Clinical practice guidelines for the management of constipation in adults. Part 1: Definition, aetiology and clinical manifestations | Gastroenterología y Hepatología (English Edition)

array:23 ["pii" => "S2444382417300408" "issn" => "24443824" "doi" => "10.1016/j.gastre.2017.02.001" "estado" => "S300" "fechaPublicacion" => "2017-03-01" "aid" => "1013" "copyright" => "Elsevier España, S.L.U., AEEH and AEG" "copyrightAnyo" => "2016" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Gastroenterol Hepatol. 2017;40:132-41" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 836 "formatos" => array:2 [ "HTML" => 542 "PDF" => 294 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0210570516300036" "issn" => "02105705" "doi" => "10.1016/j.gastrohep.2016.02.006" "estado" => "S300" "fechaPublicacion" => "2017-03-01" "aid" => "1013" "copyright" => "Elsevier España, S.L.U., AEEH y AEG" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Gastroenterol Hepatol. 2017;40:132-41" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 5447 "formatos" => array:2 [ "HTML" => 4213 "PDF" => 1234 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Revisión" "titulo" => "Guía de práctica clínica sobre el manejo del estreñimiento crónico en el paciente adulto. Parte 1: Definición, etiología y manifestaciones clínicas" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "132" "paginaFinal" => "141" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Clinical practice guidelines for the management of constipation in adults. Part 1: Definition, aetiology and clinical manifestations" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 846 "Ancho" => 2246 "Tamanyo" => 150026 ] ] "descripcion" => array:1 [ "es" => "Escala de Bristol para la evaluación de las heces. Tabla visual con ilustraciones. Fuente: Lewis y Heaton<a class="elsevierStyleCrossRef" href="#bib0420">32</a>." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jordi Serra, Juanjo Mascort-Roca, Mercè Marzo-Castillejo, Silvia Delgado Aros, Juan Ferrándiz Santos, Enrique Rey Diaz Rubio, Fermín Mearin Manrique" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Jordi" "apellidos" => "Serra" ] 1 => array:2 [ "nombre" => "Juanjo" "apellidos" => "Mascort-Roca" ] 2 => array:2 [ "nombre" => "Mercè" "apellidos" => "Marzo-Castillejo" ] 3 => array:2 [ "nombre" => "Silvia" "apellidos" => "Delgado Aros" ] 4 => array:2 [ "nombre" => "Juan" "apellidos" => "Ferrándiz Santos" ] 5 => array:2 [ "nombre" => "Enrique" "apellidos" => "Rey Diaz Rubio" ] 6 => array:2 [ "nombre" => "Fermín" "apellidos" => "Mearin Manrique" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2444382417300408" "doi" => "10.1016/j.gastre.2017.02.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382417300408?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570516300036?idApp=UINPBA00004N" "url" => "/02105705/0000004000000003/v1_201702170034/S0210570516300036/v1_201702170034/es/main.assets" ] ] "itemAnterior" => array:19 [ "pii" => "S244438241730041X" "issn" => "24443824" "doi" => "10.1016/j.gastre.2017.02.002" "estado" => "S300" "fechaPublicacion" => "2017-03-01" "aid" => "1038" "copyright" => "Elsevier España, S.L.U., AEEH and AEG" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Gastroenterol Hepatol. 2017;40:125-31" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 632 "formatos" => array:2 [ "HTML" => 499 "PDF" => 133 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Faecal calprotectin, an useful marker in discriminating between inflammatory bowel disease and functional gastrointestinal disorders" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "125" "paginaFinal" => "131" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Calprotectina fecal, marcador eficaz en la diferenciación de enfermedades inflamatorias intestinales y trastornos funcionales gastrointestinales" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1886 "Ancho" => 1659 "Tamanyo" => 104226 ] ] "descripcion" => array:1 [ "en" => "ROC curve of faecal calprotectin (inflammatory bowel disease/irritable bowel syndrome). AUC=0.872." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Maria Elena Lozoya Angulo, Ignacio de las Heras Gómez, Miriam Martinez Villanueva, Jose Antonio Noguera Velasco, Francisco Avilés Plaza" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Maria Elena" "apellidos" => "Lozoya Angulo" ] 1 => array:2 [ "nombre" => "Ignacio" "apellidos" => "de las Heras Gómez" ] 2 => array:2 [ "nombre" => "Miriam" "apellidos" => "Martinez Villanueva" ] 3 => array:2 [ "nombre" => "Jose Antonio" "apellidos" => "Noguera Velasco" ] 4 => array:2 [ "nombre" => "Francisco" "apellidos" => "Avilés Plaza" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0210570516300486" "doi" => "10.1016/j.gastrohep.2016.04.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570516300486?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S244438241730041X?idApp=UINPBA00004N" "url" => "/24443824/0000004000000003/v1_201703160041/S244438241730041X/v1_201703160041/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Clinical practice guidelines for the management of constipation in adults. Part 1: Definition, aetiology and clinical manifestations" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "132" "paginaFinal" => "141" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Jordi Serra, Juanjo Mascort-Roca, Mercè Marzo-Castillejo, Silvia Delgado Aros, Juan Ferrándiz Santos, Enrique Rey Diaz Rubio, Fermín Mearin Manrique" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Jordi" "apellidos" => "Serra" "email" => array:1 [ 0 => "jserrap.germanstrias@gencat.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Juanjo" "apellidos" => "Mascort-Roca" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Mercè" "apellidos" => "Marzo-Castillejo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 3 => array:3 [ "nombre" => "Silvia" "apellidos" => "Delgado Aros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] 4 => array:3 [ "nombre" => "Juan" "apellidos" => "Ferrándiz Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] ] ] 5 => array:3 [ "nombre" => "Enrique" "apellidos" => "Rey Diaz Rubio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] ] ] 6 => array:3 [ "nombre" => "Fermín" "apellidos" => "Mearin Manrique" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "i" "identificador" => "aff0045" ] ] ] ] "afiliaciones" => array:9 [ 0 => array:3 [ "entidad" => "Unitat de Motilitat i Trastorns Funcionals Digestius, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Asistencia Primaria (CAP) Florida Sud, Institut Català de la Salut, L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departament de Ciències Clíniques, Campus Bellvitge, Facultat de Medicina, Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unitat de Suport a la Recerca – Institut d’Investigació d’Atenció Primària (IDIAP) Jordi Gol, Direcció d’Atenció Primària Costa de Ponent, Institut Català de la Salut, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Scientist, semFYC, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Neuro-Enteric Translational Science (NETS) Group Coordinator, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM)-Parc de Salut Mar, Parc de Recerca Biomèdica de Barcelona (PRBB), Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Subdirección General de Calidad Asistencial, Consejería de Sanidad, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Hospital Clínico San Carlos, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Aparato Digestivo, Instituto de Trastornos Funcionales y Motores Digestivos, Barcelona, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guía de práctica clínica sobre el manejo del estreñimiento crónico en el paciente adulto. Parte 1: Definición, etiología y manifestaciones clínicas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 848 "Ancho" => 2187 "Tamanyo" => 138450 ] ] "descripcion" => array:1 [ "en" => "Bristol Scale for faeces assessment. Visual table with illustrations. Source: Lewis and Heaton.<a class="elsevierStyleCrossRef" href="#bib0420">32</a>" ] ] ] "textoCompleto" => "IntroductionConstipation is a symptom suffered by a large number of people and which is brought about by multifactorial causes. Many people have experienced constipation at some point in their life, although it usually occurs for a limited period of time and is not a serious problem. Long-term constipation affects women and older adults more frequently. It is a disorder that has a negative effect on people's well-being and quality of life. It is a common reason for medical consultation in primary care and is treated by self-medication by a high proportion of the affected population. Knowing the causes, preventing, diagnosing and treating constipation will benefit many of those affected.In order for clinical decisions to be appropriate, efficient and safe, professionals need to update their knowledge constantly. This clinical practice guideline (CPG) on the management of chronic constipation in adult patients sets out the efficient treatment of this disorder using a coordinated and multidisciplinary approach with the participation of primary and specialised care.MethodologyProfessional representatives of the scientific societies involved and methodologists participated in the preparation of this CPG. All the essential criteria referred to in the Appraisal of Guidelines, Research and Evaluation for Europe (AGREE) (<a href="http://www.agreecollaboration.org/">http://www.agreecollaboration.org/</a>), a tool designed to help producers and users of CPG and considered the standard for their preparation, have been taken into account in the preparation of this guideline.For the classification of the scientific evidence and the strength of the recommendations, the Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE system) (<a href="http://www.gradeworkinggroup.org/">http://www.gradeworkinggroup.org/</a>)<a class="elsevierStyleCrossRefs" href="#bib0265">1–3</a> (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>) was used.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Once a complete draft of the guide had been prepared, the external reviewers, who were representatives of the various related specialties, provided their comments and suggestions.DefinitionConstipation is characterised by difficult or infrequent bowel movements, often accompanied by excessive exertion during defecation or a feeling of incomplete evacuation.<a class="elsevierStyleCrossRef" href="#bib0280">4</a> In most cases it does not have an underlying organic cause and is considered chronic idiopathic constipation (CIC), also known as chronic functional constipation. In fact, CIC shares several symptoms with irritable bowel syndrome with constipation (IBS-C), although in IBS-C, abdominal pain/discomfort must be present to make the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0285">5</a> Even so, there are authors who consider CIC and IBS-C as 2 different entities and others that include them as subsections of the same spectrum.<a class="elsevierStyleCrossRefs" href="#bib0280">4–6</a>According to the Rome III criteria, CIC is defined as the presence during the last 3 months of 2 or more of the conditions reflected in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. Symptoms must have started at least 6 months before diagnosis, there should only be diarrhoea after laxative intake and IBS criteria should not be met.<a class="elsevierStyleCrossRef" href="#bib0285">5</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Magnitude and significance of the problemCIC is very common in the general population around the world, with a mean prevalence, as estimated in 2 systematic reviews, of between 14% (95% CI: 12–17%)<a class="elsevierStyleCrossRef" href="#bib0280">4</a> and 16% (95% CI: 0.7–79%).<a class="elsevierStyleCrossRef" href="#bib0295">7</a> The studies conducted in Spain reveal a prevalence of 14–30%.<a class="elsevierStyleCrossRefs" href="#bib0300">8–10</a> CIC is more prevalent in women<a class="elsevierStyleCrossRefs" href="#bib0280">4,7,10–12</a>; its prevalence increases progressively after 60 years of age.<a class="elsevierStyleCrossRef" href="#bib0295">7</a> CIC is normally long-term. In a recent study, it was observed that 68% of the patients were constipated for 10 years or more.<a class="elsevierStyleCrossRef" href="#bib0325">13</a>CIC is a major problem not only because of its prevalence, but also because of its personal, social, employment and economic impact. Its physical and mental impact affects quality of life and personal well-being.<a class="elsevierStyleCrossRefs" href="#bib0315">11,12,14</a> The cost of constipation healthcare and treatment are very significant. Results of a study conducted in our setting indicate that constipation consumes a significant amount of resources, both in relation to the use of laxatives and medical visits.<a class="elsevierStyleCrossRef" href="#bib0335">15</a>Risk factorsIn addition to age and the female gender, a number of aetiological factors have been studied for CIC, the assessment of which comes mostly from uncontrolled studies and short-term interventions.It is believed that a low-fibre diet contributes to constipation and many doctors recommend increased fibre intake along with other lifestyle changes such as improved hydration and exercise. However, the scientific evidence is contradictory.<a class="elsevierStyleCrossRef" href="#bib0295">7</a>Some observational studies have shown that fibre intake is associated with an improvement in constipation<a class="elsevierStyleCrossRef" href="#bib0340">16</a> while others have not.<a class="elsevierStyleCrossRefs" href="#bib0345">17,18</a> Some studies have even found that reducing fibre intake improves constipation and the associated symptoms.<a class="elsevierStyleCrossRef" href="#bib0350">18</a>The results of an observational study (10,914 people) show that low fluid intake is a predictor of constipation for both women (OR=1.3; 95% CI: 1.0–1.6) and for men (OR=2.4; 95% CI: 1.5–3.9).<a class="elsevierStyleCrossRef" href="#bib0345">17</a>Prolonged physical inactivity slows digestive activity in healthy volunteers.<a class="elsevierStyleCrossRef" href="#bib0355">19</a> Some studies show that moderate physical activity is associated with a fall in the prevalence of constipation,<a class="elsevierStyleCrossRef" href="#bib0340">16</a> while others, conversely, find otherwise.<a class="elsevierStyleCrossRefs" href="#bib0345">17,20</a>Other risk factors associated with CIC are low educational and socio-economic levels,<a class="elsevierStyleCrossRefs" href="#bib0295">7,21</a> being overweight and obesity.<a class="elsevierStyleCrossRef" href="#bib0295">7</a> A family history of constipation, anxiety, depression and stressful life events also favour constipation.<a class="elsevierStyleCrossRef" href="#bib0295">7</a>Causes of constipationConstipation is a symptom and not a disease in itself and can be a consequence of multiple causes. Secondary chronic constipation may be associated with a wide range of diseases<a class="elsevierStyleCrossRef" href="#bib0370">22</a> (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>) and/or drugs<a class="elsevierStyleCrossRef" href="#bib0370">22</a> (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>). Once secondary causes are excluded, CIC is considered, which is a consequence of primary functional impairment of the colon and anus-rectum.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Pathophysiology of primary constipationConstipation can essentially be caused by 2 mechanisms<a class="elsevierStyleCrossRef" href="#bib0375">23</a>: (1) slow transit through the different segments of the colon and (2) defecation disorders. In some patients, both mechanisms may be present, although there is a large group of patients in whom none of these abnormalities is seen. In these cases, constipation is associated with alterations in rectal sensitivity, either a decrease in sensitivity, or an increase in sensitivity and forming part of IBS-C.<a class="elsevierStyleCrossRef" href="#bib0380">24</a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1)Slow colonic transit (colonic inertia). This may be caused by metabolic or endocrine disorders, systemic diseases or by certain drugs. However, it may also be primary, possibly associated with neuropathic or myopathic disorders of the colon wall, as suggested by the decrease in the number of interstitial cells of Cajal,<a class="elsevierStyleCrossRef" href="#bib0385">25</a> or the decreased response to cholinergic stimulation observed in some of these patients.<a class="elsevierStyleCrossRef" href="#bib0390">26</a> As the intestinal contents remain longer in the colon, the absorption of water and electrolytes increases, resulting in a decrease in volume and a hardening of the stool. As a result, the volume of stools, the feeling of the need to defecate and the ease of expelling stools at defecation will all be reduced. In some cases, stagnation of the intestinal contents can lead to the formation of faecalomas. The slowing down of colonic transit may also be due to defecation disorders as evidenced by the fact that the success of treatment with anorectal biofeedback normalises colonic transit.<a class="elsevierStyleCrossRef" href="#bib0395">27</a></li><li class="elsevierStyleListItem" id="lsti0010">2)Defecation disorder. Difficulty in defecation may be due to neurological abnormalities such as Hirschsprung's disease or spinal cord injuries, or to anatomical alterations such as rectoceles, enterocele, intussusception, etc. However, in most cases there is no evidence of structural alterations or neurological lesions justifying the difficulty of expulsion, which is considered to be produced by a functional defecation disorder.<a class="elsevierStyleCrossRef" href="#bib0400">28</a> The functional defecation disorder may be due to one or more of the following conditions:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">a)Reduction of rectal sensitivity. The arrival of the faeces in the rectum stimulates sensory receptors that send impulses to the cerebral cortex through afferent nerve pathways. These inform the brain of the presence of the faeces in the rectum and will produce the desire to defecate. An alteration in the sensitivity of the rectum, sometimes associated with a decrease in rectal tone, may result in primary constipation.<a class="elsevierStyleCrossRef" href="#bib0375">23</a></li><li class="elsevierStyleListItem" id="lsti0020">b)Dyssynergic defecation or poor coordination during defecation. At the time of defecation, there is a coordinated increase in abdominal pressure, which is achieved by contracting the muscles of the abdominal wall and the diaphragm, and a relaxation of the anal sphincter, which is associated with a drop of the perineum and rectification of the angle of the rectum with the anal canal. Three types of coordination abnormality or dyssynergic defecation have been described<a class="elsevierStyleCrossRef" href="#bib0405">29</a>: type (I) Increase of adequate rectal pressure with paradoxical contraction of the anal sphincter during the defecation manoeuvre; type (II) Increased weak or insufficient rectal pressure, and type (III) Absence of sphincter relaxation with increased rectal pressure. Types I and III will produce a functional obstruction to defecation, whereas type II results in impaired propulsion. The propulsion deficiency may be associated with an insufficient abdominal press or impaired colonic contractile activity. The practical importance of identifying the mechanisms that produce defecation disorders is so that they can be corrected by anorectal biofeedback, which has been shown to be a very effective treatment of defecation disorders.<a class="elsevierStyleCrossRefs" href="#bib0410">30,31</a></li></ul></li></ul>Constipation with normal transit is defined as constipation even though the transport time of the faeces through the colon is normal.SymptomsMedical historyIn the vast majority of patients, the diagnosis of CIC is based on the description of the symptoms and/or signs recorded in the medical history and the findings of the physical examination. Three aspects must be taken into account: (1) compliance with the diagnostic criteria for chronic constipation, (2) determination of the causes of constipation and (3) detection of signs of alarm. A detailed assessment of signs and/or symptoms may help differentiate between constipation due to slow colonic transit and a functional defecation disorder.In order to evaluate compliance with the Rome III criteria<a class="elsevierStyleCrossRef" href="#bib0285">5</a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), the patient should be asked about: the onset and duration of symptoms; the shape and consistency of the stool: it is recommended to use the Bristol scale<a class="elsevierStyleCrossRef" href="#bib0420">32</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>); the difficulty in evacuation: the patient should be asked about straining during defecation, the feeling of incomplete evacuation, the sensation of blockage or anal obstruction and/or the need to use fingering manoeuvres to expel the faeces; bowel movement frequency; changes in bowel habits (alternating diarrhoea with constipation) and abdominal pain; other relevant aspects such as the presence of anal pain during defecation, defecation urgency and/or faecal incontinence.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>To determine the possible predisposing causes and factors, the patient must be asked about their dietary and lifestyle habits, substance abuse, medication (including laxatives), bowel habits, pathological history and history of diseases (obstetric events, etc.) as well as their profession.In the event of signs of alarm, additional tests should be performed to rule out an organic cause of the constipation<a class="elsevierStyleCrossRefs" href="#bib0425">33–35</a>: Signs of alarm include a sudden change in persistent usual bowel rhythm (>6 weeks) in patients over 50 years of age, rectal bleeding or bloody stool, iron deficiency anaemia, weight loss, significant abdominal pain, family or personal history of colorectal cancer (CRC) or inflammatory bowel disease and palpable mass.Physical examinationIn the event of constipation, a complete physical examination should be performed, including abdominal examination, visual inspection of the perianal and rectal region and a digital rectal examination. A physical examination is performed to look for signs of an organic disease and to evaluate the presence of masses, prolapse, haemorrhoids, fissures, rectocele, faeces in rectum, etc.The digital rectal examination evaluates the tone of the anal sphincter, both at rest and during a bowel movement, and the presence of faeces in the rectal ampulla. Recent studies show that digital rectal examination has a high probability of detecting pelvic floor dyssynergia.<a class="elsevierStyleCrossRefs" href="#bib0440">36,37</a>Comorbidities and complications of constipationThe association between constipation and related gastrointestinal and extraintestinal comorbidities is not well documented.<a class="elsevierStyleCrossRef" href="#bib0450">38</a> The available evidence is inferred from association studies and knowledge of the pathogenesis of constipation. However, in many of these studies there are several confounding factors and there is an overlap between chronic constipation and other functional gastrointestinal disorders.<a class="elsevierStyleCrossRefs" href="#bib0450">38,39</a>A review of studies published between 1980 and 2007 evaluated the association between constipation and various related comorbidities, especially the most common anorectal, colon and urological disorders.<a class="elsevierStyleCrossRefs" href="#bib0450">38,40–42</a> The most prevalent associations are: haemorrhoids, anal fissures, rectal prolapse and stercoral ulceration, faecal impaction, faecal incontinence, megacolon, volvulus, diverticular disease, urinary tract infections, enuresis and urinary incontinence. Many of these conditions have also been identified in a more recent review that includes studies published between January 2011 and March 2012.<a class="elsevierStyleCrossRef" href="#bib0455">39</a> This review also evaluates other extragastrointestinal comorbidities: overweight, obesity, depression, diabetes and urinary disorders.<a class="elsevierStyleCrossRef" href="#bib0455">39</a>The broader studies on the prevalence and association of the various concurrent conditions with chronic constipation come from retrospective cohort studies using the California Medicaid database<a class="elsevierStyleCrossRef" href="#bib0475">43</a> and the US Health Plan database<a class="elsevierStyleCrossRef" href="#bib0480">44</a> (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). The analysis of the Medicaid database, taking into account the possible detection bias, partly modifies the previously published results.<a class="elsevierStyleCrossRef" href="#bib0450">38</a><elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Anorectal complicationsHaemorrhoidsSeveral retrospective cohort studies<a class="elsevierStyleCrossRefs" href="#bib0450">38,43</a> (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>) and prospective studies have described a significant association between chronic constipation and haemorrhoids. It is suggested that the prolonged intra-abdominal pressure exerted on the venous plexuses and anorectal arteriovenous anastomosis may lead to local circulatory disorders such as internal and/or external haemorrhoids.<a class="elsevierStyleCrossRef" href="#bib0450">38</a>Anal fissureThere are different retrospective analyses that support the relationship between chronic constipation and the appearance of anal fissures<a class="elsevierStyleCrossRefs" href="#bib0450">38,43</a> (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). It has been suggested that mucosal injury is caused by a traumatic action due to the passage of hard faeces through the rectal canal during usual defecation strain, local ischaemic involvement and some anal sphincter dysfunction.<a class="elsevierStyleCrossRef" href="#bib0450">38</a>ProlapseRectal prolapse is a condition characterised by the protrusion of the rectum through the anus. Performing frequent and sustained Valsalva manoeuvres can be a contributing factor. The slowing of colonic transit and motility disorders have been related to the appearance or exacerbation of a rectal prolapse. A retrospective cohort study<a class="elsevierStyleCrossRef" href="#bib0475">43</a> described a significant association between chronic constipation and rectal prolapse (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). A systematic review (12 case series studies) shows that constipation decreases after prolapse surgery.<a class="elsevierStyleCrossRef" href="#bib0485">45</a>UlcersSeveral retrospective cohort studies<a class="elsevierStyleCrossRefs" href="#bib0450">38,43</a> have described a significant association between chronic constipation and ulcers (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). Rectal ulcers are an uncommon but probably underestimated complication since stercoral perforations are often identified as spontaneous, idiopathic or secondary. The perforation may go unnoticed clinically as minor episodes of rectal bleeding, or become extremely complicated in case of infection or even bacteraemia with stercoral peritonitis with a very severe prognosis.<a class="elsevierStyleCrossRef" href="#bib0450">38</a> It is suggested that sustained pressure of the wall of the colon and rectum by a direct effect of mass due to the constant presence of faecal matter can lead to a chronic ischaemic injury accompanied by wall necrosis, causing stercoral colonic ulcers.Faecal impaction or faecalomaAlthough studies designed to assess the aetiology and risk factors of faecal impaction in chronic constipation are limited, data from retrospective studies are consistent in suggesting a higher risk in patients with a previous diagnosis of chronic constipation. In fact, faecal impaction is one of the most frequent complications of chronic constipation.