What are the guideline sources, guidelines and references for Constipation ?
Guideline 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 American College of Gastroenterology (ACG 2021; 2014), the British Society of Gastroenterology (BSG 2021), the European Society of Gastrointestinal Endoscopy (ESGE 2020), the Canadian Association of Gastroenterologists (CAG 2019), the American Gastroenterological Association (AGA 2019; 2014; 2013), the European Society of Medical Oncology (ESMO 2018), the American Society of Colon and Rectal Surgeons (ASCRS 2016), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2014), and the American Society for Gastrointestinal Endoscopy (ASGE 2014). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 14 14 15 15 Definition Constipation is a symptom-based disorder defined as fewer than 3 bowel movements per week. 14 Epidemiology https://web.pathway.md/diseases/recgTNkhcVaq5tHQT 1/9 6/23/23, 3:35 AM Constipation Pathway 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). 15 Pathophysiology The overall prevalence of constipation in the United States is 16%. 14 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. 15 Prognosis and risk of recurrence Chronic constipation decreases quality of life and ability to function; however, only approximately 25% of patients consult physicians or use medications to manage associated symptoms. 14 Pathway Constipation Investigation Guidelines 1. 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 quality of life as part of the medical evaluation for constipation. C As per AGA 2013 guidelines, perform a careful DRE with an assessment of pelvic floor motion during simulated evacuation in patients with chronic constipation before referring for anorectal manometry, recognizing that a normal DRE does not exclude defecatory disorders. B Laboratory tests: As per ASCRS 2016 guidelines, do not obtain routine blood tests in patients with constipation in the absence of alarming symptoms, screening recommendations, or other significant https://web.pathway.md/diseases/recgTNkhcVaq5tHQT 2/9 6/23/23, 3:35 AM Constipation Pathway comorbidities. D As per AGA 2013 guidelines: Obtain a CBC as part of the initial evaluation of patients with chronic constipation. B Do not obtain metabolic tests (glucose, calcium, TSH) as part of the initial evaluation of chronic constipation, unless other clinical features warrant otherwise. D Anorectal physiology testing: As per ACG 2021 guidelines, consider performing anorectal physiology testing in patients with IBS and symptoms suggestive of a pelvic floor disorder and/or refractory constipation not responsive to standard medical therapy. E As per ASCRS 2016 guidelines, consider obtaining anorectal physiology testing to identify the underlying etiology as well as in patients with refractory constipation. B As per AGA 2013 guidelines, obtain anorectal manometry and rectal balloon expulsion test in patients not responding to laxatives. B Defecography: As per ASCRS 2016 guidelines: Do not obtain routine imaging in patients with constipation in the absence of alarming symptoms, screening recommendations, or other significant comorbidities. D Consider obtaining imaging with cinedefecography, MRI defecography or transperineal ultrasound echodefecography to identify anatomical abnormalities associated with obstructive defecation. B As per AGA 2013 guidelines, evaluate colonic transit if anorectal test results do not show a defecatory disorder or if symptoms persist despite treatment of a defecatory disorder. B Show 2 more 2. 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 As per ASGE 2014 guidelines, do not perform gastrointestinal endoscopy in the initial evaluation of patients presenting with symptoms of chronic constipation in the absence of alarm features or suspicion of organic gastrointestinal disease. D Show 3 more As per AGA 2013 guidelines, do not perform colonoscopy for the evaluation of patients with constipation in the absence of alarm features (such as blood in stools, anemia, or weight loss), unless age-appropriate colon cancer screening has not been performed. D 3. Medical management https://web.pathway.md/diseases/recgTNkhcVaq5tHQT 3/9 6/23/23, 3:35 AM Constipation