Quality appraisal of clinical guidelines for the management of constipation according to AGREE II instrument





Constipation; AGREE II; Clinical guidelines; Pharmaceutical care; Evidence-based health.


Constipation is one of the most frequent complaints in health establishments, affecting approximately 20% of the world population. The key to the successful management of this disorder is its early identification and immediate treatment with nondrug measures as the main therapeutic alternative. While clinical guidelines are informative documents that include recommendations aimed at optimizing patient care, this study aims to evaluate the quality of these documents available in the management of this condition. This study evaluated clinical guidelines available in databases, scientific societies and class councils, which had as their theme the management of constipation. The methodology used to evaluate the quality of these documents was the application of the AGREE II instrument. Kappa test of agreement between evaluators was applied to corroborate uniformity in application of the AGREE II instrument. Of the eleven documents analyzed, only three presented the criteria for recommendation proposed for use in clinical practice, with a general average of quality indexes ranging from 93 to 72%. One guideline was recommended with modifications in its structure, with a general average of quality indexes of 44%. The mean overall score among the analyzed documents was 49.01%. Methodological care and expression of information in a concise and clear way, both of the content and methodology employed, result in documents of great quality, however, no aspects were present in most of the guidelines analyzed. Furthermore, it is observed that there are still points that should be improved.


American College of Gastroenterology Chronic Constipation Task Force. (2005). An Evidence-Based Approach to the Management of Chronic Constipation in North America. The American Journal of Gastroenterology, 100(s1), S1–S4. https://doi.org/10.1111/j.1572-0241.2005.50613_1.x

American Gastroenterological Association. (2013). American Gastroenterological Association medical position statement on constipation. Gastroenterology, 144(1), 211–217. https://doi.org/10.1053/j.gastro.2012.10.029

Antunes, M. D., de Oliveira, K. C. C., Acencio, F. R., de Oliveira, D. V., Garcez, D. A. G., & Bennemann, R. M. (2019). Constipação intestinal em idosos e a relação com atividade física, alimentação e cognição. Revista de Medicina, 98(3), 202–207. https://doi.org/10.11606/issn.1679-9836.v98i3p202-207

Choung, R. S., Locke III, G. R., Schleck, C. D., Zinsmeister, A. R., & Talley, N. J. (2007). Cumulative incidence of chronic constipation: a population-based study 1988-2003. Alimentary Pharmacology & Therapeutics, 26(11–12), 1521–1528. https://doi.org/10.1111/j.1365-2036.2007.03540.x

Consórcio Agree. (2009). Instrumento para avaliação de diretrizes clínicas. Appraisal of Guidelines for Research and Evalution.

Cristóbal Cañadas, D., Requena Mullor, M. ., Alarcón Rodríguez, R., & Parrón Carreño, T. (2019). Psychosocial risks at work for paediatric health professionals. European Review of Applied Psychology, 69(5–6), 100510. https://doi.org/10.1016/j.erap.2019.100510

De, R., & Ronsoni, M. (2013). “Avaliação dos protocolos clínicos e diretrizes terapêuticas do Ministério da Saúde segundo método AGREE II (Appraisal of Guidelines for Reserach and Evaluation)” por.

Donald, I. P., Smith, R. G., Cruikshank, J. G., Elton, R. A., & Stoddart, M. E. (1985). A Study of Constipation in the Elderly Living at Home. Gerontology, 31(2), 112–118. https://doi.org/10.1159/000212689

DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T900171. (2018). Constipation in children. In [updated 2018 Nov 30, cited 2020 Mar 31]. Available from: https://www.dynamed.com/condition/constipation-in-children. Registration and login required. https://doi.org/10.15690/vsp.v11i3.309

Emmanuel, A., Mattace-Raso, F., Neri, M. C., Petersen, K. U., Rey, E., & al., E. (2017). Constipation in older people: A consensus statement. International Journal of Clinical Practice, 71(1), 1–9. https://doi.org/10.1111/ijcp.12920

Everhart, J. E., Go, V. L. W., Johannes, R. S., Fitzsimmons, S. C., Roth, H. P., & White, L. R. (1989). A longitudinal survey of self-reported bowel habits in the United States. Digestive Diseases and Sciences, 34(8), 1153–1162. https://doi.org/10.1007/BF01537261

