Document 6428501

SUMMARIES
CHRONIC CONSTIPATION:
NEW THOUGHTS ABOUT AN OLD PROBLEM*
—
Julia Pallentino, MSN, JD, ARNP-BC,† and Lawrence R. Schiller, MD, FACP, FACG‡
NEW THOUGHTS ABOUT AN OLD PROBLEM: THE IMPACT AND DIAGNOSIS OF
CHRONIC CONSTIPATION
Based on a presentation by Pallentino J
Medical Group of North Florida, Tallahassee, Florida
At first glance, chronic constipation may be considered a trivial symptom, or at least not a serious one. Yet,
for individuals experiencing chronic constipation, the
impact is significant and often far-reaching into many
aspects of quality of life and functioning.
Chronic constipation is encountered frequently in
many areas of healthcare beyond gastroenterology,
including primary care, geriatrics, psychiatry, cardiology, neurology, pain and addiction medicine, and physical rehabilitation. In fact, with a prevalence of 12% to
19% among US adults, it ranks among the most common chronic diseases, including coronary heart disease
(5.9%), asthma (6.4%), diabetes (6.7%), migraine
(15.1%), and hypertension (21.6%).1
THE BURDEN OF CHRONIC CONSTIPATION
By the time a patient presents with chronic constipation, it has already become a debilitating problem.
The patient may have been dealing with it for years,
perhaps intermittently over his or her lifetime. In one
*The following summaries are based on presentations at
a symposium held at the 2006 National Conference of the
American Academy of Nurse Practitioners, Grapevine,
Texas, June 21, 2006.
†Medical Group of North Florida, Gastroenterology
Practice, Tallahassee, Florida.
‡Gastroenterology Department, Baylor University
Medical Center, Dallas, Texas.
Address correspondence to: Julia Pallentino, MSN, JD,
ARNP-BC, Medical Group of North Florida, 2626 Care Drive,
Tallahassee, FL 32308. E-mail: [email protected].
166
study, nearly 90% of patients with constipation continued to report constipation during the 12 to 20
months of follow-up.2,3
Constipation occurs more than twice as frequently
in women than men, at a ratio of 2.2:1.2 It increases in
prevalence with age, particularly after age 65 years, and
with lower amounts of exercise. It is associated with
well-known factors, such as depression and psychological distress, in addition to several lesser known factors,
such as low socioeconomic classes (perhaps because of
a diet low in fiber), lower educational level, and nonCaucasian ethnicity.2
DIAGNOSIS—WHAT EXACTLY IS CONSTIPATION?
Most people (clinicians and patients) define constipation as too few stools per unit of time—that is,
infrequency is the primary criterion. However, for the
patient, frequency is often a less pressing concern than
other aspects of stool passage. Patients with self-reported constipation report many symptoms other than low
stool frequency, such as straining (81%), hard or
lumpy stools (72%), incomplete evacuation (54%),
inability to evacuate stools (39%), abdominal bloating
or fullness (37%), and a need to press around or in
front of the anus for evacuation (28%); by contrast,
36% report having fewer than 3 bowel movements per
week.4 In fact, some patients are quite comfortable
with once-weekly bowel movements that are easy to
pass; however, they still express concern about constipation because of the general preoccupation with frequency. Therefore, when a patient reports
constipation, it is important to help the patient define
what he or she means by this term, because the patient
may not be experiencing infrequent stools.
The American College of Gastroenterology (ACG)
Vol. 4, No. 7
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SUMMARIES
appointed a task force to examine the current diagnosis
and treatment of chronic constipation. The Task Force
criteria for constipation is unsatisfactory defecation characterized by infrequent stools, difficult stool passage
(including straining, a sense of difficulty passing stool,
incomplete evacuation, hard or lumpy stools, prolonged
time to expel stool, or need for manual maneuvers to
pass stool), or both. Manual maneuvers to ease stool passage include placing pressure on the perineum to raise it,
placing a finger inside the vagina to push the stool back,
or in the anus itself to widen the opening.5 A common
source of confusion is the difference between chronic
constipation and irritable bowel syndrome (IBS) with
constipation. In fact, they may be a continuum of a single disorder. Pain often is identified as the discriminating
factor between the 2 disorders with pain associated with
IBS. However, practically speaking the treatment for
both disorders is very similar.
