Indian Society of Gastroenterology consensus on chronic constipation in adults

M3 India Newsdesk Oct 09, 2019

The Indian Motility and Functional Diseases Association and the Indian Society of Gastroenterology developed this evidence-based practice guideline for the management of chronic constipation in Indian patients. The guidance includes diagnostic criteria, investigations, and treatment of CC in Indian patients.

Chronic constipation (CC) is a common problem all over the world. The Rome guidelines for constipation were updated in 2016; however there are considerable differences in the bowel habit, definition, epidemiology, and pathophysiology and management of CC in India as compared to the West. This led gastroenterologists and physicians in India to look into special issues on CC from an Indian perspective.


Epidemiology, clinical presentation, and diagnostic criteria

Statement No. 1. Chronic constipation is common in India

Studies indicate that CC is a common problem in India. Female population are more likely to suffer from CC than male due to slower transit, pelvic floor dysfunction due to obstetric trauma, harder stool forms, and over-reporting. The frequency of CC is also reported to increase with age.

Statement No. 2. Stool frequency is higher and forms softer in India

Colon transit time correlates inversely with Bristol stool forms; shorter transit time is associated with higher scores. Indian patients reportedly have softer stools than the patients from the West. Stool weight and stool frequency is also reported to be high in Indian population.

Statement No. 3. Constipation should be defined in India by stool forms and patients’ perception rather than by stool frequency

As the Indian population is associated with a higher daily stool frequency, the western definition of CC as a stool frequency < 3/week is expected to be insensitive and, hence, not applicable in the Indian setting.

Patient perception is vital to assess subjective symptoms; it helps categorize non-organic GI disorders that are diagnosed by symptom-based criteria. Studies suggest that patients' perception depends not only on the pathophysiology but also on socio-cultural factors.

Statement No. 4. Constipation-associated stools, defined as Bristol types I–III, increase diagnostic sensitivity of CC in India than types I–II, as defined in the West

As Indian patients reportedly have softer stools than the patients from the West, defining CC by stool forms as Bristol types I–II, may not be ideal in the Indian settings.

Statement No. 5. As abdominal pain is less in frequency and severity, functional constipation (FC) is more common than irritable bowel syndrome-constipation (IBS-C) in India

Abdominal pain is an important parameter to diagnose IBS as per the Rome criteria; however, in India, abdominal pain is less in frequency and severity among Indian patients with IBS. Thus, FC is reported to be more common than IBS-C in India.

Statement No. 6. Abdominal bloating is common in patients with CC

Abdominal bloating is significantly associated with FC and is observed more in FC patients as compared to IBS-C. Considering the fact that FC and IBS-C are quite overlapping during follow up, and have significant pathophysiological similarity, the extrapolation of data of IBS-C to FC may not be entirely inappropriate.

Statement No. 7. Detailed clinical evaluation including history and digital rectal examination helps in identifying fecal evacuation disorder

Fecal evacuation disorder (FED) can often be suspected and identified from a detailed clinical evaluation including digital rectal examination (DRE).

Statement No. 8. Fulfilling IBS criteria does not exclude fecal evacuation disorder and slow transit constipation

Diagnosis of IBS is clearly defined by the Rome foundation and Asian consensus, however, FED and slow transit constipation (STC) cannot be ruled out by these criteria alone. This point is also elaborated in the multidimensional clinical profile (MDCP) proposed by Rome IV, which considers FED and STC as physiological modifiers of CC.

Statement No. 9. Fecal evacuation disorder is more common among women than among men

Women are associated with a higher frequency of FED; this is due to the pelvic floor trauma during labor, which is considered to be a risk factor for FED.


Pathophysiology

Statement No. 10. Lifestyle factors, some systemic illnesses, several drugs, and physiological abnormalities such as slow colon transit and FED contribute to CC

Lifestyle factors are reported to contribute to CC. This includes the following:

  • Insufficient dietary fiber and fluid intake
  • Irregular and inadequate time in the toilet
  • Sedentary life
  • Prolonged bed rest
  • Systemic illnesses
  • Chronic consumption of drugs causing CC

In addition to above factors, slow colonic transit and FED also contribute to CC.

