The burden of constipation on quality of life: results of a multinational survey

The Relation between Psychiatric Diagnoses and Constipation in Hospitalized Patients: A Cross-Sectional Study

Objective. Constipation is a prevalent problem in patients with psychiatric disorders; it reduces quality of life and may lead to severe complications. The prevalence distribution of constipation across all psychiatric diagnoses in patients with severe mental illness (SMI) has hardly been studied. The aim of this study is to estimate the association between psychiatric disorders and constipation in SMI inpatients. Methods. The strength of the association between constipation (based on use of laxatives) and DSM-IV psychiatric diagnosis was studied in a cross-sectional study with "adjustment disorders" as the reference group. The association was analyzed using logistic regression. Results. Of the 4728 patients, 20.3% had constipation. In the stratum of patients older than 60 years, all psychiatric categories except for substance related disorders were significantly associated with a higher prevalence of constipation (odds ratios ranging from 3.38 to 6.52), whereas no significant associations were found in the stratum of patients between 18 and 60 years (odds ratios ranging from 1.00 to 2.03). Conclusion. In the elderly, all measured psychiatric diagnoses are strongly associated with an increased prevalence of constipation. Physicians should be extra alert for constipation in SMI patients, independent of specific psychiatric diagnoses.

Constipation and Laxative Use among Nursing Home Patients: Prevalence and Associations Derived from the Residents Assessment Instrument for Long-Term Care Facilities (interRAI LTCF)

Introduction. Constipation is a common, bothersome, and potentially dangerous condition among nursing home (NH) patients. Between 50 and 74% of NH patients use laxatives. Objective. To study prevalence and associations of laxative use and constipation using the comprehensive Norwegian version of the Resident Assessment Instrument for Long-Term Care Facilities. Methods. Cross-sectional study. Patients from 20 NH units were included. Logistic regression was used to analyze the results. Data collected in NHs might be clustered. Consequently, the multivariable models were tested against a mixed effects regression model to investigate variance both on the level of patients and on the level of NH units. Results. In all, 261 patients were included. The prevalence of constipation was 23.4%, and 67.1% used laxatives regularly. Balance problems, urinary incontinence, hypothyroidism, and Parkinson's disease were associated with constipation. Reduced ability to communicate and number of drugs were associated with laxative use. Antidementia-drugs and being involved in activities 1/3 to 2/3 of daytime were protective factors for laxative use. Mixed effects analyses identified variance on the level of NH units as nonsignificant. Conclusion. Constipation and laxative use are common. Variance is mainly explained by different patient characteristics/health deficiencies. Hence, patients might benefit from individualized care to compensate for deficiencies.

Functional Constipation and Constipation-Predominant Irritable Bowel Syndrome in the General Population: Data from the GECCO Study

Background. The prevalence of constipation in the (German) population has been shown to be 14.9% in a telephone survey, but more detailed data are required to characterize the sociographics and clinical characteristics of persons with different types of functional constipation, either constipation-predominant irritable bowel syndrome (IBS-C) or functional constipation with or without meeting Rome criteria. Methods. Of 2239 constipated individuals identified during the telephone interview, 1037 (46.3%) were willing to provide a postal address for a questionnaire, of which 589 (56.8%) returned the questionnaire, inquiring about sociographic data, clinical symptoms, and health care behavior related to constipation, as well as health-related quality-of-life (SF12). Subgroups of functionally constipated individuals were compared. Results. More than 50% of the respondents reported a somatic comorbid condition and/or regular medication intake that may contribute to constipation. We split the remaining individuals (N = 214) into three groups, matching Rome-criteria for IBS (IBS-C, n = 64) and for functional constipation (FC-R, n = 36) and FC not matching Rome criteria (n = 114). Nearly all sociographic and clinical characteristics were equal among them, and all individuals with constipation had similar and lowered QOL on the SF-12 physical health domain, but in IBS-C the scores were also significantly lower in comparison to FC-R and FC, in both the physical health and the mental health domain. Conclusion. Only a fraction of individuals with chronic constipation match Rome criteria for IBS-C or FC, but subgroups do not differ with respect to most other measures except quality-of-life profiles.

Self-administered acupressure for treating adult psychiatric patients with constipation: a randomized controlled trial

BACKGROUND

Constipation has a high prevalence rate (>30 %) in psychiatric patients with psychotropic drugs. Common pharmacological and non-pharmacological interventions for constipation might have longer-term negative and adverse effects that would outweigh their short-term efficacy in symptom reduction. This randomized controlled trial aims to investigate the effect of self-administered acupressure for the management of constipation, in hospitalized psychiatric patients.

METHODS

Seventy-eight patients were recruited in matched pairs in terms of gender, age and laxative use from five acute psychiatric wards in Hong Kong. Each of these matched pairs of patients was randomly assigned to either a self-administered acupressure (n = 39) or a sham group (n = 39), using computer-generated random numbers. After baseline measurement, the intervention and sham group received the same training in self-administered acupressure and supervised practice once per day for 10 days, except light pressure on non-acupoints was taught to the sham group. The acupoints chosen for acupressure included Zhongwan (RN12), right and left Tianshu (ST25), right and left Quchi (LI11). Participants' symptoms and quality of life regarding constipation were measured at baseline and immediately and 2 weeks after completion of the interventions with constipation assessment scale and patient assessment of constipation quality of life questionnaire, respectively.

RESULTS

After 2 weeks follow-up, participants who had received self-administered acupressure indicated significantly greater improvements in both symptom severity (P = 0.0003) and quality of life (P = 0.0004) when compared with the sham group.

CONCLUSION

The psychiatric patients with constipation who practiced self-administered acupressure for 10 days improved their symptom severity and perceived quality of life immediately and 2 weeks after completion of the intervention in comparison with the sham group.

TRIAL REGISTRATION

The trial was registered with the ClinicalTrials.gov (Reg. No: NCT02187640).

Chronic constipation in the elderly: a primer for the gastroenterologist

Constipation is a frequently reported bowel symptom in the elderly with considerable impact on quality of life and health expenses. Disease-related morbidity and even mortality have been reported in the affected frail elderly. Although constipation is not a physiologic consequence of normal aging, decreased mobility, medications, underlying diseases, and rectal sensory-motor dysfunction may all contribute to its increased prevalence in older adults. In the elderly there is usually more than one etiologic mechanism, requiring a multifactorial treatment approach. The majority of patients would respond to diet and lifestyle modifications reinforced by bowel training measures. In those not responding to conservative treatment, the approach needs to be tailored addressing all comorbid conditions. In the adult population, the management of constipation continues to evolve as well as the understanding of its complex etiology. However, the constipated elderly have been left behind while gastroenterology consultations for this common conditions are at a rise for the worldwide age increment. Aim of this review is to provide an update on epidemiology, quality of life burden, etiology, diagnosis, current approaches and limitations in the management of constipation in the older ones to ease the gastroenterologists’ clinic workload.

