Straining at stool and laxative taking in an English population

Potential risk factors for constipation in the community

Constipation is a common community health problem. There are many factors that are widely thought to be associated with constipation but real-world evidence of these associations is difficult to locate. These potential risk factors may be categorised as demographic, lifestyle and health-related factors. This review presents the available evidence for each factor by an assessment of quantitative data from cross-sectional studies of community-dwelling adults published over the last 30 years. It appears that there is evidence of an association between constipation and female gender, residential location, physical activity and some health-related factors such as self-rated health, some surgery, certain medical conditions and certain medications. The available evidence for most other factors is either conflicting or insufficient. Therefore, further research is necessary to determine if each factor is truly associated with constipation and whether it can be regarded as a potential risk factor. It is recommended that studies investigating a broad range of factors are conducted in populations in community settings. Multivariate analyses should be performed to account for all possible confounding factors. In this way, valuable evidence can be accumulated for a better understanding of potential risk factors for constipation in the community.

Laxative Use in the Community: A Literature Review

Laxatives are widely available without prescription and, as a consequence, they are commonly used for self-management of constipation by community-dwelling adults. However, it is not clear to what extent laxatives are used. Nor is it clear how laxatives are chosen, how they are used and whether consumers are satisfied with their performance. This review of published literature in the last 30 years shows the prevalence of laxative use in community-dwelling adults varied widely from 1% to 18%. The prevalence of laxative use in adults with any constipation (including both chronic and sporadic constipation) also varied widely from 3% to 59%. Apart from any geographical differences and differences in research methodologies, this wide range of estimated prevalence may be largely attributed to different definitions used for laxatives. This review also shows that laxative choice varies, and healthcare professionals are infrequently involved in selection. Consequently, satisfaction levels with laxatives are reported to be low and this may be because the laxatives chosen may not always be appropriate for the intended use. To improve constipation management in community and primary healthcare settings, further research is required to determine the true prevalence of laxative use and to fully understand laxative utilisation.

Chronic constipation

Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of 'alarm' features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.

Understanding of Constipation Symptoms and the Diagnosis and Management of Constipation in Chinese Physicians

Background and Aims

Although a range of guidelines for the diagnosis and treatment of chronic constipation has been carried out, there was very little information about the understanding on constipation. The aim of the present study was to estimate the understanding of constipation symptoms and the diagnosis and management of constipation by clinical physicians in China.

Methods

Participants were physicians and researchers in the field of gastroenterology in China who were scheduled to attend the National Conference on gastrointestinal motility(Constipation). Based on the recommendation of the Rome Foundation Board, the self-reported questionnaire was constructed.

Findings

Although most of the opinions on symptoms of constipation were consistent, there were still some differences. Opinions on the Bristol stool form during constipation were discordant, 34% of the doctors thought that it was type 1 and type 2, while 46%of the doctors suggested that type 3 should also be considered constipation. There was no significant difference between them(P = 0.05); We investigated the interpretation on the duration of defecation prolonged, 27% of the doctors suggested it should be longer than 10 minutes, 22% of the doctors suggested it should be longer than 20 minutes, and other 22% of the doctors suggested it should be time of defecation became longer compared to previously bowel habits, there was no significant difference among them(P = 0.38).Only 36% of the doctors thought that psychotherapy was most important in the treatment of severe constipation, while 37% of the doctors thought that medication treatment was most important in the treatment of severe constipation, there was no significant difference between them(P = 0.895).

Conclusion

We were able to obtain valuable information about current views on symptoms of constipation and the diagnosis and treatment of constipation among Chinese doctors. Although most of the opinions were consistent there were still some differences. This study indicated that in practice in China there was a need for further study on the role of constipation symptoms and there may also be a need for better establishment of consensus guidelines for constipation.

Epidemiology of constipation in São Paulo, Brazil: a population-based study

OBJECTIVE

Epidemiologic data on constipation in South America are limited. The main objective of this study was to assess the prevalence of self-reported symptoms of constipation in Brazil.

METHODS

Telephone and personal surveys were conducted among community-dwelling adults in homes with land-based telephones in São Paulo. Data were weighted by numbers of adults, total residents, and telephones in each household. To account for potential nonresponse and noncoverage bias, results were further adjusted according to Brazilian census data.

