List of Abbreviations
BF – Biofeedback
GI – gastrointestinal tract
SCFA – short-chain fatty acids
PEG – polyethylene glycol
IBS – irritable bowel syndrome
FDR – functional defecation disorders
EMG - electromyography
Terms and Definitions
Primary (functional) constipation is a functional disorder characterized by the absence of organic (structural) changes.
Secondary constipation is a symptom that manifests as a consequence of another underlying disease.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
The primary indicator of constipation is a change in stool consistency according to the Bristol Stool Form Scale, where types 1 and 2 correspond to constipation ("separate hard lumps, like nuts" and "sausage-shaped, but lumpy") [1].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The cause of constipation cannot always be identified, even during prolonged follow-up of the patient [2]. However, taking into account the assessment of colonic transit time and pelvic floor muscle function, groups of patients suffering from chronic constipation with predominantly the following mechanisms can be distinguished:
· slow-transit constipation;
· defecatory disorders (dyssynergic defecation);
· normal-transit constipation (constipation-predominant irritable bowel syndrome) [3].
Causes of secondary constipation are presented in Table 1.
Table 1. Causes of secondary constipation
Mechanical obstruction to fecal passage | Colorectal cancer, inflammatory bowel diseases, anal fissures, external compression of the intestine, etc. |
Neurological disorders | Autonomic neuropathy, Parkinson's disease, spinal cord tumor, acute cerebrovascular accident, multiple sclerosis, etc. |
Endocrine disorders | Diabetes mellitus, hypothyroidism, electrolyte disorders in adrenal diseases, etc. |
Mental disorders | Emotional disorders, somatoform autonomic dysfunction, anorexia nervosa, etc. |
Systemic connective tissue diseases | Dermatomyositis, systemic sclerosis, etc. |
Dietary factors | Low intake of non-digestible dietary fiber, consumption of thermally processed foods, irregular eating patterns (meals 1–2 times a day). |
Medication use | Antidepressants, Ca++ channel blockers, anticholinergic agents, iron compounds, polypharmacy, and others. |
1.3 Epidemiology of the Disease or Condition
Symptoms of constipation, such as a reduced frequency of bowel movements per unit time, change in stool consistency to hard or lumpy, excessive straining, sensation of incomplete evacuation, and abdominal bloating, occur in 12–19% of the adult population in countries such as the United States, Great Britain, Germany, France, Italy, Brazil, and South Korea. Data also indicate that constipation is more frequent in individuals over 60 years of age (36% of cases) [4]. The quality of life of patients suffering from chronic constipation is comparable to that of patients with diabetes mellitus, arterial hypertension, and depression [5].
1.4 Features of Coding the Disease or Condition
K59.0 – Constipation
1.5 Classification of the disease or condition
· Primary (functional) constipation.
· Secondary constipation (constipation as a symptom, see Table 1).
Primary constipation is significantly more common than secondary constipation [6].
1.6 Clinical presentation of the disease or condition
Constipation is characterized by decreased stool frequency (3 times a week or less). Patients experience a sensation of incomplete bowel evacuation and excessive straining during defecation, and sometimes use manual maneuvers to achieve bowel evacuation. Stool weight becomes less than 35 g per day.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Diagnostic criteria include:
- change in stool consistency according to the Bristol Stool Form Scale (types 1 and 2);
- decreased stool frequency to less than 3 times a week;
- reduced stool weight to less than 35 g per day;
- documented slow colonic transit.
2.1 Complaints and Anamnesis
Taking a medical history and assessing complaints play a crucial role in diagnosing constipation. The interview establishes the number of bowel movements per week, clarifies stool consistency (formed stool or hard lumps), determines the quality of defecation (feeling of obstruction or difficulty during evacuation, need for excessive straining, sensation of incomplete bowel evacuation, use of manual maneuvers to facilitate defecation, as well as the need for laxatives and cleansing enemas), identifies other complaints (abdominal bloating, abdominal pain, weight loss), specifies the total duration of symptoms and their onset pattern (rapid or gradual), past and concomitant diseases, surgical interventions (including urological and gynecological), and medication use. Particular attention is paid to "red flag" symptoms (blood in the stool, weight loss of more than 10% over the last 3 months, etc.) and a family history of colorectal cancer [1].
2.2 Physical Examination
In patients with constipation, abdominal palpation and digital rectal examination are recommended to rule out intra-abdominal tumors and to identify perianal excoriations, hemorrhoids, scars, anal fissures, rectocele, and changes in anal sphincter tone [1].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
2.3 Laboratory Diagnostics
In patients with constipation, a complete blood count is recommended to rule out anemia as a consequence of occult blood loss [1].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: One of the causes of constipation is colorectal cancer, which creates a mechanical obstruction to the passage of feces. An important symptom of this disease is anemia caused by occult blood loss [1].