Quality of life and healthcare resource in patients receiving opioids for chronic pain: a review of the place of oxycodone/naloxone

In patients managed with opioids for chronic pain, opioid-induced bowel dysfunction—specifically, opioid-induced constipation (OIC)—is a common side effect, which has a significant impact on quality of life (QoL). The most recent developments for management of OIC are opioid antagonists, including naloxone, a competitive antagonist of peripheral opioid receptors that reverses opioid-induced peripheral gastrointestinal (GI) effects. A prolonged-release formulation of naloxone is available in combination with oxycodone (OXN PR). To review the specific role of OXN PR in the management of chronic pain and OIC and its impact on QoL and healthcare costs, a review of available relevant literature was conducted. Healthcare costs can be up to ten times higher for patients with GI events than for those without. Assessment of QoL in patients with OIC is essential, and multiple tools for its evaluation are available. The Bowel Function Index (BFI), a tool that was specifically developed and validated to measure bowel function in patients with OIC, can be an indication of QoL. In patients with moderate-to-severe chronic pain, randomized trials have demonstrated that OXN PR has equal analgesic efficacy and safety, but results in improved bowel function, compared with prolonged-release oxycodone (Oxy PR) alone. In conclusion, randomized studies using the BFI, as well as real-world clinical practice observations, have demonstrated improved QoL for patients taking OXN PR. This combination should allow more patients to benefit from the analgesic efficacy of opioid therapy and should minimize the side effects of constipation that correspond to improvements in QoL and healthcare offsets.

Interventions for treating constipation in pregnancy

BACKGROUND

Constipation is a common symptom experienced during pregnancy. It has a range of consequences from reduced quality of life and perception of physical health to haemorrhoids. An understanding of the effectiveness and safety of treatments for constipation in pregnancy is important for the clinician managing pregnant women.

OBJECTIVES

To assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

We considered all published, unpublished and ongoing randomised controlled trials (RCTs), cluster-RCTs and quasi-RCTs, evaluating interventions (pharmacological and non-pharmacological) for constipation in pregnancy. Cross-over studies were not eligible for inclusion in this review. Trials published in abstract form only (without full text publication) were not eligible for inclusion.We compared one intervention (pharmacological or non-pharmacological) against another intervention, placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Four studies were included, but only two studies with a total of 180 women contributed data to this review. It was not clear whether they were RCTs or quasi-RCTs because the sequence generation was unclear. We classified the overall risk of bias of three studies as moderate and one study as high risk of bias. No meta-analyses were carried out due to insufficient data.There were no cluster-RCTs identified for inclusion. Comparisons were available for stimulant laxatives versus bulk-forming laxatives, and fibre supplementation versus no intervention. There were no data available for any other comparisons.During the review process we found that studies reported changes in symptoms in different ways. To capture all data available, we added a new primary outcome (improvement in constipation) - this new outcome was not prespecified in our published protocol. Stimulant laxatives versus bulk-forming laxativesNo data were identified for any of this review's prespecified primary outcomes: pain on defecation, frequency of stools and consistency of stools.Compared to bulk-forming laxatives, pregnant women who received stimulant laxatives had significantly more improvement in constipation (risk ratio (RR) 1.59, 95% confidence interval (CI) 1.21 to 2.09; 140 women, one study, moderate quality of evidence), but also significantly more abdominal discomfort (RR 2.33, 95% CI 1.15 to 4.73; 140 women, one study, low quality of evidence), and borderline difference in diarrhoea (RR 4.50, 95% CI 1.01 to 20.09; 140 women, one study, moderate quality of evidence). In addition, there was no significant difference in women's satisfaction (RR 1.06, 95% CI 0.77 to 1.46; 140 women, one study, moderate quality of evidence).No usable data were identified for any of this review's secondary outcomes: quality of life; dehydration; electrolyte imbalance; acute allergic reaction; or asthma. Fibre supplementation versus no interventionPregnant women who received fibre supplementation had significantly higher frequency of stools compared to no intervention (mean difference (MD) 2.24 times per week, 95% CI 0.96 to 3.52; 40 women, one study, moderate quality of evidence). Fibre supplementation was associated with improved stool consistency as defined by trialists (hard stool decreased by 11% to 14%, normal stool increased by 5% to 10%, and loose stool increased by 0% to 6%).No usable data were reported for either the primary outcomes of pain on defecation and improvement in constipation or any of this review's secondary outcomes as listed above. Quality Five outcomes were assessed with the GRADE software: improvement in constipation, frequency of stools, abdominal discomfort, diarrhoea and women's satisfaction. These were assessed to be of moderate quality except for abdominal discomfort which was assessed to be of low quality. The results should therefore be interpreted with caution. There were no data available for evaluation of pain on defecation or consistency of stools.

AUTHORS' CONCLUSIONS

There is insufficient evidence to comprehensively assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy, due to limited data (few studies with small sample size and no meta-analyses). Compared with bulk-forming laxatives, stimulant laxatives appear to be more effective in improvement of constipation (moderate quality evidence), but are accompanied by an increase in diarrhoea (moderate quality evidence) and abdominal discomfort (low quality evidence) and no difference in women's satisfaction (moderate quality evidence). Additionally, fibre supplementation may increase frequency of stools compared with no intervention (moderate quality evidence), although these results were of moderate risk of bias.There were no data for a comparison of other types of interventions, such as osmotic laxatives, stool softeners, lubricant laxatives and enemas and suppositories.More RCTs evaluating interventions for treating constipation in pregnancy are needed. These should cover different settings and evaluate the effectiveness of various interventions (including fibre, osmotic, and stimulant laxatives) on improvement in constipation, pain on defecation, frequency of stools and consistency of stools.

Prevalence of constipation in the German population - a representative survey (GECCO)

BACKGROUND

Variable prevalence rates between 2.4 and 35% have been reported for chronic constipation across different countries worldwide, with a low 5% for Germany.

OBJECTIVES AND METHODS

We conducted a computer-assisted telephone interview among 15,002 representative individuals in Germany, asking about health-related problems, including constipation. Those who acknowledged the presence of constipation symptoms during the preceding 12 months were questioned concerning constipation features and sociographic variables.

RESULTS

Of 15,002 individuals interviewed, 2,239 (14.9%) acknowledged having experienced constipation during the last 12 months, 864 (5.8%) reported constipation during the last 4 weeks, and 380 (2.5%) had current constipation symptoms; 4.4% had taken medication because of their constipation, and 2.6% had consulted a doctor for constipation. In comparison to non-constipated volunteers, those constipated had a lower health quality of life and poorer health, and lower income and social status.

CONCLUSION

Up to 15% of the general (German) population report symptoms of constipation depending on the definition. This matches pooled constipation rates across 18 countries (14%).

Acupuncture for functional constipation: protocol of an individual patient data meta-analysis

INTRODUCTION

Functional constipation (FC) is a common gastrointestinal disease. Systematic reviews indicate that acupuncture may be effective for patients with FC. However, this conclusion is not convincing due to the quality, sample size and methodological heterogeneity of the studies included by these systematic reviews. Therefore, it is necessary for us to conduct a meta-analysis of individual patient data (IPD) from high-quality clinical trials to determine whether acupuncture is effective for patients with FC.

METHODS AND ANALYSIS

Randomised controlled trials (RCTs) of acupuncture for adult patients with FC will be searched in several databases from inception to April 2015. The corresponding authors of eligible studies will be contacted and invited to contribute raw data. The primary outcome is the change in spontaneous defaecation per week from baseline. The secondary outcomes include the proportion of responders, changes in stool quality, mean transit time, proportion of patients using laxatives and adverse events. We will check all of the data and perform reanalysis according to the statistical methodology reported in previous publications. Then we will harmonise the raw data and use a two-step method to conduct the IPD meta-analysis. First, we will calculate the effect size of acupuncture of each trial by analysis of covariance, with the principal end point as the dependent variable and the baseline scores as the covariates. Second, the effect size of acupuncture in each original study will be combined in the meta-analysis.

DISSEMINATION

On the basis of the IPD meta-analysis of high-quality RCTs, this review will answer the question of whether acupuncture is effective for FC. The findings of the review will be disseminated through peer-review publications and conference presentations.

TRIAL REGISTRATION NUMBER

PROSPERO 2014 CRD42014009901.