patient will most likely have tried several types of fiber
supplements or over-the-counter laxatives, which were
ineffective. Thus, it is important to identify the most
distressing symptom(s) in addition to the type and frequency of laxative or fiber supplement the patient has
used. Enemas and suppositories are used frequently by
elderly patients. Herbal teas obtained at health food
stores and widely advertised on the Internet are being
used more frequently as laxatives. Identifying the
products the patient has tried unsuccessfully often can
Table 1. Alarm Features That May Suggest a
Secondary Cause of Constipation
• Hematochezia (blood in the stool)
• Family history of colon cancer
• Family history of inflammatory bowel disease
INITIAL WORKUP
• Anemia
• Positive fecal occult blood test
Because many patients are embarrassed about constipation, or any discussion of bowel movements, the onus
is on the nurse to promote and ensure good communication between patient and healthcare practitioner. First,
encourage the patient to identify specifically his or her
symptoms (eg, infrequent stool or difficult passage) and
then look for red flags that may signal a more serious
problem. Red flags (or alarm features) are listed in Table
1.5 All patients with a red flag should undergo appropriate diagnostic testing. Patients without red flags will
most likely have functional chronic constipation and will
not likely require further testing for diagnosis.
• Severe, persistent constipation that is unresponsive to treatment
• New-onset constipation in an elderly patient
Adapted with permission from Brandt et al. Am J Gastroenterol.
2005;100:S5-S21.5
Table 2. Eliciting the Patient History for Chronic
Constipation
1. What brings you to see me? What are your concerns?
2. How long have you experienced these symptoms?
ELICITING THE PATIENT HISTORY
3. Does constipation limit your daily activities?
Nurses tend to be adept at history taking, which is an
essential component of managing chronic constipation.
Table 2 lists some of the most pertinent questions to ask
the patient presenting with symptoms of constipation, as
recommended by the American Gastroenterological
Association guideline on constipation.6
The chronicity of constipation symptoms is important to define. Remember that, even in the primary
care setting, patients will have suffered with these
symptoms for a long time before seeing a healthcare
practitioner. The patient, at this point, is in a significant amount of physical and mental discomfort, in
addition to possibly being functionally impaired. The
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• Unexplained weight loss ≥10 lb
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4. What is your most distressing symptom?
5. What is your approximate intake of dietary fiber?
6. What laxatives have you tried? Are you currently using laxatives? How often? What dosage?
7. Are you using enemas or suppositories?
8. Are you taking any herbal medications or teas?
9. How often do you have bowel movements?
10. What is the consistency of your stool?
11. How often do you feel the urge to defecate? Do you always
attempt to have a bowel movement after this feeling?
12. What other symptoms do you experience—straining, feelings
of incomplete evacuation, or need for manual maneuvers?
Data from Locke et al.6
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SUMMARIES
Table 3. Medications That Commonly Cause
Constipation
Prescription Drugs
Nonprescription Drugs
Opiates
Antacids, especially calcium-containing
Anticholinergic agents
Calcium supplements
Tricyclic antidepressants
Iron supplements
Calcium channel blockers
Antidiarrheal agents
Antiparkinsonian drugs
Nonsteroidal anti-inflammatory drugs
Sympathomimetics
Antihistamines
Antipsychotics
Diuretics
Antihistamines
Patients often face the choice of relieving 1 disorder (eg, pain or depression) or relieving their constipation. It is important to reassure them that
treatments for constipation are available, thus they can continue to use
their medications when no less constipating alternative exists.
orders (eg, spinal cord injury or paralysis), collagen,
vascular, and muscular disorders (eg, multiple sclerosis
or myasthenia gravis), and pregnancy.9
Many patients want to know why they are constipated. Even if a definitive cause cannot be identified, the
treatments are the same. However, it is useful to be able
to explain the physiology of a bowel movement. Figure
1 shows a diagram of normal anorectal anatomy.10
Understanding the physiology of bowel movements can
help to align symptoms with causes. For example, lack of
urge and decreased stool frequency suggest a slow-transit
disorder. Symptoms suggestive of a defecatory disorder
include hard stools, impaction, need for digital maneuvers, feelings of anal blockage, severe straining, high anal
sphincter tone at rest, minimal (<1 cm) or excessive
(>3.5 cm) perineal descent, tender puborectalis muscle
on palpation, and defect in the anterior wall of the rectum suggestive of a rectocele.10-12
OTHER COMPONENTS OF THE CONSTIPATION WORKUP
help to more completely estimate the severity of the
problem.
