Patients with refractory constipation (RC) should not be rushed to surgery, according to a clinical practice update from the American Gastroenterological Association (AGA) that stresses careful and accurate diagnosis, maximal medical therapy, and psychological screening before considering surgery.

Surgical therapy for RC should only be considered after confirming slow-transit constipation and excluding pelvic floor dysfunction, the authors advised.

“I think the biggest shift is that [the update] it formalizes a stepwise, pathophysiology-driven approach — and makes it harder — in a good way — to skip key steps when someone is labeled ‘refractory,’” first author Kyle Staller, MD, MPH, gastroenterologist and director of the Gastrointestinal Motility Laboratory, Massachusetts General Hospital, Boston, told Medscape Medical News.

The clinical practice update on evaluation and management of RC was published online on January 7 in Clinical Gastroenterology and Hepatology. 

Relatively Rare but Challenging Population

Chronic constipation affects an estimated 8%-12% of the US population, with roughly three million patients seeking clinical care each year. Most patients with chronic constipation improve with lifestyle changes, over-the-counter (OTC) laxatives, or prescription drugs. However, a smaller but challenging subset remains refractory to standard treatment. 

“To the best of my knowledge, this is the first AGA clinical practice update focused specifically on refractory constipation as its primary subject, rather than addressing constipation more broadly,” Staller told Medscape Medical News. 

Prior guidance has focused on constipation in general — for example, the pharmacologic management of chronic idiopathic constipation but they are not “RC-specific frameworks in the way this clinical practice update is intended to be,” he explained. 

“That distinction matters,” Staller said, “because RC is relatively rare, but it’s also the group that tends to cycle through tertiary clinics and — too often — gets discussed in ‘end of the road’ terms without a consistent physiologic roadmap.”

Staller said the new guidance provides a “tighter” definition of RC anchored to persistent, infrequent, and/or unsatisfactory bowel habits despite adequate trials of lifestyle, dietary, medical therapy and pelvic floor biofeedback when indicated, in patients meeting criteria for chronic constipation or constipation-predominant irritable bowel disease. 

“Translation: fewer patients get branded ‘refractory’ just because they’ve tried a bunch of laxatives,’” Staller told Medscape Medical News. 

Look Beyond the Colon

One of the central themes is the need to look beyond the colon itself. 

“Patients with RC should be thoroughly evaluated for secondary causes of constipation such as medications, disordered eating, or comorbid neurological diseases,” the authors advised. 

Common contributors include opioids, antipsychotics, iron supplements, anorexia nervosa, endometriosis, Parkinson’s disease, and multiple sclerosis, they noted. 

Earlier, more routine anorectal physiology plus biofeedback before the RC label, is also advised, Staller told Medscape Medical News. 

Because defecatory disorder is common and often missed, the update emphasizes that most patients with chronic constipation should undergo anorectal manometry (ARM) with balloon expulsion testing (BET) and complete a course of pelvic floor biofeedback therapy, when indicated, before being labeled as having RC, Staller explained. 

Barium or magnetic resonance (MR) defecography, providing real-time imaging of anorectal and pelvic floor structures during defecation, should be considered when clinical features suggest a structural abnormality or when ARM and BET are inconclusive, the authors advised. 

Maximize Medical Therapy

Before considering surgery, patients with RC should trial all standard OTC and FDA-approved therapies for constipation as standalone therapy or in combination when accessible, the authors advised. 

Off-label prescription agents, such as pyridostigmine, may be trialed for patients with RC who have failed available OTC and FDA-approved agents. Preliminary evidence suggests that combining pyridostigmine with bisacodyl may improve outcomes, they noted. 

Trials of adjunct, nonpharmacologic approaches including transanal irrigation for RC with neurogenic bowel dysfunction, a vibrating capsule, or electroacupuncture are “reasonable,” the authors advised. 

When to Consider Surgery

Surgical treatments, such as colectomy, may be considered in patients with RC who fail available treatments. However, surgical treatment of chronic constipation is associated with increased risk for complications and a “not insignificant” number of unsatisfactory outcomes, the authors noted. 

Only patients with confirmed slow-transit constipation and no ongoing defecatory disorder should be offered colectomy with ileorectal anastomosis, they advised. 

“There is strong consensus on avoiding colectomy with ileorectal anastomosis in patients with

defecatory disorder given this interplay between slow transit constipation and defecatory disorder,” they wrote.

Staller told Medscape Medical News the guidance “pushes clinicians to document slow transit (and to be thoughtful about testing off therapy and, ideally, on maximal therapy to demonstrate ‘refractory-ness’), rather than relying on symptoms alone to justify escalation.”

Formal psychological evaluation before surgery is also recommended. “Psychological comorbidities often exacerbate symptom severity and burden, reduce quality of life, and increase demand for surgical interventions. However, these psychological factors also adversely affect surgical outcome,” the authors wrote.

Relative contraindications to surgical treatment of RC include severe, untreated psychiatric disease including active eating disorders and unresolved issues related to sexual trauma; primary complaints of bloating and/or abdominal pain; and reversible, secondary causes of constipation, they said. 

When there are concerns about efficacy or relative contraindications to surgery, a diverting loop ileostomy offers a diagnostic trial of surgical treatment, they noted. 

Reset Expectations

The guidance also encourages clinicians to counsel patients about what constitutes normal bowel function. 

“Misconceptions about what chronic and refractory constipation actually is are common on both sides of the exam room — patients and clinicians,” Staller told Medscape Medical News.

“Patients often think — If I don’t go every day, I’m constipated — but many patients don’t realize that “normal” bowel frequency is broad,” Staller explained. 

In the US, the vast majority of people have between three bowel movements a day to three a week, “which can drive anxiety, over-treatment, and disappointment with realistic goals,” he noted. 

Another misconception is that long-term use of laxatives is dangerous. “Misconceptions about chronic stimulant laxative harm persist, despite the evidence base not supporting that fear in the way many people assume,” Staller said. 

Among clinicians and systems of care, another problem is equating refractory symptoms with RC, Staller said.

He told Medscape Medical News a lot of referrals come in as “medically refractory constipation,” when the dominant driver is actually defecatory dysfunction, visceral hypersensitivity, medication effects, or unrealistic targets — all of which require different strategies than simply escalating laxatives.

This research had no commercial funding. Staller has served as a consultant for Anji, Ardelyx, GI Health Foundation, GI Supply, Gemelli, Laborie, Mahana, Restalsis, Salix, Takeda, and Sanofi; and received research support from Ardelyx and Restalsis.