Efficacy of Adaptive Biofeedback Training in Treating Constipation-Related Symptoms

Biofeedback therapy is a well-known and effective therapeutic treatment for constipation. A previous study suggested that adaptive biofeedback (ABF) training was more effective than traditional (fixed training parameters) biofeedback training. The aim of this study was to verify the effectiveness of ABF in relieving constipation-related symptoms. We noticed that in traditional biofeedback training, a patient usually receives the training twice per week. The long training sessions usually led to poor compliance. This study proposes an intensive biofeedback therapy and compares intensive therapy with nonintensive therapy in patients with constipation-related symptoms. Methods. 63 patients with constipation-related symptoms were treated with ABF between 2012 and 2013. These patients were further divided into the intensive therapy and nonintensive therapy groups. Results. A total of 63 patients were enrolled in the study, including 24 in the nonintensive therapy group and 39 in the intensive therapy group. 100% (N = 21) of constipation patients achieved the primary efficacy endpoint (≥3 bowel movements/week). There was significant improvement in constipation-related symptoms after adaptive biofeedback. The intensive biofeedback therapy did not show better performance compared to nonintensive biofeedback therapy. Conclusions. This investigation provides support for the efficacy of biofeedback for constipation-related symptoms. The efficacy of intensive therapy is similar to nonintensive therapy.

Differentiation of functional constipation and constipation predominant irritable bowel syndrome based on Rome III criteria: a population-based study

BACKGROUND

While the Rome III classification recognises functional constipation (FC) and constipation predominant IBS (IBS-C) as distinct disorders, recent evidence has suggested that these disorders are difficult to separate in clinical practice.

AIM

To identify whether clinical and lifestyle factors differentiate Rome III-defined IBS-C from FC based on gastrointestinal symptoms and lifestyle characteristics.

METHOD

3260 people randomly selected from the Australian population returned a postal survey. FC and IBS-C were defined according to Rome III. The first model used logistic regression to differentiate IBS-C from FC based on lifestyle, quality-of-life and psychological characteristics. The second approach was data-driven employing latent class analysis (LCA) to identify naturally occurring clusters in the data considering all symptoms involved in the Rome III criteria for IBS-C and FC.

RESULTS

We found n = 206 (6.5%; 95% CI 5.7-7.4%) people met strict Rome III FC whereas n = 109 (3.5%; 95% CI 2.8-4.1%) met strict Rome III IBS-C. The case-control approach indicated that FC patients reported an older age at onset of constipation, were less likely to exercise, had higher mental QoL and less health care seeking than IBS-C. LCA yielded one latent class that was predominantly (75%) FC, while the other class was approximately half IBS-C and half FC. The FC-dominated latent class had clearly lower levels of symptoms used to classify IBS (pain-related symptoms) and was more likely to be male (P = 0.046) but was otherwise similar in distribution of lifestyle factors to the mixed class.

CONCLUSION

The latent class analysis approach suggests a differentiation based more on symptom severity rather than the Rome III view.

Cost-effectiveness of prucalopride in the treatment of chronic constipation in the Netherlands

Objective: To assess the cost-effectiveness of prucalopride vs. continued laxative treatment for chronic constipation in patients in the Netherlands in whom laxatives have failed to provide adequate relief.

Methods: A Markov model was developed to estimate the cost-effectiveness of prucalopride in patients with chronic constipation receiving standard laxative treatment from the perspective of Dutch payers in 2011. Data sources included published prucalopride clinical trials, published Dutch price/tariff lists, and national population statistics. The model simulated the clinical and economic outcomes associated with prucalopride vs. standard treatment and had a cycle length of 1 month and a follow-up time of 1 year. Response to treatment was defined as the proportion of patients who achieved “normal bowel function”. One-way and probabilistic sensitivity analyses were conducted to test the robustness of the base case.

Results: In the base case analysis, the cost of prucalopride relative to continued laxative treatment was € 9015 per quality-adjusted life-year (QALY). Extensive sensitivity analyses and scenario analyses confirmed that the base case cost-effectiveness estimate was robust. One-way sensitivity analyses showed that the model was most sensitive in response to prucalopride; incremental cost-effectiveness ratios ranged from € 6475 to 15,380 per QALY. Probabilistic sensitivity analyses indicated that there is a greater than 80% probability that prucalopride would be cost-effective compared with continued standard treatment, assuming a willingness-to-pay threshold of € 20,000 per QALY from a Dutch societal perspective. A scenario analysis was performed for women only, which resulted in a cost-effectiveness ratio of € 7773 per QALY.

Conclusion: Prucalopride was cost-effective in a Dutch patient population, as well as in a women-only subgroup, who had chronic constipation and who obtained inadequate relief from laxatives.

Prevalence of constipation in the general adult population: an integrative review

Constipation affects multiple aspects of a person's health, including health-related quality of life. It is one of the most frequently reported functional gastrointestinal disorders. The purpose of this integrative review of the literature was to identify research findings pertaining to the prevalence of constipation and factors are associated with constipation in the general population. Electronic databases were searched for articles published between 2005 and 2011. All retrieved studies were evaluated with respect to quality according to the guidelines for critical appraisal of health research literature on prevalence and incidence. Eleven studies were retrieved; they reveal a prevalence of constipation that varied from 2.6% to 26.9%. The most frequently cited associated factors were female gender and advanced age, which were cited in 11 and 7 of the studies, respectively. Prevalence rates reported by the selected studies were heterogeneous. This may be partially attributed to variability in methods used to measure prevalence, including differences in criteria for constipation.

A longitudinal study of constipation and laxative use in a community-dwelling elderly population

BACKGROUND

Little is known about laxative use, the association of constipation with laxative use, risk factors for constipation and how each of these changes over time in the community-dwelling elderly.

OBJECTIVE

The aim was to explore the prevalence of laxative use and of self-reported constipation, and identify risk factors (including age) associated with constipation, in a cohort of community-dwelling elderly residents.

METHODS

Data from the Australian Longitudinal Study of Ageing (ALSA) was used to compare differences in constipation and laxative use in the community-dwelling elderly between 1992-1993 and 2003-2004.

RESULTS

Relevant data was available for 239 ALSA participants. The prevalence of self-reported constipation increased from 14% in 1992-1993 to 21% in 2003-2004. There was a corresponding increase in the prevalence of laxative use from 6% to 15% over the same period. At both time points, females reported a higher prevalence of both constipation and laxative use however the female:male prevalence ratios decreased over time indicating higher increases in the prevalence of each among males. Persistent chronic constipation occurred in 9% of the cohort. The association between laxative use and self-reported constipation was poor and laxative use was associated with self-reported constipation in less than a third of cases.

CONCLUSION

The prevalence of both constipation and laxative use increases with age in the elderly, and these increases are greater for males than for females. Discrepancies between self-reported constipation and laxative use may suggest sub-optimal management of constipation in the community-dwelling elderly and further work is needed to fully understand this.

Neurogenic mechanisms in bladder and bowel ageing

The prevalence of both urinary and faecal incontinence, and also chronic constipation, increases with ageing and these conditions have a major impact on the quality of life of the elderly. Management of bladder and bowel dysfunction in the elderly is currently far from ideal and also carries a significant financial burden. Understanding how these changes occur is thus a major priority in biogerontology. The functions of the bladder and terminal bowel are regulated by complex neuronal networks. In particular neurons of the spinal cord and peripheral ganglia play a key role in regulating micturition and defaecation reflexes as well as promoting continence. In this review we discuss the evidence for ageing-induced neuronal dysfunction that might predispose to neurogenic forms of incontinence in the elderly.