RESULTS

Among 4570 households contacted, 3050 adults (66.7%) participated. Respondents (mean [SE] age: 42.6 [2.7] years) were primarily women (53.1%). A minority of all respondents reported symptoms consistent with constipation, including a perception of incomplete voiding in 8.0%; expending efforts to defecate in 7.6%; ≤2 stools weekly in 9.0%; and hard stools in 12.7%. Prevalences of these symptoms and efforts to manage them were more frequent in women (P ≤ 0.004), but most were not significantly associated with advancing age. With increasing age, proportions of respondents with ≤2 stools per week declined (P = 0.001), whereas use of bowel enemas (P = 0.026) and digital maneuvers to disimpact stool increased (P < 0.001). Despite frequent constipation symptoms, the vast majority of respondents did not report using prescription medications, but some used natural remedies (29.5%) and/or laxatives (13.4%).

CONCLUSIONS

Symptoms of constipation are prevalent in São Paulo, particularly among women. On the other hand, most survey respondents did not use medications or other remedies that manage this condition. These findings may point to an unmet gastrointestinal treatment need. Future research is needed to corroborate our findings in rural settings and to further evaluate potential predictors and consequences of constipation in South America.

Impact of persistent constipation on health-related quality of life and mortality in older community-dwelling women

OBJECTIVES

Very little is known about whether the reported health-related impact of constipation is worse in people who experience constipation over a long period of time vs. those with more transient symptoms. We aimed to determine the impact of persistent vs. transient constipation on health-related quality of life (QOL), depression, and mortality.

METHODS

We analyzed data from 5,107 women (aged 70-75 years in 1996) who answered "Have you had constipation in the past 12 months?" in all five surveys sent out every 3 years of the Australian Longitudinal Study on Women's Health.

RESULTS

Of the 5,107 women, 20.9, 54.1, and 24.7% reported having persistent constipation on at least 4 out of 5 surveys, transient constipation reported on 1-3 surveys, or none reported over the 15-year time frame, respectively. Women who reported persistent constipation had significantly lower scores for all domains of QOL on the SF-36 except role-emotional, and had higher levels of self-reported depression, even after adjusting for number of chronic illnesses and fluid intake. Mortality rates were increased when comparing women with no reported constipation with persistently reported constipation (8.2% vs. 11%, odds ratio = 1.32, 95% confidence interval 1.0, 1.74, P = 0.05) controlling for specific chronic illnesses.

CONCLUSIONS

Persistent constipation among older women is associated with poor health outcomes.

An evidence-based systematic review of senna (Cassia senna) by the Natural Standard Research Collaboration

An evidence-based systematic review, including written and statistical analysis of scientific literature, expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing.

Origins of Western diseases

Recent gynaecological studies show that childbirth, constipation, trauma and surgery cause injuries to autonomic nerves at different anatomical sites in the female pelvis resulting in endometriosis, adenomyosis and fibroids. Re-growth of abnormal nerves causes allodynic symptoms ('light touch causing pain or discomfort') some years later including vulvodynia, dyspareunia, dysmenorrhea, irritative bladder and bowel symptoms. Further consequences of autonomic denervation include tissue hypoplasia and hyperplasia, visceral dysfunction, susceptibility to infection, alcohol, tobacco and drugs, as well as pain with sensitization of the central nervous system. The 'autonomic denervation' view extrapolates these observations from the female pelvis to the varied anatomy of branches of the cardiac and coeliac plexi to provide primary mechanisms for many forms of Western disease. This account sets out the autonomic denervation view, identifies features of autonomic denervation in extrapelvic organs, and, contrasts it with prior accounts of chronic Western diseases including those of DP Burkitt, PRJ Burch and DP Barker.

Prevalence of, and risk factors for, chronic idiopathic constipation in the community: systematic review and meta-analysis

OBJECTIVES

Chronic idiopathic constipation (CIC) is a common functional gastrointestinal disorder in the community, yet no previous systematic review and meta-analysis has estimated the global prevalence, or potential risk factors for the condition.

METHODS

MEDLINE, EMBASE, and EMBASE Classic were searched (up to December 2010) to identify population-based studies reporting the prevalence of CIC in adults (≥15 years), according to self-report, questionnaire, or specific symptom-based criteria. The prevalence of CIC was extracted for all studies, and according to country, age, gender, socioeconomic status, and presence or absence of irritable bowel syndrome (IBS) where reported. Pooled prevalence overall, and according to study location and certain other characteristics, as well as odds ratios (ORs), with 95% confidence intervals (CIs) were calculated.

