2022 Seoul Consensus on Clinical Practice Guidelines for Functional Constipation

Abstract

Chronic constipation is one of the most common digestive diseases encountered in clinical practice. Constipation manifests as a variety of symptoms, such as infrequent bowel movements, hard stools, feeling of incomplete evacuation, straining at defecation, a sense of anorectal blockage during defecation, and use of digital maneuvers to assist defecation. During the diagnosis of chronic constipation, the Bristol Stool Form Scale, colonoscopy, and a digital rectal examination are useful for objective symptom evaluation and differential diagnosis of secondary constipation. Physiological tests for functional constipation have complementary roles and are recommended for patients who have failed to respond to treatment with available laxatives and those who are strongly suspected of having a defecatory disorder. As new evidence on the diagnosis and management of functional constipation emerged, the need to revise the previous guideline was suggested. Therefore, these evidence-based guidelines have proposed recommendations developed using a systematic review and meta-analysis of the treatment options available for functional constipation. The benefits and cautions of new pharmacological agents (such as lubiprostone and linaclotide) and conventional laxatives have been described through a meta-analysis. The guidelines consist of 34 recommendations, including 3 concerning the definition and epidemiology of functional constipation, 9 regarding diagnoses, and 22 regarding managements. Clinicians (including primary physicians, general health professionals, medical students, residents, and other healthcare professionals) and patients can refer to these guidelines to make informed decisions regarding the management of functional constipation.

Keywords: Constipation; Diagnosis; Guideline; Meta-analysis; Therapeutics.

Figure 1

The Bristol Stool Form Scale. Adapted from Shin et al.

Figure 2

Initial approach of patients with chronic constipation. *Physiological test can be considered earlier in cases of strongly suspected defecatory disorders in digital rectal examination (DRE). DD, dyssynergic defecation. **Patients who have failed to respond to treatment with available laxatives (for a minimum of 12 weeks and under a recommended therapeutic regimen).

Figure 3

Diagnostic approach of functional constipation. (A) Diagnostic algorithm in specialized centers where anorectal manometry (ARM) can be available. (B) A possible diagnostic algorithm in medical institutions where ARM cannot be available. *Defecography could be performed concurrently with ARM when it is feasible or when structural abnormalities of the pelvic floor are clinically suspected. **Consider chronic constipation due to other causes such as drug, underlying disease, or IBS-C, etc. ***Apply the diagnostic algorithm in Figure 3A. BET, balloon expulsion test; CTT, colon transit time; STC, slow transit constipation; RSCTT, rectosigmoid CTT; FDD, functional defecation disorder; MDT, multidisciplinary team.

Figure 4

Algorithm for medical treatment of patients with functional constipation. *Magnesium salts should not be used in cases of abnormal renal function, and nonabsorbable carbohydrate is recommended to be prescribed in the absence of gas or ileus to improve patient compliance. **Combination treatment with bulking laxatives and osmotic laxatives can be considered at the start of treatment. If clinically needed, consider combination therapy based on action mechanisms, benefits, and cautions of the laxatives. ***Stimulant laxatives can be considered as rescue therapy due to concerns about long-term safety and abuse. ****Prucalopride, lubiprostone, and linaclotide can be used as monotherapy or in combination with each other or with laxatives already used and may be selected as a first-line agent in some cases.