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Mitchell N, Norris ML. Rectal prolapse associated with anorexia nervosa: a case report and review of the literature. J Eat Disord 2013; 1:39. [PMID: 24999417 PMCID: PMC4081793 DOI: 10.1186/2050-2974-1-39] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 10/03/2013] [Indexed: 01/27/2023] Open
Abstract
Anorexia nervosa is one of a few mental health diagnoses that affects every organ system. Patients with AN often present with multiple secondary effects of starvation at the time of first assessment, including gastrointestinal (GI) complaints. In extreme cases, severe GI complications such as rectal prolapse may be encountered as a consequence of the illness although formal studies investigating the frequency of such occurrences are lacking. We present the case of a 16 year old female previously diagnosed with anorexia nervosa that developed a rectal prolapse as a consequence of her disease as well as a detailed literature review investigating the frequency and prevalence of such occurrences in this population.
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Affiliation(s)
- Nadine Mitchell
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON Canada
| | - Mark L Norris
- Division of Adolescent Medicine, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON Canada ; Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
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52
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Brock C, Olesen SS, Olesen AE, Frøkjaer JB, Andresen T, Drewes AM. Opioid-induced bowel dysfunction: pathophysiology and management. Drugs 2012; 72:1847-65. [PMID: 22950533 DOI: 10.2165/11634970-000000000-00000] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Opioids are the most commonly prescribed medications to treat severe pain in the Western world. It has been estimated that up to 90% of American patients presenting to specialized pain centres are treated with opioids. Along with their analgesic properties, opioids have the potential to produce substantial side effects, such as nausea, cognitive impairment, addiction and urinary retention. In the gut, opioids exert their action on the enteric nervous system, where they bind to the myenteric and submucosal plexuses, causing dysmotility, decreased fluid secretion and sphincter dysfunction, which all leads to opioid-induced bowel dysfunction (OIBD). In the clinic, this is reported as nausea, vomiting, gastro-oesophageal reflux-related symptoms, constipation, etc. One of the most severe symptoms is constipation, which can be assessed using different scales for subjective assessment. Objective methods such as radiography and colonic transit time can also be used, together with manometry and evaluation of anorectal function to explore the pathophysiology. Dose-limiting adverse symptoms of OIBD can lead to insufficient pain treatment. Even though several treatment strategies are available, the side effects are still a major challenge. Traditional laxatives are normally prescribed but they are often insufficient to alleviate symptoms, especially those from the upper gastrointestinal tract. Newer prokinetics, such as prucalopride and lubiprostone, may be more effective in alleviating OIBD. Another treatment approach is co-administration of opioid antagonists, which either cannot cross the blood-brain barrier or selectively target opioid receptors in the gastrointestinal tract. However, although these new agents have proved to be more efficacious than placebo, clinical trials still need to prove their superiority to standard co-prescribed laxative regimes.
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Affiliation(s)
- Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
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Abstract
Transit assessment of the small intestine and colon is relevant in the study of physiology, pathophysiology, and pharmacodynamics, and there is increasing use of small-bowel and colonic transit measurements in clinical practice as well. The main methods that are applied in clinical practice are substrate-hydrogen breath tests for small-bowel transit and radiopaque markers for colonic transit. Over the past 2-3 decades, scintigraphy has become the preferred standard in research studies, particularly for studies of pathophysiology and pharmacodynamics. New approaches include experimental stable isotope measurement of orocecal transit and the recently approved method using a wireless motility capsule that is validated as an accurate measurement of small-bowel and colonic transit.
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Affiliation(s)
- Lawrence A Szarka
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Rao SSC, Coss-Adame E, Valestin J, Mysore K. Evaluation of constipation in older adults: radioopaque markers (ROMs) versus wireless motility capsule (WMC). Arch Gerontol Geriatr 2012; 55:289-94. [PMID: 22572600 DOI: 10.1016/j.archger.2012.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 04/03/2012] [Accepted: 04/05/2012] [Indexed: 12/11/2022]
Abstract
There is scarce information regarding assessment of constipation in older subjects. We examined regional and whole-gut transit time (WGTT) with wireless motility capsule (WMC) and compared this with radioopaque markers (ROM) transit. 39 constipated and 11 healthy older subjects (≥ 65 years) ingested a ROM capsule and WMC, wore a data receiver and kept stool diaries for 5 days. WMC recordings were analyzed for colonic transit time (CTT), WGTT and gastric emptying time (GET). Radiographs obtained on day 5 assessed ROM transit. Results for each device were compared. The CTT (p = <0.0001), WGTT (p = <0.001) and GET (p = <0.04) as measured by WMC were all slower in constipated subjects compared to healthy subjects. ROM colonic transit was also slower (p = <0.007) in constipated compared to healthy subjects. The diagnostic utility for identifying subjects with constipation as assessed by receiver operating characteristics were similar; 0.85 (WMC) versus 0.73 (ROM). Device agreement for slow colonic transit was 88% with good correlation between WMC and ROM (CTT r=0.718, p=0.0001, WGTT r=0.693, p=0.0001). Slow transit constipation was identified in 28% with ROM and 32% with WMC. No adverse events were recorded. WMC is a safe and useful device that provides objective diagnosis of delayed colonic and whole gut transit in older constipated adults. It is a radiation-free, physiologic and ambulatory technique that provides additional diagnostic information than ROM.
