Chronic constipation has historically been considered a common disorder, yet one that is frequently underestimated in its clinical complexity and pathophysiology. For years, its management was limited to symptomatic relief through empirical interventions, often disconnected from the underlying pathophysiological mechanisms. This context, still prevalent in many clinical settings, has contributed to the persistence of suboptimal outcomes and the chronification of symptoms in a significant number of patients.
Over the past few decades, the understanding of constipation has evolved substantially, compelling us to reconsider this simplistic view. Today, we understand that it is not a single condition, but rather a heterogeneous spectrum of disorders with diverse pathophysiological bases that require a far more precise diagnostic and therapeutic approach.
This issue of Clínicas de Gastroenterología de México emerges within this context of conceptual transformation. Through a careful selection of topics and authors, it aims not only to update readers but also to promote critical reflection on current diagnostic and therapeutic paradigms. From epidemiology and clinical definition to advanced therapeutic strategies, the content gathered herein reflects the field’s evolution toward mechanism-based medicine.
Understanding colonic anatomy and physiology ceases to be a merely academic exercise and becomes the cornerstone of clinical reasoning. The colon, far from being a passive organ, participates in a complex network of neuromuscular, sensory, and behavioral interactions. This perspective allows us to understand why patients with apparently similar symptoms may present with profoundly different abnormalities, and why therapeutic responses are so heterogeneous.
In this regard, the pathophysiological mechanisms of constipation represent the true turning point in its management. The integration of concepts such as colonic transit, pelvic floor dysfunction, altered rectal perception, and central modulation of symptoms redefines diagnosis beyond traditional clinical criteria. Likewise, the emerging role of the gut-brain axis and intestinal microbiota introduces new dimensions that, while still under development, promise to transform the way we conceptualize and treat this condition.
The advancement of functional diagnostic testing has been pivotal in this transition. The availability of tools such as high-resolution anorectal manometry and colonic transit studies has made it possible to objectively characterize previously invisible abnormalities, enabling a more targeted approach. Nevertheless, this progress also poses new challenges: appropriate patient selection, interpretation of results in specific clinical contexts, and the need for standardization across diverse practice settings.
In the therapeutic arena, the contrast between traditional and emerging approaches is particularly evident. While laxatives remain a fundamental tool, the development of new pharmacological agents has broadened the therapeutic spectrum. However, true innovation lies not only in the availability of new drugs but also in their strategic use, based on the patient’s pathophysiological profile. In this context, non-pharmacological therapy – particularly biofeedback – represents one of the clearest examples of mechanism-driven interventions, with outcomes superior to those of empirical approaches in selected populations.
Furthermore, dietary and lifestyle interventions, often considered universally applicable, require critical reassessment. Current evidence demonstrates that the response to these strategies is highly variable, reinforcing the need to abandon homogeneous protocols in favor of personalized approaches. This paradigm shift entails, beyond better selection of interventions, greater patient participation in their own therapeutic process.
The chapters dedicated to complications, refractory constipation, and surgical treatment address highly complex clinical scenarios in which decisions must be made with particular care. In these cases, the integration of clinical, physiological, and, at times, structural information is essential to avoid both undertreatment and unnecessary interventions. Surgery, although limited to specific indications, remains a valid alternative in well-defined situations, underscoring the importance of appropriate patient selection.
Taken together, this issue does not aim to be merely a thematic review but also an invitation to transform clinical practice. Chronic constipation represents a clear example of how modern gastroenterology is shifting toward precision medicine models, where the symptom is no longer the central axis and gives way to an understanding of the underlying mechanisms.
The challenge ahead is not insignificant; it involves consolidating the rational use of diagnostic tools, optimizing therapeutic strategies, and, above all, integrating these advances into real-world clinical practice settings, which are often resource-limited. Nevertheless, it also represents a unique opportunity to substantially improve the care of a large group of patients who, for a long time, have been managed with inadequate strategies.
As editors, we trust that this work will contribute to that paradigm shift, promoting a more critical, informed, and patient-centered perspective. Beyond offering definitive answers, we seek to generate relevant questions that will drive research and innovation in this field.
