Official AGA Constipation Guidelines Pocket Guide Flipbook.
Issue link: https://eguideline.guidelinecentral.com/i/1060349
Assessment 5 ➤ If feasible, discontinue medications that can cause constipation before further testing (Strong; Low Quality of Evidence). ➤ A careful digital rectal examination that includes assessment of pelvic floor motion during simulated evacuation is preferable to a cursory examination without these maneuvers and should be performed before referral for anorectal manometry. However, a normal digital rectal examination does not exclude defecatory disorders (Strong; Moderate Quality of Evidence). The key components of the rectal examination include: • In the left lateral position, with the buttocks separated, observe the descent of the perineum during simulated evacuation and the elevation during a squeeze aimed at retention. The perianal skin can be observed for evidence of fecal soiling and the anal reflex tested by a light pinprick or scratch. • During simulated defecation, the anal verge should be observed for any patulous opening (suspect neurogenic constipation with or without incontinence) or prolapse of anorectal mucosa. • The digital examination should evaluate resting tone of the sphincter segment and its augmentation by a squeezing effort. Above the internal sphincter is the puborectalis muscle, which should also contract during squeeze. Acute localized tenderness to palpation along the puborectalis is a feature of the levator ani syndrome. Finally, the patient should be instructed to integrate the expulsionary forces by requesting that she or he "expel my finger." • An examination should then be conducted to evaluate for a rectocele or consideration be given to g ynecologic consultation. Testing for Medical Causes ➤ In the absence of other symptoms and signs, only a complete blood cell count is necessary (Strong; Low Quality of Evidence). ➤ Unless other clinical features warrant otherwise, metabolic tests (glucose, calcium, sensitive thyroid-stimulating hormone) are not recommended for chronic constipation (Strong; Moderate Quality of Evidence). ➤ A colonoscopy should not be performed in patients without alarm features (e.g., blood in stools, anemia, weight loss) unless age- appropriate colon cancer screening has not been performed (Strong; Moderate Quality of Evidence). ➤ Anorectal manometry and a rectal balloon expulsion should be performed in patients who fail to respond to laxatives (Strong; Moderate Quality of Evidence). ➤ Defecography should not be performed before anorectal manometry and a rectal balloon expulsion test (Strong; Low Quality of Evidence).