2.4 Instrumental Diagnostics
In patients with chronic constipation older than 50 years, as well as those with "red flag" symptoms and a family history of colorectal cancer, colonoscopy is recommended to rule out organic bowel diseases [1].
GCR CLOE 5Grade of Recommendations – C (Level of Evidence – 5).
Comments: Screening colonoscopy is advisable for all patients with chronic constipation older than 50 years. Colonoscopy is mandatory in the presence of "red flag" symptoms, as well as a family history of colorectal cancer [1].
In patients with chronic constipation, colonic transit study using radiopaque markers is recommended to clarify the mechanisms of its onset [7].
GCR CLOE 5Grade of Recommendations – C (Level of Evidence – 5).
Comments: The marker-based colonic transit study is an inexpensive, accessible, and simple method that allows for the objective assessment of patients' complaints regarding motor-evacuatory gut dysfunction, documenting the degree and localization of transit delay, and determining its specific type. This method expands the diagnostic toolkit for chronic constipation and can be considered an effective functional diagnostic method, allowing for a personalized approach to treatment selection, and in surgical management, to the choice of surgical intervention.
In patients with chronic constipation and suspected pelvic floor dyssynergia, a balloon expulsion test is recommended to confirm these disorders [8, 9, 10].
ROB BLOE 1Recommendation grade – B (evidence level – 1).
Comments: The rectal balloon expulsion test is used to assess muscle coordination during defecation. The test determines the patient's ability to expel an air-filled balloon from the rectum, providing a simple and physiological assessment of defecation dynamics. Patients without pelvic floor muscle coordination disorders typically expel the balloon within 1 minute. If the patient is unable to expel the balloon within 3 minutes, pelvic floor muscle dyssynergia may be suspected. The efficacy of this approach has been demonstrated in a systematic review with meta-analysis of 15 cohort studies involving 2,140 subjects.
In patients with constipation and suspected rectocele, external and internal rectal prolapse, perineal descent, and sigmocele, proctography is recommended to confirm the diagnosis [11].
GCR CLOE 5Grade of Recommendations – C (Level of Evidence – 5).
Comments: The advantage of this method lies in the continuous assessment of the dynamic interaction between the rectum and its contents during evacuation efforts. This method is also used in diagnosing rectal intussusception, rectocele with obstructed defecation, pelvic floor muscle dyssynergia, and assessing the degree of rectal emptying.
In patients with suspected pelvic floor muscle dyssynergia, anal sphincter and pelvic floor electromyography is recommended to diagnose structural and functional disorders [1].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Electromyography is a method that evaluates the viability and functional activity of muscle fibers and determines the state of the peripheral nerve pathways innervating the muscles of the rectal sphincter apparatus. To assess the voluntary and reflex activity of the external sphincter and the levator ani muscles, an anal bipolar electrode is used to evaluate the overall bioelectric activity of the sphincter and pelvic floor muscles; a segmental anal electrode is used to assess the bioelectric activity of the sphincter by segments; and a needle electrode makes it possible to evaluate both the state of the pelvic floor muscles and the viability of transferred muscle flaps.
In patients with suspected functional defecation disorders, manifesting inter alia with pelvic floor muscle dyssynergia, anorectal manometry (including high-resolution manometry and/or anal sphincter electromyography with an additional balloon expulsion test (expulsion trial)) is recommended to confirm the diagnosis [1].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: Anorectal manometry is the most specific test for diagnosing functional defecation disorders. This study measures intrarectal pressure during an attempted defecation along with synchronous changes in intra-anal pressure or EMG activity during straining. In high-resolution manometry, Klose's three-dimensional color graphics are used to assess the functional state of the pelvic floor muscles. The recorded ratio of pressure in the anal canal to that in the rectum during straining is referred to as the manometric pattern.
There are four types of manometric patterns of functional defecation disorders: types I and III are described as dyssynergic defecation. Type I is characterized by an increase in intrarectal pressure of more than 45 mm Hg during straining and a simultaneous increase in anal canal pressure compared to resting pressure. Type III is characterized by an increase in intrarectal pressure of more than 45 mm Hg with a decrease in anal canal pressure of less than 20% from resting pressure (normally, the pressure drop during straining is 20% or more).
