ND Center for Nursing



Critical Appraisal TopicNutrition DisorderMindy OstrowskiUniversity of MaryJune 20, 2015Chronic Idiopathic ConstipationAccording to Suares & Ford (2011) chronic idiopathic constipation (CIC) is a common condition affecting the gastrointestinal tract, with an estimated prevalence of between 4% and 20% in cross-sectional community surveys (p. 209). Suares & Ford (2011) defines CIC as a functional disorder which includes infrequent and difficult passage of stools in the absence of any physiological abnormality, the condition is more common in women, the elderly, and those with lower income and is associated with reduced quality of life (p. 210). Case PresentationM. M. is a 52 year-old woman presenting to the clinic complaining of worsening constipation, abdominal discomfort and bloating for the past two months. She states that her symptoms began two months ago when she began working the pm shift versus her previous day shift schedule. She reports that she has been having only 1-2 spontaneous bowel movements per week. Self-treatment with over the counter laxatives, (specifically senna products) initiates the urge to defecate, but also causes excessive straining upon defecation. Patient is a healthy 52 year-old women with a negative past medical history. Her current medications include a multi-vitamin and fish oil. Clinical Question in PICO FormatIn adults with chronic idiopathic constipation (CIC), which treatment provides better symptom control: utilization of dietary fiber or pharmacological interventions in addition to dietary fiber? Scholarly ArticlesAttaluri A, Donahoe R, Valestin J et al. Randomized clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther 2011;33:822–8.Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis. Gut 2011; 60: 209–18.Summary and Appraisals of Key EvidenceArticle OneThis article was evaluated based on the Evan’s hierarchy of evidence (Spector, 2010). To address the varying strengths of different research designs, four levels of evidence are proposed: excellent, good fair and poor. This study, using Evans hierarchy of evidence, received a level of good (Spector, 2010). The study notes randomizations but there are notations of bias. This was a prospective RCT aimed to assess and compare the effects of dried plums and psyllium in patients with chronic constipation. Subjects were enrolled in an 8-week double blind, randomized cross-over study. Subjects received either dried plums (50 g or 6gm/day of fiber) or psyllium (11g or 6gm/day of fiber) for three weeks. Subjects maintained a stool and daily symptom diary. The mean age of the subjects were 38 years of age ranging from 18-72. The primary outcome was measurement of the effect of treatment on the mean number of (complete spontaneous bowel movements). The results of the study elicited that the mean number of CSBM/week was significantly higher during dried plum treatment than during psyllium treatment, dried plums produced softer stool when compared to psyllium. Stool consistency score was higher with dried plums when compared to baseline and when compared to psyllium. The weakness of the study is in the significant overestimation of BM’s by constipated patients. The nature of the study is unblended; therefore, there may have been a higher degree of responder bias. Article TwoThis article was also evaluated based on the Evan’s hierarchy of evidence. According to this tool, this article received a level of excellence since it was a systematic review of the literature (Spector, 2010). The validity has a strong representation related to being a systematic review. The objectives of the study were to evaluate the efficacy of soluble and insoluble fiber supplementation in the management of chronic idiopathic constipation. MEDLNE, EMBASE, and Cochrane Central Register of Controlled Trials were searched in July or September, 2010, with no language restrictions, search terms were reported. The bibliographies of identified studies were hand searched, as were relevant conference abstracts published between 2002-2010. Eligible articles were RCT’s evaluating the efficacy of soluble and insoluble fiber for the management of idiopathic constipation, in Adults. The outcome data were extracted, by two independent reviewers; according to the intention-to-treat principle (all drop outs were considered treatment failures). The result of the study was represented in a narrative synthesis. Six RTCs were included (368 participants) Compared to the placebo, soluble fiber had greater improvements in outcomes. This review concluded that soluble fiber could aid in the management of chronic idiopathic constipation, but the data for insoluble fiber was conflicting, and better evidence was needed for both types of fiber. The limitations of the evidence include time; last searches were (2010) and further evidence may be available. Clinical Bottom Line/Implications for PracticeIn summary of the findings, there may be some benefit and little risk of serious adverse events, increasing dietary fiber or the addition of fiber supplements seems a reasonable initial strategy in the management of CIC patients. Patients may enjoy improvements in bowel movement frequency and consistency. According to Suares & Ford (2011) “Effects on other symptoms commonly reported by CIC patients such as abdominal pain or bloating are more variable. Non-evidence based but practical advice on initiating therapy with fiber supplements includes starting at a nominal dose and slowly titrating up as tolerated over the course of weeks to a target dose of 20–30 g of total dietary and supplementary fiber per day. It is also reasonable to recommend clearing hard stool with an osmotic laxative before initiating fiber therapy, which may avoid cramping pain” (p. 216). Occasionally, patients will experience marked worsening of constipation related symptoms with fiber. When this occurs, there are some data to suggest that significantly delayed colon transit or dyssynergic defecation might be present (Suares & Ford, 2011). The authors stated that there is a lack of high quality evidence to support the national and international guidelines that recommend fiber in the early management of constipation, large, rigorous RTCs were needed to investigate the efficacy of fiber in managing chronic idiopathic constipation. ReferencesAttaluri A, Donahoe R, Valestin J et al. Randomized clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther 2011; 33:822–8.Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathicconstipation: systematic review and meta-analysis. Gut 2011; 60: 209–18.Spector, N. (2010). Evidence-based nursing regulation: a challenge of regulators. Journal of Nursing Regulation, 1(1), 30-36. ................
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