RESULTS

Of the 100 papers evaluated, 45 reported the prevalence of CIC in 41 separate study populations, containing 261,040 subjects. Pooled prevalence of CIC in all studies was 14% (95% CI: 12-17%). The prevalence of CIC was lower in South East Asian studies, and in studies using the Rome II or III criteria. The prevalence of CIC was higher in women (OR: 2.22; 95% CI: 1.87-2.62), and increased with age and lower socioeconomic status. The prevalence was markedly higher in subjects who also reported IBS (OR: 7.98; 95% CI: 4.58-13.92), suggesting common pathogenic mechanisms.

CONCLUSIONS

Pooled prevalence of CIC in the community was 14%, and of similar magnitude in most geographical regions. Rates were higher in women, older individuals, and those of lower socioeconomic status. Presence of IBS was strongly associated with CIC.

Epidemiology of constipation in children and adults: a systematic review

We aimed to review the published literature regarding the epidemiology of constipation in the general paediatric and adult population and to assess its geographic, gender and age distribution, and associated factors. A search of the Medline database was performed. Study selection criteria included: (1) studies of population-based samples; (2) containing data on the prevalence of constipation without obvious organic aetiology; (3) in paediatric, adult or elderly population; (4) published in English and full manuscript form. Sixty-eight studies met our inclusion criteria. The prevalence of constipation in the worldwide general population ranged from 0.7% to 79% (median 16%). The epidemiology of constipation in children was investigated in 19 articles and prevalence rate was between 0.7% and 29.6% (median 12%). Female gender, increasing age, socioeconomic status and educational level seemed to affect constipation prevalence.

Randomized clinical trial of a phytotherapic compound containing Pimpinella anisum, Foeniculum vulgare, Sambucus nigra, and Cassia augustifolia for chronic constipation

Background

A phytotherapic compound containing Pimpinella anisum L., Foeniculum vulgare Miller, Sambucus nigra L., and Cassia augustifolia is largely used in Brazil for the treatment of constipation. However, the laxative efficacy of the compound has never been tested in a randomized clinical trial. The aim of this study was to evaluate the efficacy and safety of the product.

Methods

This randomized, crossover, placebo-controlled, single-blinded trial included 20 patients presenting with chronic constipation according to the criteria of the American Association of Gastroenterology. The order of treatments was counterbalanced across subjects: half of the subjects received the phytotherapic compound for a 5-day period, whereas the other half received placebo for the same period. Both treatment periods were separated by a 9-day washout period followed by the reverse treatment for another 5-day period. The primary endpoint was colonic transit time (CTT), measured radiologically. Secondary endpoints included number of evacuations per day, perception of bowel function, adverse effects, and quality of life.

Results

Mean CTT assessed by X ray was 15.7 hours (95%CI 11.1-20.2) in the active treatment period and 42.3 hours (95%CI 33.5-51.1) during the placebo treatment (p < 0.001). Number of evacuations per day increased during the use of active tea; significant differences were observed as of the second day of treatment (p < 0.001). Patient perception of bowel function was improved (p < 0.01), but quality of life did not show significant differences among the study periods. Except for a small reduction in serum potassium levels during the active treatment, no significant differences were observed in terms of adverse effects throughout the study period.

Conclusions

The findings of this randomized controlled trial allow to conclude that the phytotherapic compound assessed has laxative efficacy and is a safe alternative option for the treatment of constipation.

Trial registration

ClinicalTrial.gov NCT00872430

Clinical Research on the Relation Between Body Mass Index, Motilin and Slow Transit Constipation

Background

Constipation is a common clinical symptom but its etiology remains unknown. The aims of the study are to discuss the relation between body mass index (BMI), motilin and the slow transit constipation (STC).

Methods

A total of 178 patients with STC and 123 healthy volunteers as controls were divided into three groups according to the BMI, group A (BMI <20), group B (BMI 20-25), and group C (BMI > 25). Fasting and one hour postprandial plasma motilin were measured and the results were analyzed.

