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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Chronic Constipation: New Thoughts About An Old Problem


GOAL
To provide nurse practitioners and physician assistants who treat irritable bowel
syndrome (IBS) and chronic constipation with up-to-date information on the various therapeutic options for these conditions.

TARGET AUDIENCE
This activity is designed for nurse practitioners and physician assistants who are responsible for the diagnosis and management of patients with IBS and chronic constipation. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine and The Institute for Johns Hopkins Nursing take responsibility for the content, quality, and scientific integrity of this CE activity. At the conclusion of this activity, the participant should be able to:

  • Describe a rational approach to the diagnosis of chronic constipation.
  • Compare and contrast the mechanism of action of various treatment options
    available for the treatment of chronic constipation.
  • Determine an appropriate therapeutic strategy for managing patients with chronic constipation.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education
for physicians.

The Institute for Johns Hopkins Nursing is accredited as a provider of continuing nursing education by the American Nurses' Credentialing Center's Commission on Accreditation.

CREDIT DESIGNATION STATEMENT
This program has been approved for 1.8 contact hours of continuing education by the American Academy of Nurse Practitioners. Program ID 0609350.

The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

This 1.8 contact hour Educational Activity (Provider Directed/Learner Paced) is provided by The Institute for Johns Hopkins Nursing (50 minutes of content = 1 contact hour). Claim only those contact hours actually spent in the activity.

The estimated time to complete this educational activity: 1.5 hours.

Release date: November 15, 2006. Expiration date: November 15, 2008.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine, The Institute for Johns Hopkins Nursing, and the American Academy of Nurse Practitioners names implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Sucampo Pharmaceuticals, Inc, and Takeda Pharmaceuticals North America, Inc.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Anthony N. Kalloo, MD  
Chief, Division of Gastroenterology & Hepatology
The Johns Hopkins Hospital
Baltimore, Maryland
Dr Kalloo reports having no significant financial or advisory relationships with
corporate organizations related to this activity.

PARTICIPATING FACULTY

Julia Pallentino, MSN, JD, ARNP-BC
Medical Group of North Florida
Gastroenterology Practice
Tallahassee, Florida
Ms Pallentino reports receiving honoraria from Novartis and Takeda Pharmaceutical Company Ltd; and serving on the speaker's bureau for Novartis and Takeda Pharmaceutical Company Ltd.

Lawrence R. Schiller, MD, FACP, FACG
Gastroenterology Department
Baylor University Medical Center
Dallas, Texas
Dr Schiller reports serving as a consultant for AstraZeneca, Braintree Laboratories, Novartis, Prometheus Laboratories Inc, Romark Laboratories, Salix Pharmaceuticals, Santarus, Inc, Sucampo Pharmaceuticals, and Takeda Pharmaceutical Company Ltd; receiving honoraria from AstraZeneca, Braintree Laboratories, Novartis, Procter & Gamble, Prometheus Laboratories Inc, Romark Laboratories, Salix Pharmaceuticals, Santarus, Inc, Sucampo Pharmaceuticals, Takeda Pharmaceutical Company Ltd, and TAP Pharmaceutical Products Inc; and serving on the speaker's bureau of AstraZeneca, Braintree Laboratories, Novartis, Procter & Gamble, Prometheus Laboratories Inc, Romark Laboratories, Salix Pharmaceuticals, Santarus, Inc, Sucampo Pharmaceuticals, Takeda Pharmaceutical Company Ltd, and TAP Pharmaceutical Products Inc.

