The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Evaluation and Management of Chronic Constipation

Abstract

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information based on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for use by all practitioners, health care workers, and patients who desire information on the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. 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. STATEMENT OF THE PROBLEM 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.1 Constipation has a worldwide prevalence of 15% and is more frequently diagnosed in North America and Europe compared with Asia, likely because of differences in diet, culture, and environment.2 Risk factors for constipation include age greater than 65 years, female sex, inactivity, low socioeconomic status, low-fiber diet, and non-White race.3 Constipation is characterized by dysfunctional colonic motility and/or outlet dysfunction. Primary constipation can be classified into 3 subtypes: constipation with normal transit, constipation with delayed transit time, and outlet dysfunction constipation. Constipation with normal transit time and irritable bowel syndrome with associated constipation (IBS-C) comprise a group of functional bowel disorders with several overlapping symptoms. The distinguishing symptom of IBS-C is the presence of abdominal pain more than once per week that resolves with flatulence or a bowel movement.4 Based on the Rome IV criteria, functional constipation (or normal transit constipation) is characterized by the presence of 2 or more of the following: fewer than 3 spontaneous defecations per week or for more than 25% of defecations: straining, lumpy, or hard stools; incomplete evacuation; sensation of anorectal blockage; or requiring manual maneuvers to assist with defecation. To meet these criteria, symptoms cannot be associated with diarrhea and must be present for 3 to 6 months before the diagnosis.5 The cause of secondary constipation is multifactorial and can include factors such as diet, medications, metabolic or neurological disorders, and psychosocial issues. 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. METHODOLOGY These guidelines were based on the previous ASCRS “Clinical Practice Guidelines for the Management of Constipation,” which was published in 2016.6 A comprehensive search was conducted in MEDLINE (Ovid), Cochrane Library (Wiley), and Scopus (Elsevier) for English-language studies including human subjects published between January 1, 2014, and February 1, 2024. The search strategy was developed in conjunction with a health sciences research librarian, and it used a combination of subject headings and keywords to identify primary literature on constipation, including chronic or idiopathic constipation, obstructed defecation, slow transit, surgery, rectocele, rectal intussusception, pelvic dyssynergia, anismus, paradoxical puborectalis, megacolon, and megarectum. Retrieved publications were limited to the English language and adult patients (see Appendix 1 at https://links.lww.com/DCR/C363 for the full search strategy). The initial search generated 4195 eligible studies, and after removing 1315 duplicates, 2880 studies were screened for initial inclusion. Abstracts were screened for relevance (details included in Fig. 1), leaving 332 studies that underwent full-text review by 5 coauthors, with all conflicts resolved by the first author. After a full-text review, 198 studies were excluded; 134 studies were included in the final article (Fig. 1). Abstract and full-text screening was performed using Covidence systematic review software.7FIGURE 1.: Preferred Reporting for Systematic Reviews and Meta-analyses literature search flow chart of studies on the management of constipation.CERTAINTY OF EVIDENCE The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. The certainty of evidence reflects the extent of our confidence in the estimates of effect. Evidence from randomized controlled trials (RCTs) start with high certainty, and evidence derived from observational studies start with low certainty. For each outcome, the evidence is graded as high, moderate, low, or very low (Table 1). The evidence can be rated down for risk of bias, inconsistency, indirectness, imprecision, and publication bias. The certainty of evidence originating from observational studies can be rated up when there is a large magnitude of effect or dose–response relationship. As per GRADE methodology, recommendations are labeled as “strong” or “conditional.” Current recommendations are stated in Table 2. When agreement regarding the evidence base or treatment guideline was incomplete, the consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. Recommendations formulated by the subcommittee were reviewed by the entire Clinical Practice Guidelines Committee. The submission was then approved by the ASCRS Executive Council and peer-reviewed in Diseases of the Colon & Rectum. In general, each ASCRS Clinical Practice Guideline is updated approximately every 5 years. No funding was received to prepare this guideline, and the authors have declared no competing interests related to this material. This guideline conforms to the Appraisal of Guidelines for Research and Evaluation checklist. TABLE 1. - Interpretation of strong and conditional recommendations using the GRADE approach Evaluation Description Recommendation Strong Most individuals should receive the intervention. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences. Conditional Different choices will be appropriate for individual patients consistent with their values and preferences. Use shared decision-making. Decision aids may be useful in helping patients make decisions consistent with their individual risks, values, and preferences. GRADE certainty rankings High The authors are confident that the true effect is similar to the estimated effect. Moderate The authors believe that the true effect is probably close to the estimated effect. Low The true effect might be markedly different from the estimated effect. Very low The true effect is probably markedly different from the estimated effect. GRADE = Grading of Recommendations, Assessments, Development, and Evaluation. TABLE 2. - Summary and strength of GRADE recommendations No. Summary Recommendation strength GRADE quality of evidence 1 A directed history and physical examination should be performed in patients presenting with constipation Strong Low 2 Objective measures assessing the nature, severity, and impact of constipation on quality of life can be useful when evaluating patients with constipation Conditional Low 3 The initial management of patients with symptomatic constipation involves dietary modifications and ensuring adequate fluid intake and fiber supplementation Strong Low 4 Osmotic laxatives are an appropriate firstline medical therapy to manage chronic constipation. Stimulant laxatives, such as bisacodyl, can be considered for rescue therapy or as second-line therapy, if needed Strong Moderate 5 Patients who fail to improve with dietary changes, fiber therapy, and osmotic laxatives should be evaluated for outlet dysfunction. Anorectal physiology testing or dynamic imaging by fluoroscopic defecography, MRI defecography, or dynamic ultrasound may help identify functional or structural causes related to an evacuation disorder Conditional Low 6 Colonic motility and transit should be measured before surgical intervention is considered Strong Low 7 Biofeedback therapy is considered a firstline treatment for patients with symptomatic pelvic floor dyssynergia Strong Moderate 8 Injecting botulinum toxin into the puborectalis and external sphincter muscle may be considered in patients with outlet dysfunction constipation related to nonrelaxing puborectalis muscle Conditional Low 9 Patients with significant outlet dysfunction from a rectocele may be considered for surgical repair after addressing any concomitant functional causes, such as nonrelaxing puborectalis muscle Conditional Moderate 10 STARR is not recommended for the repair of a rectocele or internal rectal intussusception because of the high complication rates associated with this procedure Strong Moderate 11 Repair of rectal intussusception may be considered in patients with severe obstructed defecation in whom nonoperative treatments were unsuccessful Conditional Low 12 Patients with isolated refractory colonic slow-transit constipation may benefit from total abdominal with Conditional Low may be considered in patients with constipation refractory to treatment Conditional Low GRADE = Grading of Recommendations, Assessments, Development, and STARR = rectal Evaluation and of Constipation 1. 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