CONSTIPATION. AN OLD NEW PROBLEM

Constipação. Um velho novo problema

Constipation is a common gastrointestinal condition in adults and children characterized by unsatisfactory defecation as a result of infrequent stools, difficult stool passage, or both. Definitions of this condition is influenced by variations in geography, language, culture, and level of education. This can create difficulties in interpretation and standardization of prevalence rates obtained from cross-sectional studies¹.

Clinical assessment of the patient with constipation requires careful history taking, in order to identify any red flag symptoms that would need further investigation with colonoscopy to exclude colorectal malignancy².

Global prevalence of functional constipation ranged from 15.3% using the Rome I criteria to 10.1%, when the Rome IV criteria was applied. Perhaps this is the reason why we have a significant difference between the prevalence of functional constipation when its definition has been established by the various consensuses over the years. In addition to updates within the criteria themselves, technological advances have enhanced and expanded methods of data collection^3-5.

The differentiation between constipation-predominant irritable bowel syndrome and functional (or chronic) constipation is not simple because both are remarkably similar in terms of their clinical phenotype and response to therapy, when the presence of abdominal pain, occurring on average at least 1 day/week in the last 3 months, associated with at least two of the following: Change in stool frequency (infrequent bowel movements), Change in stool form (hard stools) and related to defecation is its main differential symptom^6-8.

In this issue of Archives of Gastroenterology, two studies discuss relevant aspects related to the difficulties observed in the measurement and evaluation of constipation in terms of quantifying the changes observed in constipation as well as the diversity of therapeutic options and, a third paper seeks to evaluate and relate abdominal pain in children and to possible etiopathogenetic mechanisms, among them constipation.

Taniguchi et al. bring the proposal of a clinical score, adapted and aimed at the Brazilian population, aiming to create an environment to measure and quantify changes in intestinal dysfunction and serve as an initial guide for the choice of the best therapy⁹.

Perhaps one of the most important aspects of this work is to be adapted specifically to the Brazilian population because, as stated above, the diagnostic criteria are greatly influenced by the environment, habits, diet, and language comprehension, among other aspects. Patients and clinicians often diagnose functional constipation more pragmatically, based on the assessment of symptoms they consider important for a diagnosis.

In addition, this score system is a metric that can and should be used in the comparison of clinical complaints before and after treatment which will reflect on patient satisfaction. Patient satisfaction is an important metric in conditions such as constipation, and higher satisfaction predicts better clinical outcomes in chronic health conditions^10,11.

Passos et al., through a narrative review, from the perspective of a group of Brazilian experts cover the various aspects of functional constipation, from its pathophysiology to the current treatments of this condition, also highlighting the various alternatives for the correct diagnosis of this condition¹².

Still within the spectrum of functional diseases, Martins et al. in a retrospective epidemiological study in a child population, evaluate the prevalence of abdominal pain and its different possibilities, concluding that functional abdominal pain is the most frequent etiology followed by constipation¹³. A point of attention observed in children, is the long and extensive duration of the investigation and no evidence based medicine treatment, even in a tertiary care level^14-17.

Functional diseases, particularly constipation, continue an object of intense investigation mainly in order to better understand their pathophysiological mechanisms and establish a rationale treatment based on concrete and objective based evidence^18,19.

REFERENCES

• ¹
  Black CJ, Ford AC. Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management. Med J Aust. 2018;209:86-91.
• ²
  Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, et al. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation. Neurogastroenterol Motil. 2021;33:e14050.
• ³
  Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ, Thompson WG, et al. U. S. Householder survey of functional gastrointestinal disorders - Prevalence, sociodemography, and health impact. Dig Dis Sci 1993;38:1569-80.
• ⁴
  Mearin F, Lacy BE, Chang L, Chey WD, Lembo AJ, Simren M, et al. Bowel disorders. Gastroenterology. 2016;150:1393-407. doi: 10.1053/j.gastro.2016.02.031.
• ⁵
  Aziz I, Whitehead WE, Palsson OS, Törnblom H, Simrén M. An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation. Expert Rev Gastroenterol Hepatol. 2020;14:39-46.
• ⁶
  Mearin F, Ciriza C, Mínguez M, Rey E, Mascort JJ, Peña E, Cañones P, Júdez J. Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult. Rev Esp Enferm Dig. 2016;108:332-63.
• ⁷
  Koloski NA, Jones M, Young M, Talley NJ. Differentiation of functional constipation and constipation predominant irritable bowel syndrome based on Rome III criteria: a population-based study. Aliment Pharmacol Ther 2015;41:856-66.
• ⁸
  Quigley E. Editorial: differentiating chronic idiopathic constipation from constipation-predominant irritable bowel syndrome possible and important? Aliment Pharmacol Ther . 2015;41:1299.
• ⁹
  Taniguchi TM, Abreu GE, Portugal MM, Barroso Junior U. Cross-cultural adaptation and validation of the Constipation Scoring System for the Brazilian population. Arq Gastroenterol. 2022;59:3-8.
• ¹⁰
  Knowles CH, Eccersley AJ, Scott SM, Walker SM, Reeves B, Lunniss PJ. Linear discriminant analysis of symptoms in patients with chronic constipation: validation of a new scoring system (KESS). Dis Colon Rectum. 2000;43:1419-26.
• ¹¹
  Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD. A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum . 1996;39:681-5.
• ¹²
  Passos MCF, Alvariz RC, André EA, Barbuti RC, Fillmann HS, Murad-Regadas SM, et al. Diagnosis and management of chronic idiopathic constipation: A narrative review from a Brazilian expert task force. Arq Gastroenterol . 2022;59:137-44.
• ¹³
  Martins GP, Sandy NS, Alvarenga LR, Lomazi EA, Bellomo-Brandão MA. Functional abdominal pain is the main etiology among children referred to tertiary care level for chronic abdominal pain. Arq Gastroenterol . 2022;59:97-101.
• ¹⁴
  Hayashi T, Miwa H. Treatment Satisfaction With Current Medications for Chronic Constipation: An Internet Survey of Japanese Patients. J Clin Gastroenterol. 2022;56:e64-e70.
• ¹⁵
  Thapar N, Benninga MA, Crowell MD, Di Lorenzo C, Mack I, Nurko S, et al. Paediatric functional abdominal pain disorders. Nat Rev Dis Primers. 2020;6:89.
• ¹⁶
  Raymond M, Marsicovetere P, DeShaney K. Diagnosing and managing acute abdominal pain in children. JAAPA. 2022;35:16-20.
• ¹⁷
  Van Mill MJ, Koppen IJN, Benninga MA. Controversies in the Management of Functional Constipation in Children. Curr Gastroenterol Rep. 2019;21:23.
• ¹
  8.Leung AK, Hon KL. Paediatrics: how to manage functional constipation. Drugs Context. 2021;10:2020:11-2.
• ¹⁹
  Lu PL, Mousa HM. Constipation: Beyond the Old Paradigms. Gastroenterol Clin North Am. 2018;47:845-62.

Publication Dates

• Publication in this collection
  15 Apr 2022
• Date of issue
  Jan-Mar 2022