The impact of abdominal pain on global measures in patients with chronic idiopathic constipation, before and after treatment with linaclotide: a pooled analysis of two randomised, double-blind, placebo-controlled, phase 3 trials

BACKGROUND

Few clinical trials in chronic idiopathic constipation (CIC) patients have evaluated abdominal symptom severity and whether CIC patients with abdominal symptoms respond similarly to patients with limited abdominal symptoms.

AIMS

To examine abdominal symptom severity and relationships between symptoms and global measures at baseline; compare linaclotide's effect on symptoms in subpopulations with more or less abdominal pain; and assess relationships between symptom improvement and global measures in these two subpopulations.

METHODS

In two phase 3 trials, patients meeting modified Rome II CIC criteria were assigned to linaclotide 145 μg, 290 μg, or placebo once daily. Patients rated abdominal and bowel symptoms daily during 2-week pre-treatment and 12-week treatment periods. Linaclotide's effect on symptoms and global measures [constipation severity, health-related quality of life (HRQOL), treatment satisfaction] and their inter-relationships were assessed in post hoc analyses of abdominal pain subpopulations.

RESULTS

Of 1271 CIC patients, 23%, 32%, and 43% reported moderate-to-severe abdominal pain, discomfort, and bloating, respectively, during baseline. In more-severe abdominal pain patients, abdominal symptoms were more strongly correlated than bowel symptoms with global measures, but in less-severe abdominal pain patients, abdominal and bowel symptoms were similarly correlated with global measures, at baseline and post-treatment. Linaclotide significantly improved all symptoms and global measures in both subpopulations.

CONCLUSIONS

When abdominal pain is present in CIC, abdominal and not bowel symptoms may drive patient assessments of constipation severity, HRQOL, and treatment satisfaction. Linaclotide (145 μg and 290 μg) is an effective treatment for both abdominal and bowel symptoms, even in CIC patients with more severe abdominal pain at baseline. (Clinicaltrials.gov: NCT00765882, NCT00730015).

Systematic review: the effect of prunes on gastrointestinal function

BACKGROUND

Prunes (dried plums) are high in fibre and are perceived to promote healthy gastrointestinal (GI) function.

AIM

To assess the effect of prunes on GI function through a systematic review of randomised controlled trials (RCTs).

METHODS

Sixteen electronic databases were searched, a hand search was performed and key opinion leaders were contacted. RCTs investigating the effect of prunes on GI function were included. Two reviewers independently screened relevant articles, extracted data and assessed risk of bias.

RESULTS

Four trials met the inclusion criteria, one in constipation and three in non-constipated subjects. In constipation, 3 weeks of prune consumption (100 g/day) improved stool frequency (3.5 vs. 2.8 CSBM per week, P = 0.006) and stool consistency (3.2 vs. 2.8 on Bristol stool form scale, P = 0.02) compared with psyllium (22 g/day). In non-constipated subjects, prunes softened stool consistency in one trial and increased stool weight (628 g vs. 514 g/72 h wet weight, P = 0.001) in another trial, compared with control. No trials found differences in GI symptoms between prunes and comparator. Meta-analysis was not appropriate due to heterogeneity in populations and methods. Two of the trials were limited by unclear risk of bias.

CONCLUSIONS

In constipation, prunes appear superior to psyllium for improving stool frequency and consistency, however, the evidence for other outcomes and the effects in non-constipated subjects is weak. Although prunes may be a promising intervention for the management of constipation and increasing stool weight, this needs to be confirmed by further rigorous research.

The effect of probiotics on functional constipation in adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Functional constipation is a prevalent, burdensome gastrointestinal disorder whose treatment remains challenging. Probiotics have been increasingly investigated in its management.

OBJECTIVE

The aim was to investigate the effect of probiotics on gut transit time, stool output, and constipation symptoms in adults with functional constipation via a systematic review and meta-analysis of randomized controlled trials (RCTs).

DESIGN

Studies were identified by searching 4 electronic databases, back-searching reference lists, contacting authors, and hand-searching abstracts. RCTs that reported administration of probiotics in adults with functional constipation were included. Two reviewers independently performed the screening, data extraction, and bias assessment. Outcome data were synthesized by using weighted mean differences (WMDs) or standardized mean differences (SMDs) with the use of a random-effects model.

RESULTS

A total of 660 records were identified of which 14 were eligible (1182 patients). Overall, probiotics significantly reduced whole gut transit time by 12.4 h (95% CI: -22.3, -2.5 h) and increased stool frequency by 1.3 bowel movements/wk (95% CI: 0.7, 1.9 bowel movements/wk), and this was significant for Bifidobacterium lactis (WMD: 1.5 bowel movements/wk; 95% CI: 0.7, 2.3 bowel movements/wk) but not for Lactobacillus casei Shirota (WMD: -0.2 bowel movements/wk; 95% CI: -0.8, 0.9 bowel movements/wk). Probiotics improved stool consistency (SMD: +0.55; 95% CI: 0.27, 0.82), and this was significant for B. lactis (SMD: +0.46; 95% CI: 0.08, 0.85) but not for L. casei Shirota (SMD: +0.26; 95% CI: -0.30, 0.82). No serious adverse events were reported. Attrition and reporting bias were high, whereas selection bias was unclear due to inadequate reporting.

CONCLUSIONS

Probiotics may improve whole gut transit time, stool frequency, and stool consistency, with subgroup analysis indicating beneficial effects of B. lactis in particular. However, caution is needed with the interpretation of these data due to their high heterogeneity and risk of bias. Adequately powered RCTs are required to better determine the species or strains, doses, and duration of use of probiotics that are most efficacious.

Efficacy of a CO2-releasing suppository in dyschezia: a double-blind, randomized, placebo-controlled clinical trial

BACKGROUND

Constipation has a significant impact on quality of life. Aim of this study was to evaluate the safety and the efficacy for relieving dyschezia symptoms of a CO2-releasing suppository in a randomized, placebo-controlled, clinical trial.

METHODS

Fifty-three office-based primary care physicians and 24 gastroenterologists conducted the study in France, between November 2010 and January 2012. Patients (aged 18-75 years) with dyschezia were eligible. Patients were randomly allocated a once-a-day suppository (CO2-releasing suppository or placebo) for 21 days. Primary endpoint was the change, from Day 0 to Day 21, in the intensity of discomfort related to dyschezia based on a self-assessed 0-100 visual analogue scale.

RESULTS

A total of 323 patients were randomized, i.e. 166 into the intervention group and 157 into the placebo group. Co-variance analysis showed a greater reduction in discomfort visual analogue scale score in the intervention group (-34.5mm; standard error of the mean: 1.8mm) than in the placebo group (-26.2mm; standard error of the mean: 1.9 mm; p<0.001). The greater efficacy of the CO2-releasing suppository was confirmed for all secondary efficacy parameters. No significant side effects for either treatment were observed.

CONCLUSION

A CO2-releasing suppository is more effective than a placebo for the relief of symptoms of dyschezia. This efficacy is associated with a good safety profile.

Efficacy and safety of a magnesium sulfate-rich natural mineral water for patients with functional constipation

BACKGROUND & AIMS

Little is known about the effects of natural mineral water on constipation in adults. We assessed the effect of a magnesium sulfate-rich natural mineral water (Hépar; Nestlé Waters, Issy-les-Moulineaux, France) on gastrointestinal transit in constipated women.

