Epidemiology of constipation in children and adults: a systematic review

First-Day-of-Life Rectal Swabs Fail To Represent Meconial Microbiota Composition and Underestimate the Presence of Antibiotic Resistance Genes

The human gut microbiome plays a vital role in health and disease. In particular, the first days of life provide a unique window of opportunity for development and establishment of microbial community. Currently, stool samples are known to be the most widely used sampling approach for studying the gut microbiome. However, complicated sample acquisition at certain time points, challenges in transportation, and patient discomfort underline the need for development of alternative sampling approaches. One of the alternatives is rectal swabs, shown to be a reliable proxy for gut microbiome analysis when obtained from adults. Here, we compare the usability of rectal swabs and meconium paired samples collected from infants on the first days of life. Our results indicate that the two sampling approaches display significantly distinct patterns in microbial composition and alpha and beta diversity as well as detection of resistance genes. Moreover, the dissimilarity between the two collection methods was greater than the interindividual variation. Therefore, we conclude that rectal swabs are not a reliable proxy compared to stool samples for gut microbiome analysis when collected on the first days of a newborn's life. IMPORTANCE Currently, there are numerous suggestions on how to ease the notoriously complex and error-prone methodological setups to study the gut microbiota of newborns during the first days of life. Especially, meconium samples are regularly failing to yield meaningful data output and therefore have been suggested to be replaced by rectal swabs as done in adults as well. We find this development toward a simplified method to be producing dramatically erroneous results, skewing data interpretation away from the real aspects to be considered for neonatal health during the first days of life. We have put together our knowledge on this critical aspect with careful consideration and identified the failure of rectal swabs to be a replacement for sampling of meconium in term-born newborns.

Design of a phase 3, randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of prucalopride in pediatric patients with functional constipation

Background

A previous phase 3 trial of prucalopride in pediatric patients (6 months-18 years old) with functional constipation (FC) demonstrated no efficacy versus placebo. We designed an additional phase 3 trial to further assess the efficacy, long-term safety and tolerability of prucalopride in children and adolescents.

Methods

This multicenter trial (ClinicalTrials.gov identifier: NCT04759833; EudraCT number: 2022-003221-22) comprises a 12-week, randomized, double-blind, placebo-controlled phase, followed by a 36-week, double-blind, safety extension phase. Approximately 240 toilet-trained patients aged 3-17 years will be randomized 1:1:1 to receive low- (0.04 mg/kg) or high-dose (0.08 mg/kg) prucalopride, or placebo once daily. Fifteen non-toilet-trained patients ≥6 months old with FC will be included in an exploratory efficacy and safety analysis.

Discussion

The efficacy endpoints used in this study will differ from those used in adults and in the previous pediatric phase 3 trial; they have been adapted to be more suitable for a wider age range of pediatric patients. Both study phases will be longer than in the previous pediatric study, providing a longer time period in which to assess the efficacy and safety of prucalopride. Study participants will be identified using the modified Rome IV criteria for FC, instead of the Rome III criteria, and non-toilet-trained patients will be included, which will broaden the population of pediatric patients assessed. Patients will undergo fecal disimpaction before randomization and undergo standardized continuous behavioral therapy throughout the trial. This pediatric study of prucalopride will aim to demonstrate the efficacy and long-term safety of this treatment.

Defecation Habits in Preschoolers Are Associated with Physical Activity: A Cross-Sectional and Isotemporal Substitution Analysis

There is a lack of research on the relationship between defecation habits (DF) and physical activity (PA) in preschoolers. This study aimed to clarify the relationship between sedentary behaviour (SB), PA time, and DF in preschoolers and to estimate the effect of DF replacement in an isotemporal substitution (IS) model. The participants included 166 children (aged 4-6 years) attending childcare facilities. PA was measured using an accelerometer to calculate the daily activity and wearing time for SB, light-intensity physical activity (LPA), and moderate-to-vigorous-intensity physical activity (MVPA). DF were classified based on defecation frequency and timing. A multinomial logistic regression analysis was used for the IS model. One-way analysis of variance detected significant differences in MVPA between the DF groups (F(2) = 3.12, p < 0.05). According to the analysis results of the IS model, replacing 5 min of SB with MVPA resulted in improved DF (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.81-0.97). Conversely, replacing 5 min of MVPA with SB worsened DF (OR, 1.13; 95% CI, 1.03-1.23). The findings suggest that PA is associated with DF among preschoolers. It also indicates that replacing SB with MVPA could help improve DF in children.

Effect of constipation on acute urinary retention following transrectal prostate biopsy

PURPOSE

To evaluate the possible effect of constipation on the acute urinary retention (AUR) after transrectal ultrasound-guided prostate biopsy (TRUS PB).

MATERIALS AND METHODS

A total of 1,167 patients with prostate-specific antigen (PSA) >4 ng/mL and/or abnormal digital rectal examination underwent a standard 12 core transrectal ultrasound-guided prostate needle biopsy in our hospital and the findings were examined prospectively. Chronic constipation (CC) was defined according to the Rome IV criteria. All cases were well evaluated with respect to clinical-histopathological factors; International Prostate Symptom Score (IPSS), prostate volume, post-void residue, age, body mass index, histopathological inflammation, and AUR.

RESULTS

The mean age of patients was 64.63±8.31 years, the PSA level was 11.60±16.83 ng/mL, and the prostate volume was 54.66±25.44 mL. In 265 cases (22.7%), CC anamnesis was present and AUR developed in 28 (2.4%) of the cases. In the multivariate analysis for the risk of developing urinary retention, prostate volume, pre-operative IPSS, and presence of CC requiring manual maneuvers to facilitate defecation were found to be risk factors (p=0.023, 0.010, and 0.001, respectively).

CONCLUSIONS

Our findings demonstrated that CC may be a critical factor in the prediction of AUR formation following TRUS PB.

Interferential therapy for chronic constipation in adults: The CON-COUR randomizedcontrolled trial

BACKGROUND

Chronic constipation (CC) is a frequent condition, and the first-line treatment includes dietary rules, the use of laxatives, and biofeedback for evacuation disorders. However, almost half of the patients are dissatisfied with their current treatment. We report the first double-blind randomized multicenter trial assessing the effectiveness of transabdominal electrical stimulation by interferential therapy (IFT) in the treatment of CC in adults.

METHODS

A prospective, multicenter, randomized, double-blind, sham-controlled, parallel-group, phase 3 trial was conducted at 7 centers in France. The primary endpoint was 8-week efficacy as defined by the number of complete spontaneous bowel movements during the last 4 weeks of the 8-week stimulation period. Secondary endpoints included the evaluation of the effects of IFT on symptoms (Patient Assessment of Constipation Symptoms questionnair (PAC-SYM)), quality of life (QOL) (Patient Assessment of Constipation Quality of Life), Colonic transit time (CTT), anorectal manometry, and patient satisfaction.

RESULTS

The proportion of 8-week responders was not significantly different between the two groups (73.2% in the IFT group vs. 67.1% in the sham group). After 8 weeks of stimulation, the mean overall PAC-SYM score and the mean reduction in the overall PAC-SYM score were significantly greater in the IFT group than in the sham group. No differences were observed concerning CTT, anorectal manometry, or patient satisfaction.

CONCLUSIONS

Although the primary endpoint was not reached, IFT can significantly alleviate the symptoms and improve the QOL of CC patients. It can be assumed that new treatments require different modes of evaluation and that the assessment of patient-reported outcomes may become a priority among therapeutic targets of CC. Trial registration number NCT02381665.

Impact of the COVID-19 Pandemic on the Socioeconomic Inequality of Health Behavior Among Japanese Adolescents: A 2-Year Repeated Cross-Sectional Survey

BACKGROUND

Although disparities in socioeconomic status in health behaviors have been highlighted globally, they are not well understood in Japanese adolescents. The purpose of this study was to clarify the changes in socioeconomic disparities in adolescents' fundamental health behaviors, such as physical activity, screen time (ST), sleep, breakfast intake, and bowel movement before and during COVID-19.