Other important features that need to be defined
are stool consistency and urgency. In older patients
with intermittent loose stools, for example, fecal
impaction should be considered and ruled out. Among
younger patients with busy schedules and lifestyles, the
urge to defecate is frequently lost, particularly, in my
experience, among young professionals and students,
because normal urges to defecate (eg, after breakfast
and coffee) are ignored. Bloating is also a very common symptom of constipation and often is cited by
patients as one of the most uncomfortable.
If it is difficult to ascertain from patients their constipation symptoms, it is even more difficult to
encourage a discussion of stool type. However, this
Figure 1. Normal Anorectal Anatomy and Physiology
THE CAUSES OF CONSTIPATION
Primary causes of constipation include normaltransit constipation, defecatory disorders, IBS with
constipation, and slow-transit constipation (colonic
inertia). Defecatory disorders include rectocele (a
common cause), megarectum, perineal descent (in
which the pelvic floor cannot support the rectum, also
common), and pelvic floor dyssynergia, which is greatly underdiagnosed and undertreated.7,8
There are several secondary causes of constipation,
the most common of which is medication (Table 3).6
Other secondary causes of constipation include
mechanical obstruction, metabolic and endocrine disorders (particularly hypothyroidism), neurologic dis-
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The rectum sits almost at a right angle (the anorectal angle) to the anal sphincter, maintained by the puborectalis muscle, a loop of muscle that runs from
the front of the pelvis around the back of the rectum and can remain contracted for long periods. This muscle is most important for preserving solid
fecal continence; the anal sphincter is essential for continence with water,
stools, and flatulence. For stool to pass, the rectum needs to elongate, which
is accomplished by relaxation of the puborectalis muscle. A common cause of
constipation is the inability to relax this muscle, so that stool remains trapped
at the anorectal angle—pelvic floor dyssynergia. In primary care, approximately
33% of patients may have pelvic floor disorders associated with constipation.
Reprinted with permission from Lembo and Camilleri. N Engl J Med.
2003;349:1360-1368.10
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SUMMARIES
Figure 2. The Bristol Stool Scale
SLOW Type 1
TRANSIT
Separate hard lumps,, like nuts
Type 2
Sausage-like but lumpy
Type 3
Like a sausage but with cracks in
the surface
Type 4
Like a sausage or snake, smooth
and soft
Type 5
Soft blobs with clear-cut edges
Type 6
Fluffy pieces with ragged edges, a
mushy stool
RAPID
Type 7
TRANSIT
Watery, no solid pieces
Reprinted with permission from Lewis and Heaton. Scand J Gastroenterol.
1997;32:920-924.13
information can help to determine the cause of constipation. The Bristol Stool Scale (Figure 2) is a useful
graphical aid that patients can use to simply point to
the stool type they pass. As shown in Figure 2, the scale
also correlates well with stool transit.13-15 Prolonged
colon transit produces hard, lumpy stools whereas
rapid transit produces loose, watery stools.
The rectal examination is an important part of the
patient examination because it can demonstrate whether
the muscles in the rectal area (eg, the puborectalis) are
functioning correctly. (The puborectalis feels like a bar
that extends across the posterior of the rectum.) These
muscles are within a finger’s length of the anus. In fact,
rectal examinations should be part of a complete physical examination for healthy adults. The rectal examination also should include a gross anatomical evaluation to
Table 4. First-Line Treatments for Constipation
ACG Task Force
Recommendation
Treatment
Mechanism
Available Products
Fiber
Long-chain polysaccharides and several other plant
components, such as cellulose, lignin, and waxes, which
are not digested in the human stomach or small intestine.
Psyllium
Methylcellulose
Calcium polycarbophil
Guar gum
Grade B (psyllium)
Bulking agents
Poorly absorbed agents that act by absorbing liquids in the
intestines. The ingested bolus then swells to form a soft
bulky stool, which prompts a bowel movement.
Psyllium
Most other fiber supplements
Grade B (psyllium)
Stool softeners
Minor laxative agents that modestly reduce fluid absorption
and thereby prevent dry, hard stools from forming. These
products decrease the need for straining and facilitate the
ability to evacuate the bowel.
Laxatives
Osmotic/saline
Promote retention of water within the bowel lumen,
softening the stool and increasing bowel actions.