<a class="elsevierStyleCrossRefs" href="#bib0450">38,43</a> This condition is caused by accumulation of faeces in the rectal ampulla (although it may occur in both the rectal and colonic tracts), where a period of stasis, some loss of colonic function and anorectal sensitivity, accompanied by alterations in hydration, can lead to the onset of faecalomas that result in impaction and obstruction of the intestinal lumen.<a class="elsevierStyleCrossRef" href="#bib0450">38</a>Faecal incontinenceSeveral studies have shown a positive association between chronic constipation and faecal incontinence,<a class="elsevierStyleCrossRefs" href="#bib0450">38,43,44,46,47</a> most commonly in elderly and institutionalised patients. Clinically speaking, faecal incontinence manifests as the paradoxical leakage of loose or semi-loose faeces around the obstructed stool in the rectal ampulla (overflow faecal incontinence).Colon complicationsDiverticular diseaseThere are several retrospective studies supporting a discrete association between chronic constipation and diverticular disease<a class="elsevierStyleCrossRefs" href="#bib0450">38,43,44</a> (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). However, the role of chronic constipation remains uncertain and probably represents the coexistence of two very common entities<a class="elsevierStyleCrossRef" href="#bib0450">38</a>. It is believed that prolonged colonic transit time and low volume of faeces are associated with an increase in intraluminal pressure, which may lead to pulsion diverticula forming at the weakest points of the colon wall.MegacolonChronic megacolon may be secondary to an advanced stage of refractory chronic constipation or present as a primary colonic disease. Most adults with an idiopathic megacolon have a long history of chronic constipation.<a class="elsevierStyleCrossRef" href="#bib0450">38</a> It has been observed that the presence of megacolon in the event of previous chronic constipation was 5 times more frequent than in its absence.<a class="elsevierStyleCrossRef" href="#bib0450">38</a>VolvulusSigmoid volvulus is a common cause of bowel obstruction. It has multiple causes and is more common in patients with a longstanding megacolon. Retrospective studies have indicated that the presence of a volvulus is significantly more frequent in the context of chronic constipation.<a class="elsevierStyleCrossRef" href="#bib0450">38</a>Colorectal cancerA systematic review of observational studies (28 studies) concludes that there is no association between constipation and CRC.<a class="elsevierStyleCrossRef" href="#bib0500">48</a> The results of the 8 cross-sectional studies included show that the presence of constipation as the main indication for colonoscopy was associated with a lower prevalence of CRC (OR=0.56; 95% CI: 0.36–0.89). In the 3 cohort studies, a non-significant decrease in CRC was observed in patients with constipation (OR=0.80; 95% CI: 0.61–1.04). In the 17 case–control studies, on the other hand, the prevalence of constipation in CRC was significantly higher than in controls without CRC (OR=1.68; 95% CI: 1.29–2.18), but with significant heterogeneity and possible publication bias.Extracolonic complicationsUrological disordersRetrospective and prospective studies in both adults and children suggest that chronic constipation may have an aetiological relationship to the presence of urinary tract infections, enuresis and urinary incontinence.<a class="elsevierStyleCrossRefs" href="#bib0450">38,49–52</a>Other complicationsOther indirect complications could be caused by the therapeutic approach itself, such as the side effects of local therapies (rectal mucosal injury, even at risk of perforation especially in debilitated patients), syncopal episodes during manual removal of faecalomas or adverse effects of laxative medications.ConclusionsChronic constipation is a very common disorder that tends to affect women and the elderly and which can be triggered by multiple causes. Functional constipation, although it may be considered as a common symptom, is associated with multiple complications, both in the rectum or colon, as well as extraintestinal complications. A thorough medical history and physical examination will be key to determining the likely cause of constipation in an individual patient and will be used as a guide for the correct management of the condition.FundingSources of funding: this clinical practice guideline has received external funding from Laboratorios Shire. The sponsors have not influenced any stage of its development.Conflicts of interestJordi Serra is a consultant from Norgine and works with Almirall, Allergan, Cassen-Recordati and Zespri; Sílvia Delgado has been a consultant to Shire (Resolor) and Almirall (Constella); Enrique Rey: Conferences and research funding from Almirall and Norgine Iberia; Fermín Mearin, Advisor for Laboratorios Almirall; Juanjo Mascort, Juan Ferrandiz and Mercè Marzo have no conflict of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:18 [ 0 => array:3 [ "identificador" => "xres814543" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec811943" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres814544" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec811942" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Definition" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Magnitude and significance of the problem" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Risk factors" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Causes of constipation" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Pathophysiology of primary constipation" ] 11 => array:3 [ "identificador" => "sec0040" "titulo" => "Symptoms" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Medical history" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Physical examination" ] ] ] 12 => array:3 [ "identificador" => "sec0055" "titulo" => "Comorbidities and complications of constipation" "secciones" => array:4 [ 0 => array:3 [ "identificador" => "sec0060" "titulo" => "Anorectal complications" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Haemorrhoids" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Anal fissure" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Prolapse" ] 3 => array:2 [ "identificador" => "sec0080" "titulo" => "Ulcers" ] 4 => array:2 [ "identificador" => "sec0085" "titulo" => "Faecal impaction or faecaloma" ] 5 => array:2 [ "identificador" => "sec0090" "titulo" => "Faecal incontinence" ] ] ] 1 => array:3 [ "identificador" => "sec0095" "titulo" => "Colon complications" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "Diverticular disease" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Megacolon" ] 2 => array:2 [ "identificador" => "sec0110" "titulo" => "Volvulus" ] 3 => array:2 [ "identificador" => "sec0115" "titulo" => "Colorectal cancer" ] ] ] 2 => array:3 [ "identificador" => "sec0120" "titulo" => "Extracolonic complications" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0125" "titulo" => "Urological disorders" ] ] ] 3 => array:2 [ "identificador" => "sec0130" "titulo" => "Other complications" ] ] ] 13 => array:2 [ "identificador" => "sec0135" "titulo" => "Conclusions" ] 14 => array:2 [ "identificador" => "sec0140" "titulo" => "Funding" ] 15 => array:2 [ "identificador" => "sec0145" "titulo" => "Conflicts of interest" ] 16 => array:2 [ "identificador" => "xack273289" "titulo" => "Acknowledgements" ] 17 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-01-18" "fechaAceptado" => "2016-02-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec811943" "palabras" => array:3 [ 0 => "Constipation" 1 => "Clinical practice guidelines" 2 => "Chronic disease" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec811942" "palabras" => array:3 [ 0 => "Estreñimiento" 1 => "Guía de práctica clínica" 2 => "Enfermedad crónica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Clinical practice guidelines for the management of constipation in adults aim to generate recommendations on the optimal approach to chronic constipation in the primary care and specialized outpatient setting. Their main objective is to provide healthcare professionals who care for patients with chronic constipation with a tool that allows them to make the best decisions about the prevention, diagnosis and treatment of this condition. They are intended for family physicians, primary care and specialist nurses, gastroenterologists and other health professionals involved in the treatment of these patients, as well as patients themselves. The guidelines have been developed in response to the high prevalence of chronic constipation, its impact on patient quality of life and recent advances in pharmacological management. The Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) system has been used to classify the scientific evidence and strengthen the recommendations." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La guía de práctica clínica sobre el manejo del paciente con estreñimiento en los pacientes adultos se fundamenta en una serie recomendaciones y estrategias con el objetivo de proporcionar a los profesionales sanitarios encargados de la asistencia a pacientes con estreñimiento crónico una herramienta que les permita tomar las mejores decisiones sobre la prevención, diagnóstico y tratamiento del estreñimiento. Esta guía de práctica clínica persigue una atención eficiente del estreñimiento a partir de un trabajo coordinado y multidisciplinar con la participación de la atención primaria y especializada. La guía va dirigida a los médicos de familia, a los profesionales de enfermería de atención primaria y especializada, a los gastroenterólogos, a otros especialistas que atienden a pacientes con estreñimiento y a las personas afectadas con esta problemática. La elaboración de esta guía se justifica fundamentalmente por la elevada frecuencia del estreñimiento crónico, el impacto que este tiene en la calidad de vida de los pacientes y por los avances recientes en el manejo farmacológico del estreñimiento. Para clasificar la evidencia científica y la fuerza de las recomendaciones se ha utilizado el Grading of RecommendationsAssessment, Development and EvaluationWorking Group (sistema GRADE)." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Serra J, Mascort-Roca J, Marzo-Castillejo M, Delgado Aros S, Ferrándiz Santos J, Rey Diaz Rubio E, et al. Guía de práctica clínica sobre el manejo del estreñimiento crónico en el paciente adulto. Parte 1: Definición, etiología y manifestaciones clínicas. Gastroenterol Hepatol. 2017;40:132–141." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 848 "Ancho" => 2187 "Tamanyo" => 138450 ] ] "descripcion" => array:1 [ "en" => "Bristol Scale for faeces assessment. Visual table with illustrations. Source: Lewis and Heaton.<a class="elsevierStyleCrossRef" href="#bib0420">32</a>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "RCT, randomised clinical trial." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quality of the evidence \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study design \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reduce if<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Increase if<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RCT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Limitation of study quality significant (−1) or very significant (−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Strong association,<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> without confounding, consistent and direct factors (+1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Significant inconsistency (−1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Very strong association,<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> without significant threats to validity (non-biases) and direct evidence (+2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Observational study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Some (−1) or a lot of (−2) uncertainty about whether the evidence is direct \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dose-response gradient (+1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Very low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scarce or inaccurate data (−1) High probability of notification bias (−1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">All possible confounding factors could have reduced the observed effect (+1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1368382.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "1: move up or down one level (e.g., from high to moderate); 2: move up or down 2 levels (e.g., from high to low)." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "A statistically significant relative risk of >2 (<0.5), based on evidence consisting of 2 or more observational studies, without plausible confounding factors." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "A statistically significant relative risk of >5 (<0.2), based on direct evidence and without significant threats to validity." ] ] ] "descripcion" => array:1 [ "en" => "Assessment of the quality of evidence for each variable. GRADE System." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinicians \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Managers/planners \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Strong \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The vast majority of people would agree with the recommended action and only a small proportion would not \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Most patients should receive the recommended intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The recommendation can be adopted as health policy in most situations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weak \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Most people would agree with the recommended action but a significant number would not \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">It recognises that different options will be appropriate for different patients and that the healthcare professional must help each patient to make the decision that is most consistent with their values and preferences \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">There is a need for an important debate and the participation of stakeholders \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1368383.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Strength of recommendations. GRADE system." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. Presence of 2 or more of the following<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">a. Lumpy or hard stools \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">b. Straining during defecation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">c. Sensation of anorectal obstruction/blockage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">d. Sensation of incomplete evacuation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">e. Manual manoeuvres to facilitate defecations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">f. Fewer than three defecations per week \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. Loose stools are rarely present without the use of laxatives \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3. Insufficient criteria for irritable bowel syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1368384.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "a–e in ≥25% of defecations+for the last 3 months, with symptom onset at least 6 months prior to diagnosis. Source: Longstreth et al.<a class="elsevierStyleCrossRef" href="#bib0285">5</a>." ] ] ] "descripcion" => array:1 [ "en" => "Functional chronic constipation. Rome III criteria." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Adapted from Lindberg et al.<a class="elsevierStyleCrossRef" href="#bib0370">22</a>." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="9" align="left" valign="top">Digestive problems (structural and gastrointestinal)</td><td class="td" title="table-entry " align="left" valign="top">• Neoplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Intestinal stenosis: ischaemic colitis, inflammatory bowel disease, post-surgical changes (flanges, adhesions) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Idiopathic rectal ulcer \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Rectal intussusception \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Rectal prolapse \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Enterocele \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Rectocele \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Anal stenosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Pelvic floor weakness \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="15" align="left" valign="top">Endocrine/metabolic</td><td class="td" title="table-entry " align="left" valign="top">• Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hypothyroidism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Chronic renal failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hypercalcaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hypermagnesaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hyperparathyroidism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hypokalaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hypomagnesaemia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Multiple endocrine neoplasia ii \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Dehydration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Heavy metal poisoning \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Panhypopituitarism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Addison's Disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Pheochromocytoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Porphyria \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="7" align="left" valign="top">Neurological</td><td class="td" title="table-entry " align="left" valign="top">• Cerebrovascular disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Neoplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Autonomic neuropathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Spinal disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Spinal cord injuries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Parkinson's Disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Multiple sclerosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Psychiatric/Psychological</td><td class="td" title="table-entry " align="left" valign="top">• Depression \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Eating disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Denial of defecation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="8" align="left" valign="top">Myopathic disorders, collagenosis and vasculitis</td><td class="td" title="table-entry " align="left" valign="top">• Polymyositis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Dermatomyositis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Scleroderma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Systemic sclerosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Myotonic dystrophy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Systemic lupus erythematosus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Family visceral myopathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Amyloidosis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1368381.png" ] ] ] ] "descripcion" => array:1 [ "en" => "List of diseases associated with chronic constipation." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Adapted from Lindberg et al.<a class="elsevierStyleCrossRef" href="#bib0370">22</a>." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Central nervous system</td><td class="td" title="table-entry " align="left" valign="top">• Antiepileptics (carbamazepine, phenytoin, clonazepam, amantadine, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Antiparkinson drugs (bromocriptine, levodopa, biperiden, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Anxiolytics and hypnotics (benzodiazepines, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Antidepressants (tricyclics, selective serotonin reuptake inhibitors, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Antipsychotics and neuroleptics (butyrophenones, phenothiazines, barbiturates, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="6" align="left" valign="top">Digestive system</td><td class="td" title="table-entry " align="left" valign="top">• Antacids (containing aluminium, calcium) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Proton-pump inhibitors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Anticholinergic antispasmodics (natural alkaloids and synthetic and semisynthetic derivatives with a tertiary and quaternary amine structure such as atropine, scopolamine, butylscopolamine, methylscopolamine, trimebutine, pinaverium, etc.) or musculotropic drugs (mebeverine, papaverine, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Antiemetics (chlorpromazine, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Supplements (salts of calcium, bismuth, iron, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Antidiarrhoeal agents \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Circulatory system</td><td class="td" title="table-entry " align="left" valign="top">• Antihypertensives (beta-blockers, calcium-antagonists, clonidine, hydralazine, ganglion blockers, monoamine oxidase inhibitors, methyldopa, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Antiarrhythmics (quinidine and derivatives) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Diuretics (furosemide) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hypolipidemics (cholestyramine, colestipol, statins, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Other</td><td class="td" title="table-entry " align="left" valign="top">• Analgesics (non-steroidal anti-inflammatory drugs, opiates and derivatives, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Antihistamines against H1 receptors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Antitussives (codeine, dextromethorphan, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Metallic ions (aluminium, barium sulphate, bismuth, calcium, iron, etc.) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Cytostatic agents \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1368380.png" ] ] ] ] "descripcion" => array:1 [ "en" => "List of drugs associated with chronic constipation (abridged list)." ] ] 6 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Source: Talley et al.<a class="elsevierStyleCrossRef" href="#bib0450">38</a>, Arora et al.<a class="elsevierStyleCrossRef" href="#bib0475">43</a> and Mitra et al.<a class="elsevierStyleCrossRef" href="#bib0480">44</a>.CI, confidence interval; GERD, gastroesophageal reflux disease; NE, not evaluated; OR, odds ratio." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Method</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Retrospective analysis of claims (US Health Plan)<a class="elsevierStyleCrossRef" href="#bib0450">38</a></td><td class="td" title="table-entry " align="left" valign="top">Medical Database Review \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">California Medicaid programme<a class="elsevierStyleCrossRef" href="#bib0475">43</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Subjects</td><td class="td" title="table-entry " align="left" valign="top">48,585 (with constipation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">147,595 (with constipation) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">97,170 (controls) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">142,086 (controls with GERD) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1368385.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complication/Comorbidity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR (p-value) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anal fissure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.47 (2.12–2.84) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anal fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.72 (1.37–2.15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemorrhage (rectum/anus) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.36 (1.30–1.43) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ulcer (rectum/anus) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.11 (1.66–2.69) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diverticular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.04 (1–1.08) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Crohn's Disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.96 (0.85–1.07) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Faecal impaction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.20 (2.83–3.62) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Faecal incontinence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.16 (0.99–1.35) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemorrhoids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.24 (1.2–1.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hirschsprung's disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.42 (2.46–7.92) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Irritable bowel syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.12 (1.07–1.18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Colorectal cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.16 (1.05–1.30) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rectal prolapse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.63 (1.9–2.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bowel obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ulcerative colitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.86 (1.27–2.10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intestinal volvulus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.36 (1.07–1.72) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1368386.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Gastrointestinal comorbidities and complications of constipation." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:52 [ 0 => array:3 [ "identificador" => "bib0265" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G.H. Guyatt" 1 => "A.D. Oxman" 2 => "H.J. Schünemann" 3 => "P. Tugwell" 4 => "A. Knottnerus" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jclinepi.2010.09.011" "Revista" => array:6 [ "tituloSerie" => "J Clin Epidemiol" "fecha" => "2011" "volumen" => "64" "paginaInicial" => "380" "paginaFinal" => "382" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21185693" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0270" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Guyatt" 1 => "A.D. Oxman" 2 => "E. Akl" 3 => "R. Kunz" 4 => "G. Vist" 5 => "J. Brozek" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jclinepi.2010.04.026" "Revista" => array:6 [ "tituloSerie" => "J Clin Epidemiol" "fecha" => "2011" "volumen" => "64" "paginaInicial" => "383" "paginaFinal" => "394" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21195583" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0275" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "GRADE guidelines: 2. Framing the question and deciding on important outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.H. Guyatt" 1 => "A.D. Oxman" 2 => "R. Kunz" 3 => "D. Atkins" 4 => "J. Brozek" 5 => "G. Vist" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jclinepi.2010.09.012" "Revista" => array:6 [ "tituloSerie" => "J Clin Epidemiol" "fecha" => "2011" "volumen" => "64" "paginaInicial" => "395" "paginaFinal" => "400" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21194891" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0280" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "quiz 1581, 1592" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.C. Suares" 1 => "A.C. Ford" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/ajg.2011.164" "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "2011" "volumen" => "106" "paginaInicial" => "1582" "paginaFinal" => "1591" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21606976" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0285" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Functional bowel disorders" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G.F. Longstreth" 1 => "W.G. Thompson" 2 => "W.D. Chey" 3 => "L.A. Houghton" 4 => "F. Mearin" 5 => "R.C. Spiller" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.gastro.2005.11.061" "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "2006" "volumen" => "130" "paginaInicial" => "1480" "paginaFinal" => "1491" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16678561" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0290" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Inability of the Rome III criteria to distinguish functional constipation from constipation-subtype irritable bowel syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.K. Wong" 1 => "O.S. Palsson" 2 => "M.J. Turner" 3 => "R.L. Levy" 4 => "A.D. Feld" 5 => "M. von Korff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/ajg.2010.200" "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "2010" "volumen" => "105" "paginaInicial" => "2228" "paginaFinal" => "2234" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20502449" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0295" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of constipation in children and adults: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.M. Mugie" 1 => "M. Benninga" 2 => "C. di Lorenzo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bpg.2010.12.010" "Revista" => array:6 [ "tituloSerie" => "Best Pract Res Clin Gastroenterol" "fecha" => "2011" "volumen" => "25" "paginaInicial" => "3" "paginaFinal" => "18" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21382575" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0300" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of constipation: agreement among several criteria and evaluation of the diagnostic accuracy of qualifying symptoms and self-reported definition in a population-based survey in Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "V. Garrigues" 1 => "C. Gálvez" 2 => "V. Ortiz" 3 => "M. Ponce" 4 => "P. Nos" 5 => "J. Ponce" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Epidemiol" "fecha" => "2004" "volumen" => "159" "paginaInicial" => "520" "paginaFinal" => "526" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14977649" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0305" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subjects with irritable bowel syndrome-constipation are «more constipated» than those with chronic constipation: spectrum from a population based study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Mearin" 1 => "E. Rey" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "2012" "volumen" => "142" "numero" => "Suppl. 1" "paginaInicial" => "S818" "paginaFinal" => "S819" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0310" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence and pathophysiology of functional constipation among women in Catalonia, Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Y. Ribas" 1 => "E. Saldaña" 2 => "J. Martí-Ragué" 3 => "P. Clavé" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/DCR.0b013e31822cb5c2" "Revista" => array:6 [ "tituloSerie" => "Dis Colon Rectum" "fecha" => "2011" "volumen" => "54" "paginaInicial" => "1560" "paginaFinal" => "1569" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22067186" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0315" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology and burden of chronic constipation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.I.P. Sanchez" 1 => "P. Bercik" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Can J Gastroenterol" "fecha" => "2011" "volumen" => "25" "numero" => "Suppl. B" "paginaInicial" => "11B" "paginaFinal" => "15B" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22114752" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0320" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Levels of satisfaction with current chronic constipation treatment options in Europe – an internet survey" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Müller-Lissner" 1 => "J. Tack" 2 => "Y. Feng" 3 => "F. Schenck" 4 => "R. Specht Gryp" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/apt.12124" "Revista" => array:6 [ "tituloSerie" => "Aliment Pharmacol Ther" "fecha" => "2013" "volumen" => "37" "paginaInicial" => "137" "paginaFinal" => "145" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23126338" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0325" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Breath methane in functional constipation: response to treatment with Ispaghula husk" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.B. Vega" 1 => "A. Perelló" 2 => "L. Martos" 3 => "I. García Bayo" 4 => "M. García" 5 => "V. Andreu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/nmo.12568" "Revista" => array:6 [ "tituloSerie" => "Neurogastroenterol Motil" "fecha" => "2015" "volumen" => "27" "paginaInicial" => "945" "paginaFinal" => "953" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25952409" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0330" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systematic review: impact of constipation on quality of life in adults and children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Belsey" 1 => "S. Greenfield" 2 => "D. Candy" 3 => "M. Geraint" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2036.2010.04273.x" "Revista" => array:6 [ "tituloSerie" => "Aliment Pharmacol Ther" "fecha" => "2010" "volumen" => "31" "paginaInicial" => "938" "paginaFinal" => "949" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20180788" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0335" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Healthcare seeking for constipation: a population-based survey in the Mediterranean area of Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C. Gálvez" 1 => "V. Garrigues" 2 => "V. Ortiz" 3 => "M. Ponce" 4 => "P. Nos" 5 => "J. Ponce" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2036.2006.02981.x" "Revista" => array:6 [ "tituloSerie" => "Aliment Pharmacol Ther" "fecha" => "2006" "volumen" => "24" "paginaInicial" => "421" "paginaFinal" => "428" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16842470" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0340" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Dukas" 1 => "W.C. Willett" 2 => "E.L. Giovannucci" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1572-0241.2003.07591.x" "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "2003" "volumen" => "98" "paginaInicial" => "1790" "paginaFinal" => "1796" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12907334" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0345" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association of low dietary intake of fiber and liquids with constipation: evidence from the national health and nutrition examination survey" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.D. Markland" 1 => "O. Palsson" 2 => "P.S. Goode" 3 => "K.L. Burgio" 4 => "J. Busby-Whitehead" 5 => "W.E. Whitehead" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/ajg.2013.73" "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "2013" "volumen" => "108" "paginaInicial" => "796" "paginaFinal" => "803" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23567352" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0350" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Stopping or reducing dietary fiber intake reduces constipation and its associated symptoms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K.-S. Ho" 1 => "C.Y.M. Tan" 2 => "M.A. Mohd Daud" 3 => "F. Seow-Choen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3748/wjg.v18.i33.4593" "Revista" => array:6 [ "tituloSerie" => "World J Gastroenterol" "fecha" => "2012" "volumen" => "18" "paginaInicial" => "4593" "paginaFinal" => "4596" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22969234" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0355" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brief physical inactivity prolongs colonic transit time in elderly active men" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Liu" 1 => "T. Kondo" 2 => "Y. Toda" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1055/s-2007-1021212" "Revista" => array:6 [ "tituloSerie" => "Int J Sports Med" "fecha" => "1993" "volumen" => "14" "paginaInicial" => "465" "paginaFinal" => "467" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8300274" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0360" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of exercise and physical fitness on large intestinal function" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.A. Bingham" 1 => "J.H. Cummings" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "1989" "volumen" => "97" "paginaInicial" => "1389" "paginaFinal" => "1399" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2583406" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0365" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of constipation in Europe and Oceania: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. Peppas" 1 => "V.G. Alexiou" 2 => "E. Mourtzoukou" 3 => "M.E. Falagas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-230X-8-5" "Revista" => array:5 [ "tituloSerie" => "BMC Gastroenterol" "fecha" => "2008" "volumen" => "8" "paginaInicial" => "5" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18269746" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0370" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "World Gastroenterology Organisation global guideline: constipation – a global perspective" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "World Gastroenterology Organisation" "etal" => true "autores" => array:6 [ 0 => "G. Lindberg" 1 => "S.S. Hamid" 2 => "P. Malfertheiner" 3 => "O.O. Thomsen" 4 => "L.B. Fernandez" 5 => "J. Garisch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MCG.0b013e31820fb914" "Revista" => array:6 [ "tituloSerie" => "J Clin Gastroenterol" "fecha" => "2011" "volumen" => "45" "paginaInicial" => "483" "paginaFinal" => "487" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21666546" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0375" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Symptoms and physiology in severe chronic constipation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H. Mertz" 1 => "B. Naliboff" 2 => "E.A. Mayer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1572-0241.1999.00783.x" "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "1999" "volumen" => "94" "paginaInicial" => "131" "paginaFinal" => "138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9934743" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0380" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Altered rectal perception is a biological marker of patients with irritable bowel syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H. Mertz" 1 => "B. Naliboff" 2 => "J. Munakata" 3 => "N. Niazi" 4 => "E.A. Mayer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "1995" "volumen" => "109" "paginaInicial" => "40" "paginaFinal" => "52" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7797041" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0385" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Decreased interstitial cell of cajal volume in patients with slow-transit constipation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.L. He" 1 => "L. Burgart" 2 => "L. Wang" 3 => "J. Pemberton" 4 => "T. Young-Fadok" 5 => "J. Szurszewski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "2000" "volumen" => "118" "paginaInicial" => "14" "paginaFinal" => "21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10611149" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0390" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impaired colonic motor response to cholinergic stimulation in patients with severe chronic idiopathic (slow transit type) constipation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Bassotti" 1 => "G. Chiarioni" 2 => "B.P. Imbimbo" 3 => "C. Betti" 4 => "F. Bonfante" 5 => "I. Vantini" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dig Dis Sci" "fecha" => "1993" "volumen" => "38" "paginaInicial" => "1040" "paginaFinal" => "1045" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8508698" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0395" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Response to a behavioural treatment, biofeedback, in constipated patients is associated with improved gut transit and autonomic innervation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.V. Emmanuel" 1 => "M.A. Kamm" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Gut" "fecha" => "2001" "volumen" => "49" "paginaInicial" => "214" "paginaFinal" => "219" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11454797" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0400" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Functional disorders of the anus and rectum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "W.E. Whitehead" 1 => "A. Wald" 2 => "N.E. Diamant" 3 => "P. Enck" 4 => "J.H. Pemberton" 5 => "S.S. Rao" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Gut" "fecha" => "1999" "volumen" => "45" "numero" => "Suppl. 2" "paginaInicial" => "II55" "paginaFinal" => "II59" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10457046" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0405" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation (anismus)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.S.C. Rao" 1 => "R.S. Mudipalli" 2 => "M. Stessman" 3 => "B. Zimmerman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2982.2004.00526.x" "Revista" => array:6 [ "tituloSerie" => "Neurogastroenterol Motil" "fecha" => "2004" "volumen" => "16" "paginaInicial" => "589" "paginaFinal" => "596" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15500515" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0410" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Chiarioni" 1 => "W.E. Whitehead" 2 => "V. Pezza" 3 => "A. Morelli" 4 => "G. Bassotti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.gastro.2005.11.014" "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "2006" "volumen" => "130" "paginaInicial" => "657" "paginaFinal" => "664" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16530506" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0415" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.S.C. Rao" 1 => "K. Seaton" 2 => "M. Miller" 3 => "K. Brown" 4 => "I. Nygaard" 5 => "P. Stumbo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cgh.2006.12.023" "Revista" => array:6 [ "tituloSerie" => "Clin Gastroenterol Hepatol" "fecha" => "2007" "volumen" => "5" "paginaInicial" => "331" "paginaFinal" => "338" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17368232" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0420" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Stool form scale as a useful guide to intestinal transit time" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.J. Lewis" 1 => "K.W. Heaton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3109/00365529709011203" "Revista" => array:6 [ "tituloSerie" => "Scand J Gastroenterol" "fecha" => "1997" "volumen" => "32" "paginaInicial" => "920" "paginaFinal" => "924" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9299672" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0425" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "American Gastroenterological Association technical review on constipation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.E. Bharucha" 1 => "J.H. Pemberton" 2 => "G.R. Locke" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.gastro.2012.10.028" "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "2013" "volumen" => "144" "paginaInicial" => "218" "paginaFinal" => "238" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23261065" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0430" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Practice parameters for the evaluation and management of constipation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.A. Ternent" 1 => "A.L. Bastawrous" 2 => "N.A. Morin" 3 => "C.N. Ellis" 4 => "N.H. Hyman" 5 => "W.D. Buie" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10350-007-9000-y" "Revista" => array:6 [ "tituloSerie" => "Dis Colon Rectum" "fecha" => "2007" "volumen" => "50" "paginaInicial" => "2013" "paginaFinal" => "2022" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17665250" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0435" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consensus statement AIGO/SICCR: diagnosis and treatment of chronic constipation and obstructed defecation (part I: diagnosis)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Bove" 1 => "F. Pucciani" 2 => "M. Bellini" 3 => "E. Battaglia" 4 => "R. Bocchini" 5 => "D.F. Altomare" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3748/wjg.v18.i14.1555" "Revista" => array:6 [ "tituloSerie" => "World J Gastroenterol" "fecha" => "2012" "volumen" => "18" "paginaInicial" => "1555" "paginaFinal" => "1564" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22529683" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0440" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Digital rectal examination is a useful tool for identifying patients with dyssynergia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K. Tantiphlachiva" 1 => "P. Rao" 2 => "A. Attaluri" 3 => "S.S.C. Rao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cgh.2010.06.031" "Revista" => array:6 [ "tituloSerie" => "Clin Gastroenterol Hepatol" "fecha" => "2010" "volumen" => "8" "paginaInicial" => "955" "paginaFinal" => "960" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20656061" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0445" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical examination remains more important than anorectal function tests to identify treatable conditions in women with constipation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.J. Lam" 1 => "R.J.F. Felt-Bersma" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00192-012-1796-x" "Revista" => array:6 [ "tituloSerie" => "Int Urogynecol J" "fecha" => "2013" "volumen" => "24" "paginaInicial" => "67" "paginaFinal" => "72" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22618205" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0450" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A gap in our understanding: chronic constipation and its comorbid conditions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N.J. Talley" 1 => "K.L. Lasch" 2 => "C.L. Baum" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cgh.2008.07.005" "Revista" => array:6 [ "tituloSerie" => "Clin Gastroenterol Hepatol" "fecha" => "2009" "volumen" => "7" "paginaInicial" => "9" "paginaFinal" => "19" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18829389" "web" => "Medline" ] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0455" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comorbidities in patients with irritable bowel syndrome with constipation or chronic idiopathic constipation: a review of the literature from the past decade" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D. Nellesen" 1 => "A. Chawla" 2 => "D.L. Oh" 3 => "T. Weissman" 4 => "B.J. Lavins" 5 => "C.W. Murray" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3810/pgm.2013.03.2640" "Revista" => array:6 [ "tituloSerie" => "Postgrad Med" "fecha" => "2013" "volumen" => "125" "paginaInicial" => "40" "paginaFinal" => "50" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23816770" "web" => "Medline" ] ] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0460" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "A154" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Constipation in adults: complications and comorbidities" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Singh" 1 => "K. Kahler" 2 => "V. Bharathi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Gastroenterology" "fecha" => "2005" "volumen" => "128" "numero" => "Suppl. 2" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15825082" "web" => "Medline" ] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0465" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications and comorbidities of constipation in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Singh" 1 => "S. Vadhavkar" 2 => "H. Wang" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Gastroenterology" "fecha" => "2007" "volumen" => "132" "numero" => "Suppl. 2" "paginaInicial" => "A458" ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0470" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Healthcare costs and clinical sequelae associated with constipation in a managed care population" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Mitra" 1 => "K.L. Davis" 2 => "R.W. Baran" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "2007" "volumen" => "102" "paginaInicial" => "2" ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0475" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Concurrent conditions in patients with chronic constipation: a population-based study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Arora" 1 => "A. Mannalithara" 2 => "A. Mithal" 3 => "G. Triadafilopoulos" 4 => "G. Singh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0042910" "Revista" => array:5 [ "tituloSerie" => "PLoS ONE" "fecha" => "2012" "volumen" => "7" "paginaInicial" => "e42910" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23071488" "web" => "Medline" ] ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0480" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "All-cause health care charges among managed care patients with constipation and comorbid irritable bowel syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Mitra" 1 => "K.L. Davis" 2 => "R.W. Baran" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3810/pgm.2011.09.2467" "Revista" => array:6 [ "tituloSerie" => "Postgrad Med" "fecha" => "2011" "volumen" => "123" "paginaInicial" => "122" "paginaFinal" => "132" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21904094" "web" => "Medline" ] ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0485" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systematic review on ventral rectopexy for rectal prolapse and intussusception" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.B. Samaranayake" 1 => "C. Luo" 2 => "A.W. Plank" 3 => "A.E.H. Merrie" 4 => "L.D. Plank" 5 => "I.P. Bissett" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1463-1318.2009.01934.x" "Revista" => array:6 [ "tituloSerie" => "Colorectal Dis" "fecha" => "2010" "volumen" => "12" "paginaInicial" => "504" "paginaFinal" => "512" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19438880" "web" => "Medline" ] ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0490" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence and predictive factors of fecal incontinence" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.-W. Kang" 1 => "H.-K. Jung" 2 => "K.-J. Kwon" 3 => "E.-M. Song" 4 => "J.-Y. Choi" 5 => "S.-E. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5056/jnm.2012.18.1.86" "Revista" => array:6 [ "tituloSerie" => "J Neurogastroenterol Motil" "fecha" => "2012" "volumen" => "18" "paginaInicial" => "86" "paginaFinal" => "93" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22323992" "web" => "Medline" ] ] ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0495" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Constipation is also an important cause of fecal incontinence in old people: Author's reply" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H-K. Jung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5056/jnm.2012.18.3.346" "Revista" => array:6 [ "tituloSerie" => "J Neurogastroenterol Motil" "fecha" => "2012" "volumen" => "18" "paginaInicial" => "346" "paginaFinal" => "347" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22837888" "web" => "Medline" ] ] ] ] ] ] ] ] 47 => array:3 [ "identificador" => "bib0500" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association between constipation and colorectal cancer: systematic review and meta-analysis of observational studies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.M. Power" 1 => "N.J. Talley" 2 => "A.C. Ford" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/ajg.2013.52" "Revista" => array:6 [ "tituloSerie" => "Am J Gastroenterol" "fecha" => "2013" "volumen" => "108" "paginaInicial" => "894" "paginaFinal" => "903" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23481143" "web" => "Medline" ] ] ] ] ] ] ] ] 48 => array:3 [ "identificador" => "bib0505" "etiqueta" => "49" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care. Clinical Guideline May 2010" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "National Collaborating Centre for Women's and Children's Health (UK)" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2010" "editorial" => "RCOG Press" "editorialLocalizacion" => "London" ] ] ] ] ] ] 49 => array:3 [ "identificador" => "bib0510" "etiqueta" => "50" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence rates for constipation and faecal and urinary incontinence" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "V. Loening-Baucke" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/adc.2006.098335" "Revista" => array:6 [ "tituloSerie" => "Arch Dis Child" "fecha" => "2007" "volumen" => "92" "paginaInicial" => "486" "paginaFinal" => "489" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16857698" "web" => "Medline" ] ] ] ] ] ] ] ] 50 => array:3 [ "identificador" => "bib0515" "etiqueta" => "51" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association of non-urological diseases with lower urinary tract symptoms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Koskimäki" 1 => "M. Hakama" 2 => "H. Huhtala" 3 => "T.L. Tammela" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Scand J Urol Nephrol" "fecha" => "2001" "volumen" => "35" "paginaInicial" => "377" "paginaFinal" => "381" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11771864" "web" => "Medline" ] ] ] ] ] ] ] ] 51 => array:3 [ "identificador" => "bib0520" "etiqueta" => "52" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of urinary incontinence among institutionalized patients: a cross-sectional epidemiologic study in a midsized city in northern Italy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Aggazzotti" 1 => "F. Pesce" 2 => "D. Grassi" 3 => "G. Fantuzzi" 4 => "E. Righi" 5 => "D. de Vita" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Urology" "fecha" => "2000" "volumen" => "56" "paginaInicial" => "245" "paginaFinal" => "249" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10925087" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack273289" "titulo" => "Acknowledgements" "texto" => "The following people have acted as external reviewers: Carmen Vela Vallespín. General practitioner, Riu Nord i Sud Primary Care Centre (CAP) Catalan Health Institute Santa Coloma, Barcelona. Iván Villar Balboa. General practitioner, Florida Sud Primary Care Centre (CAP) Catalan Health Institute, L’Hospitalet de Llobregat, Barcelona. Mercè Barenys de Lacha. Gastroenterologist, Hospital de Viladecans. Professor of Gastroenterology, University of Barcelona. IDIBELL Scientific Committee. Francisco Javier Amador Romero. General practitioner, Los Ángeles Health Centre, Madrid. Miguel Mínguez Pérez. Gastroenterologist, Hospital Clínico Universitario de Valencia. This CPG has the support of the following organisations:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025">-Asociación Española de Gastroenterología (AEG) [Spanish Association of Gastroenterology].</li><li class="elsevierStyleListItem" id="lsti0030">-Sociedad Española de Medicina Familiar y Comunitaria (semFYC) [Spanish Society of Family and Community Medicine].</li></ul>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/24443824/0000004000000003/v1_201703160041/S2444382417300408/v1_201703160041/en/main.assets" "Apartado" => array:4 [ "identificador" => "64462" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Review article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24443824/0000004000000003/v1_201703160041/S2444382417300408/v1_201703160041/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382417300408?idApp=UINPBA00004N"]