METHODS

We performed a randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of Hépar in outpatients with functional constipation (based on the Rome III criteria). The study included 244 female patients, age 18 to 60 years, identified by 62 general practitioners throughout France. After a washout period, subjects drank 1.5 L natural low-mineral water daily (control, n = 77), 0.5 L Hépar and 1 L natural low-mineral water daily (Hépar 0.5 group, n = 85), or 1 L Hépar and 0.5 L natural low-mineral water daily (Hépar 1 group, n = 82) for 4 weeks. We collected information on the number and types of stools, abdominal pain, rescue medications, adverse events, and volume of water consumed.

RESULTS

We observed no significant effect at week 1. At week 2, constipation was reduced in 21.1% of patients in the control group, in 30.9% in the Hépar 0.5 group (P = .099 vs controls), and in 37.5% in the Hépar 1 group (P = .013 vs controls). The Hépar 1 group also had a decreased number of hard or lumpy stools (Bristol scale, P = .030 vs baseline) and a substantial decrease in the use of rescue medication (P = .034 vs controls). Patient responses correlated with magnesium sulfate concentrations. Safety was very good; there were no serious adverse events among patients who drank Hépar.

CONCLUSIONS

In a controlled trial, daily consumption of 1 L Hépar reduced constipation and hard or lumpy stools in a greater percentage of women with functional constipation than natural low-mineral water, as early as the second week of treatment.

Constipation severity is associated with productivity losses and healthcare utilization in patients with chronic constipation

OBJECTIVE

We sought to evaluate the association between constipation severity, productivity losses and healthcare utilization in a national sample of Italian patients with chronic non-organic constipation (CC).

METHODS

We enrolled 878 outpatients with CC. Clinical and demographic data were collected by physicians during clinical examinations. Patients completed a self-administered questionnaire (Patient Assessment of Constipation-Symptoms, PAC-SYM; Work Productivity and Activity Impairment; healthcare utilization, and Symptoms Checklist 90 Revised - Somatization Scale, SCL-90 R).

RESULTS

Mean PAC-SYM score was 1.62 ± 0.69. Mean weekly sick time due to constipation was 2.7 ± 8.6 h and productivity losses due to presenteeism was 19.7% ± 22.3%. Adjusted productivity losses in patients with severe CC (PAC-SYM score 2.3-4.0) compared to patients with mild symptoms (PAC-SYM score 0.0-1.0) was Italian Purchase Power Parity US$ 6160. Constipation severity (PAC-SYM quintiles) was associated with higher healthcare utilization (RRPAC-SYM 4/01.84; p-value for linear trend <0.01). After adjustment for somatization scores, the association of constipation severity with productivity losses and healthcare utilization rates was attenuated yet statistically significant.

CONCLUSIONS

We observed a graded increase in productivity losses and healthcare utilization with increasing constipation severity. Further studies should evaluate whether significant savings might be achieved with regimens aimed at reducing the constipation severity.

Factors affecting satisfaction with treatment in European women with chronic constipation: An internet survey

BACKGROUND

Data on factors affecting treatment satisfaction in European women with chronic constipation are limited.

OBJECTIVE

To assess factors associated with treatment satisfaction among European women with chronic constipation.

METHODS

A 2011-2012 internet survey was conducted in men and women from 12 European countries. Respondents analysed were female with self-reported chronic constipation (≥1 symptoms for ≥6 months of lumpy/hard stools, feeling of incomplete evacuation, and pain during defecation, as well as <3 bowel movements/week). For laxative users, satisfaction with treatment, factors affecting satisfaction, and interactions with healthcare professionals were collected.

RESULTS AND CONCLUSIONS

In total, 4805/50,319 participants fulfilled the inclusion criteria (female with chronic constipation). Of the laxative users (1575/4805), 57% (n = 896) were satisfied with their treatment, while 26% were neutral, and 17% dissatisfied. Dissatisfied respondents visited their GP less frequently in the past 12 months, were more likely to obtain over-the-counter laxatives, and took a dose higher than recommended more frequently than those satisfied. Respondents were most satisfied with ease of use of treatment and least satisfied with relief from bloating. Newer treatments aimed at alleviating symptoms, particularly bloating, are required for respondents neutral or dissatisfied with their current treatment.

Assessment of treatment response in chronic constipation clinical trials

Background

While chronic constipation (CC) clinical trials have focused primarily on bowel symptoms (symptoms directly related to bowel movements), abdominal symptoms are also prevalent among patients. The United States Food and Drug Administration’s (FDA’s) guidance on the use of patient-reported outcome measures to support product approvals or labeling claims recommends that endpoints be developed with direct patient input and include all symptoms important to patients.

Aim

To identify a comprehensive set of CC symptoms that are important to patients for measurement in clinical trials.

Methods

Following a targeted literature review to identify CC symptoms previously reported by patients, 28 patient interviews were conducted consistent with the FDA’s guidance on patient-reported outcomes. Subsequent to open-ended questions eliciting descriptions of all symptoms, rating and ranking methods were used to identify those of greatest importance to patients.

Results

All 67 studies reviewed included bowel symptoms; more than half also addressed at least one abdominal symptom. Interview participants reported 62 potentially distinct concepts: 12 bowel symptoms; 21 abdominal symptoms; and 29 additional symptoms/impacts. Patients’ descriptions revealed that many symptom terms were highly related and/or could be considered secondary to CC. The rating and ranking task results suggest that both bowel (for example, stool frequency and consistency) and abdominal symptoms (for example, bloating, abdominal pain) comprise patients’ most important symptoms. Further, improvements in both bowel and abdominal symptoms would constitute an improvement in patients’ CC overall.

Conclusion

Abdominal symptoms in CC patients are equal in relevance to bowel symptoms and should also be addressed in clinical trials to fully evaluate treatment benefit.

A concomitant treatment by CO2-releasing suppositories improves the results of anorectal biofeedback training in patients with dyschezia: results of a randomized, double-blind, placebo-controlled trial

BACKGROUND

Dyschezia is a defecatory disorder that places a heavy burden on a patient's quality of life. Biofeedback is the recommended treatment in most cases.

OBJECTIVE

The objective of our study was to test whether a CO2-releasing suppository for patients with dyschezia could be effective in improving biofeedback training results.

DESIGN

A randomized, double-blind, multicenter, placebo-controlled study was conducted in patients (18-75 years of age) with dyschezia defined according to the modified Rome III criteria. Patients were randomly assigned to either a CO2-releasing suppository or placebo suppository once per day for 21 days.

SETTINGS

This was a multicenter trial.

PATIENTS

A total of 122 patients were randomly assigned (62 intervention group and 60 placebo group).

MAIN OUTCOME MEASURES

The primary end point was the change from day 0 to day 21 in intensity of symptoms on the basis of a self-assessed dyschezia using a visual analog scale (range, 0-100). Analyses were performed using intention-to-treat principles.

RESULTS

A greater reduction from baseline to day 21 in symptom visual analog scale score was observed in the intervention group (-41.3 mm) than in the control group (-22.3 mm). Some secondary efficacy parameters improved more in the intervention group, including the percentage of patients who improved ≥50%, symptom intensity over 21 days, stool stains on underwear or pads, and need to practice manual maneuvers to facilitate defecation at day 21. At day 21, rectal sensitivity in the intervention group (31.4 mL) was lower than in the control group (39.1 mL).

LIMITATIONS

There was a lower number of patients recruited than planned by the protocol. The sponsor stopped the trial before the inclusion of 306 participants, with no intermediate analysis. In addition, the main analysis conducted on the full analysis set population could have led to a statistical bias.

CONCLUSIONS

The results of this multicenter trial demonstrate the added benefits of a CO2-releasing suppository in patients with dyschezia who were treated by anorectal biofeedback training.