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Affiliation(s)
- S S C Rao
- Section of Gastroenterology and Hepatology, Georgia Health Sciences University, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912, USA.
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Xue YH, Ding SQ, Ding YJ, Zhang Y, Zeng XD, Qian XJ, Liu F, Wang J. Clinical significance of pelvic floor surface electromyographic changes in patients with pelvic floor dyssynergia. Shijie Huaren Xiaohua Zazhi 2012; 20:1025-1029. [DOI: 10.11569/wcjd.v20.i12.1025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical significance of changes in pelvic floor surface electromyographic parameters in patients with pelvic floor dyssynergia.
METHODS: Seventy-three patients with pelvic floor dyssynergia and 80 healthy volunteers were enrolled. Electromyographic parameters including amplitude, coefficient of variance (CV), onset time and median frequency (MF) in resting and contraction states were acquired by using the Glazer's protocol for pelvic floor surface electromyography.
RESULTS: Compared to the control group, the pelvic floor dyssynergia group had a higher amplitude during pre-baseline step (4.93 ± 3.01 vs 3.80 ± 1.97, P < 0.05), CV during tonic step (0.38 ± 0.13 vs 0.31 ± 0.11, P < 0.05), and CV during endurance step (0.35 ± 0.14 vs 0.28 ± 0.10, P < 0.05), as well as a lower contraction amplitude during flick step (59.15 ± 28.14 vs 69.95 ± 31.05, P < 0.05). A positive correlation was found between CV during tonic and endurance steps and age of patients (both P < 0.05).
CONCLUSION: Monitoring changes in pelvic floor surface electromyographic parameters may provide some clues to the diagnosis and treatment of pelvic floor dyssynergia.
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Abstract
Constipation is one of the most frequent gastrointestinal disorders encountered in clinical practice in Western societies. Its prevalence increases with age and is more frequently reported in female patients. Chronic constipation has been associated with considerable impairment in quality of life, can result in large individual healthcare costs, and represents a burden to healthcare delivery systems. This review will focus on the definition, epidemiology, diagnostic approach, and non-pharmacologic as well as pharmacologic management of chronic constipation in the elderly, including an overview of new medications currently under clinical investigation.
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Dinning PG, Hunt L, Lubowski DZ, Kalantar JS, Cook IJ, Jones MP. The impact of laxative use upon symptoms in patients with proven slow transit constipation. BMC Gastroenterol 2011; 11:121. [PMID: 22073923 PMCID: PMC3226636 DOI: 10.1186/1471-230x-11-121] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 11/10/2011] [Indexed: 12/30/2022] Open
Abstract
Background Constipation severity is often defined by symptoms including feelings of complete evacuation, straining, stool frequency and consistency. These descriptors are mostly obtained in the absence of laxative use. For many constipated patients laxative usage is ubiquitous and long standing. Our aim was to determine the impact of laxative use upon the stereotypic constipation descriptors. Methods Patients with confirmed slow transit constipation completed 3-week stool diaries, detailing stool frequency and form, straining, laxative use and pain and bloating scores. Each diary day was classified as being under laxative affect (laxative affected days) or not (laxative unaffected days). Unconditional logistic regression was used to assess the affects of laxatives on constipation symptoms. Results Ninety four patients with scintigraphically confirmed slow transit constipation were enrolled in the study. These patients reported a stool frequency of 5.6 ± 4.3 bowel motions/week, only 21 patients reported <3 bowel motions/week. Similarly, 21 patients reported a predominant hard stool at defecation. The majority (90%) of patients reported regular straining. A regular feeling of complete evacuation was reported in just 7 patients. Daily pain and/or bloating were reported by 92% of patients. When compared with laxative unaffected days, on the laxative affected days patients had a higher stool frequency (OR 2.23; P <0.001) and were more likely to report loose stools (OR 1.64; P <0.009). Laxatives did not increase the number of bowel actions associated with a feeling of complete evacuation. Laxative use had no affect upon straining, pain or bloating scores Conclusions The reporting of frequent and loose stools with abdominal pain and/or bloating is common in patients with slow transit constipation. While laxative use is a significant contributor to altering stool frequency and form, laxatives have no apparent affect on pain or bloating or upon a patients feeling of complete evacuation. These factors need to be taken into account when using constipation symptoms to define this population.
