AGA Clinical Practice Update on Evaluation and Management of Refractory Constipation: Expert Review

Although most patients with chronic constipation respond to medical therapy, a subset experiences refractory constipation (RC), which poses unique diagnostic and therapeutic challenges. Because RC is relatively rare, clinicians should systematically (1) exclude correctable secondary causes such as medications, neurologic disorders, and defecatory disorders (DDs); (2) confirm the presence of slow colonic transit; and (3) ensure that patients have undergone adequate trials of over-the-counter and Food and Drug Administration-approved medications and nonpharmacologic therapies, including combinations thereof. Surgical treatments, such as colectomy, may be considered in patients who fail available treatments. However, surgical treatment of chronic constipation is associated with increased risk of complications and a not insignificant number of unsatisfactory outcomes. Prior to advising surgery, it is essential to confirm slow colonic transit, exclude concurrent DDs, and evaluate for severe, symptomatic delays in gastric emptying or small bowel dysmotility. Psychological comorbidities may exacerbate symptoms and adversely affect surgical outcomes. Hence, preoperative psychological evaluation is also advisable to assess suitability for surgery. Relative contraindications to surgical treatment of RC include clinically significant upper-gut dysmotility, severe, untreated psychiatric disease, and predominant complaints of bloating and/or abdominal pain. In uncertain cases, a temporary diverting loop ileostomy may help predict the potential response to colectomy. A colectomy with ileorectal anastomosis should only be offered to patients without ongoing DDs.