Prucalopride improves bowel function and colonic transit time in patients with chronic constipation: an integrated analysis

OBJECTIVES

Constipation is often characterized by slow colonic transit, but the relationship between colonic transit time (CTT) and symptoms is unclear. The aims of this study were to investigate the effect of prucalopride, a 5-hydroxytryptamine receptor-4 agonist, on CTT and assess the relationship between CTT and symptoms.

METHODS

This was an integrated analysis of three randomized, placebo-controlled, phase 2 dose-finding trials of prucalopride in patients with chronic constipation (ClinicalTrials.gov identifiers: NCT00617513; NCT00631813; and NCT00596596). Measurements of CTT were analyzed using radio-opaque markers at the start and end (4 or 12 weeks) of treatment. At these visits, patients assessed the presence and severity of their symptoms.

RESULTS

In total, 280 patients had CTT measurements before and at the end of treatment and were included in the analysis. Their mean age was 43 years, 93% were women, and mean duration of constipation was 19 years. After a once daily treatment with prucalopride 2 mg (n=98) and 4 mg (n=70), CTT was reduced by 12.0 h (95% confidence interval (CI): -18.9, -5.1) and 13.9 h (95% CI: -20.5, -7.4), respectively; CTT increased by 0.5 h (95% CI: -4.5, 5.5) with placebo (n=112). At the end of the trial, symptoms including bloating/flatulence/distension and straining were rated as severe or very severe by a higher proportion of patients with slow or very slow CTT (>48 h) than by those with normal CTT.

CONCLUSIONS

There was a clear relationship between increased CTT and increased symptom severity in patients with chronic constipation. Treatment with prucalopride accelerated CTT in these individuals.

Validity and reliability of the Japanese version of the Patient Assessment of Constipation Quality of Life questionnaire

BACKGROUND

This study aimed to provide a psychometric evaluation of the Japanese version of the Patient Assessment of Constipation Quality of Life questionnaire (JPAC-QOL).

METHODS

Data for scoring were collected prospectively from patients with constipation who visited our center from 2008 to 2010, and analyzed retrospectively. Reliability of the JPAC-QOL was evaluated using Cronbach's alpha to calculate internal consistency, and a test-retest study was performed to evaluate reproducibility. For concurrent validity assessment, the JPAC-QOL scores were compared with Constipation Scoring System (CSS) scores. In assessing responsiveness, the JPAC-QOL scores before and after treatments were compared in patients whose modified CSS (mCSS) scores decreased by >50 %.

RESULTS

Internal consistency was assessed in 295 patients (165 women; mean age 67.0 years). Cronbach's alpha was >0.7 for the overall score and all four subscales, showing a strong internal consistency. The intraclass correlations for the 145 patients available for the test-retest study were >0.7 for the overall score and for all subscales except satisfaction. The JPAC-QOL scores were significantly associated with the CSS scores in 284 patients, demonstrating concurrent validity in all four subscales and the overall score. The mean JPAC-QOL score improved significantly after treatment in the 72 patients whose mCSS scores decreased by >50 %, indicating good responsiveness in all four subscales and in the overall score.

CONCLUSIONS

Our study data confirmed the validity and reliability of the JPAC-QOL and demonstrated it ready for use in evaluating the symptom-specific QOL in Japanese patients with constipation.

Complementary effects of auricular acupressure in relieving constipation symptoms and promoting disease-specific health-related quality of life: A randomized placebo-controlled trial

OBJECTIVES

Constipation has been identified as a worldwide health problem among elderly people. Currently, it is not effectively relieved by the use of laxatives and lifestyle modification. Previous studies reported promising results in managing constipation with auricular acupressure (AA), although its effectiveness was not affirmed. This study is to evaluate the complementary effects of AA in relieving constipation symptoms and in promoting disease-specific health-related quality of life (HRQOL) among elderly residential care home (RCH) residents in Hong Kong.

DESIGN

Randomized placebo-controlled trial.

SETTING

Elderly RCH.

INTERVENTION

Ninety-nine participants were randomly assigned to either experimental group (AA using auricular plasters with magnetic pellets), placebo-controlled group (AA using auricular plasters with Semen Vaccariae), or usual care group (AA using auricular plasters only). AA was applied onto seven auricular acupoints for 10 days.

MAIN OUTCOME MEASURES

Constipation symptoms and disease-specific HRQOL were measured before AA, at the completion of AA (D10), and at the 10th-day follow-up time (D20).

RESULTS

Significant group×time interaction effect was found in the change of satisfaction subscale between the experimental group and placebo-controlled group at D10 (p=0.016) and D20 (p=0.016) relative to the baselines. For both constipation symptoms and disease-specific HRQOL, the experimental group demonstrated the greatest improvement after receiving AA at both D10 and D20 compared with the other two groups.

CONCLUSION

The current findings indicated positive clinical value of AA with magnetic pellets in managing constipation in elderly RCH residents. AA was also found to be a safe and acceptable intervention.

Linaclotide: new mechanisms and new promise for treatment in constipation and irritable bowel syndrome

Chronic idiopathic constipation (CIC) and irritable bowel syndrome (IBS) are functional disorders of the lower gastrointestinal tract. Their prevalence in the general population is between 5% and 20%. Both disorders are chronic, with a relapsing and remitting natural history. The medical treatment of both conditions is unsatisfactory at present, and they represent a huge burden to the health service. Linaclotide is a first-in-class minimally adsorbed, 14-amino-acid peptide agonist of guanylate cyclase C. The drug acts on the intestinal enterocyte. As a consequence of this, intestinal fluid secretion is increased and intestinal transit is accelerated. The efficacy of linaclotide has been studied in both CIC and constipation-predominant IBS (IBS-C). Randomized controlled trials consistently demonstrate that the drug is effective in the treatment of CIC and IBS-C, across a wide range of continuous and dichotomous endpoints. The number needed to treat with linaclotide to prevent one patient with CIC or IBS-C failing to respond to therapy is between 5 and 8 in studies that have reported these data. Overall, in the majority of trials, total numbers of adverse events have been no more frequent with linaclotide, but rates of diarrhoea have been consistently higher. While the drug is clearly effective in the treatment of CIC, there are other evidence-based therapies available, and head-to-head efficacy and cost-effectiveness studies are therefore required to further delineate the role of linaclotide in the treatment of the condition. In IBS-C there are no other licensed therapies available, and linaclotide therefore represents a novel treatment with great promise.

Chronic constipation: a critical review

Chronic constipation is a very common symptom that is rarely associated with life-threatening diseases, but has a substantial impact on patient quality of life and consumption of healthcare resources. Despite the large number of affected patients and the social relevance of the condition, no cost-effectiveness analysis has been made of any diagnostic or therapeutic algorithm, and there are few data comparing different diagnostic and therapeutic approaches in the long term. In this scenario, increasing emphasis has been placed on demonstrating that a number of older and new therapeutic options are effective in treating chronic constipation in well-performed randomised controlled trials, but there is still debate as to when these therapeutic options should be included in diagnostic and therapeutic algorithms. The aim of this review is to perform a critical evaluation of the current diagnostic and therapeutic options available for adult patients with chronic constipation in order to identify a rational patient approach; furthermore we attempt to clarify some of the more controversial points to aid clinicians in managing this symptom in a more efficacious and cost-effective manner.

Electro-acupuncture with different current intensities to treat functional constipation: a study protocol for a randomized controlled trial

Background

Functional constipation (FC) is highly prevalent in the general population of the world and has a substantial negative impact on the health-related quality of life of individuals. Many clinical trials have indicated that acupuncture is effective in the treatment of FC. However, the sample sizes of these previous studies were too small. Furthermore, there are no reports investigating the relationship between the stimulation parameter and the therapeutic effect. We therefore designed a multicenter randomized controlled trial to address these problems and hopefully provide a more conclusive answer to these questions.

