New guidelines for the evaluation and management of chronic constipation

The American Society of Colon and Rectal Surgeons (ASCRS) has just released an update to its clinical practice guidelines for the evaluation and management of chronic constipation, the previous version of which was dated 2016. Published in the journal Diseases of the Colon & Rectum, the ASCRS expert panel states in a preamble that, “The complex etiology and variable severity of constipation symptoms require an individualized approach,” and that, given the diversity of specialties that may manage it, “a collaborative approach is often warranted to achieve optimal patient outcomes.”Constipation is one of the most common gastrointestinal disorders, and when it becomes chronic it is a frequent reason for referral to a colorectal surgeon. Its worldwide prevalence is around 15%, and its diagnosis is more frequent in North America and Europe than in Asia, “probably due to differences in diet, culture and environment,” the authors wrote.Constipation is characterized by impaired colonic motility and/or impaired stool evacuation. According to the Rome IV criteria, it is defined by the presence of at least two of the following: fewer than three spontaneous defecations per week, scybala or hard stools, pushing efforts, incomplete evacuation, a sensation of anorectal blockage or the need for manual maneuvers to aid defecation. Constipation is said to be chronic when it has persisted for six months.The ASCRS panel of experts analyzed data from 134 studies published on the subject between 2014 and 2024. Based on this meta-analysis, they formulated 13 recommendations, each of which is classified as “strong” or “conditional” depending on the level of certainty of the evidence in the medical literature.The six “strong” recommendations are:The need for a personalized history and physical examinationAlthough constipation is in itself a benign condition, the authors emphasize that “history-taking and physical examination help to ensure that a serious or even life-threatening illness is not the underlying cause of constipation-related symptoms.” Patients with constipation who also report rectal bleeding, altered stool calibre, blood in the stool, weight loss, anemia or a family history of colorectal cancer should, they say, undergo endoscopic evaluation for neoplastic lesions in the intestines.Diet modification firstDietary modification, particularly increasing water and fibre intake, is considered a first-line treatment for constipation. They are “generally recommended before investigations of pelvic floor function and colonic motility.”Osmotic laxatives as first-line medical treatment Osmotic agents used in the treatment of constipation include polyethylene glycol-based (PEG) solutions and magnesium salt products. “A meta-analysis of 10 randomized controlled trials that compared PEG solutions with lactulose demonstrated superiority (of the former) in terms of improving stool frequency and consistency, relieving abdominal pain and reducing the use of other laxatives,” the authors reported. “Magnesium salt laxatives, such as magnesium sulphate, were also found to be effective in improving stool frequency and consistency,” they added, mentioning that stimulant laxatives, such as bisacodyl, may be considered as rescue or second-line treatment, if necessary.Colonic motility and transit should be measured before considering surgery“Assessment of colonic transit can elucidate the underlying cause of constipation,” explains the ASCRS panel. They believe that measuring the transit time of radiopaque markers in the colon “remains the most common motility testing modality due to its wide availability, low cost and ease of use.”Biofeedback therapy to considerAccording to a notice from the Ordre des psychologues du Québec, the term biofeedback “covers all techniques that use sensors to measure and record physiological signals such as body temperature, breathing, heart rate, muscle tension or brain waves. The information thus obtained is transmitted to the client via visual or auditory signals (feedback) live on a computer screen, for example. With the help of an appropriately trained practitioner, the patient then trains himself to modulate his physiological reactions, the aim being to regulate behaviour on a daily basis.”The ASCRS expert panel says that “biofeedback therapy is considered a first-line treatment for patients suffering from symptomatic pelvic floor dyssynergia.” After initial training, periodic reinforcement is necessary to maintain the effectiveness of biofeedback over time, they stress, specifying that, “The success of pelvic floor biofeedback therapy relies on the motivation and participation of the patient in an individualized plan, tailored to their needs.”Transanal stapled rectal resection of the lower rectum (STARR) not recommended for repair of rectal hernia or rectal intussusception This non-recommendation is based on the results of a systematic review of the postoperative outcome of STARR performed for rectal hernia (rectocele) or rectal intussusception. The results highlighted high rates of complications associated with this procedure, including bleeding, infection, pain, fecal emergencies and incontinence.The seven “conditional” recommendations are:Objective measures assessing the nature and severity of constipation can be useful when evaluating patients.Patients whose condition does not improve with dietary changes, fibre intake and osmotic laxatives should be examined to determine whether they are suffering from stool evacuation dysfunction. Anorectal physiology tests, dynamic fluoroscopic imaging, dynamic pelvic floor MRI (or defeco-MRI) or dynamic ultrasonography can help identify functional or structural etiologies linked to an evacuation disorder.Injection of botulinum toxin into the puborectal muscle and external sphincter may be considered in patients with constipation due to outlet dysfunction linked to lack of puborectal muscle relaxation. Surgical repair may be considered in patients with significant outlet dysfunction due to rectocele, after treating any concomitant functional etiologies such as lack of puborectal muscle relaxation. Repair of rectal invagination may be considered in patients with severe obstructed defecation in whom non-surgical treatments have failed.Patients suffering from isolated refractory colonic constipation with slow transit may benefit from total colectomy with ileorectal anastomosis.Fecal diversion may be considered for patients with intractable constipation refractory to other treatment options.ASCRS clinical practice guidelines can be found here.This article has been translated from its original French and was first published on our sister site Profession Santé.

New guidelines for the evaluation and management of chronic constipation

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