Statistics

Review

Clinical practice guidelines for the management of constipation in adults. Part 1: Definition, aetiology and clinical manifestations

Guía de práctica clínica sobre el manejo del estreñimiento crónico en el paciente adulto. Parte 1: Definición, etiología y manifestaciones clínicas

Jordi Serraa,

Corresponding author

jserrap.germanstrias@gencat.cat

Corresponding author.

, Juanjo Mascort-Rocab,c, Mercè Marzo-Castillejod,e, Silvia Delgado Arosf, Juan Ferrándiz Santosg, Enrique Rey Diaz Rubioh, Fermín Mearin Manriquei

a Unitat de Motilitat i Trastorns Funcionals Digestius, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain

b Centro de Asistencia Primaria (CAP) Florida Sud, Institut Català de la Salut, L’Hospitalet de Llobregat, Barcelona, Spain

c Departament de Ciències Clíniques, Campus Bellvitge, Facultat de Medicina, Universitat de Barcelona, L’Hospitalet de Llobregat, Barcelona, Spain

d Unitat de Suport a la Recerca – Institut d’Investigació d’Atenció Primària (IDIAP) Jordi Gol, Direcció d’Atenció Primària Costa de Ponent, Institut Català de la Salut, Spain

e Scientist, semFYC, Barcelona, Spain

f Neuro-Enteric Translational Science (NETS) Group Coordinator, Institut Hospital del Mar d’Investigacions Mèdiques (IMIM)-Parc de Salut Mar, Parc de Recerca Biomèdica de Barcelona (PRBB), Barcelona, Spain

g Subdirección General de Calidad Asistencial, Consejería de Sanidad, Madrid, Spain

h Hospital Clínico San Carlos, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain

i Servicio de Aparato Digestivo, Instituto de Trastornos Funcionales y Motores Digestivos, Barcelona, Spain