Pathway Avoidance of causative agents: discontinue medications that can cause constipation, if feasible, before obtaining further testing for constipation. B Laxatives: As per AGA 2023 guidelines, offer polyethylene glycol in adult patients with chronic idiopathic constipation. B Show 4 more As per ASCRS 2016 guidelines: Consider offering osmotic laxatives (such as polyethylene glycol and lactulose) for the management of chronic constipation. B Consider offering short-term stimulant laxatives (such as bisacodyl) as second-line therapy in patients with chronic constipation. B As per AGA 2013 guidelines: Offer a trial of laxatives (osmotic or stimulant) before obtaining further testing for constipation. B Offer long-term laxatives in patients with normal- or slow-transit constipation. B Secretagogues: As per AGA 2023 guidelines: Offer linaclotide or prucalopride in adult patients with chronic idiopathic constipation not responding to OTC agents. B Consider offering lubiprostone in adult patients with chronic idiopathic constipation not responding to OTC agents. C As per ASCRS 2016 guidelines, consider offering lubiprostone or linaclotide when dietary modifications and osmotic and stimulant laxatives have failed. C Prokinetics: offer prucalopride to improve symptoms of chronic idiopathic constipation. B Probiotics: insufficient evidence to support the use of probiotics in patients with chronic idiopathic constipation. I 4. Nonpharmacologic interventions Fiber supplementation: As per ACG 2023 guidelines, consider offering fiber supplementation in adult patients with chronic idiopathic constipation. C As per ASCRS 2016 guidelines, offer fiber and fluid supplementation for the initial management of symptomatic constipation. B As per AGA 2013 guidelines, offer a trial of fiber supplementation before obtaining further testing for constipation. B Suppositories and enemas: consider offering suppositories or enemas, rather than oral laxatives alone, in patients with refractory pelvic floor dysfunction. C https://web.pathway.md/diseases/recgTNkhcVaq5tHQT 4/9 6/23/23, 3:35 AM Constipation Pathway 5. Therapeutic procedures Biofeedback therapy: As per ASCRS 2016 guidelines, offer biofeedback therapy as first-line treatment for symptomatic pelvic floor dyssynergia. B As per ACG 2014 guidelines, offer biofeedback therapy, administered by a trained and skilled therapist, for relief of constipation symptoms in patients with chronic idiopathic constipation with demonstrated evidence of pelvic floor dyssynergia. B As per AGA 2013 guidelines, offer pelvic floor retraining by biofeedback therapy in preference to laxatives for the treatment of defecatory disorders. A Sacral nerve stimulation: consider performing sacral nerve stimulation in patients with chronic constipation and successful peripheral nerve evaluation test when conservative measures have failed. C 6. Surgical interventions Indications for surgery: As per ESGE 2020 guidelines, perform endoscopic cecostomy only after failing conservative management with medical therapies or retrograde lavage. B Show 4 more As per ASCRS 2016 guidelines, consider performing total abdominal colectomy with ileorectal anastomosis in patients with refractory colonic slow-transit constipation. B Consider treating pelvic floor dysfunction before total abdominal colectomy with ileorectal anastomosis in patients with refractory slow-transit constipation associated with pelvic outlet obstruction or functional disorders. Individualize treatment based on symptoms. C Show 6 more As per AGA 2013 guidelines: Consider performing subtotal colectomy, rather than continuing therapy with chronic laxatives, in patients with slow-transit constipation due to colonic motor dysfunction. C Consider performing colonic intraluminal testing (manometry, barostat) to document colonic motor dysfunction before colectomy is pursued. C 7. Specific circumstances Pediatric patients (diagnosis): use the Rome IV criteria for the definition of functional constipation. E Show 3 more Pediatric patients (evaluation): perform a digital examination to exclude underlying medical conditions in the presence of alarm signs or symptoms or in patients with intractable constipation. E