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Lacy BE, Delfini R, Fladung B, Lange R. Prevalence and patterns of laxative use in subjects with self-reported constipation: results from a multinational digestive health survey. Therap Adv Gastroenterol 2024; 17:17562848241232605. [PMID: 38445248 PMCID: PMC10913501 DOI: 10.1177/17562848241232605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/17/2024] [Indexed: 03/07/2024] Open
Abstract
Background Constipation is characterized by symptoms of straining, hard stool, difficult evacuation, and infrequent bowel movements. Online surveys provide valuable information about patients' perspectives, symptoms, management, treatment satisfaction, and risk factors. Methods This survey explored subject experiences involving 20 gastrointestinal (GI) conditions. In total, 20,099 respondents in seven countries with varied cultural and socioeconomic backgrounds participated. Post hoc analysis of 'self-reported constipation' and related symptoms experienced within the past 6 months and the last episode of constipation provided data on prevalence, demographics, frequency and duration of episodes and related symptoms, impact on quality of life (QoL), management with or without laxatives, and resulting treatment satisfaction. Results In total, 10,425 subjects reported constipation within 6 months and 2637 at the last episode. Prevalence was highest in females and younger adults. Most subjects reported various coexisting GI symptoms. Almost 80% of 6865 episodes reported by 5337 subjects occurred every 2-3 months to every 2-3 weeks. A higher frequency of constipation correlated with a greater impact on QoL. On a 10-point scale, the mean impact was 6.4. More than 90% of respondents had episodes ranging from 1 day to 1 week. More than 90% took action; 16% used laxatives, of whom 80.3% were satisfied. Conclusion Constipation, a highly prevalent disorder, spans cultures and socioeconomic classes. Its chronic recurrence has a significant impact on QoL, resulting in symptom self-management in >90% of subjects. Significantly higher satisfaction rates in subjects treated with than without laxatives reflect subjects' reports that self-reported constipation can be treated effectively with laxatives.
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Affiliation(s)
- Brian E. Lacy
- Division of Gastroenterology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Bernward Fladung
- Freelance Medical Advisor, Linnich, Germany
- Régis Delfini is currently affiliated to Boehringer Ingelheim, Ingelheim, Germany
| | - Robert Lange
- Industriepark Hoechst, Building K 607, 65929 Frankfurt am Main, Germany
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Deutsch D, Bouchoucha M, Uzan J, Airinei G, Sabate JM, Benamouzig R. Relationship Between Colonic Transit Response to Eating With Self-reported Constipation Severity in Constipated Patients According to the Phenotype. J Neurogastroenterol Motil 2024; 30:97-105. [PMID: 38173161 PMCID: PMC10774807 DOI: 10.5056/jnm21091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 04/29/2023] [Accepted: 05/11/2023] [Indexed: 01/05/2024] Open
Abstract
Background/Aims Eating is the major synchronizer of gastrointestinal motility and secretions. The present study aims to evaluate the interplay between self-perceived constipation severity (CS) and colonic response to eating in constipated patients according to the phenotype. Methods We included 387 consecutive outpatients complaining of Rome IV chronic idiopathic constipation. Likert scales for CS, abdominal pain severity, bloating severity, depression and anxiety assessment, total and segmental colonic transit time (CTT), and colonic transit response to eating (CTRE) were performed in all patients. Results Of the 387 patients included (49.7 ± 16.4 years), 320 (83%) were female, 203 had irritable bowel syndrome with constipation (IBS-C), 184 as functional constipation (FC), and 283 had defecation disorders (DD). The female gender was characterized by increased bloating severity (P = 0.011) and decreased Bristol stool form (P = 0.002). In IBS-C and FC patients, CS was related with bloating severity (P < 0.001 in both groups) and total CTT (P = 0.007 in IBS-constipation, P = 0.040 in FC). In IBS-C patients, CS was also associated with abdominal pain severity (P = 0.003) and Bristol stool form (P = 0.004). In contrast, in FC, CS was only related to left CTRE (P = 0.006), and in patients with DD, CS was associated with total CTT (P < 0.001) and left CTRE (P = 0.002). Conclusion Colonic transit response to eating was not associated to CS in IBS-C patients, but left CTRE was associated with constipation severity in FC and DD patients.
