Irritable bowel syndrome and chronic constipation: emerging drugs, devices, and surgical treatments

Stoma reversal in functional bowel disease: managing patient choice

INTRODUCTION

This study aims to assess the rate of stoma reversal in patients who have undergone stoma formation with permanent intent for functional bowel disorder. We also assessed the incidence of malignancy in defunctioned bowel.

METHODS

This is a retrospective study of the outcomes of patients undergoing planned permanent stoma formation for functional bowel disorder over a 10-year period at a single tertiary centre.

RESULTS

Of 92 patients included in the study, 11 (12%) requested and underwent stoma reversal following stoma formation for functional bowel disorder. Of 84 patients with defunctioned bowel left in situ, two (2%) developed bowel malignancy during our study period.

CONCLUSIONS

Stoma formation may be necessary for patients with incontinence and constipation when conservative treatments fail. Some patients have very firm views about the need for a stoma, but a significant proportion of patients do not cope with a stoma and request reversal, therefore patient selection and pre-procedure counselling are important. The risk of developing malignant disease in the defunctioned colon is potentially significant, and consideration should be given to appropriate surveillance in this group of patients. Evidence for stoma formation in functional gastrointestinal disorders is lacking; this study reports outcomes in a large cohort of patients over a long period, and highlights areas where further research and practice guidelines are needed. If large numbers of patients are undergoing stoma reversal posing significant mortality and morbidity risks, this suggests that patient selection and preoperative counselling need refinement.

Effectiveness of Fiber Supplementation for Constipation, Weight Loss, and Supporting Gastrointestinal Function: A Narrative Review of Meta-Analyses

Objective

The purpose of this narrative review is to determine whether published meta-analyses support the use of fiber supplementation in the treatment of constipation, weight loss, and dietary support for gastrointestinal disorders such as irritable bowel syndrome (IBS) and inflammatory bowel disease.

Methods

A PubMed search from January 1, 1980, to July 31, 2019, was conducted with the following search strategy: (fiber OR fibre) AND (meta-analysis OR systematic review) AND (constipation OR body weight OR obesity OR irritable bowel syndrome OR inflammatory bowel disease). Meta-analyses that provided quantitative statistical analysis with a measured effect size were retrieved and accepted into this review. The following was extracted and entered into an Excel spreadsheet: number of publications included in the meta-analysis, number of total participants, fiber type and daily dose, pooled treatment effects for clinical endpoints, or summary relative risks.

Results

Eighteen meta-analyses support dietary fiber supplementation for patients with constipation, weight loss, and IBS, but the significant heterogeneity and publication bias undermine the support for using dietary fiber supplementation in these conditions.

Conclusion

This narrative review of meta-analyses finds some benefits for recommending fiber supplementation to patients with constipation, obesity, and IBS, but significant heterogeneity and publication bias undermine this support.

Polyphenol-rich Mango (Mangifera indica L.) Ameliorate Functional Constipation Symptoms in Humans beyond Equivalent Amount of Fiber

SCOPE

Chronic constipation is a common gastrointestinal condition associated with intestinal inflammation and considerably impaired quality of life, affecting about 20% of Americans. Dietary fiber and laxatives aid in its treatment but do not fully address all symptoms, such as intestinal inflammation. Mango (Mangifera indica L.), a fiber- and polyphenol-rich fruit may provide anti-inflammatory effects in constipation.

METHODS AND RESULTS

The 4 week consumption of mango fruit (300 g) or the equivalent amount of fiber is investigated in otherwise healthy human volunteers with chronic constipation who are randomly assigned to either group. Blood and fecal samples and digestive wellness questionnaires are collected at the beginning and end of the study. Results show that mango consumption significantly improve constipation status (stool frequency, consistency, and shape) and increase gastrin levels and fecal concentrations of short chain fatty acid (valeric acid) while lowering endotoxin and interleukin 6 concentrations in plasma.

CONCLUSION

In this pilot study, the consumption of mango improves symptoms and associated biomarkers of constipation beyond an equivalent amount of fiber. Larger follow-up studies would need to investigate biomarkers for intestinal inflammation in more detail.

White Matter Microstructural Similarity and Diversity of Functional Constipation and Constipation-predominant Irritable Bowel Syndrome

Background/Aims

The Rome III criteria separated chronic constipation into functional constipation (FC) and constipation-predominant irritable bowel syndrome (IBS-C), but some researchers questioned the partitioning and treated both as distinct parts of a continuum. The study aims to explore the similarity and diversity of brain white matter between FC and IBS-C.

Methods

The voxel-wise analysis of the diffusion parameters was used to quantify the white matter changes of female brains in 18 FC patients and 20 IBS-C patients compared with a comparison group with 19 healthy controls by tract-based spatial statistics. The correlations between diffusive parameters and clinical symptoms were evaluated using a Pearson's correlation.

Results

In comparison to healthy controls, FC patients showed a decrease of fractional anisotropy (FA) and an increase of radial diffusivity (RD) in multiple major fibers encompassing the corpus callosum (CC, P = 0.001 at peak), external capsule (P = 0.002 at peak), corona radiata (CR, P = 0.001 at peak), and superior longitudinal fasciculus (SLF, P = 0.002 at peak). In contrast, IBS-C patients showed FA and RD aberrations in the CC (P = 0.048 at peak). Moreover, the direct comparison between FC and IBS-C showed only RD differences in the CR and SLF. In addition, FA and RD in the CC were significantly associated with abdominal pain for all patients, whereas FA in CR (P = 0.016) and SLF (P = 0.040) were significantly associated with the length of time per attempt and incomplete evacuation separately for FC patients.

