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Constipation

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Updated 2024 ASCRS guidelines for the evaluation and management of chronic constipation.

Background

Overview

Definition
Constipation is a symptom-based disorder defined as fewer than 3 bowel movements per week.
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Pathophysiology
Constipation is caused by pelvic floor dysfunction, slow colonic transit, metabolic disorders (hypercalcemia, hypothyroidism), medications (opiates, CCBs, antipsychotics), neurological disorders (diabetes mellitus, Parkinson's disease, spinal cord injury), IBS, and primary colonic disorders (strictures, cancer, anal fissure, proctitis).
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Epidemiology
The overall prevalence of constipation in the US is 16%.
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Disease course
Anomalous regulation of neuromuscular components within the colon and anorectum, and disruption in the corresponding ascending and descending pathways in the brain-gut axis result in infrequent bowel movements, excessive straining, a sense of incomplete evacuation, failed or lengthy attempts to defecate, digital manipulation to evacuate stools, abdominal bloating, and hard consistency of stools.
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Prognosis and risk of recurrence
Chronic constipation decreases QoL and ability to function; however, only approximately 25% of patients consult physicians or use medications to manage associated symptoms.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of constipation are prepared by our editorial team based on guidelines from the American Society of Colon and Rectal Surgeons (ASCRS 2024,2016), the Japanese Gastroenterological Association (JGA 2024), the American College of Gastroenterology (ACG/AGA 2023), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN 2023), the American Academy of Family ...
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Classification and risk stratification

Classification: as per JGA 2024 guidelines, classify primary chronic constipation into the following groups:
functional constipation
IBS-C
motility disorders (small/large intestine type and anorectal type).
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Diagnostic investigations

History and physical examination
As per ASCRS 2024 guidelines:
Elicit a directed history and perform a physical examination in patients with constipation.
B
Consider using objective measures assessing the nature, severity, and impact of constipation on the QoL in patients with constipation.
C
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  • Laboratory tests

  • Anorectal physiology testing

  • Abdominal imaging

  • Defecography

  • Colonic transit study

Diagnostic procedures

Colonoscopy: as per JGA 2024 guidelines, perform colonoscopy on a case-by-case basis to differentiate secondary constipation.
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Medical management

Avoidance of causative agents: as per AGA 2013 guidelines, discontinue medications that can cause constipation, if feasible, before obtaining further testing for constipation.
B
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  • Laxatives

  • Secretagogues

  • Ileal bile acid transporter inhibitors

  • Prokinetics

  • Probiotics

Nonpharmacologic interventions

Fiber supplementation: as per ASCRS 2024 guidelines, offer dietary modifications including adequate fluid intake and fiber supplementation for the initial management of patients with symptomatic constipation.
B
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  • Suppositories and enemas

  • Psychotherapy

Therapeutic procedures

Biofeedback therapy: as per ASCRS 2024 guidelines, consider offering biofeedback therapy as first-line treatment in patients with symptomatic pelvic floor dyssynergia.
B
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  • Sacral nerve stimulation

  • Botulinum toxin injections

Surgical interventions

Indications for surgery: as per ASCRS 2024 guidelines, consider performing surgical repair in patients with significant outlet dysfunction from a rectocele after addressing any concomitant functional causes, such as nonrelaxing puborectalis muscle.
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Specific circumstances

Pediatric patients, diagnosis: as per ESPGHAN/NASPGHAN 2014 guidelines, use the Rome IV criteria for the definition of functional constipation.
E
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  • Pediatric patients (evaluation)

  • Pediatric patients (nonpharmacological management)

  • Pediatric patients (pharmacotherapy)

  • Pediatric patients (therapeutic interventions)

  • Patients with IBS-C (polyethylene glycol)

  • Patients with IBS-C (5-HT4 agonists)

  • Patients with IBS-C (guanylate cyclase activators)

  • Patients with IBS-C (lubiprostone)

  • Patients with IBS-C (tenapanor)

  • Patients with opioid-induced constipation

Follow-up and surveillance

Evaluation of refractory constipation
As per AGA 2013 guidelines:
Obtain anorectal physiology testing in patients not responding to laxatives.
A
Re-evaluate anorectal physiology and colonic transit in patients with persisting symptoms despite an adequate trial of biofeedback therapy.
B
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