Inadequate propulsion (an increase in intrarectal pressure of less than 45 mm Hg) may be accompanied by both paradoxical contraction of the sphincter apparatus during straining (type II manometric pattern) and insufficient relaxation of the anal sphincters—less than 20% of resting pressure (type IV).
The balloon expulsion test can be performed using either water or air filling for 1-2 minutes with a volume of 50 ml and is used as a primary screening method without revealing the mechanisms of functional disorders. Because the balloon cannot completely mimic intestinal contents, a positive result on the expulsion trial does not always indicate the absence of functional defecation disorders.
Interference EMG can be used as a qualitative diagnostic method for the presence or absence of functional defecation disorders, without differentiating the types of functional disturbances. An increase in bioelectric activity, as well as the absence of its adequate decrease during straining, may indicate the presence of potential pelvic floor muscle dyssynergia.
2.5 Other Procedures
No
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Treatment of chronic constipation should be comprehensive and include lifestyle modifications (increased physical activity), dietary changes, and pharmacotherapy.
3.1. Diet therapy
It is recommended that patients with constipation include plant fibers in their diet [12, 13].
GOR ALOE 1Grade of Recommendation – A (Level of Evidence – 1).
Comments: Plant fibers (dietary fiber) refer to carbohydrates that are not digested by human gastrointestinal enzymes, characterized by a degree of polymerization of 3 or more monomeric units, as well as lignin [12].
A meta-analysis of 16 randomized clinical trials showed that dietary fiber supplementation is an effective treatment for functional constipation (RR: 1.48; 95% CI: 1.17–1.88; p=0.001). The meta-analysis evaluated the following types of dietary fiber: polydextrose (8–12 grams per day, 2–4 weeks), psyllium (10–40 grams per day, 2–8 weeks), inulin (12–15 grams per day, 2–4 weeks), galactooligosaccharides (5.5–11 grams per day, 21–30 days), pectin (24 grams per day, 4 weeks), wheat bran (12.5 grams per day, 4 weeks), and combination formulas including inulin with guar gum and inulin with maltodextrin (without specifying the amounts of active components). Dietary fiber supplementation led to an increased stool frequency (p=0.0001) and improved stool consistency (<0.0001). A significant drawback of this dietary therapy was the development of flatulence (p <0.00001).
The most effective dietary fibers for increasing stool frequency are psyllium (p=0.003), and for normalizing stool consistency, psyllium (p=0.0002) and inulin (p=0.03) [12].
According to a meta-analysis including 31 studies on the efficacy of various laxatives in elderly individuals, daily bowel movements were achieved in almost all patients when psyllium was prescribed; furthermore, psyllium was not inferior in efficacy to macrogol**, but significantly outperformed lactulose** [13].
It is recommended that patients with constipation include prebiotics (in the form of dietary supplements) in their diet to normalize stool output [14, 15, 16].
GCR CLOE 5Grade of Recommendations – C (Level of Evidence – 5).
Comments: Prebiotics are substances that are indigestible by human digestive enzymes but fermentable by the intestinal microbiota, leading to specific changes in the composition and/or activity of the gastrointestinal microbiota, thereby conferring a health benefit to the human host. The properties of prebiotics are similar to those of dietary fiber, although the latter are traditionally classified into a separate subgroup [14].
Prebiotics are generally assumed to have no serious side effects. However, osmotic diarrhea and flatulence may develop due to the realization of their osmotic properties in the colon [15].
Fructooligosaccharides are the most extensively studied prebiotics in the treatment of constipation [16].
It is recommended that patients with constipation include probiotic-enriched functional foods in their treatment regimens and diets to increase defecation frequency, normalize stool consistency, and improve tolerance to a high-fiber diet [17-20].
GCP BLoE 2Grade of Recommendation – B (Level of Evidence – 2).
Comments: A functional food product (FFP) is a food product intended for regular consumption as part of the diet by all age groups of the healthy population, which reduces the risk of diet-related diseases, preserves and improves health through the presence of physiologically functional food ingredients in its composition.
Physiologically functional food ingredients (PFFIs) are biologically active and/or physiologically valuable, health-safe ingredients with precise physicochemical characteristics for which properties have been identified and scientifically substantiated, and daily intake norms within food products have been established to help preserve and improve health: dietary fiber, vitamins, minerals, polyunsaturated fatty acids, probiotics, prebiotics, or synbiotics.
The status of functional foods is regulated by state standards GOST R 55577-2013 and GOST R 54059-2010, which define functional-target products and regulate the confirmation of their efficacy using approved evidence-based medicine methods [17, 18].
