World Gastroenterology Organisation Introduces Resource-Stratified Cascade for Chronic Constipation Management

The guideline, which focuses on adults, provides a tiered framework that acknowledges the significant global variations in healthcare resources, sociocultural factors, and disease epidemiology, making a single, universal "gold-standard" impractical. The guidelines aim to support clinical decision-making from primary care to specialized gastroenterology, ensuring appropriate care across diverse settings.

Chronic constipation is a common gastrointestinal disorder marked by infrequent bowel movements, typically fewer than three per week, and symptoms such as straining or hard stools, and a persistent feeling of incomplete evacuation. It affects an estimated 9% to 20% of the global population, with a higher prevalence among women and older adults.

The new WGO guideline offers a structured, hierarchical set of diagnostic, therapeutic, and management options, ranked according to available resources, to address this widespread issue. It delineates three distinct levels of intervention for the treatment of general chronic constipation, progressing from basic, widely available options to advanced therapies requiring extensive resources.

Key highlights from the guideline include:

1. Recommended cascade options for investigating severe and treatment – refractory constipation is divided in to 3 levels. Level 1 uses limited resources which involves medical history and general examination, anorectal examination, 1-week bowel habit diary card, transit study using radiopaque markers and balloon expulsion test. Level 2 uses medium resources and includes defecography. Level 3 uses extensive resources and includes MR proctography, anorectal manometry and sphincter EMG.

2. First-Level Cascade: Initial Symptomatic Treatment

This level focuses on easily implementable and widely accessible interventions:

• Lifestyle Modifications: Begin with a gradual increase in dietary fiber (20–30g/day), maintain adequate hydration, and engage in regular aerobic exercise to enhance gut motility. Encourage proper toilet habits—responding to defecation urges promptly and using a squatting position. Also, review and discontinue any medications contributing to constipation.
• Pharmacological Therapy (First-Line): Osmotic laxatives are recommended initially. Polyethylene Glycol (PEG) and lactulose are well-supported by clinical evidence, though lactulose may cause bloating and flatulence. Magnesium oxide is also used in some regions.
• Rescue Therapy: timulant laxatives like bisacodyl are reserved for short-term or intermittent use to avoid side effects such as cramping, electrolyte imbalances, and potential long-term neuromuscular risks.

3. Second-Level Cascade: Moderate Resource Interventions

When first-line strategies fail, this level introduces more specialized treatments:

• Psychological Interventions: Cognitive Behavioral Therapy (CBT) and gut-directed hypnotherapy are effective for chronic constipation, especially in patients with anxiety, depression, or maladaptive illness behaviors. These therapies improve overall symptoms and quality of life, with proven efficacy from Irritable Bowel Syndrome (IBS) management.

• Neuromodulators: Used for visceral pain, hypersensitivity, or mood disorders. Tricyclic antidepressants (TCAs) like amitriptyline are typically avoided due to anticholinergic effects worsening constipation. Instead, nortriptyline, desipramine (secondary TCAs), SNRIs for pain/mood, or SSRIs like citalopram for anxiety may be considered, as they carry a lower constipation risk.

• Surgery: In select cases of medically refractory Slow Transit Constipation (STC), subtotal colectomy with ileorectal or cecorectal anastomosis may provide relief but carries risks such as incontinence, diarrhea, bowel obstruction, or the need for a stoma. For structural issues like rectal prolapse, resection rectopexy, particularly laparoscopic ventral mesh rectopexy—shows favorable outcomes, with improved symptoms and lower recurrence.

4. Third-Level Cascade: Extensive Resource and Advanced Therapies

Applied in settings with extensive resources, this level includes advanced medications, device-based therapies, and surgical options for patients unresponsive to lower-tier treatments:

• Advanced Pharmaceuticals: Includes linaclotide, lubiprostone, elobixibat, and GC-C receptor agonists. These enhance secretion, accelerate transit, or modulate bile acid pathways to increase bowel movements in refractory cases.
• Non-Pharmacological Device-Based Interventions:

Vibrating Capsule: A swallowable device delivering vibratory stimulation to improve complete spontaneous bowel movements (CSBMs).

Percutaneous (or transcutaneous) tibial nerve stimulation (PTNS/TTNS): Targets sacral nerves regulating colonic motility; useful in specialized or research settings due to protocol variability.

Sacral nerve stimulation (SNS): Though used for fecal incontinence, lacks consistent efficacy for constipation and is not recommended outside clinical trials due to risks and costs.

Repetitive transcranial magnetic stimulation (rTMS): Still experimental, but early studies show potential benefits in bowel frequency and symptom relief.

• Advanced Surgery: Reserved for carefully selected patients in expert centers. STARR (Stapled Trans-Anal Rectal Resection) addresses obstructed defecation from rectal prolapse or rectocele. While it improves quality of life, risks include bleeding, urgency, flatus incontinence, and symptom recurrence.

5. Cascade Approach for Defecatory Disorders

The WGO guidelines also provide a specific cascade approach for patients with chronic constipation specifically linked to a defecatory disorder.

• Level One: Emphasizes lifestyle changes—boosting fiber intake, staying well-hydrated, and practicing timed bowel training. Basic laxatives or stool softeners are used to improve stool consistency.
• Level Two: For persistent symptoms, moderate-resource interventions like biofeedback therapy are introduced to retrain pelvic floor coordination. Neuromodulators and psychological therapies help manage pain, altered sensations, anxiety, or maladaptive behaviors.
• Level Three: For severe, treatment-resistant cases, high-resource options like surgical correction of anatomical defects are considered. These are reserved for carefully selected patients after thorough multidisciplinary evaluation and counseling on potential risks and outcomes.

This new WGO Global Cascade Approach offers a comprehensive and adaptable framework, aiming to standardize and improve the diagnosis and management of chronic constipation across the diverse healthcare landscapes of the world.

Reference: https://www.worldgastroenterology.org/guidelines/constipation