METHODS

This was a repeated cross-sectional study which used data from the 2019 and 2021 National Sports-Life Survey of Children and Young in Japan. Data of 766 and 725 participants in 2019 and 2021, respectively, were analyzed. Favorable health behaviors were defined as daily moderate to vigorous physical activity (MVPA) of at least 60 minutes, ST of less than 2 hours, sleep of 8 to 10 hours, daily breakfast intake, and bowel movement frequency of at least once in every 3 days. We calculated the slope index of inequality and relative index of inequality in each health behavior for equivalent household income levels for assessing absolute and relative economic inequalities.

RESULTS

Compliance with MVPA and ST recommendation significantly declined from 20.1% and 23.0% in 2019 to 11.7% and 14.9% in 2021, respectively. The slope index of inequality and relative index of inequality increased in MVPA for income levels, but decreased in daily breakfast in 2019 to 2021. Although the widening and narrowing of the disparity were inconclusive for ST, it exacerbated for the higher-income groups.

CONCLUSIONS

Our study revealed widening of economic disparities in the achievement of recommended MVPA and narrowing of it in breakfast intake among adolescents before and during COVID-19.

Effect of Bacillus coagulans Unique IS2 with Lactulose on Functional Constipation in Adults: a Double-Blind Placebo Controlled Study

In the present double-blind randomised study, the efficacy of combination of Bacillus coagulans Unique IS2 and lactulose was evaluated in the treatment of functional constipation in adults. One-fifty participants diagnosed with functional constipation (Rome III criteria) were randomised (1:1:1) and supplemented daily with 15 mL suspension of probiotic (B. coagulans Unique IS2, 2 × 10⁹ spores) with lactulose (10 g) (group 1) or lactulose (10 g) (group 2) or placebo (water) (group 3) for 4 weeks. The primary (stool frequency) and secondary outome measures (stool consistency, sensation of incomplete evacuation, defecation- and abdominal-pain) were recorded weekly for up to 4 weeks. Bacillus coagulans Unique IS2 with lactulose showed significant changes in stool frequency as compared to lactulose treatment; however, at the end of the trial, it was found insignificant due to the gradual increase of stool frequency score of lactulose treatment. The changes observed in stool consistency were early (2nd week) and remained consistent up to end of the trial. The significant reduction of sensation of incomplete evacuation, defecation-, and abdominal-pain correlated with the strains ability to produce short-chain fatty acids. No adverse events were observed in any of the groups, and all the vital parameters were normal during the course of the study. Overall, results indicated that B. coagulans Unique IS2 addition to lactulose reduced time required to relieve constipation as compared to lactulose alone. In conclusion, B. coagulans Unique IS2 with lactulose is more effective than lactulose alone to relieve symptoms of constipation in a shorter period. Trial registration: CTRI/2018/11/016399, dated 22/11/2018.

Pediatric Bowel Management Options and Organizational Aspects

A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.

An Update of Pharmacological Management in Children with Functional Constipation

Functional constipation is a common problem in childhood worldwide and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. It is a clinical diagnosis based on the Rome IV criteria. Non-pharmacological treatment involves education, demystification, lifestyle advice, and toilet training. Pharmacological treatment consists of disimpaction, maintenance treatment, and eventually weaning if possible. Polyethylene glycol is considered as the first choice of laxative for both disimpaction and maintenance treatment. Different osmotic laxatives, stimulant laxatives, lubricants, and enemas are available as alternative pharmacological treatment options. Novel drugs are emerging but evidence to support the widespread application of these drugs in the pediatric population is often lacking and more high-quality research is needed in this field. If children remain symptomatic despite optimal pharmacological treatment, botulinum toxin injections in the anal sphincter can be considered as an alternative, more invasive treatment option. This review provides an update on currently available literature concerning the pharmacologic treatment of functional constipation in children.

Inter and Intraobserver Variation in Interpretation of Fecal Loading on Abdominal Radiographs

OBJECTIVES

The current gold standard for the diagnosis of functional constipation is the ROME IV criteria. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology & Nutrition (NASPGHAN) guidelines do not support the use of abdominal X-rays in establishing the diagnosis of constipation. Despite these recommendations, abdominal radiography is frequently performed to diagnose constipation. The objective of our study is to evaluate inter and intraobserver variation in interpretation of fecal loading on abdominal radiographs.

METHODS

Electronic records of 100 children seen in the emergency room for gastrointestinal symptoms who had an abdominal radiograph performed were included. Four physicians from each specialty including gastroenterology, radiology, and emergency medicine interpreted the radiographs independently. Initially, subjective interpretations, followed by interpretations for intraobserver variation were obtained. Subsequently, all physicians were trained and asked to score the X-rays objectively using Barr and Blethyn scoring systems. Consistency between inter and intraobserver ratings of radiographic interpretation was evaluated using the Kappa coefficient ( k ) which ranges from 0 (no agreement) to 1.0 (perfect agreement).

RESULTS

For subjective interpretations, k values showed a fixed margin k of 0.18 indicating poor agreement among 12 observers. Intraobserver k to look for reproducibility showed significant variability ranging from 0.08 (poor) to 0.61 (fair) agreement. Objective scoring results for Blethyn showed a k of 0.14 indicating poor agreement among 12 providers.

CONCLUSIONS

Reliability and reproducibility of X-rays for diagnosis and grading of constipation is questionable given poor to fair agreement for both inter and intraobserver comparisons. Our study supports the current recommendation of ESPGHAN and NASPGHAN to not use abdominal X-rays to diagnose constipation.

A. macrocephala polysaccharide induces alterations to gut microbiome and serum metabolome in constipated mice

Atractylodes macrocephala polysaccharide (AC1) is extracted from the root of the Chinese herb Atractylodes Macrocephala and is used in the treatment of constipation due to its effects on strengthening cellular immunity and regulating intestinal function. In this study, Metagenomics and Metabolomic are used to analyze the effects of AC1 on the gut microbiota and host metabolites in mice models of constipation. The results show that the abundance of Lachnospiraceae_bacterium_A4, Bact-oides_vulgatus and Prevotella_sp_CAG:891 increased significantly, indicating that AC1-targeted strain modulation effectively alleviated the dysbiosis of the gut microbiota. Besides, the microbial alterations also influenced the metabolic pathways of the mice, including tryptophan metabolism, unsaturated fatty acid synthesis and bile acid metabolism. The physiological parameters of the mice treated with AC1 are improved, such as tryptophan in the colon, 5-hydroxytryptamine (5-HT) and short-chain fatty acids (SCFAs). In conclusion, AC1 as a probiotic can regulate intestinal flora to normal levels and achieve the effect of treating constipation.

Functional constipation as a risk factor for pyelonephritis and recurrent urinary tract infection in children

AIM

Acute pyelonephritis is one of the most common bacterial infections in childhood. This potentially serious condition can lead to renal scarring, loss of kidney function and hypertension. The aim of this study was to identify risk factors associated with pyelonephritis in children without kidney or urinary tract abnormalities.

METHODS

Medical records of children aged 4-18 diagnosed with 1st time pyelonephritis from 2016 to 2021 were retrospectively analysed. Children with abnormal kidney ultrasound were excluded. In addition to demographic data, information on bladder and bowel function was extracted together with habits of fluid intake.

RESULTS

A total of 105 patients were diagnosed with 1st time pyelonephritis. Of these, 47% were diagnosed with constipation according to the Rome IV criteria within a mean follow-up period of 167 days after their pyelonephritis, which is markedly higher than the estimated prevalence of constipation in the background population. Constipation was positively associated with recurrent urinary tract infection (p = 0.01).

CONCLUSION

Constipation is associated with pyelonephritis and recurrent urinary tract infection in children (primarily girls) 4-18 years of age without evident kidney or urinary tract abnormalities. We recommend systematic evaluation of bowel and bladder function after 1st time pyelonephritis in all children >4 years.

Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study

BACKGROUND

When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization.

METHODS

We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori.

KEY RESULTS

One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications.

CONCLUSIONS AND INFERENCES

Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.

Aberrant intrinsic functional brain networks in patients with functional constipation

PURPOSE

Patients with functional constipation (FCon) often suffer from mental and psychological problems. To explore the possible neurological interaction, we used resting-state functional magnetic imaging (RS-fMRI) to compare the alterations in intrinsic brain functional networks at multiple levels between patients with FCon and healthy controls (HC).