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Affiliation(s)
- David Deutsch
- Department of Gastroenterology, Hôpital Avicenne, Bobigny, France
| | - Michel Bouchoucha
- Department of Gastroenterology, Hôpital Avicenne, Bobigny, France
- Department of Physiology, Université de Paris, Paris, France
| | - Julien Uzan
- Department of Gastroenterology, Hôpital Avicenne, Bobigny, France
| | - Gheorghe Airinei
- Department of Gastroenterology, Hôpital Avicenne, Bobigny, France
| | - Jean-Marc Sabate
- Department of Gastroenterology, Hôpital Avicenne, Bobigny, France
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Ballou S, Rangan V, Eidelberg A, Proctor S, McHenry N, Nee J, Iturrino J, Lembo A, Singh P. What Is Unspecified Functional Bowel Disorder? A Commonly Seen, Rarely Recognized, and Poorly Understood Diagnosis. Am J Gastroenterol 2023; 118:1402-1409. [PMID: 37053553 DOI: 10.14309/ajg.0000000000002281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Unspecified functional bowel disorder (FBD-U) is a Rome IV diagnosis of exclusion and occurs when patients report bowel symptoms but do not meet the criteria for other functional bowel disorders (FBD; irritable bowel syndrome [IBS], functional constipation [FC], functional diarrhea [FDr], or functional bloating). Previous research suggests that FBD-U is as/more common than IBS. METHODS One thousand five hundred one patients at a single-center tertiary care center completed an electronic survey. Study questionnaires included Rome IV Diagnostic Questionnaires, anxiety, depression, sleep, health care utilization, and bowel symptom severity measures. RESULTS Eight hundred thirteen patients met Rome IV criteria for a FBD and 194 patients (13.1%) met criteria for FBD-U, representing the second most common FBD after IBS. Severity of abdominal pain, constipation, and diarrhea were lower in FBD-U compared with other FBD, whereas health care utilization was similar among the groups. Scores on measures of anxiety, depression, and sleep disturbances were similar in FBD-U compared with FC and FDr but were less severe than IBS. Between 25% and 50% of patients with FBD-U did not meet Rome IV criteria for other FBD due to timing of onset of the target symptom (e.g., constipation for FC, diarrhea for FDr, and abdominal pain for IBS). DISCUSSION FBD-U, by Rome IV criteria, is highly prevalent in clinical settings. These patients are not represented in mechanistic studies or clinical trials for not having met Rome IV criteria for other FBD. Making future Rome criteria less stringent would minimize the number fulfilling criteria for FBD-U and maximize the true representation of FBD in clinical trials.
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Affiliation(s)
- Sarah Ballou
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vikram Rangan
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew Eidelberg
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Samantha Proctor
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nicole McHenry
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Judy Nee
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Johanna Iturrino
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anthony Lembo
- Cleveland Clinic, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Prashant Singh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Cap-assisted endoscopic sclerotherapy is effective for rectal mucosal prolapse associated outlet obstructive constipation. Arab J Gastroenterol 2022:S1687-1979(22)00087-9. [DOI: 10.1016/j.ajg.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/09/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022]
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Deutsch D, Bouchoucha M, Uzan J, Raynaud JJ, Sabate JM, Benamouzig R. Abdominal Pain Severity Is Mainly Associated with Bloating Severity in Patients with Functional Bowel Disorders and Functional Abdominal Pain. Dig Dis Sci 2022; 67:3026-3035. [PMID: 34324087 DOI: 10.1007/s10620-021-07175-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/12/2021] [Indexed: 12/09/2022]
Abstract
PURPOSE Abdominal pain is a cardinal sign of functional bowel disorders (FBD), in favor of irritable bowel syndrome (IBS). However, the determinants of abdominal pain severity (APS) are unknown. The present study aimed to search the relationships between APS and demographic, psychological, and clinical parameters in tertiary care FBD outpatients. PATIENTS AND METHODS In this retrospective study, we included 2043 new outpatients with FBD or functional abdominal pain. They fulfilled the Rome III questionnaire, psychological evaluation, and four 10-points Likert scale for the perceived severity of constipation, diarrhea, bloating, and abdominal pain. Linear regression was performed for each phenotype to model the severity of abdominal pain with demographic, psychological parameters, and symptoms severity. RESULTS APS was positively associated with bloating severity in all phenotypes, but APS was also associated with other variables according to gender and phenotype. APS was negatively associated with age and positively with depression, constipation severity, and diarrhea severity in female patients. In male patients, APS was associated with state anxiety, constipation severity, and diarrhea severity. APS severity was associated with bloating severity and transit severity in IBS patients, while in non-IBS patients, APS was only associated with bloating severity. CONCLUSION Perceived abdominal pain severity is always associated with perceived bloating severity in FBD and FAP patients.