Results

There was significant difference in the constituent ratio between STC patients and healthy controls (p < 0.05). The percentage of group A, B and C in STC patients was 49.4% (88/178), 23.0% (41/178) and 27.6% (49/178), respectively; and group A had a higher percentage. Plasma motilin of fasting and one hour postprandial in STC patients of group A was significantly lower than that of group B and C (p < 0.05), but there was no difference between group B and C (p > 0.05). There was no significant difference in the results of plasma motilin of fasting and one hour postprandial among the three groups of healthy controls (p > 0.05). Plasma motilin of fasting and one hour postprandial in STC patients of group A was significantly lower than those healthy controls of group A (p < 0.05). The same results of plasma motilin of fasting and one hour postprandial could be seen in group B and C, respectively (p < 0.05).

Conclusions

A higher proportion of low BMI sufferers was found in the STC patients. The reason may be related to the lower release of the plasma motilin.

Autonomic denervation and the origins of chronic Western diseases

Many chronic Western diseases result from lifestyles that include refined diets, poor bowel habits, limited physical exercise and suboptimal patterns of childbirth. Western diets result in reduced stool weights, increased bowel transit times and persistent physical efforts during defaecation. Prolonged physical efforts during defaecation and childbirth cause latent, or direct, injuries to branches of the cardiac (thorax), coeliac (abdomen) and hypogastric (pelvis) plexi. Injuries to autonomic nerves result in impaired visceral function including visceral dysmotility, tissue hypoplasia and hyperplasia, increased susceptibility to infection, and, aberrant reinnervation with sensitisation of the central nervous system (CNS). These unrecognised injuries are vulnerable to the long list of causes of autonomic Dysfunction, e.g. stress, alcohol, drugs, infection, trauma, cancer, etc. Specific injuries at different anatomical locations in midline autonomic pathways give rise to a wide range of Western diseases from infancy to old age, through diverse and cumulative mechanisms.

Endometriosis: the elusive epiphenomenon

The denervation-reinnervation view proposes that retrograde menstruation results from loss of normal, fundocervical polarity caused by injuries to uterine nerves. Injuries may be sporadic (following vaginal delivery) or recurrent (after persistent straining during defaecation) creating very different appearances at laparoscopy. Clinical symptoms of pelvic pain, menstrual problems, dyspareunia, and dysmenorrhoea result from aberrant reinnervation that may occur with, or without deposits of pelvic endometriosis. Endometrium, delivered by retrograde menstruation, adheres to any injured tissues in the lower pelvis. Classical 'endometriosis' is largely an epiphenomenon to underlying processes of denervation and reinnervation.

Perivascular nerve fibre proliferation: The consequence of prolonged straining

Four clinical cases are described in which a history of straining to achieve defaecation over many years, was associated with prolonged pelvic pain and the neuro-immunohistochemical observation of perivascular nerve fibre proliferation (PVNFP). Specimens of uterus, vagina, vulva and bladder have all demonstrated this novel histological feature. In three of the four cases, treatment with gonadotrophin releasing hormone agonists was associated with temporary improvement of the pain.

Sustained constipation and subsequent reproductive outcomes: Is there a link?

Four cases of antenatal and intra-partum problems in nulliparous women, including early-onset pre-eclampsia, intrauterine growth retardation, placental abruption and placenta accreta, are offered with the underlying theme of sustained and persistent constipation over many years. Possible aetiological mechanisms are offered to account for these presentations.

Portal vein thrombosis related to Cassia angustifolia

INTRODUCTION

Cassia angustifolia (Senna), used as a laxative, is a plant from the Fabaceae family. It includes hydroxyanthracene glycosides, also known as Senna Sennoside. These glycosides stimulate the peristalsis of the colon and alter colonic absorption and secretion resulting in fluid accumulation and expulsion. In the literature, there are reports illustrating the hepatotoxic effects of Cassia angustifolia but there is no report of portal vein thrombosis caused by Cassia Angustifolia.

CASE REPORT

A 42-year-old woman was admitted to the emergency department with a five-day history of worsening epigastric pain, anorexia, episodic vomiting, and intermittent fever. She reported that she had boiled dried senna leaves she had bought from herbalists and drank approximately 200 mL daily for two years. Color Doppler screening found an echogen thrombus obliterating portal vein bifurcation and the right branch. The lumen was obstructed at this level and there was no blood flow through it. Treatment with thrombolytics was unsuccessful.

DISCUSSION

Severe hepatotoxicity senna use is unusual. The cause of senna-related hepatotoxicity is unclear but could be explained by the exposure of the liver to unusual amounts of toxic metabolites of anthraquinone glycosides.