Garcia, L. B., Bertolini, S., Souza, M. V, Santos, M. S. F., & Pereira, C. O. M. (2016). Constipação intestinal: aspectos epidemiológicos e clínicos. Saude e Pesquisa, 9(1), 153–162. https://doi.org/10.177651/1983-1870

Greenwald, B. J. (2010). Clinical practice guidelines for pediatric constipation. Journal of the American Academy of Nurse Practitioners, 22(7), 332–338. https://doi.org/10.1111/j.1745-7599.2010.00517.x

Griep, R. H., Dóra, C., Faerstein, E., & Lopes, C. (2003). Confiabilidade teste-reteste de aspectos da rede social no Estudo Pró-Saúde. Revista de Saúde Pública, 37(3), 379–385. https://doi.org/10.1590/S0034-89102003000300018

Harari, D., Gurwitz, J. H., Avorn, J., Bohn, R., & Minaker, K. L. (1996). Bowel habit in relation to age and gender. Findings from the National Health Interview Survey and clinical implications. Archives of Internal Medicine, 156(3), 315–320.

Jakobsson, U., & Westergren, A. (2005). Statistical methods for assessing agreement for ordinal data. Scandinavian Journal of Caring Sciences, 19(4), 427–431. https://doi.org/10.1111/j.1471-6712.2005.00368.x

Junior, A. de S. R., Bonetti, A. de F., Bagatim, B. A. de Q., Soares, C. C. R., Vilela, F. C., De Almeida, F. H. O., & al., E. (n.d.). Protocolos de Constipação. In Conselho Federal de Farmácia. Protocolos de Constipação (pp. 1–10).

Landis, J., & Biometrics, G. K.. (1977) undefined. (n.d.). The measurement of observer agreement for categorical data. JSTOR.

Ministério da Saúde. (2016). Diretrizes Metodológicas: Elaboração de Diretrizes Clínicas. 62(2), 165–166. https://doi.org/10.32635/2176-9745.rbc.2016v62n2.358

Molino, C. de G. R. C., Romano-Lieber, N. S., Ribeiro, E., & de Melo, D. O. (2016). Non-Communicable Disease Clinical Practice Guidelines in Brazil: A Systematic Assessment of Methodological Quality and Transparency. PLOS ONE, 11(11), e0166367. https://doi.org/10.1371/journal.pone.0166367

National Collaborating Centre for Women‘s and Children‘s Health. (2010). Constipation in children and young people diagnosis and management of idiopathic childhood constipation in primary and secondary care. In Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care. https://doi.org/10.13140/2.1.3573.6003

National Institute for Health and Care Excellence. (n.d.). How we develop NICE guidelines.

National Institute for Health and Care Excellence. (2014). Developing NICE guidelines: the manual.

Paquette, I. M., Varma, M., Ternent, C., Melton-Meaux, G., Rafferty, J. F., Feingold, D., & Steele, S. R. (2016). The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Evaluation and Management of Constipation. Diseases of the Colon and Rectum, 59(6), 479–492. https://doi.org/10.1097/DCR.0000000000000599

Rao, S. (n.d.). Constipation in the older adult. In UpToDate [Internet]. Waltham, MA: UpToDate Inc. https://www.uptodate.com [acessado em 05 novembro 2019]. (p. 21). https://doi.org/10.7326/0003-4819-91-2-261.BOUR

Rao, S., & Sharma, A. (n.d.). Constipação em Adultos. In BMJ Best Practice [Internet]. London: BMJ Publishing Group; 2018 [cited 2020 Mar 31]. Available from: https://bestpractice.bmj.com/.

Ribeiro, J. P., Gomes, G. C., Thofehrn, M. B., Porto, A. R., & Rodrigues, L. P. V. (2017). Ambiente de pediatria: aspectos que auxiliam no processo de trabalho e na produção de saúde. Rev. Enferm. UFPE on Line, 11(supl.12), 5275–5281.