Conclusion

These results may improve our understanding of the pathophysiological mechanisms underlying different types of constipation.

Neuroendocrine Dysregulation in Irritable Bowel Syndrome Patients: A Pilot Study

Background/Aims

Irritable bowel syndrome (IBS) is a multifactorial disorder, involving dysregulation of brain-gut axis. Our aim was to evaluate the neuroendocrine activity in IBS.

Methods

Thirty IBS and 30 healthy volunteers were enrolled. Psychological symptoms were evaluated by questionnaires. Urinary 5-hydroxyindoleacetic acid, plasma serotonin (5-hydroxytryptamine, 5-HT), endothelin, and neuropeptide Y (NPY), and plasma and urinary cortisol levels were evaluated. Fourteen IBS subjects underwent microneurography to obtain multiunit recordings of efferent postganglionic muscle sympathetic nerve activity (MSNA).

Results

Prevalent psychological symptoms in IBS were maladjustment (60%), trait (40%) and state (17%) anxiety, obsessive compulsive-disorders (23%), and depressive symptoms (23%). IBS showed increased NPY (31.9 [43.7] vs 14.8 [18.1] pmol/L, P = 0.006), 5-HT (214.9 [182.6] vs 141.0 [45.5] pg/mL, P = 0.010), and endothelin [1.1 [1.4] vs 2.1 [8.1] pg/mL, P = 0.054], compared to healthy volunteers. Moreover, plasma NPY, endothelin, cortisol and 5-HT, and urinary 5-hydroxyindoleacetic acid were associated with some psychological disorders (P ≤ 0.05). Despite a similar resting MSNA, after cold pressor test, IBS showed a blunted increase in MSNA burst frequency (+4.1 vs +7.8 bursts/min, P = 0.048; +30.1% vs +78.1%, P = 0.023). Baseline MSNA tended to be associated with urinary cortisol (ρ = 0.557, P = 0.059). Moreover, changes in heart rate after mental stress were associated with urinary cortisol (ρ = 0.682, P = 0.021) and changes in MSNA after mental stress were associated with plasma cortisol (ρ = 0.671, P = 0.024).”

Conclusion

Higher concentrations of endothelin, NPY, and 5-HT were found to be associated with some psychological disorders in IBS patients together with an altered cardiovascular autonomic reactivity to acute stressors compared to healthy volunteers.

Efficacy of Cranial Electrotherapy Stimulation Combined with Biofeedback Therapy in Patients with Functional Constipation

Background/Aims

A large number of studies have shown that function constipation (FC) has an extremely high incidence of mental and psychological disorders. Cranial electrotherapy stimulation (CES) was applied to the treatment of psychological disorders such as anxiety and depression. We explored the effects of CES combined with biofeedback therapy (BFT) on the psychological state, clinical symptoms, and anorectal function in patients with FC.

Methods

A total of 74 patients with FC were randomly divided into 2 groups. The control group received BFT. CES combined with BFT was carried out in the experiment group. All patients were assessed using the self-rating anxiety scale (SAS), self-rating depression scale (SDS), and Wexner constipation score at baseline and the end of each course. Anorectal manometry and balloon expulsion tests were performed before and after treatment.

Results

After treatment, the participants in the experiment group had significantly lower score SAS, SDS, and Wexner constipation scores than the control group (all P < 0.05). The number of successful expulsion in the experiment group was larger than the control group (P = 0.016).

Conclusions

CES combined with BFT was effective in improving the psychological status of anxiety, depression, and bowel symptoms in patients with FC.

Planar bioadhesive microdevices: a new technology for oral drug delivery

The oral route is the most convenient and least expensive route of drug administration. Yet, it is accompanied by many physiological barriers to drug uptake including low stomach pH, intestinal enzymes and transporters, mucosal barriers, and high intestinal fluid shear. While many drug delivery systems have been developed for oral drug administration, the physiological components of the gastro intestinal tract remain formidable barriers to drug uptake. Recently, microfabrication techniques have been applied to create micron-scale devices for oral drug delivery with a high degree of control over microdevice size, shape, chemical composition, drug release profile, and targeting ability. With precise control over device properties, microdevices can be fabricated with characteristics that provide increased adhesion for prolonged drug exposure, unidirectional release which serves to avoid luminal drug loss and enhance drug permeation, and protection of a drug payload from the harsh environment of the intestinal tract. Here we review the recent developments in microdevice technology and discuss the potential of these devices to overcome unsolved challenges in oral drug delivery.

Epidemiology and burden of chronic constipation

Chronic constipation is an important component of clinical gastroenterology practice worldwide. Based on the definition, either self-reported or using Rome criteria, chronic constipation can affect from 2% to 27% of the population. Constipation is physically and mentally troublesome for many patients, and can significantly interfere with their daily living and well-being. Although only a proportion of patients with constipation seek medical care, most of them use prescribed or over-the-counter medication to improve their condition. The health care costs of constipation are significant as evidenced by the hundreds of million dollars spent yearly on laxatives alone. Because constipation is more common in older patients and life expectancy is increasing, an increase in the prevalence of constipation is expected in the years to come, with the associated impact on quality of life and socioeconomic burden.