https://web.pathway.md/diseases/recgTNkhcVaq5tHQT 5/9 6/23/23, 3:35 AM Constipation Pathway Show 11 more Pediatric patients (nonpharmacological management): do not offer routine multidisciplinary treatment in pediatric patients with constipation. D Show 5 more Pediatric patients (pharmacotherapy): offer polyethylene glycol with or without electrolytes PO 1-1.5 g/kg/day for 3-6 days as first-line therapy in patients presenting with fecal impaction. E Show 8 more Pediatric patients (therapeutic interventions): do not offer biofeedback therapy as an additional treatment for childhood constipation. D Show 2 more Patients with IBS-C, polyethylene glycol: As per ACG 2021 guidelines, consider avoiding the use of polyethylene glycol products to improve global symptoms in patients with IBS-C. D As per BSG 2021 guidelines, consider offering polyethylene glycol for constipation in patients with IBS. Recognize that abdominal pain is a common side effect. C As per CAG 2019 guidelines, consider avoiding the use of osmotic laxatives (polyethylene glycol) to improve overall symptoms in patients with IBS-C. D As per AGA 2014 guidelines, consider offering polyethylene glycol laxatives in patients with IBS- C. C Patients with IBS-C, 5-HT4 agonists: As per ACG 2021 guidelines, consider offering tegaserod in < 65 years old female patients with IBS-C and 1 cardiovascular risk factor not adequately responding to secretagogues. C As per BSG 2021 guidelines, offer tegaserod, a 5-HT4 receptor agonist, as second-line therapy in patients with IBS-C in secondary care. Recognize that diarrhea is a common side effect. B As per CAG 2019 guidelines, consider avoiding the use of prucalopride to improve overall symptoms in patients with IBS-C. D Patients with IBS-C, guanylate cyclase activators: As per ACG 2021 guidelines, offer guanylate cyclase activators (linaclotide and plecanatide) to improve global symptoms in patients with IBS-C. A As per BSG 2021 guidelines, offer linaclotide or plecanatide, guanylate cyclase-C agonists, as second-line therapy in patients with IBS-C in secondary care. Recognize that diarrhea is a common side effect. A As per CAG 2019 guidelines, offer linaclotide to improve symptoms in patients with IBS-C. A As per AGA 2014 guidelines, offer linaclotide in patients with IBS-C. A Patients with IBS-C, lubiprostone: As per ACG 2021 guidelines, offer chloride channel activators (lubiprostone) to improve global symptoms in patients with IBS-C. B https://web.pathway.md/diseases/recgTNkhcVaq5tHQT 6/9 6/23/23, 3:35 AM Constipation Pathway As per BSG 2021 guidelines, offer lubiprostone, a chloride channel activator, as second-line therapy in patients with IBS-C in secondary care. Recognize that nausea is a common side effect. B As per CAG 2019 guidelines, consider offering lubiprostone to improve symptoms in patients with IBS-C. C As per AGA 2014 guidelines, consider offering lubiprostone in patients with IBS-C. C Patients with IBS-C (tenapanor): offer tenapanor, a sodium-hydrogen exchange inhibitor, is an efficacious second-line therapy in patients with IBS-C in secondary care. Recognize that diarrhea is a common side effect. A Patients with opioid-induced constipation: As per AGA 2019 guidelines, offer laxatives as first-line therapy in patients with opioid-induced constipation. B Show 2 more As per ESMO 2018 guidelines, prescribe a concomitant laxative in all patients receiving opioid analgesics unless contraindicated by preexisting diarrhea. B Show 3 more 8. Follow-up and surveillance Evaluation of refractory constipation: 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 References 1. Bas L A M Weusten, Maximilien Barret, Albert J Bredenoord et al. Endoscopic management of gastrointestinal motility disorders - part 2 European Society of Gastrointestinal Endoscopy ESGE Guideline. Endoscopy. 2020 Jul;52 7 600 614. Open 2. Bharucha AE, Dorn SD, Lembo A et al. American Gastroenterological Association medical position statement on constipation. Gastroenterology. 2013 Jan;144 1 211 7. Open 3. Alexander C Ford, Paul Moayyedi, Brian E Lacy et al. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol. 2014 Aug;109 Suppl 1 S2 26; quiz S27. Open 4. Lin Chang, William D Chey, Aamer Imdad et al. American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation. Am J Gastroenterol. 