DÄ internationalArchive46/2009The Pathophysiology, Diagnosis and Treatment of Constipation: A Very Welcome Article

Correspondence

The Pathophysiology, Diagnosis and Treatment of Constipation: A Very Welcome Article

Dtsch Arztebl Int 2009; 106(46): 765-6. DOI: 10.3238/arztebl.2009.0765c

Wirz, S

LNSLNS Müller-Lissner’s CME article on constipation, a symptom with a high prevalence, is most welcome. The author describes diagnostic and therapeutic options in an easy to read format, which is sure to improve the current state of knowledge. I wish to make some additions from my own clinical perspective.

It goes without saying that constipation can be reliably diagnosed with the aid of the Rome III criteria. However, their practical implementation in the real life scenario is difficult because these criteria cannot always be elicited from patients in everyday clinical practice.

Recommending selective serotonin reuptake inhibitors (SSRIs) as an alternative to tricyclic antidepressants results in constipation less often but is not guaranteed to prevent constipation either. Individual AWMF (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.; Association of the Scientific Medical Societies in Germany, reg. assoc.) guidelines list constipation as one possible side effect for SSRIs too. From the pathophysiological point of view, treatment with SSRIs leads to inhibition of gastrointestinal enterochromaffin serotonergic receptors in the enteric nervous system, with simul-taneously reduced peristalsis of the colon and lowered secretory capacity.

From the perspective of pain and palliative medicine, opioid induced constipation should be given more attention as a common reason for patients to stop pain therapy that is otherwise reliable and effective. Constipation prophylaxis is essential when opioid treatment is started.

The complete compendium of the different therapeutic options and recommendation of certain laxatives with a favorable ratio of effectiveness to side effects is to be welcomed. In the setting of pain and palliative medicine, using different drug mechanisms of action in an escalating stepwise scheme has proved effective. Such a stepwise scheme could be evaluated in other groups of patients too.
DOI: 10.3238/arztebl.2009.0765c

Dr. med. Stefan Wirz
Anästhesie, Interdisziplinäre Intensivmedizin,
Schmerztherapie, Palliativmedizin
Katholisches Krankenhaus im Siebengebirge
Schülgenstr. 15, 53604 Bad Honnef, Germany
stefan.wirz@cura.org

Conflict of interest statement
The author has reported associations with the companies Mundipharma, Wyeth, Cephalon, and Norgive.
1.
Cash BD, Chey WD: The role of serotonergic agents in the treatment of patients with primary chronic constipation. Aliment Pharmacol Ther 2005; 22(11–12): 1047–60. MEDLINE
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Sittig HB: Kursbuch Palliative Care. Unimed 2009: 205–17.
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Schenk M: Multimodale Tumorschmerztherapie. Unimed Verlag 2009: 84–8.
4.
Müller-Lissner S: The pathophysiology, diagnosis and treatment of constipation [Obstipation – Pathophysiologie, Diagnose und Therapie]. Dtsch Arztebl Int 2009; 106(25): 424–32. MEDLINE
1. Cash BD, Chey WD: The role of serotonergic agents in the treatment of patients with primary chronic constipation. Aliment Pharmacol Ther 2005; 22(11–12): 1047–60. MEDLINE
2. Sittig HB: Kursbuch Palliative Care. Unimed 2009: 205–17.
3. Schenk M: Multimodale Tumorschmerztherapie. Unimed Verlag 2009: 84–8.
4. Müller-Lissner S: The pathophysiology, diagnosis and treatment of constipation [Obstipation – Pathophysiologie, Diagnose und Therapie]. Dtsch Arztebl Int 2009; 106(25): 424–32. MEDLINE