Chronic constipation

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Therapy often permanent

»For every ten constipated patients, nine have to be told that long-term use of laxatives is the treatment of choice«, Professor Dr Ahmed Madisch, Centrum Gastroenterologie Bethanien in Frankfurt am Main, began his presentation. Patients with chronic constipation need to be educated so that they actually take laxatives on a long-term basis. For over 80 per cent of those affected, the symptoms, which significantly impair their quality of life, disappear.

The medic performs a number of colonoscopies every day, including on people with chronic constipation - almost always without any findings. He had a tip for patients who are due to have a colonoscopy: they should start using a laxative four days before the appointment. This increases the chance that the unpleasant procedure of bowel cleansing on the day before the examination will be sufficient. Otherwise, he often finds that people with constipation need a second bowel cleansing because otherwise the examination is not possible.

Even though chronic constipation can have various causes, 80 per cent of those affected suffer from functional constipation or irritable bowel syndrome with constipation. It is by no means only older people who are affected. Rather, the symptoms affect all age groups and often begin in infancy. »In a large proportion of patients, we see that there are naturally too few ganglia in the intestinal wall.« This deficiency has a lifelong effect on digestive activity.

According to the S2k guideline »Chronic constipation«, which was updated in 2022, constipation is initially treated with general measures, i.e. fibre. »I always start this with our patients after the colonoscopy, i.e. when the bowel is really empty«, says Madisch. Because giving fibre to an acutely constipated person does not make sense. There are patients whose constipation improves with the regular intake of fibre, but this is not the case for a large proportion of them. »In a very sluggish bowel, which works so little because there are too few nerve cells in the bowel wall from birth, fibre is actually harmful«, says the expert. These patients also need to eat a low-fibre diet. Although physical activity is definitely useful as an accompanying measure, it is rarely decisive for an improvement in symptoms.

Toilet training, another point in the guideline, is important: »You really have to take enough time at fixed times of the day, preferably in the morning, to go to the toilet in peace«. Another point is to drink enough. However, this only has an effect if a person otherwise always drinks too little. Liquids over and above the one and a half to two litres recommended for everyone have no additional effect against constipation.

If the general measures do not work, laxatives are used. The guidelines state: »Conventional laxatives should be given for the treatment of chronic constipation in patients for whom the previous basic measures were not sufficiently effective or poorly tolerated«. The word »should« in guideline language means the strongest of the possible recommendations, Madisch explained. So there is no doubt about it.

According to the guidelines, the drugs of first choice are macrogols, sodium picosulphate and bisacodyl. Very important for counselling: »Limiting the period of use is unjustified«. In addition, the agents mentioned can also be used during pregnancy and in geriatric patients. They have shown in conclusive studies and meta-analyses that stool consistency improves and symptoms decrease during treatment. Patients' quality of life improves again. »Sometimes the main symptoms of chronic constipation are flatulence. In this case, however, the constipation must be treated first«, Madisch explained.

A review has also refuted the greatest fear of patients and GPs: osmotic and stimulant laxatives could damage the intestinal wall and potentially cause cancer. The literature search covered the period from 1968 to 2023. 43 studies in total met the criteria, which aimed to determine damage to the intestinal wall or the intestinal nervous system as well as any genetic changes and carcinogenicity.

The medic summarised: »There is no evidence at all with regard to intestinal safety that we get any problems even with long-term use of laxatives«. Hence the clear statement in the guideline in favour of consistent long-term treatment of constipation. This is also so important because a person with chronic constipation generally cannot get rid of it. Although attempts can be made to discontinue the medication, experience has shown that the constipation then returns. And it can also worsen with increasing age or the onset of diseases such as Parkinson's, for example. It is therefore not a question of whether laxatives should be taken long-term for chronic constipation – a clear yes for the expert – but also in what dose.

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