Diagnosis and treatment of constipation: A clinical update based on the Rome IV criteria

Diagnóstico e tratamento da constipac¸ão: uma atualizac¸ão clínica com base nos critérios de Roma IV

Dear Editor,

Recently, a review article entitled “Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria” was published. It is a broad and updated review of the literature on constipation, including the details of its pathophysiology, diagnosis, and treatment. The objective of Sobrado and colleagues¹ was to evaluate the current guidelines published by professional associations on the diagnosis and treatment of functional constipation in adults and compare these guidelines with the authors' clinical experience.

The online search for bibliographic references was performed in the Medline/PubMed, Scielo, EMBASE, and Cochrane databases considering the terms: chronic constipation, diagnosis of intestinal constipation, management of chronic constipation, Rome IV, and surgical treatment of constipation. The authors conclude that the critical evaluation of the specialist physician responsible for the action plan to be conducted according to the clinical status of the patient is sovereign in relation to the information contained in the article.

Considering this review article of great relevance to the clinical and surgical study and management of functional intestinal constipation, we would like to respectfully add a contribution to this article highlighting an important aspect of the etiology of the disease that must be rectified.

Regarding the possible etiologies of secondary intestinal constipation, hypoparathyroidism was cited by the authors. However, after extensive search in the same databases included in the methodology described in the article, with the keywords intestinal constipation and hypoparathyroidism, no evidence was found of the relationship between these two dysfunctions.

The etiology of intestinal constipation is multifactorial and may include factors ranging from diet, medication use, neurological, and psychosocial disorders, and endocrinometabolic causes.^2-5

Bharucha et al. (2020),³ in their important study on the subject, present hypothyroidism and hyperparathyroidism as endocrine and metabolic causes for intestinal constipation, contrary to hypoparathyroidism, mainly due to hypercalcemia, since calcium acts directly on intestinal motility favoring the coordination of peristaltic movements, molecular transport through the intestinal mucosa, and in the evacuation reflexes.

Hypoparathyroidism is a metabolic disorder due to a failure of the parathyroid glands to secrete parathormone (absence or inappropriately low concentrations), generating hypocalcemia and hyperphosphatemia, which has as gastrointestinal consequence diarrhea.^6-8

Hypoparathyroidism is related to diarrhea, steatorrhea, and intestinal malabsorption syndrome, not being considered an etiological component for intestinal constipation, but hyperparathyroidism.^1,10

We respectfully thank the authors for their initiative to review the literature and contrast it with their substantial clinical experience in the subject that can certainly contribute to the standardization of procedures, the aid of clinical reasoning and decision making by medical professionals.

References

• ¹
  Sobrado CW, Neto IJFC, Pinto RA, Sobrado LF, Nahas SC, Cecconello I. Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria. J. Coloproctology. 2018;38:137-44.
• ²
  Bharucha AE, Wald A. Chronic Constipation. Mayo. Clin. Proc. 2019;94:2340-57.
• ³
  Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology. 2020;158, 1232-49.e3.
• ⁴
  Sharma A, Rao S. Constipation: pathophysiology and current therapeutic approaches. In: Handbook of Experimental Pharmacology; 2016. p. 59–74.
• ⁵
  Rao SSC, Rattanakovit K, Patcharatrakul T. Diagnosis and management of chronic constipation in adults. Nat. Rev. Gastroenterol. Hepatol. 2016;13:295-305.
• ⁶
  Hakami Y, Khan A. Hypoparathyroidism. Front Horm. Res. 2018;51:109-26.
• ⁷
  Mannstadt M, Bilezikian JP, Thakker RV, Hannan FM, Clarke BL, Rejnmark L, et al. Hypoparathyroidism. Nat. Rev. Dis. Prim. 2017;3:170055.
• ⁸
  Clarke BL, Brown EM, Collins MT, Jüppner H, Lakatos P, Levine MA, et al. Epidemiology and diagnosis of hypoparathyroidism. J. Clin. Endocrinol. Metab. 2016;101:2284-99.
• ⁹
  Ebert EC. The parathyroids and the gut. J. Clin. Gastroenterol. 2010;44:479-82.
• ¹⁰
  Abboud B, Daher R, Boujaoude J. Digestive manifestations of parathyroid disorders. World J. Gastroenterol. 2011;17:4063-6.

Publication Dates

• Publication in this collection
  07 Dec 2020
• Date of issue
  Oct-Dec 2020