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Affiliation(s)
- David Deutsch
- Gastroenterology Department, CEFRED (Centre D'Exploration Fonctionnelle Et de Rééducation Digestive), Avicenne Hospital, 125, rue de Stalingrad, 93009, Bobigny Cedex, France
| | - Michel Bouchoucha
- Gastroenterology Department, CEFRED (Centre D'Exploration Fonctionnelle Et de Rééducation Digestive), Avicenne Hospital, 125, rue de Stalingrad, 93009, Bobigny Cedex, France. .,Physiology Department, Université de Paris, Paris, France.
| | - Julien Uzan
- Gastroenterology Department, CEFRED (Centre D'Exploration Fonctionnelle Et de Rééducation Digestive), Avicenne Hospital, 125, rue de Stalingrad, 93009, Bobigny Cedex, France
| | - Jean-Jacques Raynaud
- Gastroenterology Department, CEFRED (Centre D'Exploration Fonctionnelle Et de Rééducation Digestive), Avicenne Hospital, 125, rue de Stalingrad, 93009, Bobigny Cedex, France
| | - Jean-Marc Sabate
- Gastroenterology Department, CEFRED (Centre D'Exploration Fonctionnelle Et de Rééducation Digestive), Avicenne Hospital, 125, rue de Stalingrad, 93009, Bobigny Cedex, France
| | - Robert Benamouzig
- Gastroenterology Department, CEFRED (Centre D'Exploration Fonctionnelle Et de Rééducation Digestive), Avicenne Hospital, 125, rue de Stalingrad, 93009, Bobigny Cedex, France
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Gökçınar A, Çakanyıldırım M, Price T, Adams MCB. Balanced Opioid Prescribing via a Clinical Trade-Off: Pain Relief vs. Adverse Effects of Discomfort, Dependence, and Tolerance/Hypersensitivity. DECISION ANALYSIS 2022. [DOI: 10.1287/deca.2021.0447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In the backdrop of the opioid epidemic, opioid prescribing has distinct medical and social challenges. Overprescribing contributes to the ongoing opioid epidemic, whereas underprescribing yields inadequate pain relief. Moreover, opioids have serious adverse effects including tolerance and increased sensitivity to pain, paradoxically inducing more pain. Prescribing trade-offs are recognized but not modeled in the literature. We study the prescribing decisions for chronic, acute, and persistent pain types to minimize the cumulative pain that incorporates opioid adverse effects (discomfort and dependence) and the risk of tolerance or hypersensitivity (THS) developed with opioid use. After finding closed-form solutions for each pain type, we analytically investigate the sensitivity of acute pain prescriptions and examine policies on incorporation of THS, patient handover, and adaptive treatments. Our analyses show that the role of adverse effects in prescribing decisions is as critical as that of the pain level. Interestingly, we find that the optimal prescription duration is not necessarily increasing with the recovery time. We show that not incorporating THS or information curtailment at patient handovers leads to overprescribing that can be mitigated by adaptive treatments. Last, using real-life pain and opioid use data from two sources, we estimate THS parameters and discuss the proximity of our model to clinical practice. This paper has a pain management framework that leads to tractable models. These models can potentially support balanced opioid prescribing after their validation in a clinical setting. Then, they can be helpful to policy makers in assessment of prescription policies and of the controversy around over- and underprescribing.
