. 2005. Interstitial cells of Cajal in patients with constipation due to total colonic inertia. Etiologic factors of chronic constipation: review of the scientific evidence. Abstract 15. Longstreth GF. Enteric neurodegeneration in ageing. Abstract 3. Functional bowel disorders. Wheatley MJ. 2008. Shafik AA. 2004. Chey WD. Thompson WG. and management. rates. Nighot PK. Everhart JE.org/viewarticle/707166_print 19/21 . Abstract 17. The definitive treatment is colectomy. Shafik IA.19:28-30. Rance L. Abstract 8. Wesley JR. 2007. Bharucha AE. Stool form scale as a useful guide to intestinal transit time. J Invest Surg. Houghton LA. Pezza V.20:418429.33:622-629. although still considered experimental. Abstract 13. Haskell MM. An epidemiological survey of constipation in Canada: definitions. Drossman DA. More definitive treatment is necessary. Blikslager AT. Dig Dis Sci. Heaton KW. Pare P. Sacral nerve stimulation. Moeser AJ. Abstract 2. ClC-2 chloride secretion mediates prostaglandin-induced recovery of barrier function in ischemia-injured porcine ileum. Gastroenterology. AGA technical review on anorectal testing techniques. the age-related worsening. Neurogastroenterol Motil. Gastroenterology. Abstract 7. Abstract 6. Shafik A. Irvine EJ. Am J Physiol Gastrointest Liver Physiol. El-Sibai O.100 Suppl 1:S5-S21. Thompson WG. Ueno R. Abstract 11. 1999. this is clearly a draconian step and it is worth considering less invasive alternative.130:15101518. Functional anorectal disorders. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Abstract 16.19:147-153. lubiprostone.18:613-631. 2006.116:735-760. Wald A. Wald A. Abstract 9. Recovery of mucosal barrier function in ischemic porcine ileum and colon is stimulated by a novel agonist of the ClC-2 chloride channel. Abstract 14. Abstract 10. Cowen T.

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4-week. 43. Am J Gastroenterol.23/4/2011 A Home-Bound 65-Year-Old Woman Wi… 42. in patients with chronic constipation.69:12291237. Glazener C. 2009. Lubiprostone.27:155-161. Aliment Pharmacol Ther.91:1559-1569. et al. Nighot PK. Jarrett M. Abstract 44. Panas R. Roerig B. Multicenter. Clin Interv Aging. Ann Pharmacother. Is chronic use of stimulant laxatives harmful to the colon? J Clin Gastroenterol. dose-ranging study to evaluate efficacy and safety. Lubiprostone: in constipation-predominant irritable bowel syndrome. Moeser AJ. Washington. Wald A.org/viewarticle/707166_print 21/21 . placebo-controlled trial of lubiprostone.3:357-364. Abstract 51. Jarrett ME. Morton D. Dudding TC. Sacral nerve stimulation for faecal incontinence and constipation in adults. DC. Mowatt G. Ueno R. Ambizas EM. Abstract 45. Melenhorst J. Disclaim er The material presented here does not necessarily reflect the view s of MedscapeCME or companies that support educational programming on w w w .25:1351-1361. Abstract 47. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. Ginzburg R.36:386-389. Systematic review of sacral nerve stimulation for faecal incontinence and constipation.com. Johanson JF. Jarrett M. Lacy BE. randomized. 2008. Johanson JF. May 19-23. Clinical trial: phase 2 study of lubiprostone for irritable bowel syndrome with constipation.41:957-964. Drossman DA. et al.medscapecme. 2008. Abstract 49. Abstract 46. Levy LC. Ueno R. Carter NJ. a locally acting chloride channel activator. medscape. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Program and abstracts of Digestive Diseases Week2007. Scott LJ. Drugs. Abstract 198. Sacral nerve stimulation for fecal incontinence and constipation in adults: a short version Cochrane review. Abstract 50.27:685-696. Lubiprostone: a novel treatment for chronic constipation. 2004. a locally-acting type-2 chloride channel activator. World J Gastroenterol. Ueno R. 52. Glazener C. 2007. 2003. 2007. Geenen J.103:170-177. in adult patients with chronic constipation: a double-blind. Comparison of the chloride channel activator lubiprostone and the oral laxative Polyethylene Glycol 3350 on mucosal barrier repair in ischemic-injured porcine intestine. Br J Surg. Blikslager AT. 2007. Cochrane Database Syst Rev. double-blind. 2008. 2007:CD004464. Wahle A. Kamm MA. Mowatt G. Sacral nerve stimulation for constipation: an international multicentre study. 2008. Aliment Pharmacol Ther. 2008. placebo-controlled. MedscapeCME Gastroenterology © 2009 MedscapeCME. Glazener CM. Johanson JF. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity. Neurourol Urodyn. Lubiprostone: a chloride channel activator for treatment of chronic constipation. Ueno R. Abstract 53.14:6012-6017. Mowatt G. Abstract 48.

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