| Summary: | The first step in
managing a patient with constipation is to understand the precise
nature of the complaint. Is the onset recent? What are the frequency
and form of the stools, and how much effort is required to
defecate? Is constipation steady or alternating as in irritable bowel
syndrome? Are there structural, metabolic or pharmacological
confounders? Is the patient depressed? Has dietary fibre been tried
at a sufficient dose? What are the patient’s understanding and beliefs
about the symptoms? Has there been sufficient and appropriate
investigation? Armed with the answers to these questions,
physicians can help most patients through lifestyle, dietary and
pharmacological adjustments, along with supplementary fibre.
Some patients may require regular doses of an osmotic laxative.
Those few that fail these measures should have their transit time
estimated while on a high fibre diet; if it is normal, further testing
is unlikely to help. The above efforts should be re-emphasized, and
reassurance should be offered. Some patients may require a psychological
assessment. If transit time is prolonged and the patient
may benefit from surgery for colonic inertia or biofeedback for anismus,
then colon and anorectal function should be assessed. The
decision to perform further tests should be made carefully, and unrealistic
expectations should be discouraged. Before surgery is offered,
the patient should have the benefit of receiving an expert
opinion. Biofeedback helps some patients with isolated anorectal
dysfunction.
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