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Affiliation(s)
- Abdullah Gökçınar
- Jindal School of Management, University of Texas at Dallas, Richardson, Texas 75080
| | - Metin Çakanyıldırım
- Jindal School of Management, University of Texas at Dallas, Richardson, Texas 75080
| | - Theodore Price
- School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, Texas 75080
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Functional gastrointestinal disorders as predictors of suicidal ideation. An observational study. Eur J Gastroenterol Hepatol 2021; 33:e758-e765. [PMID: 34231520 DOI: 10.1097/meg.0000000000002245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND/OBJECTIVES Suicidal ideation (SI), a symptom of depression, is known to be associated with irritable bowel syndrome (IBS) but is not known to be associated with other functional gastrointestinal disorders (FGIDs). However, the source of this association is discussed. It could be related to a possible abnormal biochemical pathway implicating neurotransmitters common to both disorders like serotonin or pain and an ill-being associated with a chronic disorder of unknown etiology. The present study aims to search for the FGIDs associated with suicidal ideation. DESIGN Observational study. METHODS A total of 1469 patients with FGIDs (71% of women) were included in the present study. They filled the Rome III questionnaire, Beck depression inventory, and state and trait anxiety questionnaires. Data were analyzed using analysis of variance with Bonferroni correction and logistic regression analysis. RESULTS Suicidal ideation was reported by 15% of patients, associated with increased scales of depression (P < 0.001), state (P = 0.006), and trait anxiety (P = 0.021). Clinically, these patients reported a higher prevalence of IBS-diarrhea subtype (P = 0.045), fecal incontinence (P = 0.020), soiling (P = 0.016), and difficult defecation (P = 0.005), and higher perceived severity for constipation, diarrhea, bloating, and abdominal pain (P < 0.001 for all scales). CONCLUSIONS This study shows that only functional bowel and functional anorectal disorders are associated with suicidal ideation. This result must be taken into account in the management of these patients.
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Biopsychosocial Model and Perceived Constipation Severity According to the Constipation Phenotype. Dig Dis Sci 2021; 66:3588-3596. [PMID: 33073331 DOI: 10.1007/s10620-020-06654-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/03/2020] [Indexed: 12/09/2022]
Abstract
PURPOSE Constipation is a frequent complaint of patients with functional bowel disorders. The present study aimed to evaluate the relationship between the perceived constipation severity with demographics, clinical, physiological, and psychological parameters in constipated patients. PATIENTS AND METHODS Four hundred seven constipated patients were included and had clinical, physiological, and psychological evaluation. The self-reported severity of constipation was analyzed using stepwise linear regression in the total population and within each clinical group. RESULTS The patients were mainly of female gender (81%) and were 47.4 ± 16.5 years old. They complained of IBS (65%), and 62% had defecation disorders. The depression scale was abnormal in 200 patients (49%). The relationships of the constipation severity varied according to the Rome IV phenotype. In all phenotypes, it was positively associated with bloating severity, and negatively with Bristol stool form. In IBS patients, perceived constipation severity was also associated with abdominal pain severity. CONCLUSION Our data support the hypothesis that perceived constipation severity is associated with clinical and physiological factors but not demographics and psychological factors. Besides, the relationships of perceived constipation severity with these factors vary according to clinical phenotypes.
