CLINICAL MANAGEMENT OF CONSTIPATION

First, it is important to find out whether the patient is complaining of infrequent defaecation, excessive straining at defaecation, abdomin al pain or bloating, a general sense of malaise attributed to constipa tion, soiling, or a combination of more than one symptom. Second, one must decide if there is a definable abnormality as a cause of the symp tom(s). Is the colon apparently normal or is its lumen widened (megaco lon)? Is the upper gut normal or is there evidence of neuropathy or my opathy? Is the ano-rectum normal or is there evidence of a weak pelvic floor, mucosal prolapse, major rectocele, an internal intussusception or solitary rectal ulcer? Is there any systemic component such as hyp othyroidism, hypercalcaemia, neurological or psychiatric disorder or r elevant drug therapy? Choice of treatment will depend on this clinical evaluation. The range of treatments available is: Reassurance and sto p current treatment: Patients with a bowel obsession may take laxative s or rectal preparations regularly without need. Increase dietary fibr e: Most cases of 'simple' constipation respond to increased dietary fi bre, possibly with an added supplement of natural bran. Toilet trainin g and altered routine of life: Young people particularly may need to r ecognise the call to stool and alter their daily routine to permit and encourage regular defaecation. Medicinal bulking agent: Ispaghula, me thyl cellulose, concentrated wheat germ or bran, and similar preparati ons are useful when patients with a normal colon find it difficult to take adequate dietary fibre. These preparations increase the bulk of s tool and soften its consistency. They may be useful for those patients with the constipated form of irritable bowel syndrome. Additional bul k does not help patients with megacolon or severe idiopathic slow tran sit constipation. Osmotic laxatives or saline perfusion: Preparations of magnesium hydroxide or sulphate, sodium sulphate, or mannitol softe n the stool and if taken in sufficient quantity produce a liquid stool . Magnesium hydroxide is a useful mild laxative for use in childhood. Patients with idiopathic megacolon need to keep the stools liquid with an osmotic laxative. Stimulant laxatives: Anthranoid preparations, bi sacodyl and its derivatives are used occasionally by many patients and regularly by some patients with severe idiopathic slow transit consti pation. Prokinetic drugs: Can be helpful as a supplement to laxatives. Rectal preparations: Useful particularly for emptying the rectum in c hildhood and elderly patients with rectal impaction and soiling. Biofe edback: Biofeedback training to increase rectal sensitivity to distens ion, relax the pelvic floor and increase the effectiveness of strainin g is proving beneficial for some patients with slow transit constipati on and many of those with marked paradoxical contraction of the pelvic floor including children with soiling. Psychological: Certain patient s, for example those with 'denied bowel actions' or eating disorders n eed primary psychiatric treatment. Other patients, for example those w ith a history of sexual abuse, may need it as a supportive measure. Su rgery: Surgery is needed for aganglionosis, a few patients with idiopa thic megacolon or idiopathic slow transit constipation or pseudoobstru ction, and for those with severe rectal mucosal prolapse.