Electrical stimulation therapy for slow transit constipation in children: a systematic review

Noninvasive Sacral Neuromodulation in Children and Adolescents: A Case-Control Study of Patients With Chronic Refractory Constipation

OBJECTIVES

In adult patients with chronic refractory constipation, invasive sacral neuromodulation (SNM) has been applied successfully. There is a need for less invasive solutions while providing comparable therapeutic effects in children and adolescents. We present a prospective, interventional case-control study on the application of noninvasive SNM.

MATERIALS AND METHODS

Patients with chronic constipation refractory to conservative treatment were prospectively included in the study from 2018 to 2021 and randomized to either SNM (SNM group: single current stimulation for 24 h/d, frequency 15 Hz, pulse width 210 μs, intensity 1-10 mA) or conventional treatment (controls: full range of pharmacologic and nonpharmacologic options). Treatment was conducted for 12 weeks. Treatment effects were collected with specialized questionnaires and quality-of-life analysis (KINDLR). Outcome variables were defecation frequency, stool consistency, fecal incontinence (FI) episodes, and abdominal pain.

RESULTS

Analysis was conducted in 28 patients with SNM and 31 controls (median age 7.0, range 3-16 years). Overall responsiveness to treatment was 86% of the SNM group and 39% of the control group (p < 0.001). All outcome variables were positively influenced by SNM treatment. Defecation frequency improved in 46% of patients with SNM and in 19% of controls (p = 0.026), as did stool consistency in 57% of patients with SNM and in 26% of controls (p = 0.014). Fecal incontinence was significantly reduced in 76% of patients with SNM (n = 16/21 vs 42% of controls [n = 11/26], p = 0.042). Quality of life improved significantly during SNM treatment (71.32 [baseline] vs 85.00 [after 12 weeks], p < 0.001) and confirmed a positive influence of SNM treatment compared with the control group (85.00 [SNM after 12 weeks] vs 79.29 [controls after 12 weeks], p = 0.047).

CONCLUSIONS

Outcome of noninvasive SNM treatment in patients with chronic refractory constipation is better than conventional treatment.

Childhood constipation: Current status, challenges, and future perspectives

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

Surgical Interventions for Functional Constipation: An Update

Chronic idiopathic constipation, also known as functional constipation, is defined as difficult and infrequent defecation without an identifiable organic cause. Medical management with laxatives is effective for the majority of constipated children. However there is a subset of patients who may need evaluation by a surgeon. As constipation progresses, it can lead to fecal retention and rectal and sigmoid distension, which impairs normal colorectal motility. Surgical interventions are influenced by the results of: a rectal biopsy, transit studies, the presence of megacolon/megarectum on contrast enema, the degree of soiling/incontinence, anorectal manometry findings, and colonic motility evaluation. In this review, we describe the different surgical options available (intestinal diversion, antegrade enemas, sacral nerve stimulation, colonic resections, and Botulinum toxin injection) and provide guidance on how to choose the best procedure for a given patient.

Preventive effects of transcutaneous electrical acustimulation on ischemic stroke-induced constipation mediated via the autonomic pathway