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Wong OWH, Lam AMW, Lai KYC, Ma SL, Hung SF, Chan S, Wong S, Leung PWL. An elevated anxiety level among prepubertal autistic boys with non-treatment-seeking functional gastrointestinal disorders: A case-control study. Autism Res 2021; 14:2131-2142. [PMID: 34114351 DOI: 10.1002/aur.2555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 12/28/2022]
Abstract
Children with autism commonly suffer from comorbid functional gastrointestinal disorders (FGID) and anxiety. The raised prevalence of both conditions in autism suggests complex reciprocal relationships, which are seldom explored in non-treatment-seeking FGID. The relationships between subtypes of FGID and anxiety are also unclear. This study recruited boys with autism and age-matched typically developing (TD) boys, aged 4-11 years, who were not actively seeking help for gastrointestinal problems. Their parents completed the Rome IV Diagnostic Questionnaires for Pediatric FGID. Four groups of children with and without autism/FGID were identified and compared on their anxiety level using the Spence children's anxiety scale. In 69 boys with autism and 69 age-matched TD boys, FGID were identified in 22 and 16 boys, respectively. ANCOVA demonstrated a significant interaction effect of autism and FGID on anxiety (F[1, 129] = 5.43, p = 0.021), while conditional logistic regression identified an interaction effect of autism and anxiety on the odds of FGID (OR 1.038, 95% CI 1.002-1.075, p = 0.038). Explorative post hoc analysis showed higher anxiety in functional nausea and vomiting disorder (p = 0.033) and functional abdominal pain disorder (p = 0.029) among boys with autism than TD boys with the same respective subtypes of FGID. In summary, among prepubertal boys with autism, the presence of FGID that are non-treatment-seeking in nature, has a significantly stronger association with higher levels of anxiety than TD boys. The strength of association may be more prominent in subtypes of FGID. Possible pathomechanisms including the underlying microbiota spectra and inflammatory paths should be explored in future studies. LAY SUMMARY: Anxiety and gastrointestinal problems are common symptoms in autism. Given that gut health could be linked to emotions, their association in young boys with autism was studied. The presence of nausea vomiting, or abdominal pain were associated with raised anxiety among boys with autism, yet this was not observed in typically developing boys. This suggests that anxiety among autistic children could be partly explained by the presence of FGID.
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Affiliation(s)
- Oscar W H Wong
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR
| | - Angela M W Lam
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR
| | - Kelly Y C Lai
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR
| | - Suk Ling Ma
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR
| | - Se Fong Hung
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR
| | - Sandra Chan
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong SAR
| | - Sunny Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR
| | - Patrick W L Leung
- Department of Psychology, The Chinese University of Hong Kong, Hong Kong SAR
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Personality of patients with fecal incontinence. Int J Colorectal Dis 2021; 36:331-337. [PMID: 33000298 DOI: 10.1007/s00384-020-03758-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Although idiopathic fecal incontinence (FI) patients have some psychological characteristics, the personality of FI patients was not described. The present study aims to describe the clinical and personality characteristics of FI patients. PATIENTS AND METHODS This retrospective observational study included 996 outpatients, 72 with fecal incontinence. They filled out the Rome III diagnostic questionnaire, the personality inventory MMPI-2, the questionnaires for urological and sexual disorders, and Likert scales for bowel disorders perceived symptom severity. The main outcome measures were the presence in FI patients of functional gastrointestinal disorders, the self-reported symptom severity, and the personality profile. RESULTS Patients were mainly females (72%). FI patients were characterized by higher age (P = 0.015), and by a higher prevalence of functional diarrhea (P = 0.001), urological (P = 0.001), and sexual disorders (P = 0.005). These patients also report higher diarrhea severity (P < 0.001) and lower abdominal pain severity (P = 0.009). The personality of FI patients is distinguished by a higher score for psychopathic deviate (P = 0.006), social responsibility (P = 0.003), Mac Andrew revised scale (P = 0.005), and antisocial practice (P = 0.007), and a lower score for type A behavior (P = 0.005). CONCLUSION FI patients are characterized not only by older age, and a high prevalence of diarrhea but also by a specific personality profile characterized by an unfavorable comparison with others.
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Abstract
PURPOSE OF REVIEW To review the epidemiology, pathogenesis, clinical features, and management of primary constipation and fecal incontinence in the elderly. RECENT FINDINGS Among elderly people, 6.5%, 1.7%, and 1.1% have functional constipation, constipation-predominant IBS, and opioid-induced constipation. In elderly people, the number of colonic enteric neurons and smooth muscle functions is preserved; decreased cholinergic function with unopposed nitrergic relaxation may explain colonic motor dysfunction. Less physical activity or dietary fiber intake and postmenopausal hormonal therapy are risk factors for fecal incontinence in elderly people. Two thirds of patients with fecal incontinence respond to biofeedback therapy. Used in combination, loperamide and biofeedback therapy are more effective than placebo, education, and biofeedback therapy. Vaginal or anal insert devices are another option. In the elderly, constipation and fecal incontinence are common and often distressing symptoms that can often be managed by addressing bowel disturbances. Selected diagnostic tests, prescription medications, and, infrequently, surgical options should be considered when necessary.