METHODS

Twenty-eight patients with FCon and twenty-nine HC were recruited for a series of examinations and RS-fMRI. Both graph theory analysis and functional connectivity (FC) analysis were used to investigate brain functional alterations between the two groups. Correlation analyses were performed among neuropsychological scores, clinical indexes, and neuroimaging data.

RESULTS

Compared with the HC, the assortativity showed significantly increased in global level in patients with FCon. In regional level, we found obviously increased nodal degree and nodal efficiency in somatosensory network (SMN), decreased nodal degree, and increased nodal efficiency in default mode network (DMN) in the FCon group. Furthermore, FC analysis demonstrated several functional alterations within and between the networks, particularly including the SMN and visual network (VN) in sub-network and large-scale network analysis. Moreover, correlation analysis indicated that nodal metrics and aberrant FC among functional brain networks were associated with emotion and scores of constipation in patients with FCon.

CONCLUSION

All these findings reflect the differences in intrinsic brain functional networks between FCon and HC. Our study highlighted SMN, DMN, and VN as critical network and may be involved in the neurophysiology of FCon, which may contribute to improve personalized treatment in patients with FCon.

The Uniformed Services Constipation Action Plan: An Effective Tool for the Management of Children with Functional Constipation

OBJECTIVE

To implement and to evaluate the effectiveness of the Uniformed Services Constipation Action Plan (USCAP) in our gastroenterology clinic for children with functional constipation.

STUDY DESIGN

This implementation science study included toilet-trained subjects aged 4 years and older who met the Rome IV criteria for functional constipation. Children were block randomized to receive either the USCAP or control. All clinic functional constipation plans recommended subjects continue pharmacotherapy for 4 months. Endpoints measured were clinical outcomes (resolution of functional constipation and achievement of a Pediatric Bristol Stool Form Scale [PBSFS] score of 3 or 4), patient-related outcomes (health-related quality of life [HRQoL] total scale score), and health confidence outcomes (Health Confidence Score [HCS]).

RESULTS

Fifty-seven treatment group subjects (44%) received a USCAP (52% male; mean age, 10.9 [4.9] years) compared with 73 controls (56%; 48% male; mean age,10.9 [5.3] years). A PBSFS score of 3 or 4 was achieved by 77% of the treatment group compared with 59% of controls (P = .03). Subjects from the treatment group were more likely than the controls to endorse adherence to the 4-month course of pharmacotherapy (P < .001). Subjects who received a USCAP had greater improvements in HRQoL total scale score by the end of the project (P = .04).

CONCLUSIONS

The USCAP is a simple, inexpensive tool that has the potential to improve global outcomes for functional constipation in children and should be recommended as standard clinical practice.

The role of rectal ultrasound in children with functional constipation

AIM

The study aimed primarily to compare the transverse rectal diameter in children with functional constipation (FC) and children without constipation in different age groups, and between cases of constipation at baseline and after treatment. Secondary aim was to determine factors that could affect the transverse rectal diameter.

METHODS

A controlled prospective study, including a total of 100 children between the ages of 2 and 11 years, who were divided into 50 patients suffering from constipation according to Rome IV criteria and 50 age- and sex-matched controls. Transverse rectal diameter was measured at presentation, and after 3 months of laxative therapy and behavioural modification.

RESULTS

Initial rectal diameter was significantly different between cases (3.55 cm (interquartile range, IQR), 3.2-4) and controls (2.3 cm (IQR, 1.8-2.5)), P value < 0.001, and it was also significantly different between those above and below 4 years, so a separate cut-off point for diagnosis of constipation was suggested being >3 cm for the former and >2.5 cm for the latter. After 3 months of follow-up, rectal diameter significantly reduced to become 2.6 (IQR, 2-2.8), P value < 0.001. Duration of symptoms positively correlated with rectal diameter.

CONCLUSIONS

Ultrasound measurement of rectal diameter is an important tool to diagnose and follow-up functional constipation in children. Different values of rectal diameter are found between those above and below 4 years of age.

Nutritional and lifestyle management of the aging journey: A narrative review

With age, the physiological responses to occasional or regular stressors from a broad range of functions tend to change and adjust at a different pace and restoring these functions in the normal healthy range becomes increasingly challenging. Even if this natural decline is somehow unavoidable, opportunities exist to slow down and attenuate the impact of advancing age on major physiological processes which, when weakened, constitute the hallmarks of aging. This narrative review revisits the current knowledge related to the aging process and its impact on key metabolic functions including immune, digestive, nervous, musculoskeletal, and cardiovascular functions; and revisits insights into the important biological targets that could inspire effective strategies to promote healthy aging.

Latilactobacillus sakei Furu2019 and stachyose as probiotics, prebiotics, and synbiotics alleviate constipation in mice

Introduction

Slow transit constipation (STC) is a common disorder in the digestive system. This study aimed to evaluate the effects of stachyose (ST) and Latilactobacillus sakei Furu 2019 (L. sakei) alone or combined on diphenoxylate-induced constipation and explore the underlying mechanisms using a mouse model.

Methods

ICR mice were randomly divided into five groups. The normal and constipation model groups were intragastrically administrated with PBS. The ST, L. sakei, and synbiotic groups were intragastrically administrated with ST (1.5 g/kg body weight), alive L. sakei (3 × 10⁹ CFU/mouse), or ST + L. sakei (1.5 g/kg plus 3 × 10⁹ CFU/mouse), respectively. After 21 days of intervention, all mice except the normal mice were intragastrically administrated with diphenoxylate (10 mg/kg body weight). Defecation indexes, constipation-related intestinal factors, serum neurotransmitters, hormone levels, short-chain fatty acids (SCFAs), and intestinal microbiota were measured.

Results

Our results showed that three interventions with ST, L. sakei, and synbiotic combination (ST + L. sakei) all alleviated constipation, and synbiotic intervention was superior to ST or L. sakei alone in some defecation indicators. The RT-PCR and immunohistochemical experiment showed that all three interventions relieved constipation by affecting aquaporins (AQP4 and AQP8), interstitial cells of Cajal (SCF and c-Kit), glial cell-derived neurotrophic factor (GDNF), and Nitric Oxide Synthase (NOS). The three interventions exhibited a different ability to increase the serum excitatory neurotransmitters and hormones (5-hydroxytryptamine, substance P, motilin), and reduce the serum inhibitory neurotransmitters (vasoactive intestinal peptide, endothelin). The result of 16S rDNA sequencing of feces showed that synbiotic intervention significantly increased the relative abundance of beneficial bacteria such as Akkermansia, and regulated the gut microbes of STC mice. In conclusion, oral administration of ST or L. sakei alone or combined are all effective to relieve constipation and the symbiotic use may have a promising preventive effect on STC.

Interdisciplinary Occupational and Physical Therapy Approach to Treating Constipation and Fecal Incontinence in Children

AIMS

This case series was completed to determine the effectiveness of an interdisciplinary (occupational and physical therapy) approach to treating constipation and fecal incontinence in children. Non-pharmacological therapies for treating constipation and incontinence are showing potential benefits, especially for children not responding to standard medical treatment, which involves oral laxatives for fecal dis-impaction (cleanout) and maintenance dosing to prevent further impaction.

METHODS

A retrospective chart review, surface electromyography (sEMG) biofeedback, and parent and child reports of progress was completed for two children ages 4 and 10 years old. Progress toward goals was measured using a therapy plan of care and progress updates every 60 days. Focus of goals included, pelvic floor muscle coordination and activation, education of anatomy and physiology of digestive system, emotional regulation, functional training in the bathroom, and hygiene.

RESULTS

Notable improvements in pelvic floor function, emotional regulation, and defecation dynamics contributed to decreased constipation and fecal incontinence as well as improved emotional regulation and confidence in both participants over a 6-month period.

CONCLUSION

A coordinated physical therapy and occupational therapy approach to treating children with constipation and fecal incontinence can be successful in reaching full continence and support children have not responded to standard medical treatment.

Associations between functional constipation and non-IgE-mediated food allergy in infants and children

BACKGROUND

The non-IgE-mediated food allergy (non-IgE-FA) is less prevalent than IgE-mediated food allergy, and their relationship with functional constipation (FC) needs to be clarified.

