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Updated evidence-based guidelines now redefine the diagnosis and management of functional constipation, integrating physiological testing and structured evaluation for patients unresponsive to laxatives.
Functional constipation continues to represent a common and heterogeneous gastrointestinal disorder with rising prevalence, variable symptom presentation, and evolving diagnostic and therapeutic approaches; therefore, the Seoul consensus clinical practice guidelines were updated to systematically evaluate available evidence and develop structured recommendations for the diagnosis and management of functional constipation.
Guideline Scope and Structure
The recommendations were developed through systematic review and meta-analysis and are intended for primary care physicians, gastroenterologists, allied healthcare professionals, trainees, and patients.
Evidence-Based Recommendations
These highlights new pharmacological options like lubiprostone and linaclotide, alongside conventional therapies, to guide clinicians and patients towards informed, effective care.
(A) DEFINITION AND EPIDEMIOLOGY
Recommendation 1: Chronic constipation is defined as decreased bowel frequency, small or hard stools, a sense of incomplete evacuation, excessive straining, anal blockage, and the need for manual manipulation during defecation.
Recommendation 2: Prevalence increases with age.
Recommendation 3: Women are more frequently affected than men.
(B) DIAGNOSTIC EVALUATION
Recommendation 4: Bristol stool form scale (BSFS) types 1–2 may predict slow-transit constipation
Recommendation 5: Digital rectal examination is useful to identify structural abnormalities such as masses, rectal prolapse, or rectocele.
Recommendation 6: Physiological testing is advised if defecatory disorders are suspected on digital rectal examination.
Recommendation 7: Colonoscopy should be performed for patients with warning signs or incomplete colorectal cancer screening.
Recommendation 8: Physiological tests are indicated for those unresponsive to laxatives after 12 weeks or suspected dyspeptic constipation.
Recommendation 9: Balloon expulsion testing may predict obstructive constipation.
Recommendation 10: Anorectal manometry is useful for diagnosing defecation disorders; use in conjunction with other tests.
Recommendation 11: Defecography evaluates pelvic floor structural or coordination disorders.
Recommendation 12: Measurement of colonic transit time differentiates slow-transit from obstructive constipation.
(C) MANAGEMENT APPROACHES
1. Lifestyle and Behavioral Interventions
Recommendation 13: Dietary fiber improves constipation by increasing stool frequency and reducing colonic transit time.
Recommendation 14: Exercise may improve constipation symptoms and is recommended for overall health.
2. Pharmacological Treatments
(i) Bulk-forming laxatives
Recommendation 15: Effective and safe to increase stool frequency.
Recommendation 16: May cause bloating, gas, or abdominal pain.
(ii) Osmotic laxatives: Magnesium salts
Recommendation 17: Improve stool frequency and consistency.
Recommendation 18: May cause hypermagnesemia in renal dysfunction.
(iii) Osmotic laxatives: Non-absorbable polysaccharides
Recommendation 19: Effective for chronic constipation.
Recommendation 20: Safe for long-term use, including in the elderly.
(iv) Osmotic laxative: Polyethylene glycol (PEG)
Recommendation 21: Effective for chronic constipation.
Recommendation 22: Has rare serious side effects, suitable for long-term use, and safe for elderly patients.
(v) Stimulant laxatives
Recommendation 23: Improves symptoms of chronic constipation.
Recommendation 24: Short-term use recommended due to limited long-term safety data.
(vi) Probiotics
Recommendation 25: May help alleviate symptoms; effectiveness depends on strain.
(vii) Novel Pharmacological Agents
Recommendation 26: Prucalopride promotes intestinal motility; effective for patients unresponsive to conventional laxatives.
Recommendation 27: Lubiprostone activates intestinal fluid secretion; safe in renal impairment.
Recommendation 28: Linaclotide is effective and safe for chronic constipation.
3. Behavioral, Local, and Surgical Treatments
Recommendation 29: Biofeedback therapy is safe and effective for constipation, particularly defecatory disorders.
Recommendation 30: Biofeedback therapy maintains long-term benefits and improves quality of life.
Recommendation 31: Enemas may be effective for obstructive constipation who do not respond well to other interventions.
Recommendation 32: Enemas should be used with caution due to risk of electrolyte imbalance or rectal injury.
Recommendation 33: Colectomy may be selectively performed for slow-transit constipation not responding to medical therapy.
Recommendation 34: Surgical correction is recommended for fecal obstruction caused by structural abnormalities such as intussusception, rectocele, or rectal prolapse.
The Korean Journal of Gastroenterology
Seoul Consensus on Clinical Practice Guidelines for Functional Constipation
Kyung Ho Song et al.
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