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Affiliation(s)
- Phil G Dinning
- Department of Human Physiology, School of Medicine, Flinders University, Adelaide, SA 5042, Australia.
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Huang CH, Su YC, Li TC, Lee SC, Lin JS, Chiu TY, Lue HC. Treatment of constipation in long-term care with Chinese herbal formula: a randomized, double-blind placebo-controlled trial. J Altern Complement Med 2011; 17:639-46. [PMID: 21711205 DOI: 10.1089/acm.2010.0150] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES This study is aimed to evaluate the therapeutic efficacy and safety of CCH1, modified from an ancient herbal formula in Traditional Chinese Medicine, for the residents with constipation in long-term care. METHODS In this randomized, double-blind, placebo-controlled trial, 90 residents from three long-term care units were randomized to 8 weeks of treatment with CCH1 or placebo and then the subjects were followed up for an additional 4 weeks. RESULTS The mean numbers of weekly spontaneous bowel movement in the CCH1 group were greater than in the placebo group during the treatment phase of 8 weeks (p < 0.05); the greatest difference was during weeks 1-4 (6.2 ± 2.2 versus 3.4 ± 2.1, p < 0.001). Smaller mean numbers of weekly rectal treatments were observed with CCH1 compared with placebo during weeks 1-8 (p < 0.05). The mean numbers of weekly rescue laxative tablets of magnesium oxide were significantly less in the CCH1 group than in the placebo group during the entire 12-week period (p < 0.01), with the greatest difference during weeks 5-8 (14.4 ± 16.3 versus 33.4 ± 23.5, p < 0.001). No significant safety concerns were noted. CONCLUSIONS The six-herb formula (CCH1), compared with placebo, is effective on the treatment of constipation in long-term care. However, its maintenance effect needs further trial. Comparison of efficacy or cost-effectiveness with current laxatives is encouraged.
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Affiliation(s)
- Chien-Hsun Huang
- Department of Community and Family Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
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59
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Zuchelli T, Myers SE. Gastrointestinal issues in the older female patient. Gastroenterol Clin North Am 2011; 40:449-66, x. [PMID: 21601791 DOI: 10.1016/j.gtc.2011.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
As the body ages, it undergoes a multitude of changes. Some of these changes are visible, whereas others are not and may be elicited during the patient encounter. Some gastrointestinal issues may be more common in the elderly population and possibly in older women. These issues range from motility disorders, such as fecal incontinence and constipation, to changes in neuropeptide function and its effect on the anorexia of aging. This article comprehensively reviews gastrointestinal issues that commonly afflict the elderly female population.
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Affiliation(s)
- Tobias Zuchelli
- Drexel University College of Medicine, 245 North 15th Street, 5th Floor New College Building, Philadelphia, PA 19107, USA.
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60
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Abstract
Adverse effects on the gastrointestinal system are problematic for pain patients receiving opioid treatment. Opioid-induced bowel dysfunction (OIBD) is often misinterpreted as constipation as this is the most frequently reported symptom of OIBD; however, it actually comprises the whole gut with symptoms such as nausea, reflux, bloating, and anorexia being very prevalent as well. Validated methods to evaluate these symptoms are essential before the action of a drug on bowel dysfunction can be evaluated, but only the effect on the most frequently reported symptom, constipation, has been evaluated systematically. Constipation is a personal symptom and there is little correlation between subjective methods for assessment of constipation and objective evaluations, such as transit time and fecal loading. Few questionnaires specific to constipation exist, since most that are regularly used form part of general gastrointestinal investigations, which furthermore are often complicated and time consuming to complete. This article gives an overview of the different evaluation regimes for OIBD with a particular focus on the most frequently reported symptom; constipation.
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61
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Chronic constipation: lessons from animal studies. Best Pract Res Clin Gastroenterol 2011; 25:59-71. [PMID: 21382579 DOI: 10.1016/j.bpg.2010.12.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Revised: 11/23/2010] [Accepted: 12/15/2010] [Indexed: 01/31/2023]
Abstract
Chronic constipation is a highly debilitating condition, affecting a significant proportion of the community. The burden to the health care system and impact on individual patients quality of life is immense. Unfortunately, the aetiology underlying chronic constipation is poorly understood and animal models are being used increasingly to investigate possible intrinsic neurogenic and myogenic mechanisms leading to relevant colonic sensori-motor dysfunction. Recently, major advances have been made in our understanding of the mechanisms that underlie propagating contractions along the large intestine, such as peristalsis and colonic migrating motor complexes in laboratory animals, particularly in guinea-pigs and mice. The first recordings of cyclical propagating contractions along the isolated whole human colon have now also been made. This review will highlight some of these advances and how impairments to these motility patterns may contribute to delayed colonic transit, known to exist in a proportion of patients with chronic constipation.