Read

22522

Times
was read the article

5463

Total PDF

17059

Total HTML

Share statistics

 array:23 [
  "pii" => "S2444382417300408"
  "issn" => "24443824"
  "doi" => "10.1016/j.gastre.2017.02.001"
  "estado" => "S300"
  "fechaPublicacion" => "2017-03-01"
  "aid" => "1013"
  "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;&#44; AEEH and AEG"
  "copyrightAnyo" => "2016"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "ssu"
  "cita" => "Gastroenterol Hepatol. 2017;40:132-41"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 836
    "formatos" => array:2 [
      "HTML" => 542
      "PDF" => 294
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0210570516300036"
      "issn" => "02105705"
      "doi" => "10.1016/j.gastrohep.2016.02.006"
      "estado" => "S300"
      "fechaPublicacion" => "2017-03-01"
      "aid" => "1013"
      "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;&#44; AEEH y AEG"
      "documento" => "article"
      "crossmark" => 1
      "subdocumento" => "ssu"
      "cita" => "Gastroenterol Hepatol. 2017;40:132-41"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:2 [
        "total" => 5447
        "formatos" => array:2 [
          "HTML" => 4213
          "PDF" => 1234
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Revisi&#243;n</span>"
        "titulo" => "Gu&#237;a de pr&#225;ctica cl&#237;nica sobre el manejo del estre&#241;imiento cr&#243;nico en el paciente adulto&#46; Parte 1&#58; Definici&#243;n&#44; etiolog&#237;a y manifestaciones cl&#237;nicas"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "132"
            "paginaFinal" => "141"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Clinical practice guidelines for the management of constipation in adults&#46; Part 1&#58; Definition&#44; aetiology and clinical manifestations"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figura 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 846
                "Ancho" => 2246
                "Tamanyo" => 150026
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Escala de Bristol</span> para la evaluaci&#243;n de las heces&#46; Tabla visual con ilustraciones&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Fuente&#58; Lewis y Heaton<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">32</span></a>&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Jordi Serra, Juanjo Mascort-Roca, Merc&#232; Marzo-Castillejo, Silvia Delgado Aros, Juan Ferr&#225;ndiz Santos, Enrique Rey Diaz Rubio, Ferm&#237;n Mearin Manrique"
            "autores" => array:7 [
              0 => array:2 [
                "nombre" => "Jordi"
                "apellidos" => "Serra"
              ]
              1 => array:2 [
                "nombre" => "Juanjo"
                "apellidos" => "Mascort-Roca"
              ]
              2 => array:2 [
                "nombre" => "Merc&#232;"
                "apellidos" => "Marzo-Castillejo"
              ]
              3 => array:2 [
                "nombre" => "Silvia"
                "apellidos" => "Delgado Aros"
              ]
              4 => array:2 [
                "nombre" => "Juan"
                "apellidos" => "Ferr&#225;ndiz Santos"
              ]
              5 => array:2 [
                "nombre" => "Enrique"
                "apellidos" => "Rey Diaz Rubio"
              ]
              6 => array:2 [
                "nombre" => "Ferm&#237;n"
                "apellidos" => "Mearin Manrique"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2444382417300408"
          "doi" => "10.1016/j.gastre.2017.02.001"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382417300408?idApp=UINPBA00004N"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570516300036?idApp=UINPBA00004N"
      "url" => "/02105705/0000004000000003/v1_201702170034/S0210570516300036/v1_201702170034/es/main.assets"
    ]
  ]
  "itemAnterior" => array:19 [
    "pii" => "S244438241730041X"
    "issn" => "24443824"
    "doi" => "10.1016/j.gastre.2017.02.002"
    "estado" => "S300"
    "fechaPublicacion" => "2017-03-01"
    "aid" => "1038"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;&#44; AEEH and AEG"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Gastroenterol Hepatol. 2017;40:125-31"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 632
      "formatos" => array:2 [
        "HTML" => 499
        "PDF" => 133
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>"
      "titulo" => "Faecal calprotectin&#44; an useful marker in discriminating between inflammatory bowel disease and functional gastrointestinal disorders"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "125"
          "paginaFinal" => "131"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Calprotectina fecal&#44; marcador eficaz en la diferenciaci&#243;n de enfermedades inflamatorias intestinales y trastornos funcionales gastrointestinales"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 1886
              "Ancho" => 1659
              "Tamanyo" => 104226
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">ROC curve of faecal calprotectin &#40;inflammatory bowel disease&#47;irritable bowel syndrome&#41;&#46; AUC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;872&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Maria Elena Lozoya Angulo, Ignacio de las Heras G&#243;mez, Miriam Martinez Villanueva, Jose Antonio Noguera Velasco, Francisco Avil&#233;s Plaza"
          "autores" => array:5 [
            0 => array:2 [
              "nombre" => "Maria Elena"
              "apellidos" => "Lozoya Angulo"
            ]
            1 => array:2 [
              "nombre" => "Ignacio"
              "apellidos" => "de las Heras G&#243;mez"
            ]
            2 => array:2 [
              "nombre" => "Miriam"
              "apellidos" => "Martinez Villanueva"
            ]
            3 => array:2 [
              "nombre" => "Jose Antonio"
              "apellidos" => "Noguera Velasco"
            ]
            4 => array:2 [
              "nombre" => "Francisco"
              "apellidos" => "Avil&#233;s Plaza"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0210570516300486"
        "doi" => "10.1016/j.gastrohep.2016.04.009"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570516300486?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S244438241730041X?idApp=UINPBA00004N"
    "url" => "/24443824/0000004000000003/v1_201703160041/S244438241730041X/v1_201703160041/en/main.assets"
  ]
  "en" => array:21 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Review</span>"
    "titulo" => "Clinical practice guidelines for the management of constipation in adults&#46; Part 1&#58; Definition&#44; aetiology and clinical manifestations"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "132"
        "paginaFinal" => "141"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Jordi Serra, Juanjo Mascort-Roca, Merc&#232; Marzo-Castillejo, Silvia Delgado Aros, Juan Ferr&#225;ndiz Santos, Enrique Rey Diaz Rubio, Ferm&#237;n Mearin Manrique"
        "autores" => array:7 [
          0 => array:4 [
            "nombre" => "Jordi"
            "apellidos" => "Serra"
            "email" => array:1 [
              0 => "jserrap&#46;germanstrias&#64;gencat&#46;cat"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Juanjo"
            "apellidos" => "Mascort-Roca"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Merc&#232;"
            "apellidos" => "Marzo-Castillejo"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Silvia"
            "apellidos" => "Delgado Aros"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Juan"
            "apellidos" => "Ferr&#225;ndiz Santos"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">g</span>"
                "identificador" => "aff0035"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Enrique"
            "apellidos" => "Rey Diaz Rubio"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">h</span>"
                "identificador" => "aff0040"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "Ferm&#237;n"
            "apellidos" => "Mearin Manrique"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">i</span>"
                "identificador" => "aff0045"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:9 [
          0 => array:3 [
            "entidad" => "Unitat de Motilitat i Trastorns Funcionals Digestius&#44; Hospital Universitari Germans Trias i Pujol&#44; Badalona&#44; Barcelona&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Centro de Asistencia Primaria &#40;CAP&#41; Florida Sud&#44; Institut Catal&#224; de la Salut&#44; L&#8217;Hospitalet de Llobregat&#44; Barcelona&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Departament de Ci&#232;ncies Cl&#237;niques&#44; Campus Bellvitge&#44; Facultat de Medicina&#44; Universitat de Barcelona&#44; L&#8217;Hospitalet de Llobregat&#44; Barcelona&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Unitat de Suport a la Recerca &#8211; Institut d&#8217;Investigaci&#243; d&#8217;Atenci&#243; Prim&#224;ria &#40;IDIAP&#41; Jordi Gol&#44; Direcci&#243; d&#8217;Atenci&#243; Prim&#224;ria Costa de Ponent&#44; Institut Catal&#224; de la Salut&#44; Spain"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Scientist&#44; semFYC&#44; Barcelona&#44; Spain"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
          5 => array:3 [
            "entidad" => "Neuro-Enteric Translational Science &#40;NETS&#41; Group Coordinator&#44; Institut Hospital del Mar d&#8217;Investigacions M&#232;diques &#40;IMIM&#41;-Parc de Salut Mar&#44; Parc de Recerca Biom&#232;dica de Barcelona &#40;PRBB&#41;&#44; Barcelona&#44; Spain"
            "etiqueta" => "f"
            "identificador" => "aff0030"
          ]
          6 => array:3 [
            "entidad" => "Subdirecci&#243;n General de Calidad Asistencial&#44; Consejer&#237;a de Sanidad&#44; Madrid&#44; Spain"
            "etiqueta" => "g"
            "identificador" => "aff0035"
          ]
          7 => array:3 [
            "entidad" => "Hospital Cl&#237;nico San Carlos&#44; Universidad Complutense de Madrid&#44; Instituto de Investigaci&#243;n Sanitaria del Hospital Cl&#237;nico San Carlos &#40;IdISSC&#41;&#44; Madrid&#44; Spain"
            "etiqueta" => "h"
            "identificador" => "aff0040"
          ]
          8 => array:3 [
            "entidad" => "Servicio de Aparato Digestivo&#44; Instituto de Trastornos Funcionales y Motores Digestivos&#44; Barcelona&#44; Spain"
            "etiqueta" => "i"
            "identificador" => "aff0045"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Gu&#237;a de pr&#225;ctica cl&#237;nica sobre el manejo del estre&#241;imiento cr&#243;nico en el paciente adulto&#46; Parte 1&#58; Definici&#243;n&#44; etiolog&#237;a y manifestaciones cl&#237;nicas"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 848
            "Ancho" => 2187
            "Tamanyo" => 138450
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Bristol Scale</span> for faeces assessment&#46; Visual table with illustrations&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Lewis and Heaton&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">32</span></a></p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Constipation is a symptom suffered by a large number of people and which is brought about by multifactorial causes&#46; Many people have experienced constipation at some point in their life&#44; although it usually occurs for a limited period of time and is not a serious problem&#46; Long-term constipation affects women and older adults more frequently&#46; It is a disorder that has a negative effect on people&#39;s well-being and quality of life&#46; It is a common reason for medical consultation in primary care and is treated by self-medication by a high proportion of the affected population&#46; Knowing the causes&#44; preventing&#44; diagnosing and treating constipation will benefit many of those affected&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In order for clinical decisions to be appropriate&#44; efficient and safe&#44; professionals need to update their knowledge constantly&#46; This clinical practice guideline &#40;CPG&#41; on the management of chronic constipation in adult patients sets out the efficient treatment of this disorder using a coordinated and multidisciplinary approach with the participation of primary and specialised care&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Professional representatives of the scientific societies involved and methodologists participated in the preparation of this CPG&#46; All the essential criteria referred to in the Appraisal of Guidelines&#44; Research and Evaluation for Europe &#40;AGREE&#41; &#40;<a href="http://www.agreecollaboration.org/">http&#58;&#47;&#47;www&#46;agreecollaboration&#46;org&#47;</a>&#41;&#44; a tool designed to help producers and users of CPG and considered the standard for their preparation&#44; have been taken into account in the preparation of this guideline&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">For the classification of the scientific evidence and the strength of the recommendations&#44; the Grading of Recommendations Assessment&#44; Development and Evaluation Working Group &#40;GRADE system&#41; &#40;<a href="http://www.gradeworkinggroup.org/">http&#58;&#47;&#47;www&#46;gradeworkinggroup&#46;org&#47;</a>&#41;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">1&#8211;3</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41; was used&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Once a complete draft of the guide had been prepared&#44; the external reviewers&#44; who were representatives of the various related specialties&#44; provided their comments and suggestions&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Definition</span><p id="par0030" class="elsevierStylePara elsevierViewall">Constipation is characterised by difficult or infrequent bowel movements&#44; often accompanied by excessive exertion during defecation or a feeling of incomplete evacuation&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">4</span></a> In most cases it does not have an underlying organic cause and is considered chronic idiopathic constipation &#40;CIC&#41;&#44; also known as chronic functional constipation&#46; In fact&#44; CIC shares several symptoms with irritable bowel syndrome with constipation &#40;IBS-C&#41;&#44; although in IBS-C&#44; abdominal pain&#47;discomfort must be present to make the diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">5</span></a> Even so&#44; there are authors who consider CIC and IBS-C as 2 different entities and others that include them as subsections of the same spectrum&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">According to the Rome III criteria&#44; CIC is defined as the presence during the last 3 months of 2 or more of the conditions reflected in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Symptoms must have started at least 6 months before diagnosis&#44; there should only be diarrhoea after laxative intake and IBS criteria should not be met&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Magnitude and significance of the problem</span><p id="par0040" class="elsevierStylePara elsevierViewall">CIC is very common in the general population around the world&#44; with a mean prevalence&#44; as estimated in 2 systematic reviews&#44; of between 14&#37; &#40;95&#37; CI&#58; 12&#8211;17&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">4</span></a> and 16&#37; &#40;95&#37; CI&#58; 0&#46;7&#8211;79&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">7</span></a> The studies conducted in Spain reveal a prevalence of 14&#8211;30&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">8&#8211;10</span></a> CIC is more prevalent in women<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">4&#44;7&#44;10&#8211;12</span></a>&#59; its prevalence increases progressively after 60 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">7</span></a> CIC is normally long-term&#46; In a recent study&#44; it was observed that 68&#37; of the patients were constipated for 10 years or more&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">13</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">CIC is a major problem not only because of its prevalence&#44; but also because of its personal&#44; social&#44; employment and economic impact&#46; Its physical and mental impact affects quality of life and personal well-being&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">11&#44;12&#44;14</span></a> The cost of constipation healthcare and treatment are very significant&#46; Results of a study conducted in our setting indicate that constipation consumes a significant amount of resources&#44; both in relation to the use of laxatives and medical visits&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Risk factors</span><p id="par0050" class="elsevierStylePara elsevierViewall">In addition to age and the female gender&#44; a number of aetiological factors have been studied for CIC&#44; the assessment of which comes mostly from uncontrolled studies and short-term interventions&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">It is believed that a low-fibre diet contributes to constipation and many doctors recommend increased fibre intake along with other lifestyle changes such as improved hydration and exercise&#46; However&#44; the scientific evidence is contradictory&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Some observational studies have shown that fibre intake is associated with an improvement in constipation<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">16</span></a> while others have not&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">17&#44;18</span></a> Some studies have even found that reducing fibre intake improves constipation and the associated symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">18</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The results of an observational study &#40;10&#44;914 people&#41; show that low fluid intake is a predictor of constipation for both women &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;3&#59; 95&#37; CI&#58; 1&#46;0&#8211;1&#46;6&#41; and for men &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;4&#59; 95&#37; CI&#58; 1&#46;5&#8211;3&#46;9&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">17</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Prolonged physical inactivity slows digestive activity in healthy volunteers&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">19</span></a> Some studies show that moderate physical activity is associated with a fall in the prevalence of constipation&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">16</span></a> while others&#44; conversely&#44; find otherwise&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">17&#44;20</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Other risk factors associated with CIC are low educational and socio-economic levels&#44;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">7&#44;21</span></a> being overweight and obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">7</span></a> A family history of constipation&#44; anxiety&#44; depression and stressful life events also favour constipation&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Causes of constipation</span><p id="par0080" class="elsevierStylePara elsevierViewall">Constipation is a symptom and not a disease in itself and can be a consequence of multiple causes&#46; Secondary chronic constipation may be associated with a wide range of diseases<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">22</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41; and&#47;or drugs<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">22</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46; Once secondary causes are excluded&#44; CIC is considered&#44; which is a consequence of primary functional impairment of the colon and anus-rectum&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pathophysiology of primary constipation</span><p id="par0085" class="elsevierStylePara elsevierViewall">Constipation can essentially be caused by 2 mechanisms<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">23</span></a>&#58; &#40;1&#41; slow transit through the different segments of the colon and &#40;2&#41; defecation disorders&#46; In some patients&#44; both mechanisms may be present&#44; although there is a large group of patients in whom none of these abnormalities is seen&#46; In these cases&#44; constipation is associated with alterations in rectal sensitivity&#44; either a decrease in sensitivity&#44; or an increase in sensitivity and forming part of IBS-C&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">24</span></a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Slow colonic transit</span> &#40;colonic inertia&#41;&#46; This may be caused by metabolic or endocrine disorders&#44; systemic diseases or by certain drugs&#46; However&#44; it may also be primary&#44; possibly associated with neuropathic or myopathic disorders of the colon wall&#44; as suggested by the decrease in the number of interstitial cells of Cajal&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">25</span></a> or the decreased response to cholinergic stimulation observed in some of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">26</span></a> As the intestinal contents remain longer in the colon&#44; the absorption of water and electrolytes increases&#44; resulting in a decrease in volume and a hardening of the stool&#46; As a result&#44; the volume of stools&#44; the feeling of the need to defecate and the ease of expelling stools at defecation will all be reduced&#46; In some cases&#44; stagnation of the intestinal contents can lead to the formation of faecalomas&#46; The slowing down of colonic transit may also be due to defecation disorders as evidenced by the fact that the success of treatment with anorectal biofeedback normalises colonic transit&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Defecation disorder</span>&#46; Difficulty in defecation may be due to neurological abnormalities such as Hirschsprung&#39;s disease or spinal cord injuries&#44; or to anatomical alterations such as rectoceles&#44; enterocele&#44; intussusception&#44; etc&#46; However&#44; in most cases there is no evidence of structural alterations or neurological lesions justifying the difficulty of expulsion&#44; which is considered to be produced by a functional defecation disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">28</span></a> The functional defecation disorder may be due to one or more of the following conditions&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">a&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Reduction of rectal sensitivity</span>&#46; The arrival of the faeces in the rectum stimulates sensory receptors that send impulses to the cerebral cortex through afferent nerve pathways&#46; These inform the brain of the presence of the faeces in the rectum and will produce the desire to defecate&#46; An alteration in the sensitivity of the rectum&#44; sometimes associated with a decrease in rectal tone&#44; may result in primary constipation&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">23</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">b&#41;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dyssynergic defecation or poor coordination during defecation&#46;</span> At the time of defecation&#44; there is a coordinated increase in abdominal pressure&#44; which is achieved by contracting the muscles of the abdominal wall and the diaphragm&#44; and a relaxation of the anal sphincter&#44; which is associated with a drop of the perineum and rectification of the angle of the rectum with the anal canal&#46; Three types of coordination abnormality or dyssynergic defecation have been described<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">29</span></a>&#58; type &#40;I&#41; Increase of adequate rectal pressure with paradoxical contraction of the anal sphincter during the defecation manoeuvre&#59; type &#40;II&#41; Increased weak or insufficient rectal pressure&#44; and type &#40;III&#41; Absence of sphincter relaxation with increased rectal pressure&#46; Types I and III will produce a functional obstruction to defecation&#44; whereas type II results in impaired propulsion&#46; The propulsion deficiency may be associated with an insufficient abdominal press or impaired colonic contractile activity&#46; The practical importance of identifying the mechanisms that produce defecation disorders is so that they can be corrected by anorectal biofeedback&#44; which has been shown to be a very effective treatment of defecation disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">30&#44;31</span></a></p></li></ul></p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Constipation with normal transit</span> is defined as constipation even though the transport time of the faeces through the colon is normal&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Symptoms</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Medical history</span><p id="par0115" class="elsevierStylePara elsevierViewall">In the vast majority of patients&#44; the diagnosis of CIC is based on the description of the symptoms and&#47;or signs recorded in the medical history and the findings of the physical examination&#46; Three aspects must be taken into account&#58; &#40;1&#41; compliance with the diagnostic criteria for chronic constipation&#44; &#40;2&#41; determination of the causes of constipation and &#40;3&#41; detection of signs of alarm&#46; A detailed assessment of signs and&#47;or symptoms may help differentiate between constipation due to slow colonic transit and a functional defecation disorder&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In order to evaluate compliance with the Rome III criteria<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">5</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; the patient should be asked about&#58; the <span class="elsevierStyleItalic">onset</span> and <span class="elsevierStyleItalic">duration</span> of symptoms&#59; the shape and <span class="elsevierStyleItalic">consistency of the stool</span>&#58; it is recommended to use the Bristol scale<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">32</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#59; the <span class="elsevierStyleItalic">difficulty in evacuation</span>&#58; the patient should be asked about straining during defecation&#44; the feeling of incomplete evacuation&#44; the sensation of blockage or anal obstruction and&#47;or the need to use fingering manoeuvres to expel the faeces&#59; bowel movement <span class="elsevierStyleItalic">frequency</span>&#59; <span class="elsevierStyleItalic">changes in bowel habits</span> &#40;alternating diarrhoea with constipation&#41; and abdominal pain&#59; other relevant aspects such as the presence of <span class="elsevierStyleItalic">anal pain</span> during defecation&#44; defecation <span class="elsevierStyleItalic">urgency</span> and&#47;or faecal <span class="elsevierStyleItalic">incontinence</span>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">To determine the possible predisposing causes and factors&#44; the patient must be asked about their dietary and lifestyle habits&#44; substance abuse&#44; medication &#40;including laxatives&#41;&#44; bowel habits&#44; pathological history and history of diseases &#40;obstetric events&#44; etc&#46;&#41; as well as their profession&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In the event of signs of alarm&#44; additional tests should be performed to rule out an organic cause of the constipation<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">33&#8211;35</span></a>&#58; Signs of alarm include a sudden change in persistent usual bowel rhythm &#40;&#62;6 weeks&#41; in patients over 50 years of age&#44; rectal bleeding or bloody stool&#44; iron deficiency anaemia&#44; weight loss&#44; significant abdominal pain&#44; family or personal history of colorectal cancer &#40;CRC&#41; or inflammatory bowel disease and palpable mass&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Physical examination</span><p id="par0135" class="elsevierStylePara elsevierViewall">In the event of constipation&#44; a complete physical examination should be performed&#44; including abdominal examination&#44; visual inspection of the perianal and rectal region and a digital rectal examination&#46; A physical examination is performed to look for signs of an organic disease and to evaluate the presence of masses&#44; prolapse&#44; haemorrhoids&#44; fissures&#44; rectocele&#44; faeces in rectum&#44; etc&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The digital rectal examination evaluates the tone of the anal sphincter&#44; both at rest and during a bowel movement&#44; and the presence of faeces in the rectal ampulla&#46; Recent studies show that digital rectal examination has a high probability of detecting pelvic floor dyssynergia&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">36&#44;37</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Comorbidities and complications of constipation</span><p id="par0145" class="elsevierStylePara elsevierViewall">The association between constipation and related gastrointestinal and extraintestinal comorbidities is not well documented&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a> The available evidence is inferred from association studies and knowledge of the pathogenesis of constipation&#46; However&#44; in many of these studies there are several confounding factors and there is an overlap between chronic constipation and other functional gastrointestinal disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;39</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">A review of studies published between 1980 and 2007 evaluated the association between constipation and various related comorbidities&#44; especially the most common anorectal&#44; colon and urological disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;40&#8211;42</span></a> The most prevalent associations are&#58; haemorrhoids&#44; anal fissures&#44; rectal prolapse and stercoral ulceration&#44; faecal impaction&#44; faecal incontinence&#44; megacolon&#44; volvulus&#44; diverticular disease&#44; urinary tract infections&#44; enuresis and urinary incontinence&#46; Many of these conditions have also been identified in a more recent review that includes studies published between January 2011 and March 2012&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">39</span></a> This review also evaluates other extragastrointestinal comorbidities&#58; overweight&#44; obesity&#44; depression&#44; diabetes and urinary disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">39</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The broader studies on the prevalence and association of the various concurrent conditions with chronic constipation come from retrospective cohort studies using the California Medicaid database<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">43</span></a> and the US Health Plan database<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">44</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; The analysis of the Medicaid database&#44; taking into account the possible detection bias&#44; partly modifies the previously published results&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Anorectal complications</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Haemorrhoids</span><p id="par0160" class="elsevierStylePara elsevierViewall">Several retrospective cohort studies<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;43</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41; and prospective studies have described a significant association between chronic constipation and haemorrhoids&#46; It is suggested that the prolonged intra-abdominal pressure exerted on the venous plexuses and anorectal arteriovenous anastomosis may lead to local circulatory disorders such as internal and&#47;or external haemorrhoids&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Anal fissure</span><p id="par0165" class="elsevierStylePara elsevierViewall">There are different retrospective analyses that support the relationship between chronic constipation and the appearance of anal fissures<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;43</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; It has been suggested that mucosal injury is caused by a traumatic action due to the passage of hard faeces through the rectal canal during usual defecation strain&#44; local ischaemic involvement and some anal sphincter dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Prolapse</span><p id="par0170" class="elsevierStylePara elsevierViewall">Rectal prolapse is a condition characterised by the protrusion of the rectum through the anus&#46; Performing frequent and sustained Valsalva manoeuvres can be a contributing factor&#46; The slowing of colonic transit and motility disorders have been related to the appearance or exacerbation of a rectal prolapse&#46; A retrospective cohort study<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">43</span></a> described a significant association between chronic constipation and rectal prolapse &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; A systematic review &#40;12 case series studies&#41; shows that constipation decreases after prolapse surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ulcers</span><p id="par0175" class="elsevierStylePara elsevierViewall">Several retrospective cohort studies<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;43</span></a> have described a significant association between chronic constipation and ulcers &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; Rectal ulcers are an uncommon but probably underestimated complication since stercoral perforations are often identified as spontaneous&#44; idiopathic or secondary&#46; The perforation may go unnoticed clinically as minor episodes of rectal bleeding&#44; or become extremely complicated in case of infection or even bacteraemia with stercoral peritonitis with a very severe prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a> It is suggested that sustained pressure of the wall of the colon and rectum by a direct effect of mass due to the constant presence of faecal matter can lead to a chronic ischaemic injury accompanied by wall necrosis&#44; causing stercoral colonic ulcers&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Faecal impaction or faecaloma</span><p id="par0180" class="elsevierStylePara elsevierViewall">Although studies designed to assess the aetiology and risk factors of faecal impaction in chronic constipation are limited&#44; data from retrospective studies are consistent in suggesting a higher risk in patients with a previous diagnosis of chronic constipation&#46; In fact&#44; faecal impaction is one of the most frequent complications of chronic constipation&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;43</span></a> This condition is caused by accumulation of faeces in the rectal ampulla &#40;although it may occur in both the rectal and colonic tracts&#41;&#44; where a period of stasis&#44; some loss of colonic function and anorectal sensitivity&#44; accompanied by alterations in hydration&#44; can lead to the onset of faecalomas that result in impaction and obstruction of the intestinal lumen&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Faecal incontinence</span><p id="par0185" class="elsevierStylePara elsevierViewall">Several studies have shown a positive association between chronic constipation and faecal