METHODS

A total of 305 infants and children with constipation treated in the Department of Pediatric Gastroenterology, Children's Hospital of Nanjing Medical University, from July 2020 to December 2021 were included in this study. Four cases with organic lesions were excluded. Among 301 diagnosed with FC, according to ROME IV criteria, 81 cases with allergy-related indicators were further evaluated for food allergy by food-specific IgG antibody test, allergen- specific IgE antibody detection, skin prick test, and food avoidance and reintroduction.

RESULTS

A total of 45 cases with FC were diagnosed with food allergy, and the incidence rate was 15%. Among the 45 patients, 35 cases (77.8%) had FC with non-IgE-FA. The main clinical symptoms or signs included anal fissure, abdominal pain, and pain during defecation. The most prevalent allergic foods were cow's milk, eggs, fish, and shrimp. Ten (22.2%) cases reported FC with mixed food allergy, including both non-IgE-mediated and IgE-mediated food allergy. This study focused on non-IgE-mediated food allergy-related FC.

CONCLUSION

Our results showed that the incidence of food allergy in infants and children with FC was 15%, which was mainly mediated by non-IgE-FA. The main clinical symptoms or signs in these cases included anal fissure, abdominal pain, and pain during defecation, and the main allergens included milk, eggs, fish, and shrimp.

Regional and seasonal variations in functional abdominal pain and functional constipation prevalence among Saudi children

Objectives:

This study aimed to evaluate functional abdominal pain disorders and functional constipation prevalence in the central region of Saudi Arabia, and compare it to that of the western region.

Methods:

This was a cross-sectional study using online questionnaires targeting the general population of Riyadh region of Saudi Arabia. Subjects were randomly selected by sharing links on social media groups. Any parent with a 3–18-year-old child was included, and children with chronic medical illnesses or symptoms of organic GI disorders were excluded.

Results:

Three hundred nineteen subjects were included in the final analysis; the prevalence of functional abdominal pain disorders overall was 6.2% and the prevalence of functional constipation was 8.1%.

Conclusions:

Functional constipation diagnosis seems to be affected by life stressors or a previous viral illness. Seasonal variations had minimal effect on functional abdominal pain disorder and functional constipation symptom frequency and severity.

Advancing human gut microbiota research by considering gut transit time

Accumulating evidence indicates that gut transit time is a key factor in shaping the gut microbiota composition and activity, which are linked to human health. Both population-wide and small-scale studies have identified transit time as a top covariate contributing to the large interindividual variation in the faecal microbiota composition. Despite this, transit time is still rarely being considered in the field of the human gut microbiome. Here, we review the latest research describing how and why whole gut and segmental transit times vary substantially between and within individuals, and how variations in gut transit time impact the gut microbiota composition, diversity and metabolism. Furthermore, we discuss the mechanisms by which the gut microbiota may causally affect gut motility. We argue that by taking into account the interindividual and intraindividual differences in gut transit time, we can advance our understanding of diet-microbiota interactions and disease-related microbiome signatures, since these may often be confounded by transient or persistent alterations in transit time. Altogether, a better understanding of the complex, bidirectional interactions between the gut microbiota and transit time is required to better understand gut microbiome variations in health and disease.

Women with functional constipation have a worse ability to relax their pelvic floor muscle: A cross sectional study

INTRODUCTION

Functional intestinal constipation (FIC) has a high prevalence worldwide. It is higher in adult and elderly women, and in those with alterations in the pelvic floor muscle (PFM) structure and function.

OBJECTIVE

The primary aim of this study was to characterize PFM function, including tone, of women with and without FIC. The secondary aim was to assess and compare the general and symptom-related quality of life (QoL) between participants with and without FIC and its correlation with the assessed PFM function.

METHODS

This was a cross-sectional observational study, the outcomes were assessed using vaginal palpation, vaginal manometry and validated questionnaires: the Pelvic Floor Impact Questionnaire Short Form 7 (PFIQ-7), the Pelvic Floor Distress inventory (PFDI-20), and the Short-Form Health Survey (SF-36). This study included 60 women, 30 with FIC and 30 without FIC. The mean age of women with FIC was 48.2 years (standard deviation [SD] 12.22) and 51 years (SD 13.47) for those without FIC. Both groups were overweight. There was a significant difference between groups in the bowel domain of the PFIQ-7 (p = 0.016) and in the anal dysfunction domain of the PFDI-20 (p < 0.001), being higher in those women with FIC. Women with FIC presented a significantly worse ability to voluntarily relax their PFM (38.3%) than those without FIC (11.7%; p = 0.008). participants without FIC presented higher values of maximum voluntary contraction (MVC) assessed by vaginal manometry compared to participants without FIC (p = 0.008). PFM tone was not different between groups.

CONCLUSION

Women with FIC have more difficulty in relaxing their PFM and lower MVC values than women without FIC. FIC negatively impacts women's symptom-related QoL. The main contribution of this study was to reavel the difficulty of the participants with FIC to relax their PFM. This finding is important to guide clinical decision making for an adequate treatment program direct to women with FIC.

Evaluation of the effects of the toilet training process on the children's quality of life

BACKGROUND

Toilet training is a significant developmental milestone for children. During the process of toilet training, voiding and defecation problems may develop, which have a major adverse impact on the child's quality of life (QoL). The aim of this study was to assess voiding and defecation problems in the process of toilet training and evaluate how these issues influenced the children's QoL.

METHODS

The children included in the study were followed up at the Department of Social Pediatrics, Ankara University School of Medicine. Participants were surveyed via a questionnaire that included sociodemographic features, the toilet training process, and the Pediatric Quality of Life Inventory.

RESULTS

The study included 177 children and their parents. There was no correlation between the parents' age, sociodemographic features, or the timing of the start of toilet training. Voiding problems were found in 55.6% and defecation problems in 23.6% of the children included in the study. Urinary retention during play and nocturnal enuresis were more frequent in the children toilet trained at 25-36 months of age. The self-reported QoL scores in children with voiding problems and with both voiding and defecation problems were lower than those in children did not have any problems.

CONCLUSIONS

Even if a child has been toilet trained, it is essential to investigate daily urination and defecation habits at every follow-up visit and to discuss with families when a physician should be consulted.

Fecal continence disparities in patients with idiopathic constipation treated at referral institutions for pediatric colorectal surgery

PURPOSE

Fecal continence is a concern for many patients with idiopathic constipation and can significantly impact quality of life. It is unknown whether racial, ethnic, and socioeconomic disparities are seen in fecal continence within the idiopathic constipation population. We aimed to evaluate fecal continence and associated demographic characteristics in children with idiopathic constipation referred for surgical evaluation.

METHODS

A multicenter retrospective study of children with idiopathic constipation was performed at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). All patients >3y of age with idiopathic constipation diagnosis were included. The primary outcome was fecal continence, categorized as complete (no accidents ever), daytime (no accidents during the day), partial (occasional incontinence day/night), and none (incontinent). We evaluated for associations between fecal continence and race, sex, age, insurance status, and other patient-level factors, employing Kruskal-Wallis and trend tests.

RESULTS

458 patients with idiopathic constipation from 12 sites were included. The median age of diagnosis was 4.1 years. Only 25% of patients referred for surgical evaluation were completely continent. Age at the visit was significantly associated with fecal continence level (p = 0.002). In addition, patients with public and mixed public and private insurance had lower levels of continence (p<0.001). Patients with developmental delay were also more likely to have lower continence levels (p = 0.009) while diagnoses such as anxiety, ADD/ADHD, autism, depression, obsessive-compulsive disorder were not associated. Approximately 30% of patients had an ACE operation (antegrade continence enema) at a median age of 9.2 years at operation. Black patients were significantly less likely to undergo ACE operation (p = 0.016) when compared to white patients.

CONCLUSION

We observed data that suggest differences in fecal incontinence rates based on payor status. Further investigation is needed to characterize these potential areas of disparate care.

LEVEL OF EVIDENCE

Level III.

Efficacy and safety of Shouhui Tongbian Capsules in the treatment of constipation: A systematic review and meta-analysis

BACKGROUND

Constipation is a common gastrointestinal disorder, which has seriously affected the quality of people's daily life. Traditional Chinese Medicine (TCM) therapy takes syndrome differentiation and treatment as the theoretical guidance with certain advantages in treating constipation with the holistic approach. However, there are few studies on the treatment of constipation with Shouhui Tongbian Capsules (SHTB).

