A NEW clinical guideline from The American Society of Colon and Rectal Surgeons (ASCRS) has updated recommendations for the management of chronic constipation, highlighting the need for a personalised and multidisciplinary approach.
Chronic constipation is a prevalent gastrointestinal disorder that frequently leads to referrals to colorectal surgeons, with a worldwide prevalence of 15%.
The updated guideline includes 13 recommendations based on 134 studies published between January 2014–February 2024, analysed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.
Key points from the recommendations included:
- Perform a directed history and physical examination for patients with constipation.
- Use objective measures to assess constipation severity and impact on quality of life.
- Start with dietary modifications, adequate fluid intake, and fibre supplementation.
- Use osmotic laxatives as the first-line medical therapy; stimulant laxatives can be second-line or rescue options.
- Evaluate for outlet dysfunction if symptoms persist; consider anorectal physiology tests or imaging.
- Measure colonic motility and transit before surgical interventions.
- Biofeedback therapy is first-line for symptomatic pelvic floor dyssynergia.
- Consider botulinum toxin injections for nonrelaxing puborectalis muscle in outlet dysfunction.
- Surgical rectocele repair may be an option after addressing functional causes.
- Avoid stapled transanal rectal resection for rectocele or internal intussusception due to high complication rates.
- Consider rectal intussusception repair for severe obstructed defecation resistant to non-surgical treatments.
- Total abdominal colectomy with ileorectal anastomosis may benefit patients with isolated refractory colonic slow-transit constipation.
- Faecal diversion can be considered for intractable constipation unresponsive to other treatments.
The guideline stresses that, while these recommendations are based on extensive research, treatment decisions should be tailored to the individual patient. “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,” wrote lead author Karim Alavi, Division of Colon and Rectal Surgery, UMass Memorial Medical Center, Massachusetts, USA.
Ada Enesco, EMJ
Reference
Alavi K et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the evaluation and management of chronic constipation. Dis Colon Rectum. 2024;67(10):1244-57.