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Affiliation(s)
- Brototo Deb
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA.
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Bharucha AE, Lacy BE. Mechanisms, Evaluation, and Management of Chronic Constipation. Gastroenterology 2020; 158:1232-1249.e3. [PMID: 31945360 PMCID: PMC7573977 DOI: 10.1053/j.gastro.2019.12.034] [Citation(s) in RCA: 231] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/20/2019] [Accepted: 12/24/2019] [Indexed: 12/12/2022]
Abstract
With a worldwide prevalence of 15%, chronic constipation is one of the most frequent gastrointestinal diagnoses made in ambulatory medicine clinics, and is a common source cause for referrals to gastroenterologists and colorectal surgeons in the United States. Symptoms vary among patients; straining, incomplete evacuation, and a sense of anorectal blockage are just as important as decreased stool frequency. Chronic constipation is either a primary disorder (such as normal transit, slow transit, or defecatory disorders) or a secondary one (due to medications or, in rare cases, anatomic alterations). Colonic sensorimotor disturbances and pelvic floor dysfunction (such as defecatory disorders) are the most widely recognized pathogenic mechanisms. Guided by efficacy and cost, management of constipation should begin with dietary fiber supplementation and stimulant and/or osmotic laxatives, as appropriate, followed, if necessary, by intestinal secretagogues and/or prokinetic agents. Peripherally acting μ-opiate antagonists are another option for opioid-induced constipation. Anorectal tests to evaluate for defecatory disorders should be performed in patients who do not respond to over-the-counter agents. Colonic transit, followed if necessary with assessment of colonic motility with manometry and/or a barostat, can identify colonic dysmotility. Defecatory disorders often respond to biofeedback therapy. For specific patients, slow-transit constipation may necessitate a colectomy. No studies have compared inexpensive laxatives with newer drugs with different mechanisms. We review the mechanisms, evaluation, and management of chronic constipation. We discuss the importance of meticulous analyses of patient history and physical examination, advantages and disadvantages of diagnostic testing, guidance for individualized treatment, and management of medically refractory patients.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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13
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Serra J, Pohl D, Azpiroz F, Chiarioni G, Ducrotté P, Gourcerol G, Hungin APS, Layer P, Mendive JM, Pfeifer J, Rogler G, Scott SM, Simrén M, Whorwell P. European society of neurogastroenterology and motility guidelines on functional constipation in adults. Neurogastroenterol Motil 2020; 32:e13762. [PMID: 31756783 DOI: 10.1111/nmo.13762] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation. DESIGN After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation. KEY RESULTS Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation. CONCLUSIONS AND INFERENCES European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.
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Affiliation(s)
- Jordi Serra
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Motility and Functional Gut Disorders Unit, University Hospital Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Badalona, Spain
| | - Daniel Pohl
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Fernando Azpiroz
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Badalona, Spain.,Digestive System Research Unit, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Giuseppe Chiarioni
- Division of Gastroenterology B, AOUI Verona, Verona, Italy.,UNC Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Philippe Ducrotté
- Department of Gastroenterology, UMR INSERM 1073, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Department of Physiology, UMR INSERM 1073 & CIC INSERM 1404, Rouen University Hospital, Rouen, France
| | - A Pali S Hungin
- General Practice, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Peter Layer
- Department of Medicine, Israelitic Hospital, Hamburg, Germany
| | - Juan-Manuel Mendive
- Sant Adrià de Besòs (Barcelona) Catalan Institut of Health (ICS), La Mina Primary Health Care Centre, Badalona, Spain
| | - Johann Pfeifer
- Department of Surgery, Division of General Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Rogler
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.,Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - S Mark Scott
- Neurogastroenterology Group, Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Barts, UK.,The London School of Medicine & Dentistry, Queen Mary University London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Whorwell
- Division of Diabetes, Endocrinology & Gastroenterology, Neurogastroenterology Unit, Wythenshawe Hospital, University of Manchester, Manchester, UK
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14