PURPOSE

This study was aimed to evaluate the clinical effect and safety of SHTB in the treatment of constipation and provide evidence-based references for clinical application.

STUDY DESIGN

A systematic review and meta-analysis of existing literature on SHTB for treating constipation.

METHODS

Chinese databases (China Network Knowledge Infrastructure, Wan Fang Database and Chinese Scientific Journal Database) and English databases (PubMed, EmBase and the Cochrane Library) were thoroughly investigated through screening randomized controlled trials on SHTB for constipation from the establishment of all databases to September 26, 2022. Data extraction and quality evaluation were performed on the literature that met the inclusion criteria and a meta-analysis was performed for selected data using Review Manager 5.4, ROB 2.0 and Stata 17.0.

RESULTS

A total of 14 RCTs (randomized controlled trial) including 1310 participants were included in the analysis. The results showed that the test group was superior to the control group in improving the total effective rate and curative effect, clinical symptom score, gastrointestinal peptide index and reducing adverse reactions and recurrence rate. The specific results were as follows: ① The total effective rate increased significantly (RR = 1.24, 95% CI [1.18, 1.30], Z = 8.25, p< 0.00001); ② The clinical symptom indexs, including the difficulty of defecation [SMD = -1.28, 95% CI (-1.44, -1.12), Z = 15.65, p< 0.00001], the frequency of spontaneous defecation [SMD = 1.28, 95% CI (1.01, 1.54), Z = 9.52, p< 0.00001], defecation interval [SMD = -1.47, 95% CI (-1.68, -1.26), Z = 13.79, p < 0.00001], incomplete defecation [SMD = -1.34, 95% CI (-1.57, -1.11), Z = 11.42, p < 0.00001], duration of defecation [SMD = -2.02, 95% CI (-2.39, -1.65), Z = 10.73, p < 0.00001], stool characteristics [SMD = -2.30, 95% CI (-2.60, -1.99), Z = 14.72, p< 0.00001] and TCM main syndrome scores [SMD = -1.25, 95% CI (-1.46, -1.05), Z = 11.79, p< 0.00001] increased observably; ③ The gastrointestinal peptide hormone indexs, including MTL Level [SMD = 0.43, 95% CI (0.24, 0.62), Z = 4.44, p < 0.00001] and SP Level [RR =0.57, 95% CI (0.37, 0.87), Z = 2.61, p = 0.009] were improved obviously; ④ The incidence of adverse reactions (RR = 0.57, 95% CI [0.37, 0.87], Z = 2.61, p = 0.009) and recurrence rate (RR = 0.31, 95% CI [0.18, 0.54], Z = 4.28, P <0.001) reduced significantly. Sensitivity analysis showed that there was no significant change in all outcome indicators, which suggested that the results of meta-analysis were relatively stable. Funnel plot and Egger test results showed that the literature included in the study might have publication bias.

CONCLUSION

SHTB can be used to treat functional constipation, especially elderly functional constipation, constipation caused by tumor chemotherapy and disease concomitant constipation. The optimal dosage of SHTB was 0.70 g (2 capsules) each time, 3 times a day, for 28 days. Combined with basic treatment, lactose oral solution, mosaic or castor oil could improve the total effective rate, clinical symptom indicators, gastrointestinal peptide hormone indicators and reduce adverse reaction rate of patients. However, due to the limitations of the included clinical trials, high-quality clinical trials with long follow ups are needed to evaluate the effectiveness and safety of SHTB in treating different types of constipation.

Total laryngectomy increases the risk of chronic constipation: a cross-sectional study of 50 patients

PURPOSE

Due to difficulties in breath holding, patients who undergo total laryngectomy may be prone to the development of chronic constipation. However, few reports have described chronic constipation in laryngectomized patients, and no report has described prevalence in patients who have undergone total pharyngolaryngectomy.

METHODS

We conducted a cross-sectional study to investigate the prevalence of chronic constipation after laryngectomy and evaluated the relationship between patient characteristics and chronic constipation. Information on patient characteristics and the details of surgery were obtained from medical records and an original questionnaire survey in 50 patients.

RESULTS

The prevalence of chronic constipation after laryngectomy was high, at 36%, with 18 cases. Patients who received total laryngectomy were significantly more likely to have chronic constipation than those who received total pharyngolaryngectomy (47.1% vs 12.5%, P = 0.026), who had a similar prevalence to the general public. Furthermore, the period from surgery to survey was significantly shorter in the constipation group than in the no constipation group (P = 0.043).

CONCLUSIONS

The prevalence of chronic constipation in patients who had undergone laryngectomy for head and neck cancer was high, particularly in patients who received total laryngectomy and in those with only a short period since surgery.

Gut microbiota: a new avenue to reveal pathological mechanisms of constipation

Constipation is very pervasive all over the world. It is a common multifactorial gastrointestinal disease, and its etiology and pathomechanism are not completely clear. Now, increasing evidence shows that intestinal flora is closely related to constipation. Intestinal flora is the largest microbiota in the human body and has powerful metabolic functions. Intestinal flora can produce a variety of metabolites, such as bile acids, short-chain fatty acids, tryptophan metabolites, and methane, which have important effects on intestinal motility and secretion. The host can also monitor the intestinal flora and regulate gut dysbacteriosis in constipation. To explore the relationship between intestinal flora and host, the combination of multiomics technology has become the powerful and effective method. Furthermore, the homeostasis restoration of intestinal flora also provides a new strategy for the treatment of constipation. This review aims to explore the interaction between intestinal flora and host in constipation, which contributes to disclose the pathogenesis of constipation and the development of novel drugs for the treatment of constipation from the perspective of intestinal flora. KEY POINTS: • This review highlights the regulation of gut microbiota on the intestinal motility and secretion of host. • The current review gives an insight into the role of the host on the recognition and regulation of intestinal ecology under constipation. • The article also introduces some novel methods of current gut microbiota research and gut microbiota-based constipation therapies.

Integrated metagenomics and targeted-metabolomics analysis of the effects of phenylalanine on loperamide-induced constipation in rats

Functional constipation is a common functional gastrointestinal disease. In our previous study, we found that the gut microbiota structure was disordered and the level of phenylalanine (Phe) in serum was decreased in constipated women. We conducted the present study to elucidate the role of Phe in remodeling the composition of gut microbiota and the relationship between gut microbiota and serum metabolites. Here, we demonstrated that Phe treatment significantly enhanced intestinal motility, suppressed inflammatory responses, and prevented intestinal barrier damage in rats with loperamide (Lop)-induced constipation. By metagenomic sequencing, the disbalanced gut microbial profile was analyzed in constipated rats. Phe treatment reversed changes in the abundance of several gut bacteria at the phylum, genus, and species levels. Further, we observed distinct metabolic patterns in constipated rats through targeted metabolomics and identified constipation-related gut microbial species linked to changes in circulating neurotransmitter metabolites. The abundances of species s_Lactobacillus murinus, s_Enterococcus italicus, s_Lactobacillus animalis, s_Lactobacillus apodemi, s_Enterococcus faecalis, and s_Lactobacillus backii were positively correlated with L-asparagine, L-Glutamic acid, Putrescine, and Spermidine levels. The abundances of s_Lactobacillus johnsonii and s_Butyricimonas virosa were negatively correlated with L-asparagine, L-Glutamic acid, Putrescine, and Spermidine levels. Taken together, our findings suggest that Phe can ameliorate the development of Lop-induced constipation in rats by remodeling the gut microbial community structure and changing metabolite levels.

Age- and Gender-Based Differences in Anorectal Function, Gastrointestinal Symptoms, and Constipation-Specific Quality of Life in Patients with Chronic Constipation

BACKGROUND

The effect of age and gender differences on anorectal function, symptoms severity, and quality of life (QoL) in patients with chronic constipation (CC) is not well studied. This study examines the impact of age and gender on anorectal function testing (AFT) characteristics, symptoms burden, and QoL in patients with CC.

