Guidance Updated for Evaluation, Management of Refractory Constipation

THURSDAY, Jan. 8, 2026 (HealthDay News) — In a clinical practice update issued by the American Gastroenterological Association and published online Jan. 7 in Gastroenterology and Hepatology, updated recommendations are presented for the evaluation and management of refractory constipation (RC).

Kyle Staller, M.D., M.P.H., from Massachusetts General Hospital in Boston, and colleagues developed Best Practice Advice statements to address 14 key clinical issues relating to RC.

The authors note that anorectal manometry with balloon expulsion testing should be used to evaluate most patients with chronic constipation, and they should complete a course of pelvic floor biofeedback therapy before being labeled with RC; before diagnosing RC, dyssynergic defecation (DD) should be diagnosed and treated. Patients with RC should undergo thorough examination for secondary causes of constipation. Patients with RC should undergo colonic transit testing off of treatments; defecography should be considered among patients with RC. All standard over-the-counter and U.S. Food and Drug Administration-approved therapies for constipation should be trialed; among those who fail these treatments, trials of off-label prescription agents are suggested. Trials of adjunct, nonpharmacologic approaches are reasonable for patients with RC. Only after confirming slow-transit constipation and excluding pelvic floor dysfunction should surgery be considered.

A colectomy with ileorectal anastomosis is recommended only to patients with RC and no evidence of an ongoing DD. Before surgical therapy for RC, patients should undergo psychological evaluation. Severe, untreated psychiatric disease, primary complaints of bloating and/or abdominal pain, and reversible, secondary causes of constipation are relative contraindications to surgical treatment of RC. Particularly when there are concerns about efficacy of colectomy with ileorectal anastomosis or relative contraindications, a diverting loop ileostomy offers a diagnostic trial of surgical treatment of RC.

“Chronic constipation affects 8 to 12 percent of the U.S. population, with 3 million patients/year seeking clinical evaluation,” the authors note.

Several authors disclosed ties to the biopharmaceutical industry.

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