incontinence&#44;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;43&#44;44&#44;46&#44;47</span></a> most commonly in elderly and institutionalised patients&#46; Clinically speaking&#44; faecal incontinence manifests as the paradoxical leakage of loose or semi-loose faeces around the obstructed stool in the rectal ampulla &#40;overflow faecal incontinence&#41;&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Colon complications</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Diverticular disease</span><p id="par0190" class="elsevierStylePara elsevierViewall">There are several retrospective studies supporting a discrete association between chronic constipation and diverticular disease<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;43&#44;44</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; However&#44; the role of chronic constipation remains uncertain and probably represents the coexistence of two very common entities<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a>&#46; It is believed that prolonged colonic transit time and low volume of faeces are associated with an increase in intraluminal pressure&#44; which may lead to pulsion diverticula forming at the weakest points of the colon wall&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Megacolon</span><p id="par0195" class="elsevierStylePara elsevierViewall">Chronic megacolon may be secondary to an advanced stage of refractory chronic constipation or present as a primary colonic disease&#46; Most adults with an idiopathic megacolon have a long history of chronic constipation&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a> It has been observed that the presence of megacolon in the event of previous chronic constipation was 5 times more frequent than in its absence&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Volvulus</span><p id="par0200" class="elsevierStylePara elsevierViewall">Sigmoid volvulus is a common cause of bowel obstruction&#46; It has multiple causes and is more common in patients with a longstanding megacolon&#46; Retrospective studies have indicated that the presence of a volvulus is significantly more frequent in the context of chronic constipation&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Colorectal cancer</span><p id="par0205" class="elsevierStylePara elsevierViewall">A systematic review of observational studies &#40;28 studies&#41; concludes that there is no association between constipation and CRC&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">48</span></a> The results of the 8 cross-sectional studies included show that the presence of constipation as the main indication for colonoscopy was associated with a lower prevalence of CRC &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#59; 95&#37; CI&#58; 0&#46;36&#8211;0&#46;89&#41;&#46; In the 3 cohort studies&#44; a non-significant decrease in CRC was observed in patients with constipation &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;80&#59; 95&#37; CI&#58; 0&#46;61&#8211;1&#46;04&#41;&#46; In the 17 case&#8211;control studies&#44; on the other hand&#44; the prevalence of constipation in CRC was significantly higher than in controls without CRC &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;68&#59; 95&#37; CI&#58; 1&#46;29&#8211;2&#46;18&#41;&#44; but with significant heterogeneity and possible publication bias&#46;</p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Extracolonic complications</span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Urological disorders</span><p id="par0210" class="elsevierStylePara elsevierViewall">Retrospective and prospective studies in both adults and children suggest that chronic constipation may have an aetiological relationship to the presence of urinary tract infections&#44; enuresis and urinary incontinence&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">38&#44;49&#8211;52</span></a></p></span></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Other complications</span><p id="par0215" class="elsevierStylePara elsevierViewall">Other indirect complications could be caused by the therapeutic approach itself&#44; such as the side effects of local therapies &#40;rectal mucosal injury&#44; even at risk of perforation especially in debilitated patients&#41;&#44; syncopal episodes during manual removal of faecalomas or adverse effects of laxative medications&#46;</p></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusions</span><p id="par0220" class="elsevierStylePara elsevierViewall">Chronic constipation is a very common disorder that tends to affect women and the elderly and which can be triggered by multiple causes&#46; Functional constipation&#44; although it may be considered as a common symptom&#44; is associated with multiple complications&#44; both in the rectum or colon&#44; as well as extraintestinal complications&#46; A thorough medical history and physical examination will be key to determining the likely cause of constipation in an individual patient and will be used as a guide for the correct management of the condition&#46;</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Funding</span><p id="par0225" class="elsevierStylePara elsevierViewall">Sources of funding&#58; this clinical practice guideline has received external funding from Laboratorios Shire&#46; The sponsors have not influenced any stage of its development&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0230" class="elsevierStylePara elsevierViewall">Jordi Serra is a consultant from Norgine and works with Almirall&#44; Allergan&#44; Cassen-Recordati and Zespri&#59; S&#237;lvia Delgado has been a consultant to Shire &#40;Resolor&#41; and Almirall &#40;Constella&#41;&#59; Enrique Rey&#58; Conferences and research funding from Almirall and Norgine Iberia&#59; Ferm&#237;n Mearin&#44; Advisor for Laboratorios Almirall&#59; Juanjo Mascort&#44; Juan Ferrandiz and Merc&#232; Marzo have no conflict of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:18 [
        0 => array:3 [
          "identificador" => "xres814543"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec811943"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres814544"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec811942"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Methodology"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Definition"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Magnitude and significance of the problem"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Risk factors"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Causes of constipation"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Pathophysiology of primary constipation"
        ]
        11 => array:3 [
          "identificador" => "sec0040"
          "titulo" => "Symptoms"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Medical history"
            ]
            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Physical examination"
            ]
          ]
        ]
        12 => array:3 [
          "identificador" => "sec0055"
          "titulo" => "Comorbidities and complications of constipation"
          "secciones" => array:4 [
            0 => array:3 [
              "identificador" => "sec0060"
              "titulo" => "Anorectal complications"
              "secciones" => array:6 [
                0 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "Haemorrhoids"
                ]
                1 => array:2 [
                  "identificador" => "sec0070"
                  "titulo" => "Anal fissure"
                ]
                2 => array:2 [
                  "identificador" => "sec0075"
                  "titulo" => "Prolapse"
                ]
                3 => array:2 [
                  "identificador" => "sec0080"
                  "titulo" => "Ulcers"
                ]
                4 => array:2 [
                  "identificador" => "sec0085"
                  "titulo" => "Faecal impaction or faecaloma"
                ]
                5 => array:2 [
                  "identificador" => "sec0090"
                  "titulo" => "Faecal incontinence"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "sec0095"
              "titulo" => "Colon complications"
              "secciones" => array:4 [
                0 => array:2 [
                  "identificador" => "sec0100"
                  "titulo" => "Diverticular disease"
                ]
                1 => array:2 [
                  "identificador" => "sec0105"
                  "titulo" => "Megacolon"
                ]
                2 => array:2 [
                  "identificador" => "sec0110"
                  "titulo" => "Volvulus"
                ]
                3 => array:2 [
                  "identificador" => "sec0115"
                  "titulo" => "Colorectal cancer"
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "sec0120"
              "titulo" => "Extracolonic complications"
              "secciones" => array:1 [
                0 => array:2 [
                  "identificador" => "sec0125"
                  "titulo" => "Urological disorders"
                ]
              ]
            ]
            3 => array:2 [
              "identificador" => "sec0130"
              "titulo" => "Other complications"
            ]
          ]
        ]
        13 => array:2 [
          "identificador" => "sec0135"
          "titulo" => "Conclusions"
        ]
        14 => array:2 [
          "identificador" => "sec0140"
          "titulo" => "Funding"
        ]
        15 => array:2 [
          "identificador" => "sec0145"
          "titulo" => "Conflicts of interest"
        ]
        16 => array:2 [
          "identificador" => "xack273289"
          "titulo" => "Acknowledgements"
        ]
        17 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-01-18"
    "fechaAceptado" => "2016-02-05"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec811943"
          "palabras" => array:3 [
            0 => "Constipation"
            1 => "Clinical practice guidelines"
            2 => "Chronic disease"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec811942"
          "palabras" => array:3 [
            0 => "Estre&#241;imiento"
            1 => "Gu&#237;a de pr&#225;ctica cl&#237;nica"
            2 => "Enfermedad cr&#243;nica"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical practice guidelines for the management of constipation in adults aim to generate recommendations on the optimal approach to chronic constipation in the primary care and specialized outpatient setting&#46; Their main objective is to provide healthcare professionals who care for patients with chronic constipation with a tool that allows them to make the best decisions about the prevention&#44; diagnosis and treatment of this condition&#46; They are intended for family physicians&#44; primary care and specialist nurses&#44; gastroenterologists and other health professionals involved in the treatment of these patients&#44; as well as patients themselves&#46; The guidelines have been developed in response to the high prevalence of chronic constipation&#44; its impact on patient quality of life and recent advances in pharmacological management&#46; The Grading of Recommendations Assessment&#44; Development and Evaluation Working Group &#40;GRADE&#41; system has been used to classify the scientific evidence and strengthen the recommendations&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La gu&#237;a de pr&#225;ctica cl&#237;nica sobre el manejo del paciente con estre&#241;imiento en los pacientes adultos se fundamenta en una serie recomendaciones y estrategias con el objetivo de proporcionar a los profesionales sanitarios encargados de la asistencia a pacientes con estre&#241;imiento cr&#243;nico una herramienta que les permita tomar las mejores decisiones sobre la prevenci&#243;n&#44; diagn&#243;stico y tratamiento del estre&#241;imiento&#46; Esta gu&#237;a de pr&#225;ctica cl&#237;nica persigue una atenci&#243;n eficiente del estre&#241;imiento a partir de un trabajo coordinado y multidisciplinar con la participaci&#243;n de la atenci&#243;n primaria y especializada&#46; La gu&#237;a va dirigida a los m&#233;dicos de familia&#44; a los profesionales de enfermer&#237;a de atenci&#243;n primaria y especializada&#44; a los gastroenter&#243;logos&#44; a otros especialistas que atienden a pacientes con estre&#241;imiento y a las personas afectadas con esta problem&#225;tica&#46; La elaboraci&#243;n de esta gu&#237;a se justifica fundamentalmente por la elevada frecuencia del estre&#241;imiento cr&#243;nico&#44; el impacto que este tiene en la calidad de vida de los pacientes y por los avances recientes en el manejo farmacol&#243;gico del estre&#241;imiento&#46; Para clasificar la evidencia cient&#237;fica y la fuerza de las recomendaciones se ha utilizado el Grading of RecommendationsAssessment&#44; Development and EvaluationWorking Group &#40;sistema GRADE&#41;&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as&#58; Serra J&#44; Mascort-Roca J&#44; Marzo-Castillejo M&#44; Delgado Aros S&#44; Ferr&#225;ndiz Santos J&#44; Rey Diaz Rubio E&#44; et al&#46; Gu&#237;a de pr&#225;ctica cl&#237;nica sobre el manejo del estre&#241;imiento cr&#243;nico en el paciente adulto&#46; Parte 1&#58; Definici&#243;n&#44; etiolog&#237;a y manifestaciones cl&#237;nicas&#46; Gastroenterol Hepatol&#46; 2017&#59;40&#58;132&#8211;141&#46;</p>"
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 848
            "Ancho" => 2187
            "Tamanyo" => 138450
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Bristol Scale</span> for faeces assessment&#46; Visual table with illustrations&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Lewis and Heaton&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">32</span></a></p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">RCT&#44; randomised clinical trial&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quality of the evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reduce if<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Increase if<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Limitation of study quality significant &#40;&#8722;1&#41; or very significant &#40;&#8722;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strong association&#44;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> without confounding&#44; consistent and direct factors &#40;&#43;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Significant inconsistency &#40;&#8722;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very strong association&#44;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> without significant threats to validity &#40;non-biases&#41; and direct evidence &#40;&#43;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Observational study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Some &#40;&#8722;1&#41; or a lot of &#40;&#8722;2&#41; uncertainty about whether the evidence is direct&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dose-response gradient &#40;&#43;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Very low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Scarce or inaccurate data &#40;&#8722;1&#41;<br>High probability of notification bias &#40;&#8722;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All possible confounding factors could have reduced the observed effect &#40;&#43;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1368382.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">1&#58; move up or down one level &#40;e&#46;g&#46;&#44; from high to moderate&#41;&#59; 2&#58; move up or down 2 levels &#40;e&#46;g&#46;&#44; from high to low&#41;&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">A statistically significant relative risk of &#62;2 &#40;&#60;0&#46;5&#41;&#44; based on evidence consisting of 2 or more observational studies&#44; without plausible confounding factors&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">A statistically significant relative risk of &#62;5 &#40;&#60;0&#46;2&#41;&#44; based on direct evidence and without significant threats to validity&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Assessment of the quality of evidence for each variable&#46; GRADE System&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinicians&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Managers&#47;planners&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Strong&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The vast majority of people would agree with the recommended action and only a small proportion would not&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Most patients should receive the recommended intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The recommendation can be adopted as health policy in most situations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weak&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Most people would agree with the recommended action but a significant number would not&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">It recognises that different options will be appropriate for different patients and that the healthcare professional must help each patient to make the decision that is most consistent with their values and preferences&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">There is a need for an important debate and the participation of stakeholders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1368383.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Strength of recommendations&#46; GRADE system&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">1&#46; Presence of 2 or more of the following</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>a&#46; Lumpy or hard stools&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>b&#46; Straining during defecation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>c&#46; Sensation of anorectal obstruction&#47;blockage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>d&#46; Sensation of incomplete evacuation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>e&#46; Manual manoeuvres to facilitate defecations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>f&#46; Fewer than three defecations per week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">2&#46; Loose stools are rarely present without the use of laxatives</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">3&#46; Insufficient criteria for irritable bowel syndrome</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1368384.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">a&#8211;e in &#8805;25&#37; of defecations<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>for the last 3 months&#44; with symptom onset at least 6 months prior to diagnosis&#46;</p> <p class="elsevierStyleNotepara" id="npar0025"><span class="elsevierStyleItalic">Source</span>&#58; Longstreth et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">5</span></a>&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Functional chronic constipation&#46; Rome III criteria&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Adapted from Lindberg et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">22</span></a>&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="9" align="left" valign="top">Digestive problems &#40;structural and gastrointestinal&#41;</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Neoplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Intestinal stenosis&#58; ischaemic colitis&#44; inflammatory bowel disease&#44; post-surgical changes &#40;flanges&#44; adhesions&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Idiopathic rectal ulcer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Rectal intussusception&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Rectal prolapse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Enterocele&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Rectocele&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Anal stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Pelvic floor weakness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="15" align="left" valign="top">Endocrine&#47;metabolic</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Hypothyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Chronic renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Hypercalcaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Hypermagnesaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Hyperparathyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Hypokalaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Hypomagnesaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Multiple endocrine neoplasia <span class="elsevierStyleSmallCaps">ii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Dehydration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Heavy metal poisoning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Panhypopituitarism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Addison&#39;s Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Pheochromocytoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Porphyria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="7" align="left" valign="top">Neurological</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Cerebrovascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Neoplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Autonomic neuropathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Spinal disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Spinal cord injuries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Parkinson&#39;s Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Multiple sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Psychiatric&#47;Psychological</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Eating disorders&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Denial of defecation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="8" align="left" valign="top">Myopathic disorders&#44; collagenosis and vasculitis</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Polymyositis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Dermatomyositis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Scleroderma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Systemic sclerosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Myotonic dystrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Systemic lupus erythematosus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Family visceral myopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Amyloidosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1368381.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">List of diseases associated with chronic constipation&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Adapted from Lindberg et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">22</span></a>&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Central nervous system</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Antiepileptics &#40;carbamazepine&#44; phenytoin&#44; clonazepam&#44; amantadine&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Antiparkinson drugs &#40;bromocriptine&#44; levodopa&#44; biperiden&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Anxiolytics and hypnotics &#40;benzodiazepines&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Antidepressants &#40;tricyclics&#44; selective serotonin reuptake inhibitors&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Antipsychotics and neuroleptics &#40;butyrophenones&#44; phenothiazines&#44; barbiturates&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">Digestive system</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Antacids &#40;containing aluminium&#44; calcium&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Proton-pump inhibitors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Anticholinergic antispasmodics &#40;natural alkaloids and synthetic and semisynthetic derivatives with a tertiary and quaternary amine structure such as atropine&#44; scopolamine&#44; butylscopolamine&#44; methylscopolamine&#44; trimebutine&#44; pinaverium&#44; etc&#46;&#41; or musculotropic drugs &#40;mebeverine&#44; papaverine&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Antiemetics &#40;chlorpromazine&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Supplements &#40;salts of calcium&#44; bismuth&#44; iron&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Antidiarrhoeal agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Circulatory system</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Antihypertensives &#40;beta-blockers&#44; calcium-antagonists&#44; clonidine&#44; hydralazine&#44; ganglion blockers&#44; monoamine oxidase inhibitors&#44; methyldopa&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Antiarrhythmics &#40;quinidine and derivatives&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Diuretics &#40;furosemide&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Hypolipidemics &#40;cholestyramine&#44; colestipol&#44; statins&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Other</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Analgesics &#40;non-steroidal anti-inflammatory drugs&#44; opiates and derivatives&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Antihistamines against H1 receptors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Antitussives &#40;codeine&#44; dextromethorphan&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Metallic ions &#40;aluminium&#44; barium sulphate&#44; bismuth&#44; calcium&#44; iron&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Cytostatic agents&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1368380.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">List of drugs associated with chronic constipation &#40;abridged list&#41;&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at6"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Talley et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a>&#44; Arora et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">43</span></a> and Mitra et al&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">44</span></a>&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">CI&#44; confidence interval&#59; GERD&#44; gastroesophageal reflux disease&#59; NE&#44; not evaluated&#59; OR&#44; odds ratio&#46;</p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Method</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Retrospective analysis of claims &#40;US Health Plan&#41;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">38</span></a></td><td class="td" title="table-entry  " align="left" valign="top">Medical Database Review&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">California Medicaid programme<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">43</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Subjects</td><td class="td" title="table-entry  " align="left" valign="top">48&#44;585 &#40;with constipation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">147&#44;595 &#40;with constipation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">97&#44;170 &#40;controls&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">142&#44;086 &#40;controls with GERD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1368385.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complication&#47;Comorbidity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR &#40;<span class="elsevierStyleItalic">p</span>-value&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anal fissure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;47 &#40;2&#46;12&#8211;2&#46;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anal fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;72 &#40;1&#46;37&#8211;2&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemorrhage &#40;rectum&#47;anus&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;36 &#40;1&#46;30&#8211;1&#46;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ulcer &#40;rectum&#47;anus&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;11 &#40;1&#46;66&#8211;2&#46;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diverticular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;04 &#40;1&#8211;1&#46;08&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Crohn&#39;s Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;96 &#40;0&#46;85&#8211;1&#46;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Faecal impaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;20 &#40;2&#46;83&#8211;3&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Faecal incontinence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;16 &#40;0&#46;99&#8211;1&#46;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemorrhoids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;24 &#40;1&#46;2&#8211;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hirschsprung&#39;s disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;42 &#40;2&#46;46&#8211;7&#46;92&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Irritable bowel syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;12 &#40;1&#46;07&#8211;1&#46;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Colorectal cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;16 &#40;1&#46;05&#8211;1&#46;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rectal prolapse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;63 &#40;1&#46;9&#8211;2&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bowel obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ulcerative colitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;86 &#40;1&#46;27&#8211;2&#46;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intestinal volvulus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;36 &#40;1&#46;07&#8211;1&#46;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1368386.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Gastrointestinal comorbidities and complications of constipation&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:52 [
            0 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "GRADE guidelines&#58; a new series of articles in the Journal of Clinical Epidemiology"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46;H&#46; Guyatt"
                            1 => "A&#46;D&#46; Oxman"
                            2 => "H&#46;J&#46; Sch&#252;nemann"
                            3 => "P&#46; Tugwell"
                            4 => "A&#46; Knottnerus"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jclinepi.2010.09.011"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Epidemiol"
                        "fecha" => "2011"
                        "volumen" => "64"
                        "paginaInicial" => "380"
                        "paginaFinal" => "382"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21185693"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "GRADE guidelines&#58; 1&#46; Introduction-GRADE evidence profiles and summary of findings tables"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Guyatt"
                            1 => "A&#46;D&#46; Oxman"
                            2 => "E&#46; Akl"
                            3 => "R&#46; Kunz"
                            4 => "G&#46; Vist"
                            5 => "J&#46; Brozek"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jclinepi.2010.04.026"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Epidemiol"
                        "fecha" => "2011"
                        "volumen" => "64"
                        "paginaInicial" => "383"
                        "paginaFinal" => "394"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21195583"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "GRADE guidelines&#58; 2&#46; Framing the question and deciding on important outcomes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46;H&#46; Guyatt"
                            1 => "A&#46;D&#46; Oxman"
                            2 => "R&#46; Kunz"
                            3 => "D&#46; Atkins"
                            4 => "J&#46; Brozek"
                            5 => "G&#46; Vist"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jclinepi.2010.09.012"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Epidemiol"
                        "fecha" => "2011"
                        "volumen" => "64"
                        "paginaInicial" => "395"
                        "paginaFinal" => "400"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21194891"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "quiz 1581&#44; 1592"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of&#44; and risk factors for&#44; chronic idiopathic constipation in the community&#58; systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "N&#46;C&#46; Suares"
                            1 => "A&#46;C&#46; Ford"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ajg.2011.164"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2011"
                        "volumen" => "106"
                        "paginaInicial" => "1582"
                        "paginaFinal" => "1591"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21606976"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Functional bowel disorders"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46;F&#46; Longstreth"
                            1 => "W&#46;G&#46; Thompson"
                            2 => "W&#46;D&#46; Chey"
                            3 => "L&#46;A&#46; Houghton"
                            4 => "F&#46; Mearin"
                            5 => "R&#46;C&#46; Spiller"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/j.gastro.2005.11.061"
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2006"
                        "volumen" => "130"
                        "paginaInicial" => "1480"
                        "paginaFinal" => "1491"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16678561"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Inability of the Rome III criteria to distinguish functional constipation from constipation-subtype irritable bowel syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46;K&#46; Wong"
                            1 => "O&#46;S&#46; Palsson"
                            2 => "M&#46;J&#46; Turner"
                            3 => "R&#46;L&#46; Levy"
                            4 => "A&#46;D&#46; Feld"
                            5 => "M&#46; von Korff"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ajg.2010.200"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2010"
                        "volumen" => "105"
                        "paginaInicial" => "2228"
                        "paginaFinal" => "2234"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20502449"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of constipation in children and adults&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46;M&#46; Mugie"
                            1 => "M&#46; Benninga"
                            2 => "C&#46; di Lorenzo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.bpg.2010.12.010"
                      "Revista" => array:6 [
                        "tituloSerie" => "Best Pract Res Clin Gastroenterol"
                        "fecha" => "2011"
                        "volumen" => "25"
                        "paginaInicial" => "3"
                        "paginaFinal" => "18"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21382575"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of constipation&#58; agreement among several criteria and evaluation of the diagnostic accuracy of qualifying symptoms and self-reported definition in a population-based survey in Spain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "V&#46; Garrigues"
