What are the treatment options for constipation and anal hysteria?

10 Board Questions on Constipation Management

The most effective first-line treatment for chronic constipation is polyethylene glycol (PEG) 17-34g daily, which should be initiated before considering other pharmacological interventions. 1

Question 1: First-line Management of Chronic Constipation

A 45-year-old patient presents with a 3-month history of infrequent bowel movements (twice weekly). Which of the following is the most appropriate initial management?

1. Docusate sodium
2. Polyethylene glycol
3. Bisacodyl
4. Methylnaltrexone
5. Total colectomy

Question 2: Opioid-Induced Constipation

A 62-year-old patient with metastatic cancer on opioid therapy has persistent constipation despite regular use of senna and polyethylene glycol. What is the most appropriate next step?

1. Increase senna dose
2. Add psyllium fiber
3. Methylnaltrexone 0.15 mg/kg subcutaneously
4. Discontinue opioids
5. Manual disimpaction

Question 3: Defecatory Disorders

A 50-year-old woman has symptoms of constipation with normal colonic transit time and evidence of pelvic floor dyssynergia on anorectal manometry. Which treatment is most appropriate?

1. Stimulant laxatives
2. Biofeedback therapy
3. Osmotic laxatives
4. Total colectomy
5. Lubiprostone

Question 4: Diagnostic Evaluation

A 35-year-old patient presents with a 6-month history of constipation unresponsive to increased fiber intake and osmotic laxatives. Which test should be performed next?

1. Colonoscopy
2. Anorectal manometry
3. CT abdomen
4. Thyroid function tests
5. Stool culture

Question 5: Surgical Management

Which patient would be most appropriate for consideration of total colectomy with ileorectal anastomosis?

1. Patient with irritable bowel syndrome with constipation
2. Patient with opioid-induced constipation
3. Patient with documented slow-transit constipation who failed aggressive medical management
4. Patient with pelvic floor dyssynergia
5. Patient with constipation of 2 weeks' duration

Question 6: Medication-Induced Constipation

A 70-year-old patient presents with new-onset constipation. Which medication is most likely to cause constipation?

1. Lisinopril
2. Furosemide
3. Amitriptyline
4. Metformin
5. Levothyroxine

Question 7: Constipation with Comorbidities

A 55-year-old patient with diabetes, hypothyroidism, and chronic constipation is not responding to fiber supplementation. Which factor is most important to address?

1. Increase fluid intake
2. Optimize thyroid replacement therapy
3. Improve glycemic control
4. Add stimulant laxatives
5. Perform colonoscopy

Question 8: Dietary Management

Which dietary recommendation has the strongest evidence for managing chronic constipation?

1. Elimination of dairy products
2. Low FODMAP diet
3. Increased soluble fiber intake
4. Gluten-free diet
5. Ketogenic diet

Question 9: Refractory Constipation

A 40-year-old patient has severe constipation despite trials of multiple laxatives, including polyethylene glycol, bisacodyl, and lubiprostone. Normal anorectal manometry and defecography. What is the next appropriate diagnostic test?

1. Colonic manometry
2. MRI defecography
3. Hydrogen breath test
4. Gastric emptying study
5. Exploratory laparoscopy

Question 10: Constipation Warning Signs

Which finding in a patient with constipation warrants immediate further evaluation?

1. Alternating constipation and diarrhea
2. Rectal bleeding
3. Constipation for 3 months
4. Bloating
5. Need for daily laxative use

Management Algorithm for Constipation

1. Initial Assessment:

   • Rule out serious causes: fecal impaction, bowel obstruction, metabolic causes (hypercalcemia, hypokalemia, hypothyroidism, diabetes) 1
   • Perform digital rectal examination to assess for impaction 1
   • Review medication list for constipating drugs (opioids, anticholinergics) 1

2. First-line Treatment:

   • Osmotic laxatives: PEG 17-34g daily 1
   • Alternatives: lactulose or magnesium hydroxide (avoid in renal impairment) 1
   • Lifestyle modifications: adequate hydration, increased physical activity 1, 2

3. If Inadequate Response:

   • Add stimulant laxatives: bisacodyl 10-15 mg, 2-3 times daily or senna 2-3 tablets twice daily 1
   • Consider adding soluble fiber (psyllium) if tolerated 3, 4

4. For Opioid-Induced Constipation:

   • Methylnaltrexone 0.15 mg/kg subcutaneously every other day 1
   • Oral alternative: naloxegol 1

5. For Suspected Defecatory Disorders:

   • Refer for anorectal testing (manometry, balloon expulsion) 3
   • Biofeedback therapy rather than continued laxative use 3, 1

6. For Refractory Cases:

   • Consider specialized testing: colonic transit studies, defecography 1
   • For documented slow-transit constipation: consider surgical options in highly selected cases (only ~5% of severe cases) 3

7. For Gastroparesis-Related Constipation:

   • Consider prokinetic agents such as metoclopramide 1

8. Newer Agents for Refractory Cases:

   • Lubiprostone for enhancing intestinal fluid secretion 3, 1
   • Linaclotide for chronic idiopathic constipation 3

Common Pitfalls to Avoid

• Relying solely on stool softeners without addressing motility 1
• Using bulk laxatives for opioid-induced constipation 1
• Using anticholinergic medications without addressing constipation first 1
• Failing to provide prophylactic laxatives when starting opioid therapy 1
• Using magnesium-based laxatives in patients with renal impairment 1
• Continuing laxative use beyond 1 week without reassessment 5
• Ignoring warning signs such as rectal bleeding, which may indicate serious conditions 6, 5