HOW TO IDENTIFY , COUNSEL , AND TREAT PATIENTS WITH CHRONIC CONSTIPATION AND IRRITABLE BOWEL SYNDROME * —

Though not a life-threatening condition, chronic constipation has a substantial adverse impact on health-related quality of life and is the source of a vast sum of annual healthcare expenditures. A possible contributing factor is an apparent disconnect between patient and physician views on what constitutes constipation. Patients tend to characterize constipation in descriptive, symptom-related terms, whereas physicians most often define constipation in terms of bowel movement frequency. Three subtypes of constipation have been identified: slowtransit constipation, defecatory disorders, and normal-transit constipation. The recognition of these subtypes in clinical practice can be useful in determining the most appropriate approach to treatment for an individual patient. A good medical history and physical examination form the basis for diagnosis of constipation. Laboratory assessment should be limited, and specialized testing has a role in few patients. Current treatment options have increased in recent years and now include lifestyle changes, fiber supplementation, polyethylene glycol, lactulose, tegaserod, and lubiprostone. New agents under investigation reflect recent advances in knowledge about the underlying pathophysiologic mechanisms of constipation. Surgery rarely has a role in the treatment of constipation. (Adv Stud Med. 2006;6(4A):S243-S249) I n the evaluation and management of chronic constipation, physicians’ and patients’ perspectives are shaped by the definitions they bring to the clinical setting. Patients use a variety of descriptive terms to define constipation, with straining, hard/lumpy stools, and incomplete emptying heading the list. Physicians tend to think in terms of bowel movement frequency when defining constipation. The disconnect between patient and physician perspectives can be seen in a study that showed only 13% of patients with constipation reported having fewer than 3 bowel movements weekly. Two sets of formal criteria have been developed to define constipation. The Rome II diagnostic criteria define constipation as having at least 2 of 6 symptoms for at least 12 weeks, not necessarily consecutive, over the past year. The American College of Gastroenterology has developed a simpler and perhaps more clinically relevant definition: unsatisfactory defecation characterized by infrequent bowel movements, difficult stool passage, or both (Table 1). Several risk factors have been associated with an increased risk for constipation, including age younger than 4 years or older than 65 years, female gender, and several concurrent diseases (ie, multiple sclerosis, dementia, or Parkinson’s disease). Other potential risk factors include low income, polypharmacy, decreased physical activity, limited education, and history of sexual abuse. Notably, low dietary fiber intake has not been linked to constipation. Chronic constipation adversely affects quality of life (QOL). One representative review showed that patients with chronic constipation had consistently lower scores on the domains of a QOL assessment, including physical functioning, role function, social functioning, mental health, perception of health, and bodily pain. PROCEEDINGS