Constipation is one of the common diseases of the digestive system, and its incidence increases with age. Recently, the American Gastroenterological Association (AGA) published guidelines for the management and treatment of chronic constipation in adults in JAMA, the core contents of which are summarized below.
Definition of chronic constipation and common problems in clinical practice
1.The AGA defines chronic constipation as the presence of 2 or more of the following symptoms for at least 3 to 6 months: decreased frequency of defecation, straining to defecate, deformation of stool, dry stool, incomplete defecation or rectal obstruction, requiring manual assistance to defecate, and rare loose stools without laxatives.
2, chronic constipation can be divided into 3 categories: defecation disorder type, slow transmission type and normal transmission type constipation.
Most patients with chronic constipation can be treated without a thorough examination, and systemic diseases or medications that may aggravate constipation need to be looked for before treating constipation. Diet, fluids, over-the-counter medications, fiber supplements, osmotic laxatives, and stimulant laxatives can be effective in treating constipation, with patient compliance being a key issue.
4. For refractory cases, professional technical means of examination and professional guidance are needed. Biofeedback therapy is recommended for all defecation dysfunctions, while surgery of the colorectum is the last option.
Specific recommendations
1.Recommended systemic treatment for constipation
(1) Patients clinically evaluated for constipation should be suspended from medications that may cause constipation until further examination (strong recommendation, low quality evidence);
(2) Rectal palpation (including assessment of pelvic floor function during stimulated defecation) is required prior to rectal manometry (strongly recommended, moderate quality evidence);
2. Assessment of possible causes of chronic constipation
(1) In the absence of other laboratory tests, only a complete blood count test is required (strongly recommended, low quality evidence); metabolic tests (e.g., glucose, calcium, thyroid stimulating hormone, etc.) are not recommended for patients with simple chronic constipation (strongly recommended, moderate quality evidence);
(2) Colonoscopy is not recommended in age-appropriate colon cancer screening patients without alarm symptoms (strong recommendation, moderate quality evidence);
(3) Rectal anorectal manometry and rectal balloon dilation should be performed in patients who do not respond to laxatives (strongly recommended, moderate quality evidence);
(4) When the cause of defecation disorder cannot be determined by rectal manometry and rectal balloon dilatation, fecal imaging should be considered (strongly recommended, low quality evidence);
3.Initial treatment
(1) After identifying the medications that may cause constipation, clinical guideline testing and experimental treatment (e.g., fiber supplementation, osmotic or stimulant laxatives) are recommended prior to rectal anorectal examination (strongly recommended, moderate quality evidence);
(2) Safe management of long-term laxatives in patients with normal-transit constipation and slow-transit constipation (strong recommendation, moderate quality evidence);
(3) pelvic floor muscle function training via biofeedback is recommended over oral laxative therapy for patients with bowel dysfunction (strong recommendation, high quality evidence).
The guideline may be used as a clinical guideline for the treatment of chronic constipation by general practitioners or other clinicians, but it does not make specific recommendations for the treatment of patients admitted to nursing homes and with opioid-induced constipation. Whether the guideline is applicable to subgroups based on symptom classification, age, gender, and race requires further study.