CONCLUSION

Chronic use of Cassia angustifolia may rarely be associated with portal vein thrombosis.

[Fiber intake and colonic transit time in functional constipated patients]

BACKGROUND

Patients with functional constipation presenting no response to treatment using fibers supplement represents important clinical issue.

AIMS

To evaluate the relations among the amount of ingested fiber, the constipation intensity and the colonic transit time in patients with functional constipation.

METHODS

We evaluated 30 patients, presenting no response to treatment using fibers supplement, and 18 healthy volunteers conducting individual inquiry into fibers intake, constipation intensity and the total and segmental colonic transit evaluation using radiopaque markers.

RESULTS

In the constipated, despite the good level of fiber intake (26.3 +/- 12.9 g, constipated x 9.3 +/- 5,2 g, control), the symptoms of constipation was serious (score = 21.3 +/- 4.07). Mean total colonic transit was 58.8h. The colonic transit was slower in the constipated group (41.0 +/- 22.8 hours, constipated x 21.8 +/- 18.5h, control). In constipated patients with slow colonic transit (>58.8h) there were colonic inertia (eight), outlet constipation (one) and slow transit in left colon (one), and among constipated patients with normal colonic transit (<58.8h), there were isolated slow transit, in the right colon (nine), left colon (three) and in the rectosigmoid segment (eight). There were no relation among the amount of ingested fiber, constipation intensity and the colon transit.

CONCLUSIONS

In the functional constipation the gravity of symptoms does not depend only on the dietary fibers intake, which is not the only responsible for the differences in the colonic transit. The colonic transit can differentiate normal from constipated patients and, among them, those with altered transit that demand approaches distinct of fiber supplementation.

A multinational survey of prevalence and patterns of laxative use among adults with self-defined constipation

BACKGROUND

While numerous studies report prevalence of constipation, use of laxatives is poorly understood.

AIM

To conduct a survey in seven countries evaluating prevalence of constipation and laxative use in its treatment.

METHODS

Thirteen thousand eight hundred seventy-nine adults [approximately 2000 each from US, UK, Germany (GE), France (FR), Italy (IT), Brazil (BR) and South Korea (SK)] completed questionnaires assessing occurrence, frequency, duration and laxative use for treating constipation.

RESULTS

Overall, 12.3% of adults had constipation [range: 5% (GE) to 18% (US)] in the prior year. A greater percent of women from all countries and elderly from all except SK and BR reported constipation; odds ratios for constipation among women and elderly were 2.43 (95% CI: 2.18-2.71) and 1.5 (95% CI: 1.25-1.73) vs. men and young subjects. Among those with constipation, 16% (SK) to 40% (US) used laxatives. Laxative use was generally associated with increasing age, symptom frequency and lower income and education. A similar percentage of men and women with constipation reported using laxatives; a greater percentage of women used laxatives for a longer time.

CONCLUSIONS

Prevalence of self-defined constipation and laxative use varies among countries. Prevalence is generally related to gender and age, whereas laxative use is related to age, but not to gender.

Laxative effect of agarwood leaves and its mechanism

We investigated the laxative activity of an extract of agarwood leaves from Aquilaria sinensis. The laxative activity was measured in mice by counting the stool frequency and stool weight, and the drugs were orally administered. An acetone extract of agarwood leaves and senna (a representative laxative drug) both increased the stool frequency and weight, but a methanol extract did not. The laxative effect of the acetone extract was milder than that of the anthraquinoid laxative, senna, and the former did not induce diarrhea as a severe side effect. We identified the main constituent contributing to the laxative effect of the acetone extract as genkwanin 5-O-beta-primeveroside (compound 4). Compound 4 strengthened the spontaneous motility and induced contraction in the ileum. This ileal contraction induced by compound 4 was inhibited by atropine, but not by azasetron, suggesting that the effect of compound 4 was mediated by acetylcholine receptors, and not by serotonin. The laxative mechanism for compound 4 may in part involve stimulation of intestinal motility via acetylcholine receptors.

Healthcare seeking for constipation: a population-based survey in the Mediterranean area of Spain

BACKGROUND

The use of healthcare resources for the management of constipation is not well-known.

