Understanding and treating refractory constipation

Abstract

Chronic constipation is a frequently encountered disorder in clinical practice. Most constipated patients benefit from standard medical approaches. However, current therapies may fail in a proportion of patients. These patients deserve better evaluation and thorough investigations before their labeling as refractory to treatment. Indeed, several cases of apparent refractoriness are actually due to misconceptions about constipation, poor basal evaluation (inability to recognize secondary causes of constipation, use of constipating drugs) or inadequate therapeutic regimens. After a careful re-evaluation that takes into account the above factors, a certain percentage of patients can be defined as being actually resistant to first-line medical treatments. These subjects should firstly undergo specific diagnostic examination to ascertain the subtype of constipation. The subsequent therapeutic approach should be then tailored according to their underlying dysfunction. Slow transit patients could benefit from a more robust medical treatment, based on stimulant laxatives (or their combination with osmotic laxatives, particularly over the short-term), enterokinetics (such as prucalopride) or secretagogues (such as lubiprostone or linaclotide). Patients complaining of obstructed defecation are less likely to show a response to medical treatment and might benefit from biofeedback, when available. When all medical treatments prove to be unsatisfactory, other approaches may be attempted in selected patients (sacral neuromodulation, local injection of botulinum toxin, anterograde continence enemas), although with largely unpredictable outcomes. A further although irreversible step is surgery (subtotal colectomy with ileorectal anastomosis or stapled transanal rectal resection), which may confer some benefit to a few patients with refractoriness to medical treatments.

Keywords: Chronic constipation, Laxatives, Medical treatment, Refractory constipation, Surgical treatment

Core tip: The majority of patients affected by chronic constipation can be managed by conventional therapeutic approaches. However, a subset of constipated patients displays a condition of actual refractoriness to standard medical treatment, even after careful clinical re-evaluation. These patients require more in-depth diagnostic evaluations to ascertain the underlying pathophysiological mechanisms, as well as more intensive, targeted and tailored therapeutic approaches, which may rely on the use of newly released drugs (enterokinetics, enteric secretagogues), rehabilitation (biofeedback), invasive measures (sacral neuromodulation, local injection of botulinum toxin, antegrade continence enemas) and surgical procedures (subtotal colectomy with ileorectal anastomosis or stapled transanal rectal resection).