Functional foods that have proven their efficacy include fermented dairy products enriched with the probiotic strain Bifidobacterium animalis ssp. lactis CNCM-I2494 (Bioregularis, CNCM-2494, DN 173010). A controlled study involving 135 patients with constipation demonstrated that daily intake of 100 ml of such a product (1.25 × 1010 CFU of the probiotic strain per day) for 14 days significantly increased the number of bowel movements per week (4.1 ± 1.7 vs. 2.6 ± 1.0; p<0.01) and improved stool consistency (0.6 ± 0.8 vs. 1.3 ± 1.0; p<0.01) compared to a control group receiving a fermented dairy product without the probiotic strain [19].
The statistically significant efficacy of this functional food in reducing flatulence severity in healthy individuals when incorporated into a high-fiber diet has also been specifically noted (p<0.05) [20].
3.2. Conservative treatment
In patients with constipation in whom dietary measures and psyllium administration prove ineffective, the prescription of macrogol**, which helps soften intestinal contents and increase its volume, is recommended as a first-line treatment to normalize stool output [21-29].
GOR ALOE 1Grade of Recommendation – A (Level of Evidence – 1).
Comments: In 2011, a meta-analysis of the efficacy of macrogol** and lactulose** was conducted, including 10 randomized placebo-controlled trials from 1997 to 2007, involving 868 patients suffering from chronic constipation, aged 3 months to 70 years. According to the studies, macrogol** demonstrated higher efficacy in terms of increasing the number of bowel movements per week, improving stool consistency, relieving abdominal pain, and the effectiveness of monotherapy [21]. Furthermore, the use of macrogol** was less frequently accompanied by nausea and abdominal bloating [22, 23, 24]. International clinical trials have demonstrated the feasibility of long-term (up to 17 months) use of macrogol** [25, 26, 27, 28]. Scheduled courses of macrogol** showed a carry-over effect—ensuring normal bowel function after drug withdrawal [29].
In patients with constipation in whom dietary measures and psyllium administration prove ineffective, the use of lactulose**, which helps soften intestinal contents and increase its volume, is recommended as first-line therapy to normalize stool consistency [17, 29].
Level of Evidence CGrade of Recommendation 4Level of Evidence – C (Grade of Recommendation – 4).
Comments: High efficacy and good tolerability of the osmotic laxative lactulose**, which also possesses prebiotic effects, have been demonstrated in the treatment of patients with functional constipation and the constipation-predominant irritable bowel syndrome. Lactulose** is considered the drug of choice in the treatment of constipation during pregnancy and the postpartum period, as well as in elderly individuals requiring long-term laxative therapy.
In patients with constipation in whom dietary measures and psyllium administration prove ineffective, the use of lactitol, which helps soften intestinal contents and increase its volume, is recommended as first-line therapy to normalize stool consistency [17, 23].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Lactitol is a semi-synthetic disaccharide characterized by the fact that its osmotic properties reside not in the active substance itself, but in its metabolic products—short-chain fatty acids (SCFAs) (lactic, acetic, butyric, and propionic acids), which lead to a decrease in intra-intestinal pH, thereby promoting the activation of colonic propulsive motility, an increase in intestinal content volume, and its liquefaction. The favorable safety profile of osmotic laxatives allows their use in pregnant and lactating women.
In patients with constipation, the short-term (2 weeks) administration of stimulant laxatives (ATC A06AB) is recommended to normalize stool consistency [30, 31].
GCR CLOE 5Grade of Recommendations – C (Level of Evidence – 5).
Comments: Stimulant laxatives (bisacodyl**, sodium picosulfate, anthraquinones [sennosides A and B**]), which enhance motility by stimulating nerve endings in the intestinal mucosa, have confirmed their higher efficacy in treating chronic constipation compared to placebo [30].
However, the use of stimulant laxatives is often associated with various adverse effects. They frequently cause diarrhea with crampy abdominal pain and flatulence rather than normal stools, lead to electrolyte disturbances (hypokalemia), cause degenerative changes in the cells of Meissner's and Auerbach's plexuses, induce tolerance, and contribute to the development of "lazy bowel syndrome" [31]. For this reason, long-term use of stimulant laxatives (more than two weeks) is not recommended.
In patients with constipation in whom laxative therapy proves insufficiently effective, the administration of prokinetics from the 5-HT4 receptor agonist group (A06AX - Other drugs for constipation) is recommended [32-34].
ROB BLOE 1Recommendation grade – B (evidence level – 1).
Comments: The only drug of this class currently available in Russia, prucalopride, has proven its efficacy in 3 major randomized controlled trials, with a good response rate of 73% [32].