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62
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Efficacy of a Chinese herbal proprietary medicine (Hemp Seed Pill) for functional constipation. Am J Gastroenterol 2011; 106:120-9. [PMID: 21045817 DOI: 10.1038/ajg.2010.305] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Functional constipation (FC) is a common clinical complaint. Despite a lack of consolidated evidence, Chinese herbal medicine (CHM) has become a popular alternative treatment for this condition. The aim of this study was to assess, with a rigidly designed study, the efficacy and safety of a CHM proprietary medicine, Hemp Seed Pill (HSP), in optimal dosage for treating FC. METHODS This study comprised two parts: trial I, a dose determination study, and trial II, a placebo-controlled clinical study. In trial I, the optimal dosage of HSP was first determined from among three doses (2.5, 5.0, and 7.5 g b.i.d.). In trial II, a randomized double-blind study, the efficacy and safety of HSP for FC patients (Rome III criteria) in excessive syndrome as defined by traditional Chinese medicine (TCM) theory were compared with placebo. All participants in trials underwent a 2-week run-in, an 8-week treatment, and an 8-week follow-up. The primary end point was the responder rate for complete spontaneous bowel movement (CSBM) during treatment. Participants with a mean increase of CSBM ≧ 1/week compared with their baselines were defined as responders. Secondary outcome measures included responder rate during follow-up, individual and global symptom assessments, and reported adverse effects (AEs). RESULTS The dose of 7.5 g b.i.d. showed better therapeutic effect than that of 2.5 and 5.0 g b.i.d. among 96 subjects (32 per arm) in trial I and was therefore selected for comparison with placebo in trial II. In trial II, 120 subjects were randomized into two arms (60 per arm). Responder rates for the HSP and placebo groups were 43.3 and 8.3% during treatment and 30.0 and 15.0% in the follow-up period, respectively (P<0.05). Those in the HSP group showed benefit in terms of increased CSBM, relief in the severity of constipation and straining of evacuation, and effective reduction in the use of rescue therapy when compared with placebo. No serious AE was reported. CONCLUSIONS HSP (7.5 g b.i.d.) is safe and effective for alleviating FC for subjects in excessive syndrome. Optimal dose determination may be crucial for all CHM studies.
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63
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Abstract
Constipated patients who are refractory to simple lifestyle interventions will usually resort to laxatives, whether prescribed or over the counter. Clinical trial evidence is scarce for older medications such as laxatives, especially with a condition as chronic and subjective as constipation. Newer polyethylene glycol-based laxatives have been investigated under rigorous clinical trial settings, but comparisons between different laxatives are not available. Newer prokinetic agents, targeting peristalsis, intestinal secretion and the colonic flora, have been developed for laxative refractory constipation. This review focuses on the evidence for each of these agents, and the relative indications for each of them.
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Myung SJ, Lee TH, Huh KC, Choi SC, Sohn CI. [Diagnosis of constipation: a systematic review]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 55:316-24. [PMID: 20697191 DOI: 10.4166/kjg.2010.55.5.316] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
To diagnose constipation accurately in self-reported constipated patients is very important not to miss organic disease and prevent therapeutic abuse. To investigate the etiology of functional constipation is also important to determine the therapeutic modality of constipation. In this systemic review, the clinical usefulness of symptom evaluation, diagnostic tests to rule out organic and systemic disease, and functional tests to discriminate underlying pathophysiology in the diagnosis of constipation were discussed. No specific symptoms or tests were available to predict organic versus functional constipation or differentiate slow transit constipation versus evacuation disorder. Therefore, collaborative studies are necessary to determine the pathophysiology of this disorder.
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Affiliation(s)
- Seung-Jae Myung
- Department of Medicine, Sungkyunkwan University, School of Medicine, Seoul, Korea
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65
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Abstract
Constipation is one of the most common digestive problems in North America with significant psychosocioeconomic implications. It is caused by either a primary disorder of colonic and anorectal function or by many secondary conditions such as constipating drugs, metabolic disorders and other colorectal problems. Given the heterogeneity of problems that cause constipation, defining the underlying pathophysiology is increasingly being recognized as a key step toward optimal management. Colonic manometry with sensation and tone assessment (barostat) and anorectal manometry with rectal sensation and compliance assessment and balloon expulsion test can provide a comprehensive evaluation of colonic and anorectal sensorimotor function and facilitate a diagnosis of slow transit constipation, dyssynergic defecation or irritable bowel syndrome, or an overlap of these disorders. This review provides a critical appraisal of the role of manometric techniques toward augmenting our understanding of colonic and anorectal physiology, both in health and constipation and discussing their clinical utility in the diagnosis and management of chronic constipation.