METHODS

This is a retrospective analysis of prospectively collected data from 2550 adults with CC who completed AFT. Collected data include demographics, sphincter response to simulated defecation during anorectal manometry (ARM), balloon expulsion testing (BET), and validated surveys assessing constipation symptoms and QoL. DD was defined as both the inability to relax the anal sphincter during simulated defecation and an abnormal BET.

RESULTS

2550 subjects were included in the analysis (mean age = 48.6 years). Most patients were female (81.6%) and Caucasian (82%). 73% were < 60 years old (mean = 41) vs. 27% ≥ 60 years old (mean = 69). The prevalence of impaired anal sphincter relaxation on ARM, abnormal BET, and DD in patients with CC was 48%, 42.1%, and 22.9%, respectively. Patients who were older and male were significantly more frequently diagnosed with DD and more frequently had impaired anal sphincter relaxation on ARM, compared to patients who were younger and female (p < 0.05). Conversely, CC patients who were younger and female reported greater constipation symptoms severity and more impaired QoL (p ≤ 0.004).

CONCLUSION

Among patients with CC referred for anorectal function testing, men and those older than 60 are more likely to have dyssynergic defecation, but women and patients younger than 60 experience worse constipation symptoms and QoL.

A clinical study to observe the efficacy and safety of Besunyen Detox Tea for constipation

INTRODUCTION

Functional constipation (FC) is a common functional gastrointestinal disease and is one of the most common outpatient diseases. The purpose of this study was to investigate the efficacy and safety of the traditional Chinese medicine Besunyen Detox Tea (BDT) for FC and to compare the effect of BDT between constipation patients with and non-dryness-heat syndrome.

METHODS AND ANALYSIS

This multicenter, prospective, observational registry study included 1000 participants diagnosed with FC. This study will collaborate with 3 comprehensive hospitals and 15 community hospitals and recruit patients into the registry between July 2022 and July 2023. After enrollment, we will collect the individual characteristics of each patient, anthropometric data and general condition, bowel movement, patient assessment of constipation symptoms, patient assessment of constipation quality of life, TCM syndrome scale, and time to take the laxative product again after treatment. We will also record adverse events and economic indicators at each visit.

DISCUSSION

This is the first registry-based study to collect real-world data of participants diagnosed with FC receiving BDT treatment. The results of this registry may also reflect these characteristics and provide direct clinical evidence to verify the importance of syndrome differentiation and treatment for the use of TCM health care products.

Effect and mechanism of functional compound fruit drink on gut microbiota in constipation mice

Compound fruit drink (CFD) is a functional drink prepared with fruit, Chinese herbs and prebiotic fructooligosaccharide as the main ingredients. Loperamide hydrochloride was used to establish a mouse model of constipation. And the effect of CFD on the improvement of constipation and the impact on gut microbiota were studied. The results showed that CFD significantly enhanced intestinal motility in constipated mice (P < 0.05). It significantly improved serum levels of gastrointestinal regulatory-related peptides, elevated the short-chain fatty acids (SCFAs) content and alleviated colonic injury. Meanwhile, CFD also up-regulated the mRNA expression levels of AQP3, AQP9, SCF and c-Kit and the related protein expression levels. Fecal microbial results showed that the CFD medium-dose group significantly increased species richness. Furthermore, CFD increased the abundance of potentially beneficial bacteria and reduced the number of potentially pathogenic bacteria. This study indicated that CFD was a promising functional drink for effectively relieving constipation.

Childhood constipation: Current status, challenges, and future perspectives

Constipation in children is a major health issue around the world, with a global prevalence of 9.5%. They present to clinicians with a myriad of clinical signs. The Rome IV symptom-based criteria are used to diagnose functional constipation. Functional constipation is also a huge financial burden for healthcare system and has a detrimental impact on health-related quality of life of children. There are various risk factors identified globally, including centrally connected factors such as child abuse, emotional and behavioral issues, and psychological stress. Constipation is also precipitated by a low-fiber diet, physical inactivity, and an altered intestinal microbiome. The main pathophysiological mechanism is stool withholding, while altered rectal function, anal sphincter, pelvic floor, and colonic dysfunction also play important roles. Clinical evaluation is critical in making a diagnosis, and most investigations are only required in refractory patients. In the treatment of childhood constipation, both nonpharmacological (education and de-mystification, dietary changes, toilet training, behavioral interventions, biofeedback, and pelvic floor physiotherapy), and pharmacological (osmotic and stimulant laxatives and novel drugs like prucalopride and lubiprostone) interventions are used. For children with refractory constipation, transanal irrigation, botulinum toxin, neuromodulation, and surgical treatments are reserved. While frequent use of probiotics is still in the experimental stage, healthy dietary habits, living a healthy lifestyle and limiting exposure to stressful events, are all beneficial preventive measures.

Pediatric Tuina for functional constipation in children: study protocol for a randomized controlled trail

BACKGROUND

Functional constipation (FC) is a common functional gastrointestinal disorder, which brings many negative impacts to the children's daily life. Pediatric Tuina has been proved to be a potential therapy for FC. However, the evidence for its effectiveness and safety is insufficient due to the lack of high-quality study. This study aims to evaluate the efficacy and safety of pediatric Tuina for children with FC.

METHODS/DESIGN

This study is a randomized, controlled, multicentre, clinical trial. We will include 176 children with FC from five hospitals. The participants will be randomly allocated into two groups: the pediatric Tuina group and the Medilac-Vita group. This study will include a 1-week actual treatment period and a 2-week follow-up period. Primary outcomes are weekly spontaneous bowel movements and weekly complete spontaneous bowel movements. The secondary outcomes are effective rate, stool form, distress sensation, and glycerine enema rate. The assessment will be performed each week. Adverse event will be monitored in the treatment period and follow-up period.

DISCUSSION

This study is designed to evaluate the efficacy and safety of pediatric Tuina for children with FC, and we hypothesize that pediatric Tuina is more effective than probiotics. It will provide reliable evidence and support for the treatment of FC by pediatric Tuina.

TRIAL REGISTRATION

This protocol was registered in the Chinese Clinical Trial Registry (ChiCTR2100046485). .

Colonic volume in patients with functional constipation or irritable bowel syndrome determined by magnetic resonance imaging

BACKGROUND

Functional constipation (FC) and irritable bowel syndrome constipation type (IBS-C) share many similarities, and it remains unknown whether they are distinct entities or part of the same spectrum of disease. Magnetic resonance imaging (MRI) allows quantification of intraluminal fecal volume. We hypothesized that colonic volumes of patients with FC would be larger than those of patients with IBS-C, and that both patient groups would have larger colonic volumes than healthy controls (HC).

METHODS

Based on validated questionnaires, three groups of participants were classified into FC (n = 13), IBS-C (n = 10), and HC (n = 19). The colonic volume of each subject was determined by MRI. Stool consistency was described by the Bristol stool scale and colonic transit times were assessed with radiopaque makers.

KEY RESULTS

Overall, total colonic volumes were different in the three groups, HC (median 629 ml, interquartile range (IQR)(562-868)), FC (864 ml, IQR(742-940)), and IBS-C (520 ml IQR(489-593)) (p = 0.001). Patients with IBS-C had lower colonic volumes than patients with FC (p = 0.001) and HC (p = 0.019), but there was no difference between FC and HC (p = 0.10). Stool consistency was similar in the two patient groups, but patients with FC had longer colonic transit time than those with IBS-C (117.6 h versus 43.2 h, p = 0.019).

CONCLUSION

Patients with IBS-C have lower total colonic volumes and shorter colonic transit times than patients with FC. Future studies are needed to confirm that colonic volume allows objective distinction between the two conditions.

Knowledge and practice of pediatricians regarding childhood constipation in the Arab world: results from a multicenter survey

Objectives

We aimed to evaluate knowledge and practice styles among medical providers with different professions and working in different Arab countries regarding their approach to childhood constipation.

Methods

We conducted a cross-sectional multinational survey in eight Arab countries. Pediatric care providers (PCPs), including pediatric specialists (PSs), pediatric residents (PRs), pediatric consultants (PCs), pediatric gastroenterologists (PGs), general practitioners (GPs), and pediatric surgeons (PSu), were included in our study. The survey was anonymous, and participants provided input on the definition and management of constipation.