Grade B
Saline laxatives (eg, magnesium
Grade A (polyethylene
hydroxide [milk of magnesia],
glycol and lactulose)
magnesium citrate, and sodium
phosphate)
Nonabsorbable sugars or sugar alcohols
(eg, lactulose, sorbitol, mannitol, or lactitol)
Certain polymers (eg, polyethylene glycol)
Irritant/stimulant Act on the intestinal wall, stimulating secretion of water
and salt by the mucosa and increasing muscle contractions
to move the stool.
Lubricant
Coats the bowel and is incorporated into the stool mass,
keeping it soft and easing passage through the digestive tract.
None
Mineral oil
None
ACG = American College of Gastroenterology.
Data from Brandt et al.5
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SUMMARIES
look for external and internal hemorrhoids, anal fissures,
rectal prolapse, and rectocele.7
The final part of the constipation workup is the laboratory tests. Some of the basic clinical laboratory tests
that may be performed for patients with constipation
include a complete blood count, thyroid function tests
(thyroid-stimulating hormone, free thyroxine), and measurements of calcium and electrolytes.10 The ACG Task
Force does not recommend diagnostic testing in patients
without alarm signs or symptoms (other than routine
colon cancer screening for all patients aged ≥50 years).5
Nonetheless, these tests can be useful as a general measure of overall health.
With appropriate diagnostic skills, a thorough evaluation, and a sense of empathy and comfort from the
nurse, chronic constipation can be better managed in
any of the varied clinical areas in which it is so frequently encountered.
NEW TREATMENTS FOR AN OLD PROBLEM:
CHRONIC CONSTIPATION
Based on a presentation by Schiller LR
Baylor University Medical Center, Dallas, Texas
Patients suffering from chronic constipation are
often willing to try anything to relieve their pain and
discomfort. However, first-line treatments for constipation are, in fact, very simple: increased dietary fiber,
fluids, exercise, and allocating time to have a bowel
movement. Patients will most likely have tried the first
3 treatments on their own. It is important to document what has been tried and the results. On the other
hand, allocating a dedicated and sufficient time for a
bowel movement is often not considered, but is a common remedy for chronic constipation. The best time
for a bowel movement is in the morning, after breakfast, when digestive stimuli prompt the urge to evacuate the bowels. If that urge is ignored, it tends to
diminish over time. With the exception of increased
dietary fiber, scientific evidence showing the efficacy of
these simple treatments is lacking (and they are not
discussed in this article), but this has not diminished
their popularity or usefulness.
If the patient is not consuming sufficient fiber (>20 g
daily), he or she should begin with lower doses (4–6 g
daily) of dietary fiber, such as bran, or medicinal fiber,
such as psyllium, and increase it gradually to avoid
bloating and flatulence. There are many types of med-
170
icinal fiber supplements available (Table 4).5 The fiber
content for different foods is available on some Web
sites (Table 5) and on the nutrition labeling of products. The total recommended daily intake of fiber (diet
+ supplementation) is 20 to 25 g, but could be
increased to 30 g if necessary.16 Bulking agents improve
bowel frequency and consistency (Table 4).5 Stool softeners (Table 4) are often the second treatment patients
try after bulking agents. They may not be as effective
as psyllium for increasing stool frequency, but many
patients have had great success with them.5
There are several types of laxatives (Table 4).
Although there is insufficient scientific evidence to
support a recommendation about using magnesium
hydroxide for chronic constipation, many patients try
it because it is promoted as a “more gentle treatment
that works overnight.” The taste of milk of magnesia is
an issue for many patients and some claim that it
“stops working” after a while, although it is not clear
why this occurs. Sugar alcohol laxatives have the possible disadvantage of causing excessive flatus produced
by bacterial metabolism of these fermentable substrates in the colon.5 Of note, any osmotic laxative can
create fluid or electrolyte abnormalities if used inappropriately and may cause hypovolemia or diarrhea.5,10
Stimulant (irritant) laxatives may induce cramping
and discomfort associated with bowel movement and
occasionally electrolyte imbalances. Allergic reactions
complicate the use of some of the plant-based products. Therefore, they should be used for short-term
relief rather than as a long-term solution to a chronic
problem.5,10 Mineral oil is sometimes used as an acute
Table 5. Web Sites Listing the Fiber Content of
Common Foods
Harvard University Health Services, Nutrition Know How
http://huhs.harvard.edu/PDF/FiberContentNutritiionFall2004a.pdf
Continuum Health Partners, Dietary Fiber Chart
http://www.wehealnewyork.org/healthinfo/dietaryfiber/fibercontentchart.html
The Mayo Clinic
http://www.mayoclinic.com/health/fiber/NU00033
University of Arizona, College of Agriculture and Life Sciences
http://cals.arizona.edu/pubs/health/az1127.html
American Dietetic Association, Fiber Facts
http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/nutrition_5440_E
NU_HTML.htm
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SUMMARIES
treatment for children, less so with adults. Aspiration
of mineral oil produces a lipoid pneumonia that may
be difficult to treat.
