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Constipation

What's new

Updated 2023 AGA/ACG guidelines for the management of chronic idiopathic 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 College of Gastroenterology (ACG/AGA 2023), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN 2023), the American College of Gastroenterology (ACG 2021,2014), the British Society of Gastroenterology (BSG 2021), the European Society of Gastrointestinal Endoscopy (ESGE ...
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Diagnostic investigations

History and physical examination
As per ASCRS 2016 guidelines:
Elicit a directed history and perform a physical examination in patients with constipation.
A
Consider using validated measures assessing the nature, severity and impact of constipation on QoL as part of the medical evaluation for constipation.
C
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  • Laboratory tests

  • Anorectal physiology testing

  • Defecography

Diagnostic procedures

Colonoscopy: as per ASCRS 2016 guidelines, do not perform routine endoscopy in patients with constipation in the absence of alarming symptoms, screening recommendations, or other significant comorbidities.
D

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

  • Prokinetics

  • Probiotics

Nonpharmacologic interventions

Fiber supplementation: as per ACG/AGA 2023 guidelines, consider offering fiber supplementation in adult patients with chronic idiopathic constipation.
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  • Suppositories and enemas

Therapeutic procedures

Biofeedback therapy: as per ASCRS 2016 guidelines, offer biofeedback therapy as first-line treatment for symptomatic pelvic floor dyssynergia.
B

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  • Sacral nerve stimulation

Surgical interventions

Indications for surgery: as per ESGE 2020 guidelines, perform endoscopic cecostomy only after failing conservative management with medical therapies or retrograde lavage.
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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.
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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.
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Re-evaluate anorectal physiology and colonic transit in patients with persisting symptoms despite an adequate trial of biofeedback therapy.
B