Results

Of 4000 PCPs, 2579 completed the survey (response rate of 64.5%). Although the majority of respondents were aware of the Rome IV criteria to diagnose constipation, significant differences in the percentage of participants in different geographic countries regarding the definition of constipation were noted. Polyethylene glycol (PEG) was prescribed as a first-line treatment of fecal disimpaction significantly more frequently by pediatricians (PSs, PRs, PCs, PGs) than GPs and PSu (12.8% versus 7.2%, respectively; p < 0.001). Additionally, we found that pediatricians used special milk (high magnesium) as a first-choice formula significantly more often than other physicians (53.7% versus 37%, P < 0.001). For maintenance therapy, both pediatricians and nonpediatricians used dietary management with a special milk formula more than other treatment options (84.2% and 84%, respectively).

Conclusions

Despite increased awareness of the Rome IV criteria, significant differences in knowledge and practice patterns regarding fecal disimpaction exist among PCPs from different Arab countries. The identification of these gaps may be helpful for policy-makers to produce targeted instructional resources on constipation for PCPs.

Fecal disimpaction in children with enuresis and constipation does not make them dry at night

BACKGROUND

Constipation, daytime incontinence and nocturnal enuresis often overlap. Treatment of constipation has been shown to be an important aspect of therapy for children with daytime incontinence. However, the value of fecal disimpaction, as a part of constipation therapy, in children with enuresis has not been evaluated.

AIM

Our aim was to evaluate the antienuretic effect of fecal disimpaction in children with enuresis and concomitant constipation.

METHODS

The bladder and bowel function was assessed noninvasively in children aged six to ten years who sought help for enuresis for the first time. If they were constipated according to the Rome IV criteria or had a rectal diameter exceeding 30 mm, as assessed by ultrasound, they were given standard evacuation with mini-enemas and macrogol therapy for at least two weeks. Enuresis frequency was documented 14 nights preceding and following therapy.

RESULTS

In total, 66 children (20 girls, 46 boys) were evaluated, 23 (35%) of whom were constipated. There were no differences in age, sex or baseline bladder function between the two groups. The enuresis frequency per two weeks was 9.8 ± 4.1 nights before and 9.3 ± 5.1 nights after constipation therapy (p = 0.43).

DISCUSSION

This study found that fecal disimpaction in children with enuresis who are also constipated did not alleviate nocturnal enuresis. Bowel problems may still need to be addressed but the child should not be given the false hope that this approach alone will make them dry at night. It might be that evidenced based therapies, such as the enuresis alarm and desmopressin, could be less efficient in children with enuresis and constipation unless their bowel disturbance is first properly addressed.

CONCLUSIONS

Fecal disimpaction in children with enuresis and concomitant constipation will, by itself, not make the children dry at night.

Saccharomyces boulardii and Lactulose for Childhood Functional Constipation: A Multicenter Randomized Controlled Trial

Background/Aims

The effects of probiotics in children vary based on diseases and probiotic strains. We aim to investigate the effectiveness of Saccharomyces boulardii and lactulose for treating childhood functional constipation.

Methods

This open-label randomized controlled trial was conducted at 10 university hospitals in Korea. Children who were diagnosed with functional constipation were allocated to 3 groups (lactulose monotherapy, combination therapy, and S. boulardii monotherapy). The primary outcome was treatment success rate that was accordingly defined as ≥ 3 bowel movements without incontinence at week 12. The cumulative successful maintenance and drug maintenance rates without drug changes were calculated throughout the study period. We compared stool frequency, incontinence, consistency, and painful defecation at week 2 among the 3 groups.

Results

Overall, 187 children were assigned to the lactulose monotherapy (n = 69), combination therapy (n = 68), or S. boulardii monotherapy (n = 50) groups. The primary outcome was significantly higher in the lactulose monotherapy group (26.1%) or combination therapy group (41.2%) than in the S. boulardii monotherapy group (8.0%). The S. boulardii monotherapy group showed a significantly lower cumulative successful maintenance and drug maintenance rate than the other 2 groups. There were no significant intergroup differences in the frequency of defecation, incontinence, painful defecation, or stool consistency during the follow-up at week 2.

Conclusion

S. boulardii monotherapy was not superior to lactulose monotherapy or combination therapy and showed a higher drug change rate, supporting the current recommendation of probiotics in the treatment of childhood functional constipation.

Abnormal bile acid metabolism is an important feature of gut microbiota and fecal metabolites in patients with slow transit constipation

Destructions in the intestinal ecosystem are implicated with changes in slow transit constipation (STC), which is a kind of intractable constipation characterized by colonic motility disorder. In order to deepen the understanding of the structure of the STC gut microbiota and the relationship between the gut microbiota and fecal metabolites, we first used 16S rRNA amplicon sequencing to evaluate the gut microbiota in 30 STC patients and 30 healthy subjects. The α-diversity of the STC group was changed to a certain degree, and the β-diversity was significantly different, which indicated that the composition of the gut microbiota of STC patients was inconsistent with healthy subjects. Among them, Bacteroides, Parabacteroides, Desulfovibrionaceae, and Ruminiclostridium were significantly upregulated, while Subdoligranulum was significantly downregulated. The metabolomics showed that different metabolites between the STC and the control group were involved in the process of bile acids and lipid metabolism, including taurocholate, taurochenodeoxycholate, taurine, deoxycholic acid, cyclohexylsulfamate, cholic acid, chenodeoxycholate, arachidonic acid, and 4-pyridoxic acid. We found that the colon histomorphology of STC patients was significantly disrupted, and TGR5 and FXR were significantly downregulated. The differences in metabolites were related to changes in the abundance of specific bacteria and patients’ intestinal dysfunction. Analysis of the fecal genomics and metabolomics enabled separation of the STC from controls based on random forest model prediction [STC vs. control (14 gut microbiota and metabolite biomarkers)—Sensitivity: 1, Specificity: 0.877]. This study provided a perspective for the diagnosis and intervention of STC related with abnormal bile acid metabolism.

Intra and inter: Alterations in functional brain resting-state networks in patients with functional constipation

Background

Functional constipation (FCon), is a symptom-based functional gastrointestinal disorder without an organic etiology and altering brain structure and function. However, previous studies mainly focused on isolated brain regions involved in brain plasticity. Therefore, little is known about the altered large-scale interaction of brain networks in FCon.

Methods

For this study, we recruited 20 patients with FCon and 20 healthy controls. We used group independent component analysis to identify resting-state networks (RSNs) and documented intra- and inter-network alterations in the RSNs of the patients with FCon.

Results

We found 14 independent RSNs. Differences in the intra-networks included decreased activities in the bilateral caudate of RSN 3 (strongly related to emotional and autonomic processes) and decreased activities in the left precuneus of RSN 10 (default mode network). Notably, the patients with FCon exhibited significantly decreased interactive connectivity between RSNs, mostly involving the connections to the visual perception network (RSN 7–9).

Conclusion

Compared with healthy controls, patients with FCon had extensive brain plastic changes within and across related RSNs. Furthermore, the macroscopic brain alterations in FCon were associated with interoceptive abilities, emotion processing, and sensorimotor control. These insights could therefore lead to the development of new treatment strategies for FCon.

Functional Constipation in Elderly and Related Determinant Risk Factors: Malnutrition and Dietary Intake

AIM

The objective of this study was to evaluate the relationship between FC and physical activity, dietary intake and malnutrition in the elderly.

METHOD

A cross-sectional study was conducted on 883 adults aged >65 years from nursing homes and community health centers in Turkey. Constipation status was evaluated according to Rome IV criteria and Bristol Stool Form Scale. Dietary intake was assessed using a food consumption record (24-hour food recall). The dietary energy and nutrients were analyzed using the "Nutrition Information Systems Package Program". The nutritional status of participants was evaluated using the Mini-Nutritional Assessment (MNA) test. The International Physical Activity Questionnaire (IPAQ, short form) was used to assess physical activity status.

