CLINICAL MANAGEMENT OF INTRACTABLE CONSTIPATION

Purpose: To review current management of intractable constipation. Data Sources: Original articles and reviews published in the English-language literature between 1965 and 1993 identified by MEDLINE search. Verbal feedback from attendees after presentation of the document as a clinical symposium at the 14th International Symposium on Gastrointestinal Motility in September 1993. Study Selection: Key words included constipation, epidemiology, colonic inertia, pseudo-obstruction, pelvic floor dysfunction, and results of therapeutic interventions, particularly the effects of biofeedback training and subtotal colectomy. Results: In most patients, constipation is usually due to lack of dietary fiber and responds to simple measures to correct these factors, often without consulting a physician. In some, probably fewer than 10% of patients who consult their physicians, structural diseases of the colon and rectum, systemic disease, or medications that slow gut transit should be excluded, and regular exercise, dietary fiber, and an osmotic laxative prescribed. In a series of 277 highly selected patients from a tertiary referral center who had intractable constipation, only 29% had a definable abnormality; identification of abnormal transit facilitates selection of patients for further investigations identifying colonic inertia or pelvic floor dysfunction. Conclusion: An algorithmic approach can carefully select patients with intractable constipation for behavioral modification and biofeedback; the long-term outcome is excellent, with at least 75% success in several series. In a minority of patients with slow transit constipation unresponsive to medical treatment, subtotal colectomy with ileorectostomy is indicated and effective.