AGA Constipation Guidelines

Constipation is a ubiquitous problem.  Updated guidelines and a technical review for adults with constipation have been published (Gastroenterol 2013; 144: 211-17, Gastroenterol 2013; 144: 218-38). AGA Institute Policy and Position Statements – Gastroenterology 

For pediatric gastroenterologists, the 2006 NASPGHAN guidelines (Evaluation and Treatment of Constipation – North American Soci) are more useful.  Nevertheless, these AGA guidelines offer some helpful insights.

Definition: “physicians often regard constipation to be synonymous with infrequent bowel movements, typically fewer than 3 per week, patients have a broader set of symptoms” that are considered constipation including hard stools, abdominal discomfort, incomplete evacuation, and excessive straining.  Rome  III criteria: “symptoms for ≥ 6 months and ≥ 2 of the following symptoms for more than one-fourth of defecations during the past 3 months: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction, manual maneuvers to facilitate defecations; ❤ defecations/wk, loose stools are not present and there are insufficient criteria for IBS”

In adults, medical testing:

  • “In the absence of other symptoms and signs, only a complete blood count is necessary.”  Not needed unless other features: TSH, calcium, colonoscopy
  • Anorectal manometry and rectal balloon expulsion should be performed in patients who fail to respond to laxatives.  Defocography should be considered subsequently.  Colonic transit should be evaluated if anorectal test results do not show a defecatory disorder.

Recommended Treatment:

  • Start with increased fiber and laxatives (e.g. PEG, milk of magnesia, bisacodyl).  Newer pharmaceutical agents (e.g. lubiprostone and linaclotide) can be considered if no improvement.
  • Both “normal transit constipation and slow transit constipation can be safely managed with long-term use of laxatives.” (strong recommendation, moderate-quality evidence).  “Contrary to earlier studies, stimulant laxatives (senna, bisacodyl) do not appear to damage the enteric nervous system.  Neurologic damage might just as readily be the cause, not the result.”
  • Pelvic floor retraining by biofeedback rather than laxatives is recommended for defecatory disorders
  • Additional workup in those who do not respond.  Surgical treatment of slow transit constipation (subtotal colectomy or colectomy with ileorectal anastomosis) only when well-documented failure of aggressive prolonged laxatives/prokinetics

The technical review has a table that lists medications associated with constipation, describes pathophysiology in detail, lists the conditions associated with constipation, and explains the testing/medical management in-depth.

Related blog entries:

PEG vsFiber for constipation | gutsandgrowth
Stimulants for constipation | gutsandgrowth
It’s worth the cost | gutsandgrowth
ACE report -10 year effectiveness | gutsandgrowth
Linaclotide –not for kids | gutsandgrowth
Clues about constipation and more than 2.5 million  – gutsandgrowth

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