2023 May 19. Online ahead of print. Open 5. Brian E Lacy, Mark Pimentel, Darren M Brenner et al. ACG Clinical Guideline: Management of Irritable Bowel Syndrome. Am J Gastroenterol. 2021 Jan 1;116 1 17 44. Open https://web.pathway.md/diseases/recgTNkhcVaq5tHQT 7/9 6/23/23, 3:35 AM Constipation Pathway 6. Ian M Paquette, Madhulika Varma, Charles Ternent et al. The American Society of Colon and Rectal Surgeons' Clinical Practice Guideline for the Evaluation and Management of Constipation. Dis Colon Rectum. 2016 Jun;59 6 479 92. Open 7. Weinberg DS, Smalley W, Heidelbaugh JJ et al. American Gastroenterological Association Institute Guideline on the pharmacological management of irritable bowel syndrome. Gastroenterology. 2014 Nov;147 5 1146 8. Open 8. Tabbers MM, DiLorenzo C, Berger MY et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014 Feb;58 2 258 74. Open 9. Dipesh H Vasant, Peter A Paine, Christopher J Black et al. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut. 2021 Jul;70 7 1214 1240. Open 10. Moayyedi P, Andrews CN, MacQueen G et al. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome IBS . J Can Assoc Gastroenterol. 2019 Apr;2 1 6 29. Open 11. Seth D Crockett, Katarina B Greer, Joel J Heidelbaugh et al. American Gastroenterological Association Institute Guideline on the Medical Management of Opioid-Induced Constipation. Gastroenterology. 2019 Jan;156 1 218 226. Open 12. ASGE Standards of Practice Committee, Brooks D Cash, Ruben D Acosta et al. The role of endoscopy in the management of constipation. Gastrointest Endosc. 2014 Oct;80 4 563 565. Open 13. Larkin PJ, Cherny NI, La Carpia D et al. Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Ann Oncol. 2018 Oct 1;29 Suppl 4):iv111-iv125. Open 14. Maria Ines Pinto Sanchez, Premysl Bercik. Epidemiology and burden of chronic constipation. 2011 Oct;25 Suppl B Suppl B 11B 15B.2011 Oct;25 Suppl B Suppl B 11B 15B. Open 15. Sharma A, Rao S. Constipation: Pathophysiology and Current Therapeutic Approaches. Handb Exp Pharmacol. 2017;239 59 74. Open 16. Peter D R Higgins, John F Johanson. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004 Apr;99 4 750 9. Open 17. William J Elliott, C Venkata S Ram. Calcium channel blockers. J Clin Hypertens Greenwich). 2011 Sep;13 9 687 9. Open 18. Philip S Mehler, Mori J Krantz, Katherine V Sachs. Treatments of medical complications of anorexia nervosa and bulimia nervosa. J Eat Disord. 2015 Apr 5;3 15. Open 19. M J Arnaud. Mild dehydration: a risk factor of constipation?. Eur J Clin Nutr. 2003 Dec;57 Suppl 2 S88 95. Open 20. Maria Ines Pinto Sanchez, Premysl Bercik. Epidemiology and burden of chronic constipation. Can J Gastroenterol. 2011 Oct;25 Suppl B Suppl B 11B 15B. Open 21. Magan Trottier, Aida Erebara, Pina Bozzo. Treating constipation during pregnancy. Can Fam Physician. 2012 Aug;58 8 836 8. Open 22. Stefan M ller-Lissner. The pathophysiology, diagnosis, and treatment of constipation. Dtsch Arztebl Int. 2009 Jun;106 25 424 31; quiz 431 2. Open https://web.pathway.md/diseases/recgTNkhcVaq5tHQT 8/9 6/23/23, 3:35 AM Constipation Pathway 23. Mojgan Forootan, Nazila Bagheri, Mohammad Darvishi. Chronic constipation: A review of literature. Medicine Baltimore). 2018 May;97 20):e10631. Open 24. Huikuan Chu, Xiaohua Hou. Understanding of Constipation Symptoms and the Diagnosis and Management of Constipation in Chinese Physicians. PLoS One. 2016 Mar 31;11 3):e0152801. Open 25. James R Gray. What is chronic constipation? Definition and diagnosis. Can J Gastroenterol. 2011 Oct;25 Suppl B Suppl B 7B 10B. Open 26. Imran Aziz, William E Whitehead, Olafur S Palsson et al. An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation. Expert Rev Gastroenterol Hepatol. 2020 Jan;14 1 39 46. Open 27. Arnold Wald, Adil E Bharucha, Berkeley Limketkai et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. 2021 Oct 1;116 10 1987 2008. Open 28. Lin Chang, Shahnaz Sultan, Anthony Lembo et al. AGA Clinical Practice Guideline on the Pharmacological Management of Irritable Bowel Syndrome With Constipation. Gastroenterology. 2022 Jul;163 1 118 136. Open https://web.pathway.md/diseases/recgTNkhcVaq5tHQT 9/9