Guideline Video

Guideline Resources

  • Evaluation and Management of Refractory Constipation
  • American Gastroenterological Association
  • January 7th, 2026
  • Summary
  • Full-text

Video Transcription

Published January 7th, 2026, the American Gastroenterological Association’s newest clinical practice update on Evaluation and Management of Refractory Constipation, also known as RC.

The objective of this update is to provide best practice advice on the diagnosis, treatment, and medical and surgical management of patients with RC.

In today’s rapid update, we’ll be going over 14 best practice advice statements. Let’s get started. 

  • RC is defined by infrequent and/or unsatisfactory bowel habits, with or without abdominal pain, despite an adequate trial of lifestyle, dietary, medical, and/or pelvic floor biofeedback therapy when indicated in adults who satisfy criteria for chronic constipation, or constipation-predominant IBS. 
  • Most patients with chronic constipation should be evaluated with anorectal manometry with balloon expulsion testing and complete a course of pelvic floor biofeedback therapy, when indicated, before being labelled as having RC. 
  • Patients with RC should be thoroughly evaluated for secondary causes of constipation, such as medications, disordered eating, or comorbid neurological diseases. 
  • Clinicians caring for RC patients should describe its typical course and set realistic expectations. 
  • Patients with RC should undergo colonic transit testing off of treatments to document slow-transit constipation and ideally also on a maximal laxative regimen to document the refractory nature of symptoms. 
  • Among patients with RC, defecography should be considered. 
  • Patients with RC should trial all standard over-the-counter and FDA-approved therapies for constipation as standalone therapy or in combination when accessible. 
  • The AGA suggests trials of off-label prescription agents for patients with RC who have failed available OTC and FDA-approved agents. 
  • Trials of adjunct, non-pharmacologic approaches, including transanal irrigation for RC with neurogenic bowel dysfunction, a vibrating capsule, or electroacupuncture, are reasonable in patients with RC. 
  • Surgical therapy for RC should only be considered after confirming slow-transit constipation and excluding pelvic floor dysfunction. Only patients with RC and no evidence of an ongoing defecatory disorder should be offered a colectomy with ileorectal anastomosis. 
  • Preoperative evaluation should include regional gut transit testing. 
  • Patients should undergo a psychological evaluation before surgical therapy for RC. 
  • Relative contraindications to surgical treatment of RC include severe, untreated psychiatric disease, including active eating disorders and unresolved issues related to sexual trauma; primary complaints of bloating and/or abdominal pain; and reversible, secondary causes of constipation. 
  • A diverting loop ileostomy offers a diagnostic trial of surgical treatment of RC, especially where there are concerns about efficacy or relative contraindications.

And there you have it. Make sure to check out the full guideline from the American Gastroenterological Association and other related clinical decision support tools at guidelinecentral.com.

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