ACG 2014 Guidelines for Management of Chronic Constipation

What Your Doctor Knows About Treating Chronic Constipation

Female doctor with digital tablet talking with senior male patient in examination room

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The American College of Gastroenterology periodically publishes guidelines, based on extensive research reviews, for the treatment of various digestive disorders. This article summarizes the findings of the most recent review for the treatment of chronic idiopathic constipation (CIC), which shares similar symptoms with constipation-predominant (IBS-C), but without the symptom of pain that is the hallmark of IBS. The ACG guidelines are intended to serve as a "best practices" for physicians in working with their patients. Having knowledge as to what your doctor knows can help to enhance the extremely important doctor-patient relationship.

The following are the main tools that your doctor has in their tool bag for helping you to manage your chronic constipation:


Although overall, the ACG reviewers recommend fiber as an effective management intervention of CIC, they make it a point to differentiate between the two types of fiber. They conclude that soluble fiber may be more helpful than insoluble fiber, due to an increase in symptoms related to gas and bloating when too much insoluble fiber is taken in too quickly. Psyllium is a form of soluble fiber, while bran is a form of insoluble fiber.


1. Osmotic laxatives: The ACG reviewers recommend the use of Miralax (PEG) and lactulose. Research studies to date seem to indicate that the risk of side effects of osmotic laxatives is fairly low.

2. Stimulant laxatives: The reviewers recommend the stimulant laxatives, sodium picosulfate, and bisacodyl. Due to a lack of research, they do not recommend the use of other types of stimulant laxatives.


1. 5-HT 4 Medications: These medications are designed to stimulate the neurotransmitter serotonin, which is thought to increase liquid within the intestines, enhance motility and decrease transit time, all of which will help to ease constipation. The reviewers conclude that two 5-HT 4 medications are beneficial for CIC - prucalopride and velusetrag. However, neither medication is available in the US. Prucalopride is available in Canada under the name "Resotran" and in Europe under the name "Resolar." The reviewers note that these medications do not appear to carry the risk of serious cardiovascular problems that resulted in their predecessor Zelnorm being pulled from the market.

2. Prosecretory Medications: Medications in this class include Linzess, also known as Constella, (linaclotide) and Amitiza (lubiprostone). The ACG recommends the use of Linzess, noting strong research support for its effectiveness and its safety profile. The main side effect reported is diarrhea. The reviewers were also quite positive about Amitiza, also citing its record of strong research support. Diarrhea and nausea are listed as side effects. However, they make it a point to say that neither medication has been compared to the use of laxatives or fiber, therefore no opinion can be rendered as to which treatment should be recommended first.


The reviewers conclude that biofeedback can be effective in treating chronic constipation in patients who have been identified as having pelvic floor dysfunction. They note that it is hard for patients to find therapists who are truly proficient in this area.

Of note, the reviewers conclude that there is not enough research support to indicate that probiotics are effective for chronic constipation.

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