Statement No. 11. Obstetric trauma may contribute to the pelvic floor and anorectal abnormalities contributing to CC

Damage to pelvic connective tissue, nerves, and muscles during childbirth may lead to pelvic floor dysfunction (PFD). PFD manifests as severe constipation, obstructed defecation, rectocele, hemorrhoids, rectal prolapse, or incontinence. Older age, higher parity, and vaginal mode of delivery are some risk factors for PFD in females.

Statement No. 12. Indian toilet is more physiological than a western toilet for defecation

Defecatory postures vary as per the culture - squatting and sitting are the most common. As per the consensus, squatting is the ideal posture for defecation due to the following advantages:

  • Better relaxation of puborectalis and hence widening of recto-anal angle
  • Faster, easier, and more complete evacuation
  • Prevents excessive straining thereby protecting pelvic nerves from becoming stretched and damaged

Statement No. 13. Bristol stool form correlates with colon transit

Stool form is often used as a clinical surrogate for colon transit in constipated patients and Bristol stool form scale has been widely used for the same. Correlations have been observed between BSFS and whole-gut transit time. The use of Bristol stool form scale has been duly endorsed by the Rome Foundation too.

Statement No. 14. Specific pathophysiological abnormalities at the molecular level (myopathic, neuropathic, others) have been shown in a subset of patients with CC

Studies suggest that a subset of patients with CC may have some organic basis. However, demonstration of histological abnormalities in patients with CC is essentially limited to resected colon specimens, hence, these results cannot be generalized to patients with CC.

Statement No. 15. Excessive methane production slows gut transit and is associated with CC

Healthy humans harbor methane-producing bacteria in their gut. Methane inhibits GI motility and hence its level may inversely correlate with stool form and frequency - various studies support this fact. Additionally, the area under the curve (AUC) for breath methane has been shown to correlate with severity of constipation. Moreover, the finding that treatment with antibiotics against gut methanogens improves intestinal transit and constipation further strengthens this claim.

Statement No. 16. Psychological issues are common in patients with CC

Psychological disorders have been reported to be associated with CC and IBS. These co-morbidities impair quality of life in patients with CC. Patients with dyssynergic defecation and normal transit constipation or IBS-C are more prone to psychological distress as compared to slow transit constipation.

Statement No. 17. Solitary rectal ulcer syndrome is associated with FED

Solitary rectal ulcer syndrome (SRUS) is a chronic benign rectal disorder which presents with rectal bleeding, mucorrhea, tenesmus, constipation, and feeling of incomplete evacuation. Etiopathogenesis of SRUS is not clear, however, a few recent studies report the role of FED in the pathogenesis of SRUS. There is limited data for the frequency of FED in Indian patients with SRUS.


Investigations and treatment

Statement No. 18. Alarm feature which may necessitate invasive investigations like colonoscopy includes age > 45 years, visible or occult GI bleed, family history of colon cancer, unintended weight loss, abdominal mass, and fever

Alarm features help to screen patients for possible organic pathologies such as colon cancer. Screening for these features and appropriate investigations to exclude organic disease such as colon cancer is advisable. Fecal occult blood test (FOBT) either immunochemical (fecal immunochemical test, FIT) or guaic based can be used for screening. The FIT is a preferred test as it does not require dietary restrictions.

Statement No. 19. Initial treatment of CC should include lifestyle modification and osmotic laxatives

Even though there is lack of scientific data to prove their efficacy, lifestyle factors, may play some role in patients with CC. The following lifestyle measures are recommended by physicians:

  • Adequate dietary fiber intake
  • Drinking plenty of water
  • Regular exercise
  • A healthy sleep pattern
  • Defecating in squatting posture

For the first line treatment of CC, osmotic laxatives are preferred by most physicians.

