New guideline highlights ‘individualized approach’ in management of chronic constipation
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Key takeaways:
- Initial management and first-line treatment for chronic constipation includes dietary modifications and osmotic laxatives.
- Providers should measure colonic motility and transit before surgical intervention.
An updated clinical practice guideline from The American Society of Colon and Rectal Surgeons underscored the need for collaborative, cross-specialty care to achieve “optimal patient outcomes” in chronic constipation.
“Constipation is one of the most common GI disorders seen in ambulatory medicine clinics and is a common reason for referral to a colorectal surgeon,” Karim Alavi, MD, MPH, of the division of colon and rectal surgery at UMass Memorial Medical Center, and colleagues wrote in Diseases of the Colon & Rectum. “The complex cause and variable severity of constipation symptoms mandate an individualized approach to evaluation and treatment. Given the range of specialties that manage constipation, a collaborative approach is often warranted to achieve optimal patient outcomes.”
Seeking to update the 2016 guideline on the management of constipation, Alavi and colleagues searched MEDLINE, Cochrane Library and Scopus for English-language studies of adults conducted from January 2014 to February 2024. They included 134 studies and developed 13 recommendations, which were labeled “strong” or “conditional” using the Grading of Recommendations, Assessment, Development and Evaluation system.
Highlights include:
- Providers should perform a directed history and physical examination in patients with constipation.
- The initial management of symptomatic constipation includes dietary modifications as well as adequate fluid intake and fiber supplementation.
- Osmotic laxatives are appropriate first-line treatment for chronic constipation, while rescue or second-line therapy, if needed, may include stimulant laxatives such as bisacodyl.
- Patients who do not improve with initial management and first-line treatment should be evaluated for outlet dysfunction. Functional or structural etiologies related to an evacuation disorder may be identified by anorectal physiology testing or dynamic imaging by fluoroscopic defecography, MRI defecography or dynamic ultrasound.
- Providers should measure colonic motility and transit before surgical intervention.
- Biofeedback therapy is a first-line treatment for patients with symptomatic pelvic flood dyssynergia.
- Stapled transanal rectal resection is not recommended for rectocele or internal rectal intussusception repair due to high complication rates.
“Although not proscriptive, these guidelines provide information based on which decisions can be made and do not dictate a specific form of treatment,” Alavi and colleagues wrote. “The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient.”
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