Prucalopride has a positive effect on all symptoms of constipation, including concomitant ones (bloating, abdominal pain), improves quality of life, and provides a sustained effect with long-term use [33]. The efficacy of prucalopride was also confirmed in a meta-analysis of 16 RCTs involving 3,943 adult patients with functional (chronic) constipation [34].
The drug is distinguished by ease of administration and dosing (1 mg once daily in individuals over 65 years or 2 mg once daily in those under 65 years) and predictability of effect. Adverse effects of the drug, usually mild (headache, abdominal pain), are most commonly noted on the 1st day of treatment, resolve spontaneously in most cases, and do not require drug discontinuation. The tolerability of prucalopride, with the exception of the first day of administration, is identical to placebo [34]. Prucalopride has been approved since 2009 in European countries for the treatment of chronic constipation when laxatives fail to provide adequate relief of symptoms.
In patients with functional constipation, the administration of strain-specific probiotics (antidiarrheal microorganisms, lactobacilli, dietary supplements, functional foods) with proven efficacy is recommended to increase stool frequency and improve stool consistency [15, 19, 35, 36].
GOR ALOE 1Grade of Recommendation – A (Level of Evidence – 1).
Comments: Probiotics are live microorganisms that confer a health benefit on the host when administered in adequate amounts.
A recent meta-analysis of 15 randomized controlled trials showed that probiotic intake reduces colonic transit time (p=0.001), increases stool frequency (p=0.001), and improves stool consistency (p=0.02). The superiority of multi-strain probiotics (RR=1.37; 95% CI: 0.72-2.01; p<0.0001) over single-strain probiotics (RR=1.18; 95% CI: −0.59 to 2.96; p=0.19) regarding the improvement of stool consistency was noted [35].
Along with high efficacy in the treatment of functional constipation, probiotics are characterized by high safety and a low incidence of adverse effects [36]. The efficacy of probiotics in functional constipation depends on the bacterial strains included in their composition [15].
The probiotic strain Bifidobacterium animalis ssp. lactis CNCM-I2494 (Bioregularis, CNCM-2494, DN 173010) has proven efficacy in patients with constipation [19].
3.3. Surgical treatment
In patients with clinically manifest constipation caused by slow transit, confirmed by gastrointestinal transit time study, without evacuation disorders or upper gastrointestinal motility disorders, in whom improvement cannot be achieved with prolonged and persistent treatment using osmotic and stimulant laxatives or prokinetics, and in whom constipation significantly impairs quality of life and limits daily activities, the consideration of surgical treatment is recommended to determine further management tactics [37-41].
Level of Evidence CGrade of Recommendation 4Level of Evidence – C (Grade of Recommendation – 4).
Comments:
In the second half of the 20th and early 21st centuries, surgical intervention has been considered in most countries as a justified therapeutic option for intractable slow-transit constipation that is refractory to persistent conservative therapy [37, 38, 39]. However, this does not mean that all patients with marked colonic slow transit, confirmed by objective tests and in the absence of evacuation disorders and upper GI motility disorders, are candidates for surgery. Even in major tertiary centers, the number of patients in whom surgery is genuinely deemed justified does not exceed 5% of those seeking such treatment and meeting the aforementioned criteria. It should be kept in mind that chronic constipation is a benign functional disorder that significantly impacts the quality of life, but does not generally threaten life or overall health. Under these circumstances, employing a potentially hazardous treatment method fraught with numerous adverse consequences, such as surgery, requires serious justification. Surgical intervention is primarily aimed at accelerating the transit time of colonic contents by shortening its length. Accordingly, the main positive outcome of the surgery is an increased stool frequency. Based on this, J. Pfeifer et al. (1996), in a meta-analysis of more than 30 publications, established an efficacy of colectomy of 89% [37]. According to a review by C.H. Knowles et al., published in 2009, a favorable outcome of colectomy with ileorectal anastomosis in intractable chronic constipation is observed in 40–100% of cases [38]. The American Gastroenterological Association in 2013, using the term "surgical satisfaction," reported a good effect of this surgery in 90–100% of patients [39]. Finally, in the currently only systematic review of surgical outcomes for chronic constipation in adults, the meta-analysis showed an overall effectiveness rate of colonic resection of 85.6% [40]. However, all reviews and guidelines emphasize that the effectiveness of colectomy regarding concomitant symptoms (abdominal pain, bloating) does not exceed 50%. Yet it is precisely these symptoms that have the greatest impact on patients' quality of life.