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Abstract
Chronic constipation is a common digestive problem in North America, with significant psychosocioeconomic implications. Dietary and lifestyle measures and low-cost traditional over-the-counter laxatives are usually the first line of therapy but help only half of the patients. Several newer agents that act by increasing colonic peristalsis, altering colonic secretion, and/or antagonizing enteric opioid receptors have been developed that are effective in treating constipation and its related symptoms as well as improving quality of life. This article focuses on the pharmacology of traditional and newer agents for the treatment of constipation.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology/Hepatology, Department of Internal Medicine, University of Iowa Carver College of Medicine, University of Iowa Hospitals and Clinics, 4612 JCP, Iowa City, IA 52242, USA
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67
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Rao SSC, Go JT. Update on the management of constipation in the elderly: new treatment options. Clin Interv Aging 2010; 5:163-71. [PMID: 20711435 PMCID: PMC2920196 DOI: 10.2147/cia.s8100] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2010] [Indexed: 12/12/2022] Open
Abstract
Constipation disproportionately affects older adults, with a prevalences of 50% in community-dwelling elderly and 74% in nursing-home residents. Loss of mobility, medications, underlying diseases, impaired anorectal sensation, and ignoring calls to defecate are as important as dyssynergic defecation or irritable bowel syndrome in causing constipation. Detailed medical history on medications and co-morbid problems, and meticulous digital rectal examination may help identify causes of constipation. Likewise, blood tests and colonoscopy may identify organic causes such as colon cancer. Physiological tests such as colonic transit study with radio-opaque markers or wireless motility capsule, anorectal manometry, and balloon expulsion tests can identify disorders of colonic and anorectal function. However, in the elderly, there is usually more than one mechanism, requiring an individualized but multifactorial treatment approach. The management of constipation continues to evolve. Although osmotic laxatives such as polyethylene glycol remain mainstay, several new agents that target different mechanisms appear promising such as chloride-channel activator (lubiprostone), guanylate cyclase agonist (linaclotide), 5HT4 agonist (prucalopride), and peripherally acting μ-opioid receptor antagonists (alvimopan and methylnaltrexone) for opioid-induced constipation. Biofeedback therapy is efficacious for treating dyssynergic defecation and fecal impaction with soiling. However, data on efficacy and safety of drugs in elderly are limited and urgently needed.
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Affiliation(s)
- Satish S C Rao
- Section of Neurogastroenterology, Division of Gastroenterology-Hepatology, Department of Internal Medicine, Iowa City, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
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Comparison of Prevalence, Related Medical History, Symptoms, and Interventions Regarding Bowel Dysfunction in Persons With Multiple Sclerosis. J Neurosci Nurs 2010. [DOI: 10.1097/jnn.0b013e3181e26bfb] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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69
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Shin JK, Cheon JH, Kim ES, Yoon JY, Lee JH, Jeon SM, Bok HJ, Park JJ, Moon CM, Hong SP, Lee YC, Kim WH. Predictive capability of anorectal physiologic tests for unfavorable outcomes following biofeedback therapy in dyssynergic defecation. J Korean Med Sci 2010; 25:1060-5. [PMID: 20592899 PMCID: PMC2890884 DOI: 10.3346/jkms.2010.25.7.1060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Accepted: 12/30/2009] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study is to evaluate the predictive capability of anorectal physiologic tests for unfavorable outcomes prior to the initiation of biofeedback therapy in patients with dyssynergic defecation. We analyzed a total of 80 consecutive patients who received biofeedback therapy for chronic idiopathic functional constipation with dyssynergic defecation. After classifying the patients into two groups (responders and non-responders), univariate and multivariate analyses were performed to determine the predictors associated with the responsiveness to biofeedback therapy. Of the 80 patients, 63 (78.7%) responded to biofeedback therapy and 17 (21.3%) did not. On univariate analysis, the inability to evacuate an intrarectal balloon (P=0.028), higher rectal volume for first, urgent, and maximal sensation (P=0.023, P=0.008, P=0.007, respectively), and increased anorectal angle during squeeze (P=0.020) were associated with poor outcomes. On multivariate analysis, the inability to evacuate an intrarectal balloon (P=0.018) and increased anorectal angle during squeeze (P=0.029) were both found to be independently associated with a lack of response to biofeedback therapy. Our data show that the two anorectal physiologic test factors are associated with poor response to biofeedback therapy for patients with dyssynergic defecation. These findings may assist physicians in predicting the responsiveness to therapy for this patient population.
