Constipation is a prevalent gastrointestinal disorder, affecting approximately 15% of the global population. It is more commonly diagnosed in North America and Europe compared to Asia, likely due to variations in diet, culture, and environment. Risk factors for constipation include age over 65, female gender, sedentary lifestyle, low socioeconomic status, low-fiber diet, and non-White race. Chronic idiopathic constipation (CIC) is characterized by persistent constipation symptoms without an identifiable cause through standard diagnostic tests, impacting around 8%-12% of the US population.
This Guidelines Side-By-Side article provides a detailed comparison of the current clinical practice guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) and the American College of Gastroenterology (ACG)/American Gastroenterological Association (AGA). By examining these recommendations, this article aims to equip healthcare providers with valuable insights and best practices for evaluating chronic constipation and CIC. This evidence-based approach aims to enhance health outcomes for individuals affected by this complex condition.
Titles of Comparison:
| ASCRS | ACG/AGA | |
|---|---|---|
| Titles | Evaluation and Management of Chronic Constipation | Pharmacological Management of Chronic Idiopathic Constipation |
| Society | American Society of Colon and Rectal Surgeons (ASCRS) | American College of Gastroenterology (ACG)American Gastroenterological Association (AGA) |
| Publication Date | September 10, 2024 | May 18, 2023 |
| Objective | This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information based on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for use by all practitioners, health care workers, and patients who desire information on the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient. | Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation. |
| Target Population | The target audience for these guidelines includes primary care, internal medicine, family medicine, and gastroenterology healthcare providers; patients; and policymakers. | These guidelines are intended for use by all practitioners, health care workers, and patients who desire information on the management of the conditions addressed by the topics covered in these guidelines. The population of interest was adults (18 years or older) diagnosed with CIC. |
| Methodology | The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. | The GRADE approach was used to assess the certainty of evidence for the effect of the intervention on each outcome using the software GradePro. |
| Graded Strength of Recommendations | Yes | Yes |
| Graded Level of Evidence | Yes | Yes |
| Systematic Review Conducted | Yes | Yes |
| Literature Review Conducted | Yes | Yes |
| COIs & Funding Source(s) Disclosed | Yes | Yes |
| Full-text | The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Evaluation and Management of Chronic Constipation | American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation |
| Summary | ASCRS Evaluation and Management of Chronic Constipation Guideline Summary | AGA/ACG Pharmacological Management of Chronic Idiopathic Constipation Guideline Summary |
| Other Links | Pocket Guide: ACG/AGA Pharmacological Management of Chronic Idiopathic Constipation Guideline Pocket Guide |
Assessment Overview
| ASCRS | ACG/AGA | |
|---|---|---|
| Focus | Comprehensive evaluation and management of chronic constipation | Pharmacological management of chronic idiopathic constipation |
| Initial Approach | Directed history and physical examination | Use of fiber supplementation and osmotic laxatives |
| Lifestyle Modifications | Emphasizes dietary and lifestyle changes ensuring adequate fluid intake and fiber supplementation | Recommends fiber supplementation over management without fiber supplements and adequate hydration |
| Osmotic Laxatives | Polyethylene glycol (PEG) and magnesium salts | Polyethylene glycol (PEG), magnesium oxide, lactulose |
| Stimulant Laxatives | Bisacodyl, sodium picosulfate | Bisacodyl, sodium picosulfate, senna |
| Secretagogues | Not specifically mentioned | Lubiprostone, linaclotide, plecanatide, prucalopride |
| Biofeedback | Recommended for patients with pelvic floor dysfunction | Not specifically mentioned |
| Multidisciplinary Care | Encourages a team-based approach | Focuses on pharmacological interventions |
| Patient-Centered Goals | Individualized treatment plans based on patient needs | Shared decision-making based on patient preferences and medication cost |
Key Similarities:
- Patient-Centered Care:
- Both emphasize individualized treatment based on patient history and response to previous therapies.
- Non-Pharmacological Interventions:
- They highlight the importance of dietary fiber and lifestyle modifications before moving to pharmacological treatments.
- Stepwise Approach:
- Each recommends a structured approach—starting with less invasive options, then moving to more intensive treatments if necessary.
- Over-the-Counter (OTC) Agents:
- Both guidelines suggest the use of OTC laxatives and supplements as first-line treatments.
- Monitoring and Follow-Up:
- They underscore the need for ongoing assessment and adjustment of treatment plans based on patient progress.
Key Differences:
- Initial Approach:
- The ASCRS guidelines emphasize a comprehensive evaluation and lifestyle modifications, while the ACG/AGA guidelines focus on pharmacological management.
- Lifestyle Modifications:
- ASCRS guidelines provide detailed recommendations for dietary and lifestyle changes, whereas ACG/AGA guidelines recommend fiber supplementation and hydration.
- Biofeedback:
- ASCRS guidelines recommend biofeedback for pelvic floor dysfunction, which is not mentioned in the ACG/AGA guidelines.
- Secretagogues:
- The ACG/AGA guidelines specifically recommend secretagogues like lubiprostone, linaclotide, plecanatide, and prucalopride, which are not mentioned in the ASCRS guidelines.
The guidelines for managing chronic constipation and chronic idiopathic constipation (CIC) emphasize a patient-centered, stepwise approach, beginning with non-pharmacological interventions such as dietary fiber and lifestyle modifications. In terms of evaluation, it is recommended to discontinue constipating medications, conduct digital rectal exams, and consider additional tests and colonoscopy based on specific indicators. When it comes to pharmacological management, both guidelines suggest utilizing over-the-counter agents such as fiber supplements, polyethylene glycol, and magnesium oxide as first-line treatments. The ASCRS guideline delves into surgical approaches, while the ACG/AGA focuses on pharmaceutical approaches. Each guideline serves as a valuable resource for addressing these common conditions.
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