At the same time, the adverse consequences of the surgical intervention itself, both immediate and long-term, can affect the patient's quality of life to an extent equal to or even greater than constipation itself.
To evaluate the frequency of complications and outcomes of colectomy performed for constipation, A. Dudekula et al. (2015) utilized data from the US Nationwide Inpatient Sample from 1998 to 2011 and more detailed databases from the states of California and Florida (State Inpatient Database of California and Florida) for 2005–2011.
The perioperative 30-day mortality rate was 0%. However, the cumulative rate of immediate postoperative complications exceeded 40%. Furthermore, 16% of patients required continued care at home or in rehabilitation facilities after discharge.
The outcomes of colectomy were evaluated separately in 166 out of 181 patients operated on in California and Florida from 2005 to 2011. The median follow-up duration was 630 days before surgery and 463 days after.
Among the 166 patients, there was a total of 1,494 emergency department visits and 861 hospitalizations. Of the outpatient visits, 55% occurred before colectomy and 45% after, while among all hospitalizations, 43% occurred before surgery and 57% after. The most frequent reason for post-operative hospitalization (over 40%) was gastrointestinal complaints and postoperative complications. Only 16% of patients did not seek medical care following surgery. The reoperation rate during the follow-up period exceeded 10%, performed primarily for bowel obstruction and incisional hernias. Within the first 30 days post-surgery, 28.9% of patients were hospitalized at least once, and 15.6% received outpatient treatment. The authors concluded that a careful and critical assessment of surgical approaches for chronic constipation is necessary. Although surgery can indeed increase stool frequency, acute and chronic postoperative complications are very common. In addition, the need for reoperations frequently arises [41].
Patients with intractable constipation are recommended to be referred to specialized proctology clinics to address the feasibility of surgical treatment, where there is the capability and expertise to perform the full range of necessary functional tests, including gastrointestinal transit time studies, as well as radiological and physiological methods for assessing defecation disorders [39, 40].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: According to the American Gastroenterological Association guidelines on the diagnosis and management of constipation, the outcomes of surgical treatment in patients with constipation were better in studies where instrumental tests confirmed delayed transit and ruled out evacuation disorders, compared to studies where the diagnosis was established solely on the basis of history and physical examination [39]. A systematic review by C.H. Knowles et al. (2017) also indicates that surgical outcomes can be improved by selecting patients with proven slow colonic transit [40].
In patients with slow-transit constipation, colectomy with ileorectal, cecorectal, or ascendorectal anastomosis is recommended as part of surgical treatment to normalize bowel movements [39, 40, 42–46].
Level of Evidence CGrade of Recommendation 4Level of Evidence – C (Grade of Recommendation – 4).
Comments: Currently, the most common surgical approach for slow-transit constipation is colectomy with ileorectal anastomosis at the upper ampullary rectum. Alternatives include less radical resections with cecorectal (isoperistaltic or antiperistaltic), ascendorectal, or ileosigmoidal anastomosis [42]. Creation of an ileorectal anastomosis is most effective in increasing defecation frequency and reducing the risk of persistent constipation. According to the systematic review by C.H. Knowles et al. (2017), the recurrence rate of constipation with ileorectal anastomosis was 8.7% compared to 26.8% for less extensive procedures. On the other hand, preserving the ileocecal valve and cecum has the advantage of lowering the likelihood of postoperative diarrhea and incontinence, which is generally supported by literature data [40]. Specifically, C.Q. Jiang et al. (2008) in a retrospective analysis found a statistically significant difference in Wexner incontinence scores and quality of life indices in favor of antiperistaltic cecorectal anastomosis compared to ileorectal anastomosis [43]. F. Li et al. (2014) also noted a significantly higher frequency of antidiarrheal drug use after ileorectal anastomosis compared to cecorectal anastomosis [44].
Subtotal colectomy with ileosigmoid anastomosis is generally considered a low-efficacy treatment for slow-transit constipation, carrying a high risk of constipation recurrence and the need for reoperations [39], although several authors describe advantages of ileosigmoid anastomosis over cecorectal anastomosis [45]. In the presence of dolichocolon and/or coloptosis, segmental colonic resections and various fixation procedures are not recommended, as neither colonic elongation nor fixation anomalies (left-sided, right-sided, or total coloptosis) cause impaired colonic propulsive activity and, consequently, chronic constipation [46].
In patients with a combination of refractory slow-transit constipation and functional defecation disorders, biofeedback (BFB) therapy is recommended for preoperative correction of existing evacuation disorders [39, 40, 46, 48, 49, 50].
Level of Evidence CGrade of Recommendation 4Level of Evidence – C (Grade of Recommendation – 4).