Robin, S. G., Keller, C., Zwiener, R., Hyman, P. E., Nurko, S., Saps, M., Di Lorenzo, C., Shulman, R. J., Hyams, J. S., Palsson, O., & van Tilburg, M. A. L. (2018). Prevalence of Pediatric Functional Gastrointestinal Disorders Utilizing the Rome IV Criteria. The Journal of Pediatrics, 195, 134–139. https://doi.org/10.1016/j.jpeds.2017.12.012

Ronsoni, R. D. M., Pereira, C. C. de A., Stein, A. T., Osanai, M. H., & Machado, C. J. (2015). Avaliação de oito Protocolos Clínicos e Diretrizes Terapêuticas (PCDT) do Ministério da Saúde por meio do instrumento AGREE II: um estudo piloto. Cadernos de Saúde Pública, 31(6), 1157–1162. https://doi.org/10.1590/0102-311X00118814

Sandler, R. S., Jordan, M. C., & Shelton, B. J. (1990). Demographic and dietary determinants of constipation in the US population. American Journal of Public Health, 80(2), 185–189. https://doi.org/10.2105/AJPH.80.2.185

Santana, R. S., Lupatini, E. D. O., Zanghelini, F., Ronsoni, R. D. M., Rech, N., & Leite, S. N. (2018). The different clinical guideline standards in Brazil: High cost treatment diseases versus poverty-related diseases. PLoS ONE, 13(10), 1–12. https://doi.org/10.1371/journal.pone.0204723

Silva, M. de S., & Sabino Pinho, C. P. (2016). Constipação intestinal: prevalência e fatores associados em pacientes atendidos ambulatorialmente em hospital do Nordeste brasileiro. Nutrición Clínica y Dietética Hospitalaria, 36(1), 75–84. https://doi.org/10.12873/361sousa

Sim, J., & Wright, C. C. (2005). The Kappa Statistic in Reliability Studies : Use , Interpretation , and. Physical Therapy, 85(3), 257–268. http://www.ncbi.nlm.nih.gov/pubmed/15733050

Sood, M. (n.d.). Constipation in infants and children: Evaluation. UpToDate [Internet]. Waltham, MA: UpToDate Inc. Https://Www.Uptodate.Com [Acessado Em 05 Novembro 2019].

Talley, N J, Fleming, K. C., Evans, J. M., O’Keefe, E. A., Weaver, A. L., Zinsmeister, A. R., & Melton, L. J. (1996). Constipation in an elderly community: a study of prevalence and potential risk factors. The American Journal of Gastroenterology, 91(1), 19–25.

Talley, Nicholas J, O’Keefe, E. A., Zinsmeister, A. R., & Melton, L. J. (1992). Prevalence of gastrointestinal symptoms in the elderly: A population-based study. Gastroenterology, 102(3), 895–901. https://doi.org/10.1016/0016-5085(92)90175-X

Tooth, L. R., & Ottenbacher, K. J. (2004). The κ statistic in rehabilitation research: An examination11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the a. Archives of Physical Medicine and Rehabilitation, 85(8), 1371–1376. https://doi.org/10.1016/j.apmr.2003.12.002

van den Berg, M. M., Benninga, M. A., & Di Lorenzo, C. (2006). Epidemiology of Childhood Constipation: A Systematic Review. The American Journal of Gastroenterology, 101(10), 2401–2409. https://doi.org/10.1111/j.1572-0241.2006.00771.x

Wald, A., Scarpignato, C., Mueller-Lissner, S., Kamm, M. A., Hinkel, U., Helfrich, I., Schuijt, C., & Mandel, K. G. (2008). A multinational survey of prevalence and patterns of laxative use among adults with self-defined constipation. Alimentary Pharmacology & Therapeutics, 28:917. https://doi.org/10.1111/j.1365-2036.2008.03806.x

Whitehead, W. E., Drinkwater, D., Cheskin, L. J., Heller, B. R., & Schuster, M. M. (1989). Constipation in the Elderly Living at Home. Journal of the American Geriatrics Society, 37(5), 423–429. https://doi.org/10.1111/j.1532-5415.1989.tb02638.x

World Gastroenterology Organisation. (2010). Constipação: uma perspectiva mundial. In World Gastroenterology Organisation Practice Guidelines (pp. 2–13).




How to Cite

LIMA, B. F. R. .; ALVES, B. M. C. S. .; TAVARES, N. U. L. .; LIMA, R. F. .; GINANI, V. C. .; REIS, T. M. dos .; SANTANA, R. S. Quality appraisal of clinical guidelines for the management of constipation according to AGREE II instrument. Research, Society and Development, [S. l.], v. 11, n. 3, p. e57911327086, 2022. DOI: 10.33448/rsd-v11i3.27086. Disponível em: https://rsdjournal.org/index.php/rsd/article/view/27086. Acesso em: 19 jun. 2024.



Health Sciences