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Singh P, Lee HN, Rangan V, Ballou S, Lembo J, Katon J, McMahon C, Friedlander D, Iturrino J, Nee J, Lembo A. Similarities in Clinical and Psychosocial Characteristics of Functional Diarrhea and Irritable Bowel Syndrome With Diarrhea. Clin Gastroenterol Hepatol 2020; 18:399-405.e1. [PMID: 31442602 PMCID: PMC6962545 DOI: 10.1016/j.cgh.2019.08.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 08/04/2019] [Accepted: 08/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There have been few published studies of clinical and psychological characteristics of patients with functional diarrhea (FDr). We studied the clinical and psychological characteristics of patients with FDr presenting to a tertiary care clinic, and compared symptom profiles of FDr with those of IBS-diarrhea (IBS-D). METHODS Consecutive patients with a diagnosis of FDr (n = 48) or IBS-D (n = 49), per Rome IV criteria, completed a detailed symptom survey from October 2017 through July 2018. Abdominal pain and diarrhea severity were assessed using patient-reported outcomes measurement information system (PROMIS) questionnaires. Patients with anxiety, depression, or sleep disturbances were identified based on PROMIS T-score of 60 or more. Mean and proportions were compared using the Student t test and chi-square analyses, respectively. RESULTS A significantly lower proportion of patients with FDr reported abdominal pain (77.1%) than patients with IBS-D (100%, P < .001). The proportion of patients reporting abdominal bloating and level of severity did not differ significantly between groups. Proportions of bowel movements with diarrhea did not differ significantly between groups (P = .54), but the mean diarrhea PROMIS T-score was significantly higher among patients with IBS-D (P = .03). This difference resulted from the significantly higher levels of fecal urgency-related distress reported by patients with IBS-D (P = .007). Proportions of patients with anxiety, depression, or sleep disturbance, and their severities, did not differ significantly between groups. CONCLUSIONS In an analysis of about 100 patients with FDr or IBS-D, we found overlap in gastrointestinal and psychosomatic symptoms. These 2 entities appear to be a continuum.
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Affiliation(s)
- Prashant Singh
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ha-Neul Lee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Vikram Rangan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sarah Ballou
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joseph Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jesse Katon
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Courtney McMahon
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel Friedlander
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Johanna Iturrino
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Judy Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Anthony Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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15
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Nee J, Sugarman MA, Ballou S, Katon J, Rangan V, Singh P, Zubiago J, Kaptchuk TJ, Lembo A. Placebo Response in Chronic Idiopathic Constipation: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2019; 114:1838-1846. [PMID: 31592782 DOI: 10.14309/ajg.0000000000000399] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Chronic idiopathic constipation (CIC), like other functional gastrointestinal disorders, has been associated with a high placebo response rate. However, the placebo response in randomized controlled trials has not been described. METHODS We conducted a search of the medical literature following the protocol outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement using MEDLINE, EMBASE and EMBASE Classic, Web of Science, and the Cochrane Central Register of Controlled Trials for all drugs used for the treatment of CIC. Two independent reviewers performed eligibility assessment and data extraction. The mean response rate was examined for the following 2 responder endpoints: (i) greater than or equal to 3 complete spontaneous bowel movements (CSBMs)/wk (≥3 CSBMs/wk responders) and (ii) mean increase of ≥1 CSBM/wk compared with baseline (increase in ≥1 CSBM/wk responders). RESULTS A total of 23 placebo-controlled trials met our inclusion criteria and were included in this meta-analysis. The placebo response in CIC trials ranged from 4% to 44%. The magnitude of the placebo response was 13% (95% confidence interval 11%-16%) with the ≥3 CSBM/wk responder endpoint and 28% (95% confidence interval 21%-30%) with the increase of ≥1 in the CSBM responder endpoint. Higher baseline CSBM, older age, and trials with more male participants were significantly associated with a stronger placebo response for both the ≥3 CSBMs/wk endpoint and increase in the ≥1 CSBM/wk endpoint. Trial characteristics such as location (Europe vs Asia/United States) and laxative class (prokinetic vs secretagogue) revealed key differences in the placebo response for both endpoints. The placebo response was not significantly affected by the number of study visits, study duration, year of publication, number of drop outs, or likelihood of receiving active drug. DISCUSSION The placebo response in CIC trials ranges from 4% to 44% depending on the endpoint. Modifying factors of the placebo response include multiple subject and trial characteristics.