                            1 => "C&#46; G&#225;lvez"
                            2 => "V&#46; Ortiz"
                            3 => "M&#46; Ponce"
                            4 => "P&#46; Nos"
                            5 => "J&#46; Ponce"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Epidemiol"
                        "fecha" => "2004"
                        "volumen" => "159"
                        "paginaInicial" => "520"
                        "paginaFinal" => "526"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14977649"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subjects with irritable bowel syndrome-constipation are &#171;more constipated&#187; than those with chronic constipation&#58; spectrum from a population based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "F&#46; Mearin"
                            1 => "E&#46; Rey"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2012"
                        "volumen" => "142"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "S818"
                        "paginaFinal" => "S819"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and pathophysiology of functional constipation among women in Catalonia&#44; Spain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Y&#46; Ribas"
                            1 => "E&#46; Salda&#241;a"
                            2 => "J&#46; Mart&#237;-Ragu&#233;"
                            3 => "P&#46; Clav&#233;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/DCR.0b013e31822cb5c2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dis Colon Rectum"
                        "fecha" => "2011"
                        "volumen" => "54"
                        "paginaInicial" => "1560"
                        "paginaFinal" => "1569"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22067186"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology and burden of chronic constipation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46;I&#46;P&#46; Sanchez"
                            1 => "P&#46; Bercik"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Can J Gastroenterol"
                        "fecha" => "2011"
                        "volumen" => "25"
                        "numero" => "Suppl&#46; B"
                        "paginaInicial" => "11B"
                        "paginaFinal" => "15B"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22114752"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Levels of satisfaction with current chronic constipation treatment options in Europe &#8211; an internet survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46; M&#252;ller-Lissner"
                            1 => "J&#46; Tack"
                            2 => "Y&#46; Feng"
                            3 => "F&#46; Schenck"
                            4 => "R&#46; Specht Gryp"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/apt.12124"
                      "Revista" => array:6 [
                        "tituloSerie" => "Aliment Pharmacol Ther"
                        "fecha" => "2013"
                        "volumen" => "37"
                        "paginaInicial" => "137"
                        "paginaFinal" => "145"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23126338"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Breath methane in functional constipation&#58; response to treatment with Ispaghula husk"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;B&#46; Vega"
                            1 => "A&#46; Perell&#243;"
                            2 => "L&#46; Martos"
                            3 => "I&#46; Garc&#237;a Bayo"
                            4 => "M&#46; Garc&#237;a"
                            5 => "V&#46; Andreu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/nmo.12568"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurogastroenterol Motil"
                        "fecha" => "2015"
                        "volumen" => "27"
                        "paginaInicial" => "945"
                        "paginaFinal" => "953"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25952409"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systematic review&#58; impact of constipation on quality of life in adults and children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Belsey"
                            1 => "S&#46; Greenfield"
                            2 => "D&#46; Candy"
                            3 => "M&#46; Geraint"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2036.2010.04273.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Aliment Pharmacol Ther"
                        "fecha" => "2010"
                        "volumen" => "31"
                        "paginaInicial" => "938"
                        "paginaFinal" => "949"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20180788"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0335"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Healthcare seeking for constipation&#58; a population-based survey in the Mediterranean area of Spain"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46; G&#225;lvez"
                            1 => "V&#46; Garrigues"
                            2 => "V&#46; Ortiz"
                            3 => "M&#46; Ponce"
                            4 => "P&#46; Nos"
                            5 => "J&#46; Ponce"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2036.2006.02981.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Aliment Pharmacol Ther"
                        "fecha" => "2006"
                        "volumen" => "24"
                        "paginaInicial" => "421"
                        "paginaFinal" => "428"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16842470"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association between physical activity&#44; fiber intake&#44; and other lifestyle variables and constipation in a study of women"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Dukas"
                            1 => "W&#46;C&#46; Willett"
                            2 => "E&#46;L&#46; Giovannucci"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1572-0241.2003.07591.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2003"
                        "volumen" => "98"
                        "paginaInicial" => "1790"
                        "paginaFinal" => "1796"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12907334"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of low dietary intake of fiber and liquids with constipation&#58; evidence from the national health and nutrition examination survey"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46;D&#46; Markland"
                            1 => "O&#46; Palsson"
                            2 => "P&#46;S&#46; Goode"
                            3 => "K&#46;L&#46; Burgio"
                            4 => "J&#46; Busby-Whitehead"
                            5 => "W&#46;E&#46; Whitehead"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ajg.2013.73"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2013"
                        "volumen" => "108"
                        "paginaInicial" => "796"
                        "paginaFinal" => "803"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23567352"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Stopping or reducing dietary fiber intake reduces constipation and its associated symptoms"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "K&#46;-S&#46; Ho"
                            1 => "C&#46;Y&#46;M&#46; Tan"
                            2 => "M&#46;A&#46; Mohd Daud"
                            3 => "F&#46; Seow-Choen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3748/wjg.v18.i33.4593"
                      "Revista" => array:6 [
                        "tituloSerie" => "World J Gastroenterol"
                        "fecha" => "2012"
                        "volumen" => "18"
                        "paginaInicial" => "4593"
                        "paginaFinal" => "4596"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22969234"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Brief physical inactivity prolongs colonic transit time in elderly active men"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F&#46; Liu"
                            1 => "T&#46; Kondo"
                            2 => "Y&#46; Toda"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/s-2007-1021212"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Sports Med"
                        "fecha" => "1993"
                        "volumen" => "14"
                        "paginaInicial" => "465"
                        "paginaFinal" => "467"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8300274"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of exercise and physical fitness on large intestinal function"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;A&#46; Bingham"
                            1 => "J&#46;H&#46; Cummings"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "1989"
                        "volumen" => "97"
                        "paginaInicial" => "1389"
                        "paginaFinal" => "1399"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2583406"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of constipation in Europe and Oceania&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46; Peppas"
                            1 => "V&#46;G&#46; Alexiou"
                            2 => "E&#46; Mourtzoukou"
                            3 => "M&#46;E&#46; Falagas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1471-230X-8-5"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Gastroenterol"
                        "fecha" => "2008"
                        "volumen" => "8"
                        "paginaInicial" => "5"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18269746"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "World Gastroenterology Organisation global guideline&#58; constipation &#8211; a global perspective"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "World Gastroenterology Organisation"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Lindberg"
                            1 => "S&#46;S&#46; Hamid"
                            2 => "P&#46; Malfertheiner"
                            3 => "O&#46;O&#46; Thomsen"
                            4 => "L&#46;B&#46; Fernandez"
                            5 => "J&#46; Garisch"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/MCG.0b013e31820fb914"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Gastroenterol"
                        "fecha" => "2011"
                        "volumen" => "45"
                        "paginaInicial" => "483"
                        "paginaFinal" => "487"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21666546"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0375"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Symptoms and physiology in severe chronic constipation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46; Mertz"
                            1 => "B&#46; Naliboff"
                            2 => "E&#46;A&#46; Mayer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1572-0241.1999.00783.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "1999"
                        "volumen" => "94"
                        "paginaInicial" => "131"
                        "paginaFinal" => "138"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9934743"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0380"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Altered rectal perception is a biological marker of patients with irritable bowel syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "H&#46; Mertz"
                            1 => "B&#46; Naliboff"
                            2 => "J&#46; Munakata"
                            3 => "N&#46; Niazi"
                            4 => "E&#46;A&#46; Mayer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "1995"
                        "volumen" => "109"
                        "paginaInicial" => "40"
                        "paginaFinal" => "52"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7797041"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0385"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Decreased interstitial cell of cajal volume in patients with slow-transit constipation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;L&#46; He"
                            1 => "L&#46; Burgart"
                            2 => "L&#46; Wang"
                            3 => "J&#46; Pemberton"
                            4 => "T&#46; Young-Fadok"
                            5 => "J&#46; Szurszewski"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2000"
                        "volumen" => "118"
                        "paginaInicial" => "14"
                        "paginaFinal" => "21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10611149"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0390"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impaired colonic motor response to cholinergic stimulation in patients with severe chronic idiopathic &#40;slow transit type&#41; constipation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Bassotti"
                            1 => "G&#46; Chiarioni"
                            2 => "B&#46;P&#46; Imbimbo"
                            3 => "C&#46; Betti"
                            4 => "F&#46; Bonfante"
                            5 => "I&#46; Vantini"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Dig Dis Sci"
                        "fecha" => "1993"
                        "volumen" => "38"
                        "paginaInicial" => "1040"
                        "paginaFinal" => "1045"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8508698"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0395"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Response to a behavioural treatment&#44; biofeedback&#44; in constipated patients is associated with improved gut transit and autonomic innervation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;V&#46; Emmanuel"
                            1 => "M&#46;A&#46; Kamm"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Gut"
                        "fecha" => "2001"
                        "volumen" => "49"
                        "paginaInicial" => "214"
                        "paginaFinal" => "219"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11454797"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0400"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Functional disorders of the anus and rectum"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "W&#46;E&#46; Whitehead"
                            1 => "A&#46; Wald"
                            2 => "N&#46;E&#46; Diamant"
                            3 => "P&#46; Enck"
                            4 => "J&#46;H&#46; Pemberton"
                            5 => "S&#46;S&#46; Rao"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Gut"
                        "fecha" => "1999"
                        "volumen" => "45"
                        "numero" => "Suppl&#46; 2"
                        "paginaInicial" => "II55"
                        "paginaFinal" => "II59"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10457046"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Investigation of the utility of colorectal function tests and Rome II criteria in dyssynergic defecation &#40;anismus&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46;S&#46;C&#46; Rao"
                            1 => "R&#46;S&#46; Mudipalli"
                            2 => "M&#46; Stessman"
                            3 => "B&#46; Zimmerman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2982.2004.00526.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurogastroenterol Motil"
                        "fecha" => "2004"
                        "volumen" => "16"
                        "paginaInicial" => "589"
                        "paginaFinal" => "596"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15500515"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0410"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46; Chiarioni"
                            1 => "W&#46;E&#46; Whitehead"
                            2 => "V&#46; Pezza"
                            3 => "A&#46; Morelli"
                            4 => "G&#46; Bassotti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/j.gastro.2005.11.014"
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2006"
                        "volumen" => "130"
                        "paginaInicial" => "657"
                        "paginaFinal" => "664"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16530506"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0415"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized controlled trial of biofeedback&#44; sham feedback&#44; and standard therapy for dyssynergic defecation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;S&#46;C&#46; Rao"
                            1 => "K&#46; Seaton"
                            2 => "M&#46; Miller"
                            3 => "K&#46; Brown"
                            4 => "I&#46; Nygaard"
                            5 => "P&#46; Stumbo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cgh.2006.12.023"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Gastroenterol Hepatol"
                        "fecha" => "2007"
                        "volumen" => "5"
                        "paginaInicial" => "331"
                        "paginaFinal" => "338"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17368232"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0420"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Stool form scale as a useful guide to intestinal transit time"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;J&#46; Lewis"
                            1 => "K&#46;W&#46; Heaton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3109/00365529709011203"
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Gastroenterol"
                        "fecha" => "1997"
                        "volumen" => "32"
                        "paginaInicial" => "920"
                        "paginaFinal" => "924"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9299672"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0425"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "American Gastroenterological Association technical review on constipation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;E&#46; Bharucha"
                            1 => "J&#46;H&#46; Pemberton"
                            2 => "G&#46;R&#46; Locke"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/j.gastro.2012.10.028"
                      "Revista" => array:6 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2013"
                        "volumen" => "144"
                        "paginaInicial" => "218"
                        "paginaFinal" => "238"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23261065"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0430"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Practice parameters for the evaluation and management of constipation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46;A&#46; Ternent"
                            1 => "A&#46;L&#46; Bastawrous"
                            2 => "N&#46;A&#46; Morin"
                            3 => "C&#46;N&#46; Ellis"
                            4 => "N&#46;H&#46; Hyman"
                            5 => "W&#46;D&#46; Buie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10350-007-9000-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dis Colon Rectum"
                        "fecha" => "2007"
                        "volumen" => "50"
                        "paginaInicial" => "2013"
                        "paginaFinal" => "2022"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17665250"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0435"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Consensus statement AIGO&#47;SICCR&#58; diagnosis and treatment of chronic constipation and obstructed defecation &#40;part I&#58; diagnosis&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Bove"
                            1 => "F&#46; Pucciani"
                            2 => "M&#46; Bellini"
                            3 => "E&#46; Battaglia"
                            4 => "R&#46; Bocchini"
                            5 => "D&#46;F&#46; Altomare"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3748/wjg.v18.i14.1555"
                      "Revista" => array:6 [
                        "tituloSerie" => "World J Gastroenterol"
                        "fecha" => "2012"
                        "volumen" => "18"
                        "paginaInicial" => "1555"
                        "paginaFinal" => "1564"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22529683"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib0440"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Digital rectal examination is a useful tool for identifying patients with dyssynergia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "K&#46; Tantiphlachiva"
                            1 => "P&#46; Rao"
                            2 => "A&#46; Attaluri"
                            3 => "S&#46;S&#46;C&#46; Rao"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cgh.2010.06.031"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Gastroenterol Hepatol"
                        "fecha" => "2010"
                        "volumen" => "8"
                        "paginaInicial" => "955"
                        "paginaFinal" => "960"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20656061"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0445"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical examination remains more important than anorectal function tests to identify treatable conditions in women with constipation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "T&#46;J&#46; Lam"
                            1 => "R&#46;J&#46;F&#46; Felt-Bersma"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00192-012-1796-x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int Urogynecol J"
                        "fecha" => "2013"
                        "volumen" => "24"
                        "paginaInicial" => "67"
                        "paginaFinal" => "72"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22618205"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib0450"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A gap in our understanding&#58; chronic constipation and its comorbid conditions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "N&#46;J&#46; Talley"
                            1 => "K&#46;L&#46; Lasch"
                            2 => "C&#46;L&#46; Baum"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cgh.2008.07.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Gastroenterol Hepatol"
                        "fecha" => "2009"
                        "volumen" => "7"
                        "paginaInicial" => "9"
                        "paginaFinal" => "19"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18829389"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0455"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comorbidities in patients with irritable bowel syndrome with constipation or chronic idiopathic constipation&#58; a review of the literature from the past decade"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "D&#46; Nellesen"
                            1 => "A&#46; Chawla"
                            2 => "D&#46;L&#46; Oh"
                            3 => "T&#46; Weissman"
                            4 => "B&#46;J&#46; Lavins"
                            5 => "C&#46;W&#46; Murray"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3810/pgm.2013.03.2640"
                      "Revista" => array:6 [
                        "tituloSerie" => "Postgrad Med"
                        "fecha" => "2013"
                        "volumen" => "125"
                        "paginaInicial" => "40"
                        "paginaFinal" => "50"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23816770"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0460"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "A154"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Constipation in adults&#58; complications and comorbidities"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Singh"
                            1 => "K&#46; Kahler"
                            2 => "V&#46; Bharathi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2005"
                        "volumen" => "128"
                        "numero" => "Suppl&#46; 2"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15825082"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0465"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Complications and comorbidities of constipation in adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Singh"
                            1 => "S&#46; Vadhavkar"
                            2 => "H&#46; Wang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Gastroenterology"
                        "fecha" => "2007"
                        "volumen" => "132"
                        "numero" => "Suppl&#46; 2"
                        "paginaInicial" => "A458"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0470"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Healthcare costs and clinical sequelae associated with constipation in a managed care population"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Mitra"
                            1 => "K&#46;L&#46; Davis"
                            2 => "R&#46;W&#46; Baran"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2007"
                        "volumen" => "102"
                        "paginaInicial" => "2"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0475"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Concurrent conditions in patients with chronic constipation&#58; a population-based study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46; Arora"
                            1 => "A&#46; Mannalithara"
                            2 => "A&#46; Mithal"
                            3 => "G&#46; Triadafilopoulos"
                            4 => "G&#46; Singh"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0042910"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS ONE"
                        "fecha" => "2012"
                        "volumen" => "7"
                        "paginaInicial" => "e42910"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23071488"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0480"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "All-cause health care charges among managed care patients with constipation and comorbid irritable bowel syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Mitra"
                            1 => "K&#46;L&#46; Davis"
                            2 => "R&#46;W&#46; Baran"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3810/pgm.2011.09.2467"
                      "Revista" => array:6 [
                        "tituloSerie" => "Postgrad Med"
                        "fecha" => "2011"
                        "volumen" => "123"
                        "paginaInicial" => "122"
                        "paginaFinal" => "132"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21904094"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0485"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systematic review on ventral rectopexy for rectal prolapse and intussusception"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46;B&#46; Samaranayake"
                            1 => "C&#46; Luo"
                            2 => "A&#46;W&#46; Plank"
                            3 => "A&#46;E&#46;H&#46; Merrie"
                            4 => "L&#46;D&#46; Plank"
                            5 => "I&#46;P&#46; Bissett"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1463-1318.2009.01934.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Colorectal Dis"
                        "fecha" => "2010"
                        "volumen" => "12"
                        "paginaInicial" => "504"
                        "paginaFinal" => "512"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19438880"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0490"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence and predictive factors of fecal incontinence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;-W&#46; Kang"
                            1 => "H&#46;-K&#46; Jung"
                            2 => "K&#46;-J&#46; Kwon"
                            3 => "E&#46;-M&#46; Song"
                            4 => "J&#46;-Y&#46; Choi"
                            5 => "S&#46;-E&#46; Kim"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5056/jnm.2012.18.1.86"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurogastroenterol Motil"
                        "fecha" => "2012"
                        "volumen" => "18"
                        "paginaInicial" => "86"
                        "paginaFinal" => "93"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22323992"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0495"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Constipation is also an important cause of fecal incontinence in old people&#58; Author&#39;s reply"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "H-K&#46; Jung"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.5056/jnm.2012.18.3.346"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurogastroenterol Motil"
                        "fecha" => "2012"
                        "volumen" => "18"
                        "paginaInicial" => "346"
                        "paginaFinal" => "347"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22837888"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association between constipation and colorectal cancer&#58; systematic review and meta-analysis of observational studies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;M&#46; Power"
                            1 => "N&#46;J&#46; Talley"
                            2 => "A&#46;C&#46; Ford"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/ajg.2013.52"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Gastroenterol"
                        "fecha" => "2013"
                        "volumen" => "108"
                        "paginaInicial" => "894"
                        "paginaFinal" => "903"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23481143"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Constipation in children and young people&#58; diagnosis and management of idiopathic childhood constipation in primary and secondary care&#46; Clinical Guideline May 2010"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "National Collaborating Centre for Women&#39;s and Children&#39;s Health &#40;UK&#41;"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2010"
                        "editorial" => "RCOG Press"
                        "editorialLocalizacion" => "London"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0510"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence rates for constipation and faecal and urinary incontinence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "V&#46; Loening-Baucke"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/adc.2006.098335"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dis Child"
                        "fecha" => "2007"
                        "volumen" => "92"
                        "paginaInicial" => "486"
                        "paginaFinal" => "489"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16857698"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0515"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of non-urological diseases with lower urinary tract symptoms"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46; Koskim&#228;ki"
                            1 => "M&#46; Hakama"
                            2 => "H&#46; Huhtala"
                            3 => "T&#46;L&#46; Tammela"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Scand J Urol Nephrol"
                        "fecha" => "2001"
                        "volumen" => "35"
                        "paginaInicial" => "377"
                        "paginaFinal" => "381"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11771864"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib0520"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of urinary incontinence among institutionalized patients&#58; a cross-sectional epidemiologic study in a midsized city in northern Italy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Aggazzotti"
                            1 => "F&#46; Pesce"
                            2 => "D&#46; Grassi"
                            3 => "G&#46; Fantuzzi"
                            4 => "E&#46; Righi"
                            5 => "D&#46; de Vita"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Urology"
                        "fecha" => "2000"
                        "volumen" => "56"
                        "paginaInicial" => "245"
                        "paginaFinal" => "249"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10925087"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:4 [
        "identificador" => "xack273289"
        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0235" class="elsevierStylePara elsevierViewall">The following people have acted as external reviewers&#58;</p> <p id="par0240" class="elsevierStylePara elsevierViewall">Carmen Vela Vallesp&#237;n&#46; General practitioner&#44; Riu Nord i Sud Primary Care Centre &#40;CAP&#41; Catalan Health Institute Santa Coloma&#44; Barcelona&#46;</p> <p id="par0245" class="elsevierStylePara elsevierViewall">Iv&#225;n Villar Balboa&#46; General practitioner&#44; Florida Sud Primary Care Centre &#40;CAP&#41; Catalan Health Institute&#44; L&#8217;Hospitalet de Llobregat&#44; Barcelona&#46;</p> <p id="par0250" class="elsevierStylePara elsevierViewall">Merc&#232; Barenys de Lacha&#46; Gastroenterologist&#44; Hospital de Viladecans&#46; Professor of Gastroenterology&#44; University of Barcelona&#46; IDIBELL Scientific Committee&#46;</p> <p id="par0255" class="elsevierStylePara elsevierViewall">Francisco Javier Amador Romero&#46; General practitioner&#44; Los &#193;ngeles Health Centre&#44; Madrid&#46;</p> <p id="par0260" class="elsevierStylePara elsevierViewall">Miguel M&#237;nguez P&#233;rez&#46; Gastroenterologist&#44; Hospital Cl&#237;nico Universitario de Valencia&#46;</p> <p id="par0265" class="elsevierStylePara elsevierViewall">This CPG has the support of the following organisations&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">Asociaci&#243;n Espa&#241;ola de Gastroenterolog&#237;a &#40;AEG&#41; &#91;Spanish Association of Gastroenterology&#93;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">Sociedad Espa&#241;ola de Medicina Familiar y Comunitaria &#40;semFYC&#41; &#91;Spanish Society of Family and Community Medicine&#93;&#46;</p></li></ul></p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/24443824/0000004000000003/v1_201703160041/S2444382417300408/v1_201703160041/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "64462"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Review article"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/24443824/0000004000000003/v1_201703160041/S2444382417300408/v1_201703160041/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382417300408?idApp=UINPBA00004N"
]