Methods

Participants will be included if they meet all of the following conditions: (1) diagnosed with functional constipation according to the Roman III standard; (2) aged between 18 and 65 years; (3) not taking any drugs that promote gastrointestinal movements at least during the 1 week prior to randomization; (3) willing to sign an informed consent form; (4) willing to return to the study site for their study visits. The participants will be randomly assigned to three groups in a 1:1:1 ratio: high current intensity group, low current intensity group, and mosapride citrate control group. The total study period is 9 weeks for each patient, 1 week for baseline, 4 weeks for treatment, and 4 weeks for follow-up. The primary outcome in this trial is the number of defecating events per week. The secondary outcomes will include the shape and properties of the stool, intensity of defecating difficulty, Patient Assessment of Constipation Quality of Life (PAC-QOL), MOS item Short Form health survey (SF-36), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS).

Discussion

This study will provide significant evidence for the application of acupuncture in FC and will identify a suitable stimulation parameter for treatment.

Trial registration

ClinicalTrials.gov ID: NCT01274793.

Association between constipation and colorectal cancer: systematic review and meta-analysis of observational studies

OBJECTIVES

Constipation is common in the community, and may affect survival adversely. An association between constipation and development of colorectal cancer (CRC) could be one possible explanation. We performed a systematic review and meta-analysis examining this issue.

METHODS

We searched MEDLINE, EMBASE, and EMBASE Classic (through July 2012). Eligible studies were cross-sectional surveys, cohort studies, or case-control studies reporting the association between constipation and CRC. For cross-sectional surveys and cohort studies, we recorded number of subjects with CRC according to the constipation status, and for case-control studies, number of subjects with constipation according to CRC status were recorded. Study quality was assessed according to published criteria. Data were pooled using a random effects model, and the association between CRC and constipation was summarized using an odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

The search strategy identified 2,282 citations, of which 28 were eligible. In eight cross-sectional surveys, presence of constipation as the primary indication for colonoscopy was associated with a lower prevalence of CRC (OR=0.56; 95% CI 0.36-0.89). There was a trend toward a reduction in odds of CRC in constipation in three cohort studies (OR=0.80; 95% CI 0.61-1.04). The prevalence of constipation in CRC was significantly higher than in controls without CRC in 17 case-control studies (OR=1.68; 95% CI 1.29-2.18), but with significant heterogeneity, and possible publication bias.

CONCLUSIONS

Prospective cross-sectional surveys and cohort studies demonstrate no increase in prevalence of CRC in patients or individuals with constipation. The significant association observed in case-control studies may relate to recall bias.

Laxative effects of Salecan on normal and two models of experimental constipated mice

Background

Constipation is one of the most common gastrointestinal complaints with a highly prevalent and often chronic functional gastrointestinal disorder affecting health-related quality of life. The aim of the present study was to evaluate the effects of Salecan on fecal output and small intestinal transit in normal and two models of drug-induced constipation mice.

Methods

ICR mice were administrated intragastrically (i.g.) by gavage with 100, 200 and 300 mg/kg body weight (BW) of Salecan while the control mice were received saline. The constipated mice were induced by two types of drugs, loperamide (5 mg/kg BW, i.g.) and clonidine (200 μg/kg BW, i.g.), after Salecan treatment while the control mice were received saline. Number, weight and water content of feces were subsequently measured. Small intestinal transit was monitored by phenol red marker meal.

Results

Salecan (300 mg/kg BW) significantly increased the number and weight of feces in normal mice. In two models of drug-induced constipation, Salecan dose-dependently restored the fecal number and fecal weight. The water content of feces was markedly affected by loperamide, but not by clonidine. Treatment with Salecan significantly raised the fecal water content in loperamide-induced constipation mice. Moreover, Salecan markedly stimulated the small intestinal transit in both loperamide- and clonidine-induced constipation model mice.

Conclusions

These results suggest that Salecan has a potential to be used as a hydrophilic laxative for constipation.

[Chronic constipation in adults]

Chronic constipation is a very common condition, which is responsible for a major socioeconomic burden. Primary management must rule out secondary constipation before recognizing chronic idiopathic constipation, which is the most common diagnosis. Initial treatment frequently associates simple lifestyle modifications, whose efficacy is limited, with osmotic laxatives or bulking agents. If those measures do not relieve symptoms, a switch of laxatives or a combination must be proposed. Pharmacological treatments of constipation represent a new alternative approach in case of failure of previously mentioned measures. In case of chronic constipation reluctant to all conservative therapies, specific tests are required before considering biofeedback intervention or exceptionally a surgical option.

Kiwifruit modulation of gastrointestinal motility

Disorders of gastrointestinal motility are common, resulting in a decreased quality of life of individuals, and an economic burden. Gastrointestinal motility is categorized according to location within the gastrointestinal tract: stomach, small intestine, and colon, with the colon being the dominant compartment in determining overall gastrointestinal transit. Constipation results from gastrointestinal dysmotility and is a significant chronic health issue globally. Clinical studies in a range of adult populations consistently indicate that kiwifruit are a highly effective dietary option to promote laxation. This, together with emerging evidence for the putative effects of kiwifruit in beneficially promoting gastric emptying and digesta mixing, suggests that kiwifruit are physiologically active throughout the gastrointestinal tract. Although the mechanisms of this action remain unknown, the unique behavior of kiwifruit fiber during digestion and the potential action of bioactive components in kiwifruit may contribute to the effectiveness of kiwifruit in modulating gastrointestinal motility.

Levels of satisfaction with current chronic constipation treatment options in Europe - an internet survey

BACKGROUND

Data on treatment satisfaction in European men and women with chronic constipation are limited.

AIM

To assess satisfaction with current treatment among European men and women with chronic constipation.

METHODS

An internet-based survey was conducted in 2009 in 10 European countries: Austria, Germany, France, Ireland, Italy, Spain, Switzerland, the UK, Belgium and the Netherlands. Participants had self-reported chronic constipation (<3 bowel movements/week and ≥1 symptoms for ≥6 months of: pain during defecation; lumpy/hard faeces; and feeling of incomplete evacuation). Demographic data and disease history were collected. For participants using laxatives, drug name/class, satisfaction with treatment and interest in other treatments were collected.

RESULTS

Of the 1941 participants screened, 1355 had chronic constipation and met the inclusion criteria (chronic constipation population). The majority of the chronic constipation population who disclosed their sex (n = 811) were women (82%). Sixty-eight per cent of respondents (n = 855/1255) reported using laxatives, with the proportion of laxative users differing between subsets. Twenty-eight per cent (n = 225/793) were (very) satisfied with their treatment, whereas 44% (n = 345/793) were neutral and 28% (n = 223/793) (very) dissatisfied. There was no relationship between type of laxative and degree of (dis)satisfaction. Interest in other treatments was high with 83% (n = 686/827) of respondents 'absolutely' or 'probably' interested. Respondents dissatisfied with their treatment were more likely to be interested in other treatments.

CONCLUSIONS

Laxative-use is common for chronic constipation. In this large survey, 28% of participants were dissatisfied with their treatment, with the majority interested in other treatments.

Interferential therapy: a new treatment for slow transit constipation. a pilot study in adults

AIM

The study aimed to assess, for the first time, the effectiveness of interferential therapy (IFT) in the treatment of slow transit constipation in adults and its impact on the quality of life.