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Affiliation(s)
- Jae Kook Shin
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Sook Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Young Yoon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Ha Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soung Min Jeon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Jung Bok
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Jun Park
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Mo Moon
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Pil Hong
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine and Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Clark K, Urban K, Currow DC. Current Approaches to Diagnosing and Managing Constipation in Advanced Cancer and Palliative Care. J Palliat Med 2010; 13:473-6. [DOI: 10.1089/jpm.2009.0274] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Katherine Clark
- Royal Hospital for Women, Darlinghurst, New South Wales, Australia
- Cunningham Centre for Palliative Care, University of Notre Dame Australia, Darlinghurst, New South Wales, Australia
| | - Kat Urban
- Sydney Institute of Palliative Care Sydney, New South Wales, Australia
| | - David C. Currow
- Department of Supportive and Palliative Care, Flinders University, Adelaide, South Australia, Australia
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Do stool form and frequency correlate with whole-gut and colonic transit? Results from a multicenter study in constipated individuals and healthy controls. Am J Gastroenterol 2010; 105:403-11. [PMID: 19888202 DOI: 10.1038/ajg.2009.612] [Citation(s) in RCA: 168] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Despite a lack of supportive data, stool form and stool frequency are often used as clinical surrogates for gut transit in constipated patients. The aim of this study was to assess the correlation between stool characteristics (form and frequency) and gut transit in constipated and healthy adults. METHODS A post hoc analysis was performed on 110 subjects (46 chronic constipation) from nine US sites recording stool form (Bristol Stool Scale) and frequency during simultaneous assessment of whole-gut and colonic transit by wireless motility capsule (WMC) and radio-opaque marker (ROM) tests. Stool form and frequency were correlated with transit times using Spearman's rank correlation. Accuracy of stool form in predicting delayed transit was assessed by receiver operating characteristic analysis. RESULTS In the constipated adults (42 females, 4 males), moderate correlations were found between stool form and whole-gut transit measured by WMC (r=-0.61, P<0.0001) or ROM (-0.45, P=0.0016), as well as colonic transit measured by WMC (-0.62, P<0.0001). A Bristol stool form value <3 predicted delayed whole-gut transit with a sensitivity of 85% and specificity of 82% and delayed colonic transit with a sensitivity of 82% and specificity of 83%. No correlation between stool form and measured transit was found in healthy adults, regardless of gender. No correlation was found between stool frequency and measured transit in constipated or healthy adults. The correlation between stool frequency and measured transit remained poor in constipated adults with <3 bowel movements per week. CONCLUSIONS Stool form predicts delayed vs. normal transit in adults. However, only a moderate correlation exists between stool form and measured whole-gut or colonic transit time in constipated adults. In contrast, stool frequency is a poor surrogate for transit, even in those with reduced stool frequency.
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72
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Suttor VP, Prott GM, Hansen RD, Kellow JE, Malcolm A. Evidence for pelvic floor dyssynergia in patients with irritable bowel syndrome. Dis Colon Rectum 2010; 53:156-60. [PMID: 20087090 DOI: 10.1007/dcr.0b013e3181c188e8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE Although functional constipation is known to often manifest concomitant features of pelvic floor dyssynergia, the nature of pelvic floor symptoms and anorectal dysfunction in non-diarrhea predominant irritable bowel syndrome is less clear. This study aims to compare anorectal sensorimotor function and symptoms of patients who have non-diarrhea predominant irritable bowel syndrome with those who have functional constipation. METHODS We studied 50 consecutive female patients referred with constipation and 2 or more symptoms of pelvic floor dyssynergia, who also satisfied Rome II criteria for either non-diarrhea predominant irritable bowel syndrome (n = 25; mean age, 47 +/- 3 y) or functional constipation (n = 25; 49 +/- 3 y). Assessments included the Rome II Integrative Questionnaire, a validated constipation questionnaire, Hospital Anxiety and Depression scale, visual analog scores for satisfaction with bowel habit and for impact on quality of life, and a comprehensive anorectal physiology study. RESULTS Both groups displayed physiological evidence of pelvic floor dyssynergia; but patients with non-diarrhea predominant irritable bowel syndrome exhibited a higher prevalence of abnormal balloon expulsion (P < .01) and less paradoxical anal contraction with strain (P = .045) than patients with functional constipation. These patients with irritable bowel syndrome also reported more straining to defecate (P = .04), a higher total constipation score (P = .02), lower stool frequency (P = .02), a trend toward harder stools (P = .06), and less satisfaction with bowel habit (P = .03) than patients with functional constipation. CONCLUSION Patients with non-diarrhea predominant irritable bowel syndrome with symptoms of pelvic floor dyssynergia exhibit overall pelvic floor dyssynergia physiology similar to that of patients with functional constipation. Certain features, however, such as abnormal balloon expulsion, may be more prominent in the patients with irritable bowel syndrome. Therapeutic modalities, such as biofeedback, that are effective in patients with functional constipation with pelvic floor dyssynergia should therefore be considered in selected patients with irritable bowel syndrome with pelvic floor dyssynergia.