Statement No. 20. Fiber supplement should be avoided if the patient is already on high fiber diet and/or abdominal bloating is a prominent symptom

Fiber supplementation such as ispaghula husk is recommended for the treatment of CC, particularly if dietary fiber intake is low and bloating is not a major symptom. This provides soluble fiber in contrast to dietary fibers, which are often insoluble and cause gas and bloating.

Statement No. 21. Patients refractory to initial treatment should be investigated for pathophysiological factors like slow colon transit and FED

Refractory cases of CC, needs to be investigated for the complex pathophysiological issues such as slow colon transit and FED.

Statement No. 22. A through rectal examination evaluating resting and squeeze pressure and relaxation during attempted defecation is useful to screen for FED

FED is common among patients with CC. Laxative therapy alone is often unsatisfactory in such patients. As anorectal manometry is not widely available, it is important to know the common clinical parameters indicating the presence of FED in patients with CC. Resting and squeeze sphincter pressure in FED can be grossly assessed by digital rectal examination (DRE). The guideline states that it is important to recapitulate how DRE is performed as studies show that many doctors are not well-versed in performing DRE.

Statement No. 23. Western protocol for colonic transit study may not hold well in India

As the colon transit is much faster in Indian population, the protocol for assessment of colon transit time (CTT) developed in the Western countries may not apply well in the India settings. In Indian studies, which followed the western protocol of administering 20 radio-opaque markers each at 0, 24, and 48 h, and abdominal radiograph at 72 h, most of the markers were found expelled even in patients with CC.

Statement No. 24. Multiple test positivity including balloon expulsion test (BET), anorectal manometry, and defecography has better accuracy than a single test for diagnosis of FED

The use of a single test to diagnose FED may lead to over-diagnoses. Besides, considerable overlap exists between slow transit and FED, both of which requires therapeutic attention. An appropriate clinical setting in patients with CC and positive results in multiple tests [(anorectal manometry, BET, colon transit time (CTT), and defecography)] may detect FED with better accuracy.

BET is a simple bedside test to rule out FED. The test may be especially helpful when rectal manometry is not available. The sensitivity of BET for the diagnosis of FED is about 56%. Endoscopic ultrasonography of anal sphincter using the radial endosonoscope at a high frequency (12 Mhz) can be used to study the anatomy of the anal sphincter. In patients with SRU with FED, anal sphincter has been found to be thicker.

Statement No. 25. The top-down approach may be preferred in selected patients with CC in the open healthcare system of India, particularly in the tertiary care environment

The step-up approach is currently recommended as per guidelines to treat CC. However, most patients who have already received most of the conventional treatment like lifestyle and dietary modifications and common laxatives are unlikely to improve and be satisfied with a step-up approach. The authors have included this statement to motivate researchers,

particularly from the Asian countries, to undertake more research in this subject as it is very important issue in clinical practice and there is scarcity of data on this issue.

Another option instead of proceeding to top-down, may include step-up approach from whatever level the patients was treated in the past.

Statement No. 26. Drugs stimulating colonic motility should be preferred for management of slow transit constipation (STC)

Colokinetic agents such as Prucalopride and stimulant laxatives target the primary pathophysiological abnormality and increases colonic transit. Hence, they are recommended to treat STC.

Statement No. 27. Biofeedback should be the initial treatment for FED

Biofeedback is associated with a significant improvement in symptoms and complete spontaneous bowel movements (CSBM), and hence should be the initial treatment for FED.

Statement No. 28. Surgery should be reserved for patients with refractory CC with specific functional and or structural abnormalities

There is lack of evidence on surgery for CC from India. Even though some studies have demonstrated increased spontaneous bowel movement following surgery, it should be noted that the study population included patients with severe STC, large rectocele, and adult Hirschsprung’s disease. Hence, these results cannot be extrapolated to unselected patients with refractory CC.

Statement No. 29. Psychological evaluation must be performed before surgical treatment

As psychiatric illness may contribute to CC, it is important to perform psychological evaluation and proper counselling regarding the post-surgical outcome before surgical treatment.

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