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Affiliation(s)
- Judy Nee
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Sarah Ballou
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jesse Katon
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Vikram Rangan
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Prashant Singh
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Julia Zubiago
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Ted J Kaptchuk
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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16
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Chronic constipation: new insights, better outcomes? Lancet Gastroenterol Hepatol 2019; 4:873-882. [DOI: 10.1016/s2468-1253(19)30199-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 02/07/2023]
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17
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Abstract
Constipation is a common symptom that may be primary (idiopathic or functional) or associated with a number of disorders or medications. Although most constipation is self-managed by patients, 22% seek health care, mostly to primary care physicians (>50%) and gastroenterologists (14%), resulting in large expenditures for diagnostic testing and treatments. There is strong evidence that stimulant and osmotic laxatives, intestinal secretagogues, and peripherally restricted μ-opiate antagonists are effective and safe; the lattermost drugs are a major advance for managing opioid-induced constipation. Constipation that is refractory to available laxatives should be evaluated for defecatory disorders and slow-transit constipation using studies of anorectal function and colonic transit. Defecatory disorders are often responsive to biofeedback therapies, whereas slow-transit constipation may require surgical intervention in selected patients. Both efficacy and cost should guide the choice of treatment for functional constipation and opiate-induced constipation. Currently, no studies have compared inexpensive laxatives with newer drugs that work by other mechanisms.
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Affiliation(s)
- Adil E. Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Arnold Wald
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison
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18
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Bouchoucha M, Fysekidis M, Rompteaux P, Airinei G, Sabate JM, Benamouzig R. Influence of Age and Body Mass Index on Total and Segmental Colonic Transit Times in Constipated Subjects. J Neurogastroenterol Motil 2019; 25:258-266. [PMID: 30982242 PMCID: PMC6474702 DOI: 10.5056/jnm18167] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/04/2018] [Accepted: 03/13/2019] [Indexed: 12/12/2022] Open
Abstract
Background/Aims Discordant data are found in the literature for the relationships between total and segmental colonic transit time (CTT) and demographic parameters. The aim of this study is to examine the influence of age, and body mass index (BMI) on total and segmental CTT in constipated subjects. Methods We included 354 constipated patients on this cross-sectional study. According to the Rome III criteria, patients were classified as having irritable bowel syndrome with constipation, or functional constipation. All patients filled the Bristol stool form, and reported the severity of constipation, bloating, and abdominal pain on a 10-point Likert scale. Total and segmental CTT were measured using radiopaque markers. Results Females were 84% of patients, with a mean age of 46.0 ± 15.9 years. The association between total and segmental CTT with age and BMI was significant after adjustment for gender, clinical phenotype, the presence of defecation disorders, and abdominal pain or bloating intensity despite the severity of symptoms, and the frequency of defecation disorders were higher in irritable bowel syndrome with constipation than in functional constipation patients. By comparison with subjects less than 30 years, rectosigmoid transit time (RSTT) was lower in patients between 30 and 60 years. Age was negatively associated with RSTT (P = 0.004). By comparison with patients with normal BMI, RSTT and total CTT were lower in patients of the overweight group. BMI was negatively associated with RSTT (P < 0.001). The severity of constipation was correlated with total (P < 0.001), right (P = 0.002), and left CTT (P = 0.049). Conclusion Age and BMI are both associated with RSTT in constipated patients.
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Affiliation(s)
- Michel Bouchoucha
- Université Paris V René Descartes, Paris, France.,Service de'gastroentérologie, Hôpital Avicenne, Bobigny, France
| | - Marinos Fysekidis
- Service d'endocrinologie et diabétologie, Hôpital Avicenne, Bobigny, France
| | | | - Gheorge Airinei
- Service de'gastroentérologie, Hôpital Avicenne, Bobigny, France
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19
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), 200 First St. S.W, Rochester, MN, 55905, USA.
| | - Mayank Sharma
- Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Clinical and Enteric Neuroscience Translational and Epidemiological Research Program (C.E.N.T.E.R.), 200 First St. S.W, Rochester, MN, 55905, USA
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