Epidemiology of Constipation in North America: A systematic review

N Engl J Med 2003;349:1360-8. Copyright © 2003 Massachusetts Medical Society. onstipation is a common symptom affecting between 2 percent 1,2 and 27 percent 3 of the population in Western countries. In the United States, it results in more than 2.5 million visits to physicians, 92,000 hospitalizations, 2 and laxative sales of several hundred million dollars a year. Constipation is more prevalent in women than in men, 4 in nonwhites than in white persons, 5 in children than in adults, 6 and in elderly than in younger adults. 5 Severe constipation (e.g., bowel movements only twice a month) is seen almost exclusively in women. 4 Physical inactivity, low income, limited education, a history of sexual abuse, and symptoms of depression are all risk factors for constipation. 7

Current concepts: Chronic constipation

PURPOSE: The purpose of this study was to assess whether any method of hemorrhoid therapy has been shown to be superior in randomized, controlled trials. METHOD: A meta-analysis was performed of all randomized, controlled trials assessing two or more treatment modalities for symptomatic hemorrhoids. Outcome variables included response to therapy, need for further therapy, complications, and pain. RESULTS: A total of 18 trials were available for analysis. Hemorrhoidectomy was found to be significantly more effective than manual dilation of the anus (P=0.0017), with less need for further therapy (P=0.034), no significant difference in complications (P=0.60), but significantly more pain (P<0.0001). Patients undergoing hemorrhoidectomy had a better response to treatment than did patients treated with rubber band ligation (P=0.001), although complications were greater (P=0.02) as was pain (P<0.0001). Rubber band ligation was better than sclerotherapy in response to treatment for all hemorrhoids (P=0.005) as well as for hemorrhoids stratified by grade (Grades 1 to 2;P=0.007; Grade 3 hemorrhoids,P=0.042), with no difference in the complication rate (P=0.35). Patients treated with sclerotherapy (P=0.031) or infrared coagulation (P=0.0014) were more likely to require further therapy than those treated with rubber band ligation, although pain was greater after rubber band ligation (P=0.03 for sclerotherapy;P<0.0001 for infrared coagulation).CONCLUSION: Rubber band ligation is recommended as the initial mode of therapy for Grades 1 to 3 hemorrhoids. Although hemorrhoidectomy showed better response rates, it is associated with more complications and pain than rubber band ligation, thus should be reserved for patients who fail to respond to rubber band ligation.

Comparison of hemorrhoidal treatment modalities. A meta-analysis.

Risk Factors for ERCP-related Complications: A Prospective Multicenter Study

https://www.rima.org/web/medline_pdf/AmJGastroenterol_936-71.pdf

Efficacy and Safety of Traditional Medical Therapies for Chronic Constipation: Systematic Review

https://www.gastrojournal.org/article/0016-5085(90)90828-O/pdf

The prevalence of hemorrhoids and chronic constipation: An epidemiologic study

Using health statistics from the United States and England and Wales, we review the epidemiology of constipation and possible etiologies of this disorder as suggested by its epidemiologic distribution. The analysis revealed that constipation is one of the most common chronic digestive disorders in the United States, affecting one of every 50 people. The occurrence of constipation increased with advancing age, showing an exponential increase in prevalence after the age of 65. The age distribution of constipation was similar in both sexes, but overall constipation was three times more common in women than in men. Constipation more frequently affected nonwhites than whites, and people from families with low income or less formal education. The characteristic epidemiologic pattern of constipation suggests the influence of environmental factors. Insufficient dietary fiber is widely believed to be a major cause of constipation, yet it is difficult to devise a mechanism by which dietary fiber alone could produce the marked differences observed between gender, race, and socioeconomic status. Recent evidence suggests that disruption of neural regulation of colonic motility plays an important role in the development of chronic constipation. This loss of neural regulation may result from mechanical damage to the pelvic nerves due to childbirth or pelvic surgery, exposure to environmental toxins (e.g., organochlorine insecticides or heavy metals), or possibly exposure to an infectious agent. Other environmental factors that may play a role in the pathogenesis of chronic constipation have not yet been elucidated. Consequently, studies examining the epidemiology of chronic constipation are important for providing insight into potential environmental risk factors relevant to the etiology of this disorder.

Clinical epidemiology of chronic constipation.

Although numerous etiologic risk factors have been proposed, the pathogenesis of hemorrhoids remains unknown. The present investigation assesses the temporal distribution of hemorrhoids as depicted by physician visits, hospital discharges, and surgical procedures to provide further insight into potential etiologic risk factors. The analysis was based on five data sources: from the United States, the National Disease and Therapeutic Index (NDTI), the National Hospital Discharge Survey (NHDS), and the Commission on Professional Hospital Activities (CPHA); from England and Wales, the Morbidity Statistics from General Practice (MSGP) and the Hospital In-patient Enquiry (HIPE). Results demonstrated a consistent decline in all data sources from the United States. The decrease occurred in males and females similarly and was most striking in those aged 45-64 years. Physician visits and hospital discharges for hemorrhoids in England and Wales likewise declined although the decrease was not as dramatic. The consistency of the temporal distributions among the two countries, as well as among the different sources, suggests that the observed decline may, in fact, reflect an overall decrease in the occurrence of hemorrhoidal disease.

John F. Johanson

Papers

The prevalence of hemorrhoids and chronic constipation: An epidemiologic study

Clinical epidemiology of chronic constipation.

Temporal changes in the occurrence of hemorrhoids in the United States and England.