The aim of this study was to explore the preventive effect and possible mechanisms of transcutaneous electrical acustimulation (TEA) on stroke-induced constipation. A total of 86 ischemic stroke patients were randomly allocated to 2-wk TEA or sham-TEA group. Bowel dairy and Bristol Stool Form Scale were recorded daily. Constipation and dyspeptic symptom assessment was performed at the end of the 14-day treatment. Electrocardiogram was recorded for the assessment of autonomic function. The correlation between autonomic function at admission and stroke severity was assessed. The univariate and multivariate regression analyses were performed to investigate the risk factors for stroke-induced constipation. The cumulative incidence of stroke-induced constipation was 68.2% at the acute stage. Sympathetic nerve activity at admission was positively correlated with stroke severity ( R = 0.47, P < 0.001). Sympathetic nerve activity and stroke severity were independent risk factors for stroke-induced constipation. TEA decreased cumulative incidence of stroke-induced constipation (42.9 vs. 68.2%, P = 0.029). TEA significantly increased frequency of bowel movements (4.5 vs. 5.5, P = 0.001) and spontaneous bowel movements (3.0 vs. 4.5, P = 0.003) per week. TEA decreased straining defecations (0.2 vs. 0, P < 0.001) and laxative use (1 vs. 0, P < 0.001). TEA improved stool consistency and patients' quality of life ( P < 0.05, resp.). TEA increased vagal activity ( P < 0.001 vs. baseline) and decreased sympathetic activity ( P < 0.001 vs. baseline). Ischemic stroke patients are predisposed to autonomic function imbalance. TEA was effective in the prevention of stroke-induced constipation, and the effect was possibly mediated via the autonomic function. NEW & NOTEWORTHY This study illustrated that the brain-gut dysfunction, primarily autonomic function imbalance, was correlated with the stroke-induced constipation. This was the first study to report that transcutaneous electrical acustimulation had a preventive effect on stroke-induced constipation, suggesting a potential novel therapy for bowel problem management. The effect was possibly mediated via the autonomic function.

Neuromodulation via Interferential Electrical Stimulation as a Novel Therapy in Gastrointestinal Motility Disorders

The concept of therapeutic percutaneous neuromodulation has, until recently, been limited by the ability to penetrate deeply enough to stimulate internal organs. By utilizing 2 medium frequency, slightly out of phase electrical currents passing diagonally through the abdomen, a third, low frequency current is created at the point of bisection. This interferential current appears to stimulate nerve fibers in the target organs and may have a therapeutic action. The aim of the study is to review the use of transcutaneous interferential electrical stimulation with a focus on its application in gastroenterology, particularly in motility disorders. Studies involving use of interferential current therapy were searched from Medline, PubMed, and Scopus databases, and articles pertaining to history, its application and all those treating abdominal and gastrointestinal disorders were retrieved. Seventeen studies were identified, 13 involved children only. Eleven of these were randomised controlled trials (3 in adults). Four trials were from the one center, where each paper reported on different outcomes such as soiling, defecation frequency, quality of life, and colon transit studies from the one pool of children. All studies found statistically significant improvement in symptom reduction. However, weaknesses in study design were apparent in some. In particular, finding an adequate placebo to interferential current therapy has been difficult. Interferential current therapy shows potential as a novel, non-pharmacological and economical means of treating gastrointestinal dysfunction such as constipation. More studies are needed particularly in the adult population. However, the design of a suitable placebo is challenging.

Yangyin Runchang Decoction Improves Intestinal Motility in Mice with Atropine/Diphenoxylate-Induced Slow-Transit Constipation

This study assessed the efficacy and mechanism of action of Yangyin Runchang decoction (YRD) in the treatment of slow-transit constipation (STC). ICR mice were randomly divided into four groups (n = 10/group) and treated with saline (normal control; NC), atropine/diphenoxylate (model control; MC; 20 mg/kg), or atropine/diphenoxylate plus low-dose YRD (L-YRD; 29.6 g/kg) or high-dose YRD (H-YRD; 59.2 g/kg). Intestinal motility was assessed by evaluating feces and the intestinal transit rate (ITR). The serum level of stem cell factor (SCF) and changes in interstitial cells of Cajal (ICCs) were also evaluated. Additionally, the expression of SCF and c-kit and the intracellular Ca²⁺ concentration [Ca²⁺]_I were investigated. Fecal volume and ITR were greater in the L-YRD and H-YRD groups than in the MC group. The serum SCF level was lower in the MC group than in the NC group; this effect was ameliorated in the YRD-treated mice. Additionally, YRD-treated mice had more ICCs and elevated expression of c-kit and membrane-bound SCF, and YRD also increased [Ca²⁺]_I in vitro in isolated ICCs. YRD treatment in this STC mouse model was effective, possibly via the restoration of the SCF/c-kit pathway, increase in the ICC count, and enhancement of ICC function by increasing [Ca²⁺]_i.

