Review article: diagnosis, management and patient perspectives of the spectrum of constipation disorders

Abstract

Summary Background Chronic constipation is a common, heterogeneous disorder with multiple symptoms and pathophysiological mechanisms. Patients are often referred to a gastroenterology provider after laxatives fail. However, there is limited knowledge of the spectrum and management of constipation disorders. Aim To discuss the latest understanding of the spectrum of constipation disorders, tools for identifying a pathophysiologic‐based diagnosis in the specialist setting, treatment options and the patient's perspective of constipation. Methods Literature searches were conducted using PubMed for constipation diagnostic criteria, diagnostic tools and approved treatments. The authors provided insight from their own practices. Results Clinical assessment, stool diaries and Rome IV diagnostic criteria can facilitate diagnosis, evaluate severity and distinguish between IBS with constipation, chronic idiopathic constipation and dyssynergic defecation. Novel smartphone applications can help track constipation symptoms. Rectal examinations, anorectal manometry and balloon expulsion, assessments of neuromuscular function with colonic transit time and colonic manometry can provide mechanistic understanding of underlying pathophysiology. Treatments include lifestyle and diet changes, biofeedback therapy and pharmacological agents. Several classes of laxatives, as well as prokinetic and prosecretory agents, are available; here we describe their mechanisms of action, efficacy and side effects. Conclusions Constipation includes multiple overlapping subtypes identifiable using detailed history, current diagnostic tools and smartphone applications. Recognition of individual subtype(s) could pave the way for optimal, evidence‐based treatments by a gastroenterology provider.

Chronic Idiopathic Constipation in Adults: A Review on Current Guidelines and Emerging Treatment Options

“…European, French, Spanish and Korean therapeutic guidelines have been compared and discussed with respect to the different methodological criteria and results. Based on the available evidence, a high fiber diet and PEG represent the recommended first-line therapeutic approach; 72 , 73 it is worth noting that this approach is useful also as over-the-counter therapy. 74 Stimulating laxatives and new agents like prucalopride and plecanatide can be proposed as a second-line therapy in patients unresponsive to osmotic laxatives; of interest, literature evidence suggest that prucalopride has the potential for being a first-line treatment for CIC.…”

Current Treatment Options and Therapeutic Insights for Gastrointestinal Dysmotility and Functional Gastrointestinal Disorders

“…Based on previous clinical trials and meta-analyses, prokinetics have been recommended to treat gastroparesis, FD, IBS-C, and chronic constipation ( Simren and Tack, 2018 ; Carbone et al, 2019 ; Grover et al, 2019 ; Camilleri and Atieh, 2021 ; Sharma et al, 2021 ). The pharmacological classes of prokinetics include serotonin 5-HT4R agonists, 5-HT1AR agonists, ghrelin receptor agonists, dopamine-2 receptor antagonists, and muscarinic receptor antagonists.…”

“…Gastroparesis is characterized by upper GI symptoms, including early satiety, vomiting, bloating, nausea, upper abdominal pain, postprandial fullness, along with delayed gastric emptying of solids without any mechanical obstruction ( Grover et al, 2019 ; Camilleri and Sanders, 2021 ). Functional constipation is comprised within the clinical spectrum of IBS-C, and defecatory disorders and can be caused by colonic myopathies or motor disorders, which typically correlate with low-amplitude contractions that result in colonic stasis and impaired propulsion ( Sharma et al, 2021 ). These altered colonic functions increase the reabsorption of water and hardening of stool, which is typically associated with a reduction in the sensation of the need to defecate.…”

“…Prokinetics, antispasmodics, centrally acting neuromodulators, fecal microbiota transplantation (FMT), and modified lifestyle (dietary, probiotic, and/or antibiotic interventions), are currently available treatment options for these disorders. Current proposed pharmacological agents modulating pathophysiological mechanisms include prokinetic agents (5-HT4R agonists, 5-HT3R antagonists, 5-HT1AR agonists, ghrelin receptor agonists, dopamine-2 receptor antagonists, and muscarinic receptor antagonists) for altered gut motility, mast cell stabilizer for gut immune dysfunction, acid suppression therapy and histamine receptor-1 (HRH1) antagonists for impaired duodenal clearance of gastric acid and visceral hypersensitivity, μ-Opioid receptor (μ-OR) ligands and cannabinoid type 2 receptor (CB2R) agonist for visceral pain, chloride channel 2 (CCL2) and guanylate cyclase-C (GC-C) receptor agonists for altered GI secretion, farnesoid X receptor (FXR) agonist and ileal bile acid transporter (IBAT) antagonist for altered BA secretion, central and visceral neuromodulators [tricyclic anti-depressant (TCA), tetracyclic anti-depressants (TeCA), serotonin noradrenaline reuptake inhibitors (SNRIs), and selective serotonin reuptake inhibitors (SSRIs)] for altered gut-brain axis ( Drossman et al, 2018 ; Simren and Tack, 2018 ; Grover et al, 2019 ; Masuy et al, 2019b ; Black et al, 2020b ; Ghoshal, 2020 ; Camilleri, 2021 ; Sharma et al, 2021 ) ( Figure 1 ). However, it is of utmost importance to unearth alternative treatment options that target the pathophysiological mechanisms underlying these conditions.…”

Letter: non‐invasive transabdominal stimulation device for the treatment of chronic constipation—proof‐of‐principle study in adults

“…In their recent review, 1 Sharma et al highlight that while continuous sacral nerve stimulation is a minimally surgically invasive option available for patients with chronic idiopathic constipation (CIC), efficacy data are lacking. We report on the results from a proof-of-principle study testing whether a novel non-invasive TENS device (Rhythm.IC) that has eight electrodes arranged in a belt designed to deliver TENS IFC stimulation to the mid and lower abdomen is able to improve symptoms of chronic constipation and quality of life in adults.…”