In patients with a combination of refractory slow-transit constipation and clinically significant rectocele causing evacuation disorders, rectocele correction is recommended as the first stage of surgical treatment [39, 40].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
In patients with a combination of refractory slow-transit constipation and evacuation disorders whose constipation persists after successful correction of defecation disorders, colectomy may be considered [39, 40, 47–50].
Level of Evidence CGrade of Recommendation 4Level of Evidence – C (Grade of Recommendation – 4).
Comments: According to a systematic review by C.H. Knowles et al. (2017), data on the impact of concomitant evacuation disorders on colectomy outcomes are contradictory. For instance, a study by A. Bernini et al. (1998) demonstrated that patients with pelvic floor dyssynergia experienced defecation difficulties significantly more often after colectomy (38% vs. 4%) and their satisfaction rate with the surgery was considerably lower (56% vs. 78%) [47]. On the other hand, three other studies, including research from the Cleveland Clinic based on the treatment of 144 patients, showed that the impact of concomitant evacuation disorders on the functional outcomes of surgical treatment was very minor [48-50]. Nevertheless, the recommendations of the review authors, as well as the American Gastroenterological Association, advise that concomitant organic or functional defecation disorders should be corrected prior to colectomy [39, 40].
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Patients with primary chronic constipation are recommended spa-and-resort treatment to consolidate the effect of pharmacotherapy [51, 52].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: To consolidate the therapeutic effect of pharmacotherapy for constipation, spa-and-resort treatment using methods such as physiotherapy, mineral water intake, and hydrocolonotherapy is possible [45, 52].
5. Prevention and Dispensary Observation
Individuals prone to constipation are recommended to maintain a specific lifestyle for its prevention and to improve their quality of life [53].
GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5).
Comments: The prevention of constipation involves a set of measures, including a rational diet rich in ballast substances (dietary fiber), adequate fluid intake, and high physical activity [45, 53].
6. Organization of Medical Care
The provision of planned specialized medical care for patients with chronic constipation is carried out in both outpatient and inpatient settings, in accordance with the standard of medical care for adults with constipation (diagnostics and treatment, approved by Order of the Russian Ministry of Health No. 652n dated October 6, 2022).
7. Additional Information
No.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Level of Evidence | Level of recommendation certainty recommendations |
|---|---|---|---|
1. | Performing colonoscopy in patients over 50 years of age, as well as in the presence of "alarm symptoms" and a positive family history of colorectal cancer | C | 5 |
2. | Prescribing general measures (lifestyle modification, dietary recommendations) | C | 5 |
3. | Prescribing plant fibers or psyllium when general measures are insufficiently effective | A | 1 |
4. | Prescribing osmotic laxatives (macrogol**) for 4–6 weeks if constipation symptoms persist | A | 1 |
5. | Prescribing prucalopride for 4–6 weeks if constipation symptoms persist | C | 1 |
6 | Referring a patient with refractory constipation to a specialized center for further evaluation (assessment of colonic transit time, balloon expulsion test, anorectal manometry) | C | 2 |
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Appendix A1. Working Group Composition
Aleshin Denis Viktorovich, Candidate of Medical Sciences, Member of the Association of Coloproctologists of Russia. No conflict of interest.
Achkasov Sergey Ivanovich, Doctor of Medical Sciences, Professor, laureate of the Russian Government Prize in Science and Technology (2016), Member of the Association of Coloproctologists of Russia. No conflict of interest.
Baranskaya Elena Konstantinovna, Doctor of Medical Sciences, Professor, laureate of the Russian Government Prize in Science and Technology (2007), Member of the Russian Gastroenterological Association. No conflict of interest.
Ivashkin Vladimir Trofimovich, Doctor of Medical Sciences, Professor, Academician of the Russian Academy of Sciences, laureate of the Russian Government Prize in Science and Technology (2007), in Education (2013), Honored Doctor of the Russian Federation, Honored Scientist of the Russian Federation, President of the Russian Gastroenterological Association. No conflict of interest.
Kulikova Natalia Dmitrievna, Physician, Member of the Russian Gastroenterological Association. No conflict of interest.
Lapina Tatiana Lvovna, Candidate of Medical Sciences, Associate Professor, laureate of the Russian Government Prize in Science and Technology (2007), Member of the Russian Gastroenterological Association. No conflict of interest.
Maev Igor Veniaminovich, Doctor of Medical Sciences, Professor, Academician of the Russian Academy of Sciences, laureate of the Russian Government Prize in Science and Technology (2006), Honored Doctor of the Russian Federation, Honored Scientist of the Russian Federation, Member of the Russian Gastroenterological Association. No conflict of interest.
