Evidence-Based Clinical Guidelines for Chronic Constipation 2023

Abstract

The Japan Gastroenterological Association published the first version of its clinical guidelines for chronic constipation 2023. Based on the latest evidence, these guidelines describe the definition, classification, diagnostic criteria, diagnostic testing methods, epidemiology, pathophysiology, and treatment of chronic constipation. They include flowcharts for both diagnosis and treatment of chronic constipation. In the treatment of chronic constipation, the first step involves differentiating between secondary forms, such as organic disease-associated constipation, systemic disease-associated constipation, and drug-induced constipation. The next step is to determine whether the chronic constipation stems from a motility disorder, a form of primary chronic constipation. For functional constipation and constipation-predominant irritable bowel syndrome, treatment should be initiated after evaluating symptoms like reduced bowel movement frequency type or defecation difficulty type. The first line of treatment includes the improvement of lifestyle habits and diet therapy. The first drugs to consider for oral treatment are osmotic laxatives. If these are ineffective, secretagogues and ileal bile acid transporter inhibitors are candidates. However, stimulant laxatives are exclusively designated for as-needed use. Probiotics, bulk-forming laxatives, prokinetics, and Kampo medicines, for which there is insufficient evidence, are considered alternative or complementary therapy. Providing the best clinical strategies for chronic constipation therapy in Japan, these clinical guidelines for chronic constipation 2023 should prove useful for its treatment worldwide. The Japan Gastroenterological Association published the first version of its clinical guidelines for chronic constipation 2023. Based on the latest evidence, these guidelines describe the definition, classification, diagnostic criteria, diagnostic testing methods, epidemiology, pathophysiology, and treatment of chronic constipation. They include flowcharts for both diagnosis and treatment of chronic constipation. In the treatment of chronic constipation, the first step involves differentiating between secondary forms, such as organic disease-associated constipation, systemic disease-associated constipation, and drug-induced constipation. The next step is to determine whether the chronic constipation stems from a motility disorder, a form of primary chronic constipation. For functional constipation and constipation-predominant irritable bowel syndrome, treatment should be initiated after evaluating symptoms like reduced bowel movement frequency type or defecation difficulty type. The first line of treatment includes the improvement of lifestyle habits and diet therapy. The first drugs to consider for oral treatment are osmotic laxatives. If these are ineffective, secretagogues and ileal bile acid transporter inhibitors are candidates. However, stimulant laxatives are exclusively designated for as-needed use. Probiotics, bulk-forming laxatives, prokinetics, and Kampo medicines, for which there is insufficient evidence, are considered alternative or complementary therapy. Providing the best clinical strategies for chronic constipation therapy in Japan, these clinical guidelines for chronic constipation 2023 should prove useful for its treatment worldwide.

Keywords: Chronic constipation; Constipation-predominant irritable bowel syndrome; Definition; Functional constipation; Guidelines.

Fig. 1.

Classification of chronic constipation. Chronic constipation is classified into primary and secondary constipations. Primary constipation includes functional constipation, constipation-predominant IBS, and motility disorders (small/large intestine type and anorectal type). Secondary constipation includes drug-induced constipation (including OIC), systemic disease-associated constipation, and organic disease-associated constipation. From the viewpoint of symptoms, chronic constipation is classified into “reduced bowel movement frequency type” and “defecation difficulty type.” IBS, irritable bowel syndrome.

Fig. 2.

Therapeutic response rate of lubiprostone for chronic constipation. A meta-analysis showing that the therapeutic response rate of lubiprostone for chronic constipation by targeting RCTs lasting 4 weeks or longer is shown. Responders were analyzed using complete spontaneous bowel movements as an index.

Fig. 3.

Therapeutic response rate of linaclotide for chronic constipation and constipation-predominant irritable bowel syndrome (IBS-C). A meta-analysis showing that the therapeutic response rate of linaclotide for chronic constipation (a) and IBS-C (b) by targeting RCTs lasting 4 weeks or longer is shown. Responders were analyzed using complete spontaneous bowel movements as an index.

Fig. 4.

Initial medical treatment strategy of chronic constipation. First, the patients with chronic constipation are assessed through a medical interview, physical findings, blood tests, fecal occult blood tests, abdominal X-ray examinations. If patients exhibit alarm signs and risk factors, or abnormal test findings, further studies including colonoscopy, barium enema, ultrasound, CT, and MRI were conducted to rule out organic disease-associated constipation and motility disorder-associated constipation. Subsequently, drug-induced constipation and systemic disease-associated constipation are excluded. The remaining patients are likely diagnosed with functional constipation or constipation-predominant IBS. These patients should then be classified into either reduced bowel movement frequency type or defecation difficulty type for targeted treatment. CT, computed tomography; IBS, irritable bowel syndrome; MRI, magnetic resonance imaging.

Fig. 5.

Medical treatment strategy for functional constipation or constipation-predominant IBS with reduced bowel movement frequency type. Initially, improvements in lifestyle habits, dietary guidance, and dietary therapy are recommended. If these are ineffective, osmotic laxatives are applied. Should these have a poor response, the use of secretagogues and IBAT inhibitors should be considered. Stimulant laxatives are recommended for as-needed rescue or short-term therapy. Probiotics, bulk-forming laxatives, prokinetics, Kampo medicines may be used as alternative or complementary therapies. If these medications prove ineffective, motility disorder-associated constipation or outlet obstructive constipation should be ruled out. IBS, irritable bowel syndrome.

Fig. 6.

Medical treatment strategy for motility disorder-associated constipation of small intestinal/colonic type. If improvement of lifestyle habits, dietary guidance, dietary therapy, and all forms of medication treatments prove ineffective, assess whether the patient is a candidate for colectomy. Before deciding on colectomy, it is essential to rule out gastroparesis and outlet obstructive constipation. Colectomy is often ineffective in the patients who also suffer from gastroparesis or outlet obstructive constipation.

Fig. 7.

Medical treatment strategy for chronic constipation of the defecation difficulty type. Rectal digital examination, rectal ultrasound, and computed tomography help determine whether the patient has obvious outlet obstruction. If on obvious outlet obstruction is present, treatments such as suppositories, enemas, manual evacuation, pelvic floor physical therapy, improvements of lifestyle habits, diet guidance, and medication treatments are conducted. If these treatments are ineffective, anorectal manometry with balloon expulsion test and defecography should be conducted to assess functional defecation disorders. If obvious outlet obstruction is present, anorectal manometry with balloon expulsion test and defecography should initially be conducted to determine whether the patient suffers from motility disorder-associated constipation of the anorectal type or from functional defecation disorders.

Fig. 8.

Medical treatment strategy for OIC. Chronic constipation in cancer patients may be caused by decreased food intake and non-opioid medications. Laxatives should be selected based on individual’s conditions. If chronic constipation is exclusively caused by opioid use, peripherally acting μ-opioid receptor antagonists are recommended. Lubiprostone has been shown to be effective for OIC.