In general, regular intake of currently available laxatives is considered unlikely to be harmful to the colon
and data do not support a potential for addiction.5
However, although laxative preparations are effective
for short-term relief, they tend to cause unpleasant
side effects that preclude their long-term use.5,10 The
ACG Task Force specifically recommended psyllium,
stool softeners, polyethylene glycol, and lactulose for
use as laxatives, citing insufficient data to make recommendations for any other laxative treatments.5
NEWER TREATMENTS FOR CONSTIPATION
TEGASEROD
Tegaserod is indicated for IBS with constipation in
women and for chronic constipation in men and
women under age 65. The ACG Task Force gave
tegaserod a grade A recommendation for the treatment
of chronic constipation.5 Tegaserod acts by enhancing
the peristaltic reflex (and thus moving the fecal bolus
through the gastrointestinal [GI] tract) by mimicking
serotonin. Tegaserod also may decrease visceral sensitivity, thus decreasing the amount of pain associated
with IBS with constipation.17-19
Two published, large, placebo-controlled clinical
trials show the efficacy of tegaserod in chronic constipation, increasing the number of complete spontaneous bowel movements per week by at least 1 over the
first 4 weeks of treatment (Figure 3).20,21 Tegaserod produced statistically significant improvement over placebo for the full 12 weeks of treatment and when
treatment is extended to 13 months beyond the initial
12-week treatment period.20-22
Tegaserod is well tolerated.20,21 The most frequent
side effect is diarrhea that typically lasts from 1 to 2
days when first starting the medication. There are no
clinically relevant drug-drug interactions with
tegaserod, and no prolongation of QT intervals on
electrocardiography.20-22 Also, there is no apparent
rebound effect when tegaserod was discontinued over
a 4-week withdrawal period.20,21 There is a precaution
noted in the labeling for tegaserod regarding recently
reported cases of ischemic colitis with tegaserod use:
“[tegaserod] should be discontinued immediately in
patients who develop symptoms of ischemic colitis,
such as rectal bleeding, bloody diarrhea, or new or
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n
worsening abdominal pain.”23 However, a causal association has not been established, and the occurrence of
ischemic colitis may be no higher with the drug than
with the underlying condition alone.
LUBIPROSTONE
Lubiprostone is indicated for the treatment of
chronic constipation in adults.24 It selectively activates
a specific subset of chloride channels (ClC-2 channels)
on the cells lining the GI tract, thus enhancing fluid
secretion into the intestine. This promotes spontaneous bowel movements, softens the stool, and
reduces abdominal discomfort/pain and bloating.25,26 It
does not have detectable systemic absorption.27,28
Lubiprostone has been studied in 2 large clinical
trials, producing significantly more spontaneous bowel
movements per week than placebo (Figure 4).28-30
Lubiprostone is equally effective in men and women
and, importantly, is effective in elderly patients.31,32
The most common side effects with lubiprostone
were nausea, diarrhea, and headache.28,33-37 Nausea can
be minimized by taking lubiprostone with food or by
reducing the dose. Most study subjects tolerated the
nausea in order to relieve their constipation; however,
approximately 10% of patients discontinued lubipros-
Figure 3. Responder Rate During the First 4 Weeks
of 12-Week Studies of Tegaserod vs Placebo
Placebo
Responder rates, %
Tegaserod 2 mg BIID
Tegaserod 6 mg BID
50
41*
43*
50
40
40*
40
36 †
30
25
20
27
20
10
0
30
10
0
n = 447 n = 450 n = 451
n = 416 n = 417 n = 431
Responders had an increase of ≥1 spontaneous complete bowel movement/wk and completed ≥7 days of treatment. Responder rates were significantly higher than placebo for the primary study endpoint (weeks 1–4)
and the secondary endpoint (weeks 1–12, not shown).