AIM

To analyse healthcare seeking for constipation, defined by three different criteria, and its related factors and to assess the frequency of use of laxatives, suppositories and enemas for the treatment of constipation.

METHODS

A cross-sectional study in the general community. A questionnaire comprising 21-items was developed and delivered by mail to a random sample of 506 subjects aged 18-65 years, and belonging to a Spanish population.

RESULTS

Seeking of health care was high in the sample (16%) and was similar for all definitions of constipation (over 40% of constipated subjects). It was associated with female gender, a higher educational level and two symptoms, such as prolonged defecation and abdominal pain. A 14% of the sample used laxatives, and about a 25% of constipated subjects used laxatives at least once a week. Utilization was more frequent in women, with no differences by age group.

CONCLUSIONS

Chronic constipation is a problem that causes an important consumption of resources in our setting, derived from laxative use and the seeking of medical help to combat the problem. The use of these resources is higher in women.

Patterns of constipation in urogynecology: clinical importance and pathophysiologic insights

OBJECTIVE

We have analyzed the prevalence and patterns of constipation in women with urinary symptoms and/or genital prolapse.

STUDY DESIGN

Seven hundred and eighty-six consecutive urogynecologic patients underwent a questionnaire and structured clinical assessment. Comparison between constipated and nonconstipated women was made. Fisher exact test, Wilcoxon rank sum test, and logistic regression were used for statistical analysis (P < .05 for significance).

RESULTS

Thirty-two percent of women were constipated (172 difficult stool passage, 13 reduced stool frequency, 64 both). A genital prolapse > or = 2 degree Half Way System (HWS) was present in 44% of women. A posterior colpocele was more frequent in constipated women (35% vs 19%; P < .0001), resulting in a risk factor for constipation (OR 2.31; 95% CI 1.63-3.27). By contrast, higher degrees of anterior colpocele appeared to protect against constipation (OR 0.80; 95% CI 0.66-0.96). No differences in prevalence of constipation were observed for urinary symptoms or urodynamic diagnosis.

CONCLUSION

Bowel dysfunction correlates exclusively with posterior aspects of the pelvic floor support.

Prevalência de constipação em adolescentes matriculados em escolas de São José dos Campos, SP, e em seus pais

RACIONAL: Existem poucas informações a respeito da constipação em adolescentes. OBJETIVO: Avaliar a prevalência de constipação em adolescentes matriculados em escolas de São José dos Campos, SP, Brasil, e a concomitância de constipação em seus pais biológicos. MÉTODOS: Neste estudo transversal foi analisada amostra de conveniência composta por alunos com idade entre 9 anos e 9 meses e 18 anos e 7 meses e seus respectivos pais biológicos em cinco escolas de São José dos Campos. Para a coleta dos dados foi utilizado um questionário individual. Foram analisados 372 adolescentes cujos pais também responderam ao questionário. Constipação foi caracterizada quando o adolescente apresentava eliminação de fezes com consistência obrigatoriamente endurecida e a ocorrência de pelo menos uma das seguintes características: dor ou dificuldade para evacuar, escape fecal e sangue em torno das fezes. Fezes com formato de cíbalos ou em pelotas grandes e secas e intervalo entre as evacuações maior ou igual a três dias foram considerados critérios que isoladamente caracterizavam constipação. Para os pais, constipação foi caracterizada de acordo com os critérios de Roma II. RESULTADOS: A prevalência de constipação nos adolescentes foi igual a 22,3%, sendo mais freqüente no sexo feminino (27,4%) do que no masculino (14,9%). Constipação nos pais (7,3%; 20/274) foi menos freqüente do que nas mães (27,3%; 88/322). Observou-se concordância muito leve quanto à concomitância de constipação no adolescente e em sua mãe (kappa = 0,12) e à concomitância de constipação no adolescente e em seu pai (kappa = 0,05). CONCLUSÕES: Constipação intestinal é um distúrbio prevalente neste grupo de adolescentes. Não se constatou concordância relevante entre constipação nos adolescentes e em seus pais biológicos.