Article information

ISSN: 24443824
Original language: English

DOI:10.1016/j.gastre.2017.02.001

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	22	7	29
2024 October	315	62	377
2024 September	498	106	604
2024 August	355	72	427
2024 July	371	65	436
2024 June	343	71	414
2024 May	395	81	476
2024 April	383	87	470
2024 March	381	148	529
2024 February	459	131	590
2024 January	614	95	709
2023 December	389	86	475
2023 November	490	98	588
2023 October	519	157	676
2023 September	483	106	589
2023 August	362	64	426
2023 July	468	84	552
2023 June	336	81	417
2023 May	454	78	532
2023 April	324	97	421
2023 March	321	97	418
2023 February	220	108	328
2023 January	231	82	313
2022 December	176	59	235
2022 November	178	68	246
2022 October	140	56	196
2022 September	185	75	260
2022 August	198	54	252
2022 July	234	158	392
2022 June	149	57	206
2022 May	140	64	204
2022 April	176	80	256
2022 March	180	84	264
2022 February	209	152	361
2022 January	334	65	399
2021 December	138	69	207
2021 November	158	81	239
2021 October	232	106	338
2021 September	232	78	310
2021 August	250	84	334
2021 July	232	97	329
2021 June	311	104	415
2021 May	254	85	339
2021 April	880	325	1205
2021 March	455	189	644
2021 February	350	111	461
2021 January	289	133	422
2020 December	283	123	406
2020 November	278	120	398
2020 October	204	62	266
2020 September	186	72	258
2020 August	119	42	161
2020 July	126	49	175
2020 June	98	32	130
2020 May	134	54	188
2020 April	95	64	159
2020 March	130	43	173
2020 February	112	37	149
2020 January	70	30	100
2019 December	45	27	72
2019 November	41	42	83
2019 October	79	42	121
2019 September	34	16	50
2019 August	17	4	21
2019 July	28	27	55
2019 June	29	17	46
2019 May	71	29	100
2019 April	41	22	63
2019 March	21	10	31
2019 February	1	0	1
2018 February	0	1	1
2018 January	0	1	1
2017 October	1	0	1
2017 September	1	0	1
2017 June	1	0	1
2017 April	1	0	1

Show all

Indexed in:

Follow us:

Subscribe:

Statistics

Indexed in:

Follow us:

Subscribe:

Statistics

Subscribe to our newsletter