RESULTS

Among the 883 participants, 29.6% were classified into the FC group (32.2% of females, 25.8% of males). The FC group had significantly lower total energy, fluid, water, protein, carbohydrate, magnesium, zinc, phosphorus, potassium, soluble fiber, insoluble fiber, total fiber, and fiber (g)/1000 kcal intake than the non-FC group (p < 0.05). The multivariate logistic regression analysis showed that total dietary fiber intake was significantly associated with a lower prevalence of FC (OR: 0.98, 95% Cl: 0.96-0.99). According to MNA, participants at risk of malnutrition (OR: 5.21, 95% Cl: 3.09-9.77) and malnourished participants (OR: 3.03, 95% Cl: 1.62-5.68) had a greater likelihood of FC compared with normal participants. Participants in the middle lower quartile of water intake (OR: 0.63, 95% CI: 0.42-0.95) had a decreased likelihood of FC compared with participants in the lowest quartile.

CONCLUSION

FC is a common gastrointestinal disorder among the elderly in Turkey. Low dietary fiber intake, low water intake and malnutrition were important risk factors associated with FC in the elderly.

Diagnosis of colonic dysmotility associated with autonomic dysfunction in patients with chronic refractory constipation

We report the first study assessing human colon manometric features and their correlations with changes in autonomic functioning in patients with refractory chronic constipation prior to consideration of surgical intervention. High-resolution colonic manometry (HRCM) with simultaneous heart rate variability (HRV) was performed in 14 patients, and the resulting features were compared to healthy subjects. Patients were categorized into three groups that had normal, weak, or no high amplitude propagating pressure waves (HAPWs) to any intervention. We found mild vagal pathway impairment presented as lower HAPW amplitude in the proximal colon in response to proximal colon balloon distention. Left colon dysmotility was observed in 71% of patients, with features of (1) less left colon HAPWs, (2) lower left colon HAPW amplitudes (69.8 vs 102.3 mmHg), (3) impaired coloanal coordination, (4) left colon hypertonicity in patients with coccyx injury. Patients showed the following autonomic dysfunction: (1) high sympathetic tone at baseline, (2) high sympathetic reactivity to active standing and meal, (3) correlation of low parasympathetic reactivity to the meal with absence of the coloanal reflex, (4) lower parasympathetic and higher sympathetic activity during occurrence of HAPWs. In conclusion, left colon dysmotility and high sympathetic tone and reactivity, more so than vagal pathway impairment, play important roles in refractory chronic constipation and suggests sacral neuromodulation as a possible treatment.

Relationship between Fatigue and Self-Perception of Constipation in Community-Dwelling Older Adults during the COVID-19 Pandemic

Fatigue and constipation are common symptoms among community-dwelling older adults; however, no studies have explored the relationship between both symptoms in said group. Therefore, this study aimed to examine the relationship between fatigue and self-perception of constipation in community-dwelling older adults during the COVID-19 pandemic. A cross-sectional survey was conducted among 97 older people (response rate: 73.2%) between July and November 2021. Backward−forward stepwise linear regression was performed to identify possible predictors of fatigue among the explanatory variable (self-perception of constipation) and possible confounders, which included (a) age, (b) motor fitness scale, (c) economic satisfaction, (d) subjective memory impairment, (e) subjective health, (f) depression, (g) living alone or not, (h) sex, and (i) frequency of exercise. The intercept of the fatigue score was 42.48 points (95% CI = 32.40 to 49.99, p < 0.001). The results showed that the fatigue score in community-dwelling older adults who had self-perception of constipation was significantly lower (i.e., they had higher fatigue; B = −4.49, 95% CI = −6.58 to −2.40, p < 0.001) compared to those who did not have self-perception of constipation. Therefore, there is a need to develop self-management strategies that older people can use to improve the self-perception of constipation.

Abdominal Massage in Functional Chronic Constipation: A Randomized Placebo-Controlled Trial

OBJECTIVE

The aim of this study was to investigate the effects of abdominal massage on the severity of constipation, bowel function, and quality of life (QoL) in patients with functional chronic constipation in a randomized placebo-controlled design.

METHODS

Seventy-four patients diagnosed with functional constipation according to the Rome IV diagnostic criteria were included. Patients were randomly assigned to the intervention group (abdominal massage plus lifestyle advice) or the control group (placebo therapeutic ultrasound plus lifestyle advice). Abdominal massage or placebo ultrasound was applied for 4 weeks. The primary outcome measure was the Constipation Severity Instrument score. Bowel diary data and the Patient Assessment of Constipation Quality of Life Questionnaire score were used as secondary outcome measures. Differences in outcome measures within and between groups were analyzed by repeated-measures analysis of variance.

RESULTS

Although constipation severity, bowel function indicators (defecation frequency and duration and stool consistency), and QoL were found to improve significantly over time in both groups, improvements in both primary and secondary outcomes were much more significant in the abdominal massage group. In addition, group × time interaction effects were found to be significant for constipation severity, bowel function findings, and QoL. There were approximately 70% and 28% reductions in constipation severity, 56% and 38% improvement rates in QoL, and 70% and 43% increases in defecation frequency in the intervention and placebo groups, respectively.

CONCLUSION

Abdominal massage should be one of the first-line conservative approaches in the management of functional chronic constipation. Further randomized placebo-controlled studies with long-term follow-up are needed.

IMPACT

For functional constipation, which is a common gastrointestinal problem, abdominal massage should be considered as an option in first-line therapy because of its effect beyond the placebo effect.

LAY SUMMARY

If you have functional constipation, your physical therapist may be able to provide abdominal massage to help reduce your symptoms.

Short-term acute constipation and not short-term acute diarrhea altered cardiovascular variables in male Wistar rats

Gastrointestinal dysmotility is a substantial public health challenge globally. Based on previous findings in developed countries, it has been observed that there is an association between diarrhea, constipation, and some cardiovascular variables. This study investigated the effects of experimentally-induced short-term acute constipation and short-term acute diarrhea on certain cardiovascular variables in rats. Thirty (30) male Wistar rats (150 -180 g) were divided into three groups; Control, Diarrhoea, and Constipation. The experiment was carried out in 2 phases, the period after induction and the recovery period, and 5 animals per group were used for each phase. The control group received an equivalent amount of distilled water while Diarrhoea and the Constipation group were induced by oral administration of 2ml Castor oil and administration of Loperamide (3mg/kg, b.d, orally x 3 days), respectively. Cardiovascular variables were assessed using the Edan Scientific® Electrocardiography and  Heart Rate Variability machine. Recovery was allowed for 4 days after the onset of the procedure and cardiovascular parameters were reassessed. Post-induction Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP) and Heart Rate (HR) significantly increased in constipated rats (153.2 ± 2.9 mmHg; 109.0 ± 3.7 mmHg;     123.7 ± 3.2 mmHg; 123.4±5.6 bpm) when compared with the control values (95.5±4.8 mmHg; 61.2 ± 3.5 mmHg; 72.6 ± 3.6 mmHg; 72.3 ± 5.2 bpm), respectively. The recovery SBP, DBP, MAP, and Heart Rate in the constipated group remained significantly higher compared to the control. Diarrhea had no significant effect on the parameters determined in both post-induction and recovery phases. The electrical activities did not change in both experimental groups compared to the control. This study revealed increased SBP, DBP, MAP, and HR in short-term acute constipated rats but not so with short-term acute experimental diarrhea.

Six-year-old children had greater risks of functional gastrointestinal disorders if their parents had mental health conditions

Aim

This study examined any associations between parents' mental health conditions and hospital diagnoses of functional gastrointestinal disorders (FGIDs) in offspring at the age of six. We also examined any associations between children who met these criteria and attended routine Danish preventive child health appointments.

Methods

Nationwide registers identified all children born in Denmark from 2000 to 2011 and parents' mental health conditions. Negative binomial regression analyses estimated the incidence rate ratios (IRRs) with 95% confidence intervals (CIs) of children receiving their first hospital diagnosis for an FGID at the age of six.

Results

We identified 750,379 children and 38% had at least one parent with a mental health condition: 24% were minor, 12% were moderate, and 2% were severe. These children faced a higher risk of an FGID diagnosis than children whose parents did not have mental health conditions. The IRRs were highest for maternal exposure: minor (1.35, 95% CI 1.29–1.42), moderate (1.58, 95% CI 1.48–1.67) and severe (1.58, 95% CI 1.38–1.81). Attending routine preventive child health examinations was associated with a higher risk of FGIDs associated with parents' mental health conditions.

Conclusion

Paediatric FGIDs were associated with parents' mental health conditions, especially mothers, and attending routine preventive child health examinations.