Spasmogenic activity and acute toxicity of Yumijangquebo, a herbal laxative formulation

We evaluated the pharmacological properties and spasmogenic activities of Yumijangquebotrade mark, a Korean herbal laxative formulation. Doses in the range 12-50 microg/ml induced a large spasmogenic effect in isolated guinea pig ileum, similar to that induced by acetylcholine. Pre-treating the tissue with atropine (0.2 microM) completely abolished the contractile effect of Yumijangquebo. The spasmogenic effect of Yumijangquebo and the inhibition of this effect by atropine suggest that a cholinergic mechanism is responsible for its effects. Yumijangquebo increased the gastrointestinal motility in ICR mice at doses between 10 and 37 mg/kg. Yumijangquebo exhibited higher activity than three other laxatives tested, which had activities about 85% of that of Yumijangquebo. In an acute toxicity study using Sprague-Dawley rats, the median lethal dose (LD50) of Yumijangquebo was greater than 2000 mg/kg, and we found no pathological changes in macroscopic examination by necropsy of rats treated with Yumijangquebo. We conclude that Yumijangquebo may be safely used as a herbal spasmogenic laxative agent.

Fruit and fibre (Pajala porridge) in the prevention of constipation

BACKGROUND AND AIMS

Constipation is a common problem in geriatric wards and in the elderly population. Although high-fibre diets can help relieve constipation non-pharmacologically in many patients, traditional laxatives still remain the standard treatment. A fibre supplement in the form of raw bran is not always well tolerated. We wanted to study the effects of a daily consumption of a fruit- and fibre-rich porridge on stool frequency, perceived well-being and the costs for laxatives, when compared with traditional treatment with laxatives, in geriatric patients.

METHODS

Twenty patients in secondary geriatric wards (hospital rehabilitation wards) were randomized into an intervention group (porridge group) and a control group (standard diet without porridge) for a 1-week run-in and 2-week study, with registration of clinical data, e.g. medical treatment, laxative consumption, stool frequency and perceived well-being.

RESULTS

The patients in the porridge group had a daily defaecation without laxatives on average 76% of the time (10.7/14 days) compared with 23% of the time (3.3/14 days) in the non-porridge group (p = 0.003). The discomfort was less in the porridge group (2.5 vs. 6.5 on a 10-degree visual analogue scale, p = 0.008) when compared with the control group. The cost for laxatives was 93% lower in the intervention group (2.5 vs. 37.5) for the 2-week study.

CONCLUSIONS

A fibre-rich porridge was effective, well liked and tolerated and reduced the need for laxatives in geriatric patients. We conclude that a daily fibre-rich meal ought to be included in the treatment strategies of constipation in hospital wards.

Tegaserod for the treatment of chronic constipation: a randomized, double-blind, placebo-controlled multinational study

OBJECTIVES

Chronic constipation is a common, persistent disorder with limited effective treatment options. This study investigated the efficacy, safety, and tolerability of tegaserod in the treatment of chronic constipation.

METHODS

After a 2-wk baseline period, patients were randomized to double-blind treatment of 12 wk with tegaserod (2 or 6 mg b.i.d.) or placebo. Response during weeks 1-4 (primary variable) was defined as an increase in complete spontaneous bowel movement (CSBM)/wk. Secondary variables included response during weeks 1-12, patient evaluation of individual symptoms, and global assessment of bowel habits and constipation.

RESULTS

One thousand two hundred and sixty-four patients were randomized to tegaserod or placebo. Responder rates for the primary efficacy variable were 35.6% for tegaserod 2 mg b.i.d. (p= 0.0059 vs placebo), 40.2% for 6 mg b.i.d. (p < 0.0001 vs placebo) and 26.7% for placebo. The number needed to treat was 7.3 for the 6 mg b.i.d. dose compared with 11.1 for tegaserod 2 mg b.i.d. Tegaserod 6 mg b.i.d. reduced straining, abdominal bloating/distension, and abdominal pain/discomfort during the 12-wk treatment period compared with placebo (p < 0.05 for all symptoms). Significant improvements were also seen in stool form and in global assessment of bowel habits and constipation. The most common adverse events, headache and abdominal pain, were more frequent with placebo than with tegaserod.

CONCLUSIONS

Tegaserod was efficacious in relieving symptoms of chronic constipation and was well tolerated.