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Affiliation(s)
- V P Suttor
- GI Investigation Unit, Royal North Shore Hospital, University of Sydney, Australia
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Hasler WL, Saad RJ, Rao SS, Wilding GE, Parkman HP, Koch KL, McCallum RW, Kuo B, Sarosiek I, Sitrin MD, Semler JR, Chey WD. Heightened colon motor activity measured by a wireless capsule in patients with constipation: relation to colon transit and IBS. Am J Physiol Gastrointest Liver Physiol 2009; 297:G1107-14. [PMID: 19808653 DOI: 10.1152/ajpgi.00136.2009] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Relationships of regional colonic motility to transit in health, constipation, and constipation-predominant irritable bowel syndrome (C-IBS) are poorly characterized. This study aimed to 1) characterize regional differences in colon pressure, 2) relate motor differences in constipation to colon transit, and 3) quantify the role of IBS in altered contractility with constipation. Colon pH and pressure were measured by wireless capsules in 53 healthy and 36 constipated subjects. Numbers of contractions >25 mmHg and areas under curves (AUC) were calculated for colon transit quartiles by time. Constipation was classified as normal transit (<59 h), moderate slow transit (STC) (59-100 h), and severe STC (>100 h). Twelve out of 36 constipated subjects had C-IBS; 24 had functional constipation. Numbers of contractions and AUCs increased from the first to the fourth quartile in health (P < 0.0001). Mean numbers of contractions in constipated subjects were similar to controls. Mean AUCs with normal transit (P = 0.01) and moderate STC (P = 0.004) but not severe STC (P = NS) were higher than healthy subjects. IBS was associated with greater mean numbers of contractions (P = 0.05) and AUCs (P = 0.0006) vs. controls independent of transit. Numbers of contractions increased from the first to fourth quartiles in moderate STC, C-IBS, and functional constipation; AUCs increased from the first to fourth quartiles in all groups (all P < 0.05). In conclusion, colon pressure activity is greater distally than proximally in health. Constipated patients with normal or moderately delayed transit show increased motor activity that is partly explained by IBS. These findings emphasize differential effects on transit and motility in different constipation subtypes.
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Cook IJ, Talley NJ, Benninga MA, Rao SS, Scott SM. Chronic constipation: overview and challenges. Neurogastroenterol Motil 2009; 21 Suppl 2:1-8. [PMID: 19824933 DOI: 10.1111/j.1365-2982.2009.01399.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite its high prevalence and cost implications, our understanding of the pathophysiology of constipation remains primitive, and available therapies have limited efficacy. The purpose of this supplement is to address critically the reasons for the current lack of understanding and to propose avenues of future research to address these deficiencies.
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Affiliation(s)
- I J Cook
- University of New South Wales, Department of Gastroenterology, St George Hospital, Sydney, NSW, Australia.
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Raza N, Bielefeldt K. Discriminative value of anorectal manometry in clinical practice. Dig Dis Sci 2009; 54:2503-11. [PMID: 19093206 DOI: 10.1007/s10620-008-0631-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2008] [Accepted: 11/12/2008] [Indexed: 12/13/2022]
Abstract
Guidelines recommend anorectal manometry in patients with fecal incontinence and chronic constipation. However, limited evidence supports the utility of manometric testing. We retrospectively reviewed tracings obtained between November 2005 and May 2008. A total of 298 patients (86% women; average age 52 years) were included. The main indications were incontinence (51%) and constipation (42%). Patients suffering from incontinence were older and had lower resting and squeeze pressure compared to continent patients. However, the discriminative power of manometric pressure data was poor, with low sensitivity and specificity. An abnormal straining pattern suggesting dyssynergic defecation was seen in 43% of constipated patients compared to 13% of patients with fecal incontinence. A concordance between manometric patterns and the balloon expulsion test was seen in 72%. The low sensitivity and specificity of manometric parameters does not support the routine use of anorectal manometry in patients with defecation disorders.