METHOD

All consecutive patients with slow transit constipation diagnosed by symptomology and a colonic transit time (CTT) of > 100 h measured with radiopaque markers were included in this prospective study. IFT was performed for 1 h/day over 3 months. Clinical improvement was based on the stool diary and the Knowles-Eccersley-Scott Symptom and Cleveland Clinic Constipation Scores. Quality of life was assessed with the Gastrointestinal Quality of Life Index questionnaire.

RESULTS

Eleven patients with a median age of 51 years were included. At the end of the follow-up period, seven (63.6%) had significantly improved after IFT with a median of 0.66 stools per week [interquartile range (IQR) 0.33-0.66] before treatment and 1.66 (IQR 1.33-1.66) after (P = 0.007). The Knowles-Eccersley-Scott Symptom score changed from 30 (IQR 27-33) before treatment to 19 (IQR 17-26) after treatment (P = 0.005) and the Cleveland Clinic Constipation Score from 26 (IQR 25-28) to 17 (IQR 13-24; P = 0.005). The CTT improved from 103 h (IQR 101-113) to 98 h (IQR 94-107; P = 0.02). The Gastrointestinal Quality of Life Index score improved from 60 (IQR 57-63) to 95 (IQR 68-100; P = 0.005).

CONCLUSION

IFT is a new non-invasive treatment for slow transit constipation. Further studies to confirm these results with longer follow-up are necessary.

The impact of functional constipation on quality of life of middle-aged Black Americans: a prospective case-control study

PURPOSE

To quantify the impact of constipation on health-related quality of life (HRQoL) in Black Americans.

METHODS

Case-control design. Black subjects referred for colon cancer screening with a Bristol Stool Score of 3-5 for >75% of bowel movements served as controls. Frequency-matched functional constipation subjects had to fulfill Rome III criteria. Both groups completed demographic and health surveys. Short Form-36 assessed HRQoL.

RESULTS

We recruited 102 constipated patients and 100 controls. The groups were well matched demographically. After adjustment for comorbidities, SF-36 scores for vitality, bodily pain, social functioning, and role-emotional were significantly lower in constipated patients. Unadjusted physical and mental component summary scores (PCS and MCS) were significantly higher in the control group (47.1 ± 10.6 vs. 43.3 ± 8.6; P = 0.005 and 50.6 ± 12.4 vs. 43.4 ± 11.8; P < 0.001, respectively). After adjustment for comorbidities, PCS differences were no longer significant (P = 0.54); however, MCS differences were significant (P = 0.004). Marginal mean scores for the MCS for controls and constipated subjects were 49.9 ± 1.2 and 43.6 ± 1.2, respectively. The presence of a comorbidity was independently associated with PCS (P < 0.001) and MCS (P = 0.026) results.

CONCLUSIONS

Functional constipation has a significant impact on HRQoL in middle-aged Black Americans, particularly in regard to mental well-being.

Prucalopride in the treatment of chronic constipation in patients from the Asia-Pacific region: a randomized, double-blind, placebo-controlled study

BACKGROUND

The study evaluated efficacy and safety of the 2 mg dose of prucalopride compared to placebo in patients with chronic constipation (CC) from the Asia-Pacific region.

METHODS

Randomized, placebo-controlled, parallel-group, phase III study with 2-week run-in, 12-week treatment phase, and 1-week follow-up. Adult patients with CC (≤2 spontaneous bowel movements per week) received 2 mg prucalopride or placebo, once-daily, for 12 weeks. Primary efficacy measure was percentage of patients with average of ≥3 spontaneous complete bowel movements (SCBMs) per week (Responders) during the 12-week treatment. A key secondary endpoint was Responders during first 4 weeks of treatment. Other efficacy assessments were based on patient diaries, their assessments of symptoms and quality of life, and investigator's assessment on efficacy of treatment. Safety assessments included adverse events, laboratory values, and cardiovascular events.

KEY RESULTS

Efficacy and safety were evaluated for 501 patients who received study drug. On the primary endpoint, prucalopride was significantly more effective than placebo with 83 (33.3%) vs 26 (10.3%) patients having a weekly average of ≥3 SCBMs during the 12-week treatment (P < 0.001). Respective percentages were 34.5%vs 11.1% over first 4 weeks (P < 0.001). On other secondary endpoints, clinical improvement was generally larger and statistically superior (P < 0.001) in the prucalopride group. Most frequently reported adverse events were diarrhea, nausea, abdominal pain, and headache.

CONCLUSION & INFERENCES

Prucalopride 2 mg given once-daily significantly improved bowel function, associated symptoms, and satisfaction in CC over a 12-week treatment period, and was safe and well tolerated by patients in the Asia-Pacific region.

The effect of biofeedback training on patients with functional constipation

The aim of this prospective quasi-experimental study was to explore the influence of biofeedback training on patients with functional constipation (FC). Changes in clinical symptoms, psychological status, quality of life, and autonomic nervous function in 21 FC patients before and after biofeedback training were investigated. The psychological status and quality of life were evaluated with the Zung Self-Rating Anxiety Scale (SAS), Zung Self-Rating Depression Scale (SDS), and a Chinese version of the MOS 36-Item Short-Form Health Survey. Autonomic nervous function was assessed on the basis of heart rate variability recorded with a HANS-1000 autonomic nervous biofeedback apparatus. After a complete course of training (10 sessions), clinical symptoms were greatly improved (p < .01), and the SAS and SDS scores were markedly decreased. There was a significant difference in the SAS and SDS scores before and after biofeedback (p < .01). The scores of general health perceptions, physical functioning, emotional role functioning, bodily pain, and vitality were increased significantly (p < .05), especially the scores of general health perceptions and emotional role functioning (p < .01), which indicated that quality of life in FC patients was significantly improved. No marked improvement of autonomic nervous function was found. Although a slight improvement in autonomic nervous activity was found, there was no significant statistical findings (p > .05). We conclude that biofeedback training can improve clinical symptoms, psychological status, and quality of life in FC patients, but further research is needed to determine whether biofeedback training can improve the autonomic nervous function in FC patients.

Recent advances in the management of difficult constipation

Constipation is a highly prevalent disorder. Some patients suffer from acute, intermittent episodes of constipation. Others, however, suffer from chronic constipation, a term that refers to those patients with symptoms of constipation for more than 6 months. In clinical practice, chronic constipation is often used interchangeably with the term functional constipation, which is currently defined using the Rome III criteria. Symptoms can be burdensome, leading to a reduction in patients' quality of life. In addition, chronic constipation is important because it imposes a significant economic impact to the health care system. Some patients with chronic constipation have persistent symptoms despite implementing lifestyle changes and using either over-the-counter agents or prescription medications. These patients may be categorized as having difficult constipation. This report will focus on recent advances in the management of difficult constipation, and include a discussion of new and upcoming medications as well as new diagnostic tests and procedures.

Chronic constipation: new diagnostic and treatment approaches

Chronic constipation is a highly prevalent disorder that affects approximately 15% of the US population. Chronic constipation refers to patients who have had symptoms for more than 6 months. In clinical practice, chronic constipation is often used interchangeably with the term functional constipation. This is best defined using the Rome III criteria, which involves an evaluation of stool frequency in addition to symptoms of straining, feelings of incomplete evacuation, and the need to use manual maneuvers to assist with stool evacuation. Symptoms can be burdensome, leading to a reduction in patients' quality of life. As a national healthcare issue, chronic constipation is also important because it imposes a significant economic impact on the healthcare system. A number of treatment options are currently available, both over-the-counter and by prescription, although not all patients respond to these therapies. This review will focus on new medical treatment options for the management of chronic constipation, and the safety and efficacy of these agents will be reviewed. In addition, the efficacy of new diagnostic tests to evaluate colonic motility and anorectal function are described.