The health-related quality of life and economic burden of constipation

Constipation is a prevalent condition that disproportionately affects women and older adults and leads to self-medication and/or medical consultation. It occurs as a result of functional idiopathic causes or secondarily as a result of a variety of factors including dietary and exercise patterns, adverse effects of medication and disease processes. Constipation is often perceived to be a benign, easily treated condition with short-term treatment being relatively straightforward; however, chronic constipation is associated with mild complications that, left untreated, can develop into more serious bowel complaints (faecal impaction, incontinence and bowel perforations) with further implications for healthcare costs and the patient's health-related quality of life (HR-QOL). This review summarises the evidence of the HR-QOL impact and economic burden of constipation on patients. Relatively few studies have systematically explored the HR-QOL and economic impact of constipation; however, the existing evidence suggests that HR-QOL is lower in patients with constipation than in non-constipated individuals, and treatments for constipation improve HR-QOL. Additionally, constipation represents an economic burden for the patient and healthcare provider. Resource utilisation associated with the diagnosis and management of constipation is a significant cost driver, whereas constipation prevention programmes have demonstrated cost savings.

Effect of tegaserod in chronic constipation: a randomized, double-blind, controlled trial

BACKGROUND AND AIMS

Chronic constipation is a common gastrointestinal disorder. The aim of this study was to evaluate the efficacy, safety, and tolerability of tegaserod, a serotonin subtype 4 receptor partial agonist in patients with chronic constipation.

METHODS

This was a randomized, double-blind, placebo-controlled study. After a 2-week baseline, patients received tegaserod 2 mg twice daily (n = 450), tegaserod 6 mg twice daily (n = 451), or placebo (n = 447) for 12 weeks, followed by a 4-week withdrawal period. Responders were those patients having been treated for at least 7 days with an increase of > or =1 complete spontaneous bowel movement/week vs. baseline during weeks 1-4 (primary variable) and weeks 1-12 (secondary variable). Other secondary variables included patient assessment of constipation symptoms (number of bowel movements, stool form, abdominal bloating/distention, straining, and abdominal pain/discomfort), and global assessment of constipation and bowel habits.

RESULTS

Responder rates for complete spontaneous bowel movement during weeks 1-4 were significantly greater ( P < 0.0001) in the tegaserod 2 mg twice daily (41.4%) and 6 mg twice daily groups (43.2%) vs. placebo (25.1%). This effect was maintained over 12 weeks. Statistically significant improvements over placebo were observed across the majority of secondary variables for both tegaserod doses. No rebound effect was observed after treatment withdrawal. Tegaserod was well tolerated; headache and nasopharyngitis, the most frequent adverse events, were more common in the placebo group than in either tegaserod group.

CONCLUSIONS

Over 12 weeks, tegaserod treatment produced significant improvements in chronic constipation symptoms and was also safe and well tolerated.

Constipation: evaluation and management

Constipation is a common symptom that can result from several disorders. Most patients with chronic constipation do not have a medical disorder contributing to the constipation and, therefore, require limited evaluation. Initial intervention should include dietary measures and fiber supplements; however, if fiber supplementation is ineffective, other agents can be used. Surgery should be reserved for patients who meet specific clinical criteria.

Apoptosis induction by sennoside laxatives in man; escape from a protective mechanism during chronic sennoside use?

Chronic sennoside use induces melanosis coli (MC) and possibly increases colorectal cancer risk. Sennosides alter colonic crypt length, proliferative activity, and bcl-2 expression 18 h after administration. To investigate possible mechanisms for carcinogenesis, the effects of acute sennoside use and the presence of MC on colorectal epithelium were studied. Colorectal biopsies from 15 subjects receiving sennosides 6 h before sigmoidoscopy (Sen), 15 controls (NSen), and 27 with MC [11 moderate (MMC) and 16 severe (SMC)]. were analysed for degree of apoptosis (H&E staining), immunohistochemical p53, p21/WAF and bcl-2 expression, and proliferative activity (labelling index, LI). Apoptosis (p=0.0004), intensity of p53 staining (p=0.01), and p21/WAF expression (p=0.008) were increased in Sen and SMC compared with NSen and MMC. p53 expression was increased in Sen (p=0.004). No difference in bcl-2 expression or LI was observed. Crypts were shorter in Sen (p=0.05) and longer in SMC (p=0.04) than in NSen. It is concluded that sennosides acutely induce apoptosis of colonic epithelial cells, presumably by a p53, p21/WAF-mediated pathway, resulting in shorter crypts. In severe melanosis coli, apoptosis seems to be delayed, causing longer crypts without a rise in proliferative activity or bcl-2 expression. This escape from a presumably protective mechanism may enhance the risk of carcinogenesis during chronic sennoside use.