Notice: The audience is advised that the articles in this CE activity contain no reference(s) to unlabeled or unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Chronic Constipation: New Thoughts About An Old Problem
Anthony N. Kalloo, MD*

Although the lay media has the nation's attention focused on some of our "number 1 killers" (eg, cardiovascular disease, obesity, cancer), clinical practitioners treat patients with myriad disorders that range in severity and chronicity. Acute disorders naturally tend to grab our immediate attention, but for patients with chronic illnesses or those on long-term medication, the sequelae or adverse events may seem less important. For example, headache and dry mouth are often referred to as minor adverse events. Patients taking a medication with these side effects may tolerate them if they are taking the medication for a short period of time, but it can become intolerable if the patient is facing several years or a lifetime of taking this medication. Likewise, dealing with a periodic bout of constipation may be uncomfortable and may result in abdominal distention or mood changes, but it usually is tolerable.  However, for patients who feel this way every day for several months or even years, constipation can become a serious issue when almost every bowel movement is painful or causes anxiety.

This issue of Johns Hopkins Advanced Studies in Medicine reviews the topic of chronic constipation, which is constipation that continues for at least 12 of the last 26 weeks. The content of this monograph is based on a symposium held at the American Academy of Nurse Practitioners 2006 National Conference in Grapevine, Texas, on June 21, 2006.

As Julia Pallentino, MSN, JD, ARNP-BC, notes in her article, chronic constipation does not receive much attention as a disorder; yet it is one of the most common gastrointestinal disorders. Additionally, although many patients may be too embarrassed to speak of it, constipation is definitely a disorder of interest. For example, an Internet search of  "chronic constipation" yields 413 000 hits.

Most people know how to address bouts of constipation: increased fluid and fiber intake, in addition to frequent, brisk walks. However, those strategies have most likely been tried by the time the patient presents to the healthcare practitioner, as Lawrence R. Schiller, MD, FACP, FACG, explains. Most patients are desperate for relief from constipation when they finally broach the subject with their nurse practitioner, physician assistant, or physician, and are embarrassed to discuss it. Defecation is a taboo subject in most cultures, so approaching a patient with constipation requires a gentle approach, understanding, and demonstration of commitment to solve the problem. Importantly, it also requires relieving patient fears and anxiety over concerns of more serious problems (eg, rectal or colon cancer), once those diagnoses have been eliminated.

Ms Pallentino discusses the epidemiology and impact of chronic constipation to help healthcare providers understand what patients are experiencing. She also reviews the causes and definition of chronic constipation, which is an important concept because constipation means different things to different people. Ms Pallentino explains the diagnosis and workup for a patient presenting with constipation, in addition to tools for eliciting the patient history, which is critical to forming an accurate diagnosis.

Dr Schiller continues this discussion with a description of the currently available treatments for constipation—both nonprescription and prescription—including a review of the treatments recommended by the American College of Gastroenterology Task Force, of which he was a member. He also provides the gastroenterologist's view of the differential diagnosis of constipation and what patients can expect if they are referred to a gastroenterology specialist (including when to refer the patient). In the last few years, 2 new drugs have been approved by the US Food and Drug Administration for the treatment of chronic constipation—lubiprostone and tegaserod—which have mechanisms of action that are different from other traditional constipation treatments. Dr Schiller reviews some of the clinical data with those 2 drugs, in addition to any precautions associated with their use.

This monograph also includes a summary of the question-and-answer session from the symposium, which covers a wide range of topics, including off-label use of lubiprostone and tegaserod in specific patient populations, other drug-specific questions, diagnosis and assessment, and management issues.

Although chronic constipation may not command headlines, it secretly decreases quality of life for millions of patients, such as the elderly, patients with diabetes, young girls afraid to use the bathrooms at school, postsurgical patients, and patients taking multiple medications. The goal of this monograph is to help nurse practitioners and physician assistants become more knowledgeable about chronic constipation so they can, in turn, help patients to not only discuss defecation problems openly but also work together toward a solution.

*Chief, Division of Gastroenterology & Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland.
Address correspondence to: Anthony N. Kalloo, MD, Chief, Division of Gastroenterology & Hepatology, The Johns Hopkins Hospital, Room 1m12, Clinical Research Building II, 1550 Orleans Street, Baltimore, MD 21231.
E-mail: akalloo@jhmi.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.