A comparative study of transcutaneous interferential electrical stimulation plus behavioral therapy and behavioral therapy alone on constipation in postoperative Hirschsprung disease children

PURPOSE

We assessed the effectiveness of transcutaneous interferential (IF) electrical stimulation on constipation in postoperative Hirschsprung's disease (HD) patients.

METHODS

Thirty HD children (18 boys and 12 girls) with constipation who had no surgical complication were enrolled and then randomly divided into two treatment groups. The control group underwent only behavioral therapy comprising high fiber diet, hydration, toilet training and pelvic floor muscles exercises while; the IF group underwent behavioral therapy plus IF electrical stimulation. Patients underwent anorectal manometry before and 6months after the treatment. In addition, a complete bowel diary with data on the frequency of defecation per week, stool form and the number of fecal soiling episodes, a constipation score and a visual pain score were obtained from all patients before, after treatment and 6months later.

RESULTS

Constipation symptoms were improved in 10 (66%) and 4 (26.6%) patients in IF and control groups, respectively at 6months of follow up (P<0.03). Frequency of defecation per week significantly increased after the treatment in the IF group compared with control group at the 6months of follow up (5.4±2.1 vs. 3.3±1.8 per week, respectively; P<0.009). In addition, mean pain score was significantly decreased in IF group compared with controls after treatment (P<0.05).

CONCLUSION

IF electrical stimulation is an effective adjunct to behavioral therapy to overcome symptoms of constipation in postoperative HD patients.

Functional Disorders: Slow-Transit Constipation

Constipation is a very common complaint, with slow-transit constipation (STC) accounting for a significant proportion of cases. Old age, female gender, psychiatric illness, and history of sexual abuse are all associated with STC. The exact cause of STC remains elusive; however, multiple immune and cellular changes have been demonstrated. Diagnosis requires evidence of slowed colonic transit which may be achieved via numerous modalities. While a variety of medical therapies exist, these are often met with limited success and a minority of patients ultimately require operative intervention. When evaluating a patient with STC, it is important to determine the presence of concomitant obstructed defecation or other forms of enteric dysmotility, as this may affect treatment decisions. Although a variety of surgical procedures have been reported, subtotal colectomy with ileorectal anastomosis is the most commonly performed and well-studied procedure, with the best track record of success.

Transcutaneous electric nerve stimulation in treatment of functional constipation: A systematic review

AIM: To evaluate the effect of transcutaneous electric nerve stimulation (TENS) on symptoms, psychology and quality of life in patients with functional constipation (FC).

METHODS: The reported studies about the efficacy of TENS in improving symptom of FC were retrieved up to May 2015 based on five English databases including PubMed, Embase, Cochrane Library, ScienceDirect, and Web of Science and four Chinese databases including China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP Database and China Biology Medicine disc (CBM). The methodological quality was evaluated using the Jadad scale. Meta-analysis of eligible studies was performed using RevMan5.1. Data which were unable to convent or merge were described via descriptive analysis.

RESULTS: A total of 8 studies were included. Results of analysis indicated that: (1) TENS was superior to mosapride citrate or sham transcutaneous neuromodulation (TN) in improving the symptoms of constipation and showed the same effect as polyethylene glycol or electroacupuncture (except stool consistency) (P < 0.05); (2) TENS outperformed laxative or sham TN in accelerating colonic transit (MD = -4.62, 95%CI: -5.15--4.09, P < 0.00001); (3) Compared with electroacupuncture or sham TN, TENS could significantly reduce the anxiety and depression levels and improve the quality of life (SAS score: MD = 4.10, 95%CI: 3.53-4.67, MD = 2.77, 95%CI: 2.16-3.38, P < 0.00001; SDS score, MD = 4.22, 95%CI: 3.36-5.08, P < 0.00001).

CONCLUSION: TENS had a certain therapeutic effect on FC, and it could reduce the anxiety and depression levels and improve the quality of life of the patients. Compared with laxative or electroacupuncture, TENS is user-friendly and shows fewer side effects.