Osipenko Marina Fedorovna, Doctor of Medical Sciences, Professor, Member of the Russian Gastroenterological Association. No conflict of interest.
Poluektova Elena Alexandrovna, Doctor of Medical Sciences, Member of the Russian Gastroenterological Association, Member of the LLC "Scientific Society for the Promotion of Clinical Study of the Human Microbiome". No conflict of interest.
Simanenkov Vladimir Ilyich, Doctor of Medical Sciences, Professor, Member of the Russian Gastroenterological Association. No conflict of interest.
Trukhmanov Alexander Sergeevich, Doctor of Medical Sciences, Professor, Member of the Russian Gastroenterological Association. No conflict of interest.
Ulyanin Anatoly Igorevich, Physician, Member of the Russian Gastroenterological Association, Member of the LLC "Scientific Society for the Promotion of Clinical Study of the Human Microbiome". No conflict of interest.
Fomenko Oksana Yuryevna, Doctor of Medical Sciences, Associate Professor, Member of the Association of Coloproctologists of Russia. No conflict of interest.
Khlynov Igor Borisovich, Doctor of Medical Sciences, Associate Professor, Member of the Russian Gastroenterological Association. No conflict of interest.
Shelygin Yury Anatolyevich, Doctor of Medical Sciences, Professor, Academician of the Russian Academy of Sciences, two-time laureate of the Russian Government Prize in Science and Technology (2003 and 2016), Honored Doctor of the Russian Federation, Honored Scientist of the Russian Federation, President of the Association of Coloproctologists of Russia. No conflict of interest.
Sheptulin Arkady Alexandrovich, Doctor of Medical Sciences, Professor, member of the Russian Gastroenterological Association. No conflict of interest.
Shifrin Oleg Samuilovich, Doctor of Medical Sciences, Professor, member of the Russian Gastroenterological Association. No conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
The proposed guidelines aim to provide practitioners with up-to-date concepts on the etiology and pathogenesis of constipation, and to introduce current algorithms for its diagnosis and treatment.
Target audience of these clinical guidelines:
Gastroenterologists
General practitioners (family physicians)
Internists
Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
1. | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials (RCTs) using meta-analysis |
2. | Individual studies with reference standard control, or individual randomized controlled trials, and systematic reviews of studies of any design except randomized controlled trials using meta-analysis |
3. | Studies without sequential reference standard control, or studies with a reference standard not independent of the evaluated method, or non-randomized comparative studies, including cohort studies |
4. | Non-comparative studies, case reports |
5. | Only mechanism of action rationale or expert opinion is available |
Table 2. Levels of evidence (LoE) indicating the classification used for levels of evidence
LoE | Definitions |
1. | Systematic review of randomized clinical trials with meta-analysis |
2. | Individual randomized controlled trials and systematic reviews of studies of any design except randomized controlled trials using meta-analysis |
3. | Non-randomized comparative studies, including cohort studies |
4. | Non-comparative studies, case reports or case series, case-control studies |
5. | Only rationale of the intervention's mechanism of action (preclinical studies) or expert opinion is available |
Table 3. Grades of recommendation (GoR) indicating the classification used for grades of recommendation
GoR | Definitions |
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or satisfactory methodological quality, and their conclusions regarding the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or satisfactory methodological quality, and/or their conclusions regarding the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions regarding the outcomes of interest are inconsistent) |
Appendix A3. Reference Materials
These clinical guidelines have been developed taking into account the following regulatory and legal documents:
Order of the Ministry of Health of the Russian Federation No. 906n dated November 12, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile 'Gastroenterology'."
Order of the Ministry of Health of the Russian Federation No. 652n dated October 6, 2022, "On Approval of the Standard of Medical Care for Adults with Constipation (Diagnosis and Treatment)"
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Constipation is defined as a decrease in the frequency of bowel movements (less than 3 times per week) with the formation of a harder stool consistency (hard lumps or "sheep feces"). Since constipation can occur in various diseases, various laboratory and instrumental diagnostic methods are necessary to rule out organic (secondary) constipation. In the absence of signs of organic bowel diseases or other causes of constipation (endocrine, neurological diseases, etc.), the patient is diagnosed with functional constipation. The causes of its development include a low dietary fiber intake, insufficient water consumption, and low physical activity. Treatment of constipation includes lifestyle normalization (diet, increased physical activity) as well as the administration of various drugs (laxatives, entero-kinetics) prescribed by a physician after examination.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
No.