BID = twice a day.
*P <.0001; †P <.01.
Adapted with permission from Johanson et al. Clin Gastroenterol
Hepatol. 2004;2:796-80520 and Kamm et al. Am J Gastroenterol.
2005;100:362-372.21
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SUMMARIES
and appropriate specialized investigations are essential
for the diagnosis and selection of appropriate treatment for chronic constipation. Patients should be
referred to a gastroenterologist if they present with
new-onset constipation with any alarm symptoms, if
they require high doses of medication to adequately
treat the constipation, or if constipation is not alleviated with any of the recommended treatments.
Patients also should be referred if they are thought to
Figure 4. Efficacy of Lubiprostone vs Placebo in 4Week Studies
(A)
7
‡
SBMs per week
6
*
5
‡
LUB
PL
†
4
†
3
2
1
Table 6. Tests to Determine Cause of Constipation
0
(B)
7
†
6
SBMs per week
Test
5
†
†
†
Anorectal
manometry10,40
Assesses the internal and external anal sphincters (voluntary relaxation and contraction), rectal sensation,
pelvic floor, and associated nerves
Screening test of choice for outlet obstruction
Especially useful for detecting pelvic floor dyssynergia
Balloon
expulsion10,40
Simple, office-based test
Detects defecatory disorders
Method: Involves placing and inflating a balloon (50 mL)
inside rectum; most individuals can expel the balloon
within 60 sec
4
3
2
1
0
Baseline
Wk 1
Wk 2
Wk 3
Wk 4
In these studies, 237 patients (A) or 242 patients (B) received oral lubiprostone 24 µg or placebo BID for 4 weeks, preceded by a 2-week drug-free
washout period.
BID = twice a day; LUB = lubiprostone; PL = placebo; SBM = spontaneous
bowel movement.
*P <.05 vs placebo; †P <.007 vs placebo; ‡P ≤.0004 vs placebo.
Reprinted with permission from McKeage et al. Drugs. 2006;66:873-879.28
tone because of nausea.24 Lubiprostone does not cause
any electrolyte imbalances or renal dysfunction, and
systemic drug-drug interactions have not been a problem.38 Finally, the prescribing information suggests
that lubiprostone be used in women only if they are
not pregnant (verified by a negative pregnancy test)
because of the potential for fetal loss observed in
guinea pigs who received lubiprostone.24
WHEN TO REFER TO A GASTROENTEROLOGIST
An accurate history, careful physical examination,
172
Use
Defecography10,40 Detects structural abnormalities of the rectum, assesses
degree of bowel evacuation, and measures the anorectal angle
Operator dependent, can cause performance anxiety in
patient, poor reliability, not widely available
Method: Balloon is inserted into the rectum and inflated to simulate stool, prompting the urge to evacuate
the bowels. Patients are asked to note how this feels
and to relax the sphincter muscles and pelvic floor
while contracting the diaphragm and abdominal wall
muscles to increase intra-abdominal pressure
Colonic transit
study10,40
Measures rate at which fecal mass moves through colon
Essential for diagnosis of slow-transit constipation
Should always be performed before considering surgery
for chronic constipation
Method: Patient ingests radio-opaque markers in a
gelatin capsule; abdominal radiography performed
120 h later
Biofeedback10,39,41
Emphasizes coordination of appropriate muscles during
defecation
Rapport with therapist is crucial to success
Approximately 70% success rate; effects appear to be
long lasting (up to 1 year)
Only 12 major motility centers in the United States
Method: Patient views pressure signals of the anal
sphincter on a monitor during relaxing and squeezing
to train pelvic floor muscles
Data from Lembo and Camilleri10; Rao et al39; Rao et al40; and Chiarioni et al.41
Vol. 4, No. 7
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November 2006
SUMMARIES
have pelvic floor dyssynergia (also known as functional outlet obstruction or anismus).
When patients are referred, the gastroenterologist
may perform colonoscopy to exclude causes of secondary constipation, such as obstructing lesions, or
they may perform any of several tests to discern the
pathophysiology of constipation. In clinical practice,
the most useful pathophysiologic tests are anorectal
manometry, balloon expulsion, defecography, and
colonic marker transit study (Table 6).10,39-41
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