5 WORLD GASTROENTEROLOGY NEWS MAY 2017 Editorial | Expert Point of View | WCOG at ACG 2017 | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events Treatment Chronic constipation is associated with impaired quality of life, increased health-care costs and with excess work absenteeism and about half of those who are seen by physicians are not sat-isfied with their response to therapy, leading to refractory constipation.(12) Bowel training can lead to im-provement in symptoms so it should be tried as a first-line treatment. It includes keeping a detailed diet log, a diary of stool frequency and consis-tency along with associated symptoms such as straining, the need for manual or positional maneuvers to facilitate defecation is important to empha-size.( 13) The day should begin with mild physical activity, consumption of a hot and preferably caffeinated beverage and a breakfast that includes a form of soluble fiber to induce high-amplitude peristaltic contractions within an hour of waking, taking advantage of several known factors that stimulate defecation.(2) Biofeedback using pelvic floor rehabilitation is the most effective treatment for PFD. Patients receive education about the process of defeca-tion, how to coordinate abdominal pressure with pelvic floor muscle relaxation during evacuation, and practice simulated defecation with a balloon.(14) During anorectal bio-feedback, patients are trained to use breathing techniques with relaxation of the pelvic floor muscles to produce a propulsive force that facilitates effec-tive evacuation. Biofeedback has been shown to be superior to laxatives, with a durable effect when used in patients with PFD.(15) Concomitant slow transit constipation frequently requires simultaneous treatment and can improve once the PFD has been rehabilitated. Supplementation with fiber is a mainstay in the management of chronic constipation and has been shown to be beneficial for mild to moderate constipation.(16) It facilitates bowel function by increasing the water absorption capacity of stool increasing stool bulk and facilitating its passage resulting in increased stool frequency.(17) Adequate hydration while using fiber is important. Ben-efits may not be evident for days and those with PFD may actually note worsening in their symptoms and it may even lead to fecal impaction, thus initiation at low doses and with cau-tion is recommended.(8) Laxatives have a common purpose of stimulating defecation or softening the consistency of stool in order to facilitate evacuation and newer agents have been developed to facilitate treat-ment of refractory cases None of the laxatives nor the newer agents have been evaluated in patients with PFD. (10) Lubiprostone and lineclotide have both been shown to be effective at Treatment may be as simple as lifestyle modifications or the addition of fiber but may require pharmacologic approach. increasing the number of spontaneous bowel movements, but neither has been specifically evaluated in patients with dyssynergic defecation. There is promising research investigating the use of bile salt inhibition and a synthetic form of ghrelin receptor analog.(2) Use of sacral nerve stimulation for refractory cases has been described but with conflicting results. Benefit has been found primarily with normal or slow transit constipation.(18) It is unclear if any additional value would be gained in those with PFD. Surgery for defecatory disorders should only be considered in those pa-tients who have evidence of retained contrast during a defecography and failed conservative approaches and pelvic floor rehabilitation.(19) Colecto-my with ileorectal anastomosis is the most commonly performed surgery and care has to be taken to rule out pan-intestinal dysmotility and those with pelvic floor dysfunction will have limited success due to the underlying physiology not being corrected. Finally, botox, a potent neurotoxin that inhibits presynaptic release of acetylcholine has been used to treat defecatory disorders by injection into the puborectalis muscle with mixed results.(20) A recent study used electro-myography to guide botox placement with improvement in pelvic floor pain and quality of life measures, but did not evaluate its impact on defecation. (21) Targeted therapy may therefore be the key to finding an effect for those with pelvic floor dyssynergy, specifi-cally for those with type I or type II manometric findings. Conclusions Constipation is common in the general population and teasing out the underlying etiology is key in order to provide the appropriate therapeutic intervention. Treatment may be as simple as lifestyle modifications or the addition of fiber but may require a pharmacologic approach. Often multiple treatment modalities are nec-essary to improve outcomes. Biofeed-back remains the mainstay of therapy for those with pelvic floor dyssynergy and it has shown to have durable effect. Refractory cases may need re-peated evaluation with consideration for surgery or botox injection. References 1. Higgins PD, Johanson JF. Epide-miology of constipation in North America: a systematic review. Am J Gastroenterol. 2004;99:750–9.
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