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Affiliation(s)
- Naeem Raza
- Division of Gastroenterology, University of Pittsburgh, Pittsburgh, PA 15213, USA
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Pomerri F, Dodi G, Nardin M, Muzzio P. Colonic total and segmental transit times in healthy Italian adults. Radiol Med 2009; 114:925-34. [DOI: 10.1007/s11547-009-0409-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Accepted: 11/03/2008] [Indexed: 12/15/2022]
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Rao SSC, Kuo B, McCallum RW, Chey WD, DiBaise JK, Hasler WL, Koch KL, Lackner JM, Miller C, Saad R, Semler JR, Sitrin MD, Wilding GE, Parkman HP. Investigation of colonic and whole-gut transit with wireless motility capsule and radiopaque markers in constipation. Clin Gastroenterol Hepatol 2009; 7:537-44. [PMID: 19418602 DOI: 10.1016/j.cgh.2009.01.017] [Citation(s) in RCA: 205] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Colonic transit time (CTT) traditionally is assessed with radiopaque markers (ROMs), which requires radiation and is hindered by lack of standardization and compliance. We assessed regional and CTT with the SmartPill (SmartPill Corporation, Buffalo, NY), a new wireless pH and pressure recording capsule, in constipated and healthy subjects and compared this with ROM. METHODS Seventy-eight constipated (Rome II) and 87 healthy subjects ingested a 260-kcal meal, a ROM capsule, and the SmartPill. Subjects wore a data receiver and kept daily stool diaries for 5 days. SmartPill recordings assessed CTT, whole-gut transit time (WGTT), small-bowel transit time, and gastric emptying time. Abdominal radiographs on days 2 and 5 assessed ROM transit. Sensitivity/specificity and receiver operating characteristics (ROCs) of each technique and utility were compared. RESULTS Gastric emptying time, CTT, and WGTT were slower (P < .01) in constipated subjects than controls. CTT was slower in women than men (P = .02). Day 2 and day 5 ROM transits were slower (P < .001) in constipated subjects. Correlation of the SmartPill CTT with ROMs expelled on day 2/day 5 was r = 0.74/r = 0.69 in constipation, and r = 0.70/r = 0.40 in controls, respectively. The diagnostic accuracy of the SmartPill CTT to predict constipation from ROC was 0.73, with a specificity of 0.95. These were comparable with those of day 5 ROM (ROC, 0.71; specificity, 0.95). CONCLUSIONS The SmartPill is a novel ambulatory technique of assessing regional (gastric, small bowel, colonic) and WGTT without radiation. It reveals hitherto unrecognized gender differences and upper-gut dysfunction in constipation. It correlates well with ROM and offers a standardized method of discriminating normal from slow colonic transit.
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Affiliation(s)
- Satish S C Rao
- Department of Medicine, University of Iowa, Iowa City, Iowa 52242-1009, USA.
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Gladman MA, Knowles CH. Surgical treatment of patients with constipation and fecal incontinence. Gastroenterol Clin North Am 2008; 37:605-25, viii. [PMID: 18793999 DOI: 10.1016/j.gtc.2008.06.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Patients with constipation and fecal incontinence usually come to the attention of the surgeon when conservative measures have failed to alleviate sufficiently severe symptoms. Following detailed clinical and physiologic assessment, the surgeon should tailor the procedure to specific underlying physiologic abnormalities to restore function. This article describes the rationale, indications (including patient selection), results, and current position controversies of surgical procedures for constipation and fecal incontinence, dividing these into those regarded as historical, contemporary, or evolving. Reported surgical outcome data must be interpreted with caution because for most studies the evidence is of low quality, making comparison of different procedures problematic and emphasizing the need for better designed and conducted clinical trials.
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Affiliation(s)
- Marc A Gladman
- Centre for Academic Surgery, Institute of Cell and Molecular Science, Barts, London, UK
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Saad R, Chey WD. Lubiprostone for chronic idiopathic constipation and irritable bowel syndrome with constipation. Expert Rev Gastroenterol Hepatol 2008; 2:497-508. [PMID: 19072397 DOI: 10.1586/17474124.2.4.497] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Lubiprostone, a locally acting highly selective type-2 chloride channel activator, has been US FDA approved since January 2006 for the treatment of adults with chronic idiopathic constipation and FDA approved since April 2008 for the treatment of woman aged 18 years or older suffering from irritable bowel syndrome (IBS) with constipation. Through activation of the type-2 chloride channels located on the luminal side of intestinal epithelial cells, it promotes fluid secretion, increasing the liquid content of stool and accelerating small bowel as well as colonic transit. Lubiprostone has demonstrated efficacy with respect to increasing weekly spontaneous bowel movements and improving stool consistency, straining and constipation severity, both in short- and long-term studies. It has also demonstrated efficacy in the treatment of IBS with constipation, with beneficial effects on global symptoms, abdominal pain, constipation-related symptoms and overall quality of life. There is no evidence of a rebound in constipation or IBS symptoms following cessation of lubiprostone. In general, lubiprostone is well tolerated, with the most common side effects including nausea, headache and diarrhea.
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Affiliation(s)
- Richard Saad
- Division of Gastroenterology, Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
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Affiliation(s)
- Julia Ho
- University of Kentucky Healthcare, Lexington, Kentucky, USA
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