Partnering With Gastroenterologists to Evaluate Patients With Chronic Constipation

Brian E. Lacy, MD, PhD; Stephen A. Brunton, MD

In This Article

Abstract and Introduction


Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and imposes a heavy economic burden on patients and society. Most patients with chronic constipation are evaluated and treated in the primary care setting. Primary care clinicians often underestimate how much they can accomplish in the evaluation of a patient with constipation before they make a referral. There are numerous steps that primary care clinicians can take to address these issues and maximize the benefits of the referral process, including understanding key elements of an effective diagnostic work-up, familiarizing themselves with the utility of various diagnostic tests of colonic and anorectal function, implementing strategies/instruments to optimally communicate what they are striving to achieve through the referral process (eg, via a referral form), and developing a network of long-term working relationships with local gastroenterologists.


Constipation is a highly prevalent disorder that affects approximately 12% to 19% of North Americans -- estimates vary widely depending on study design and methodology.[1,2,3,4,5,6] For many persons, constipation is a chronic problem, lasting from several months to several years.[2] The multiple symptoms of chronic constipation encompass much more than reduced stool frequency; many patients report straining, feelings of incomplete evacuation, abdominal pain/discomfort, bloating, hard and/or small stools, or a need for digital manipulation to enable defecation.[5,7,8,9,10,11,12] For research purposes (eg, enrolling patients into clinical trials), the Rome II diagnostic criteria for constipation are generally used ( Table 1 ).[2,13]

Chronic constipation leads to decreased quality of life. The general well-being of patients with this disorder is lower than that of comparable normal populations,[14,15] and symptom severity has a negative correlation with perceived quality of life (ie, the more severe the symptoms, the lower the quality of life).[14]

The economic impact of constipation is substantial both for patients and society as a whole. Between 1979 and 1981, constipation resulted in 13.7 million days per year of restricted activity; in 1975, 3.43 million days per year of bed disability[16] occurred; and annually in the United States, over-the-counter (OTC) laxative sales total more than $800 million.[1] Although they account for only approximately one third of those with chronic constipation, adults with chronic constipation who seek medical care consume significant and costly healthcare resources. For instance, total healthcare costs for patients with constipation enrolled in the California Medicaid program (n = 105,130) for a 15-month period amounted to $18,891,007.[17]

Most patients with chronic constipation are evaluated and treated in the primary care setting. In 2000, constipation was 13th on the list of leading physician diagnoses for gastrointestinal (GI) disorders in outpatient clinic visits in the United States. Furthermore, constipation was ranked as the sixth leading GI symptom that prompts outpatient visits.[16] One study estimated ambulatory healthcare use related to constipation in the United States by assessing data from the 2001 National Ambulatory Medical Care Survey and the 2001 National Hospital Ambulatory Medical Care Survey. Study findings showed that more than 5.7 million visits related to constipation were made in the outpatient setting in 2001. Of these, constipation was the primary reason for a visit or was the primary diagnosis in 44%, 51%, and 56% of visits to physician offices, hospital outpatient clinics, and emergency rooms, respectively.[18]

Primary care clinicians are often frustrated when faced with patients who do not respond to empiric treatment measures. When, how, and to whom to refer such patients is often unclear, and expectations of the referral process -- to gain a better understanding of the underlying cause of the constipation and guidance on management strategies -- are often not met (see Sidebar). Furthermore, primary care physicians often underestimate how much they can accomplish in the evaluation of a patient with constipation before they make a referral.

This article discusses common communication barriers between primary care clinicians and gastroenterologists in the care of patients with chronic constipation, and suggests strategies and tools that can be used to facilitate effective communication and optimize patient care. Suggestions for conducting a thorough prereferral work-up for patients with constipation are also presented, and the usefulness of various diagnostic tests that are commonly employed is discussed.[19]


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