[Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]

The role of Nrf2 signaling in parasitic diseases and its therapeutic potential

In response to invading parasites, one of the principal arms of innate immunity is oxidative stress, caused by reactive oxygen species (ROS). However, oxidative stresses play dual functions in the disease, whereby free radicals promote pathogen removal, but they can also trigger inflammation, resulting in tissue injuries. A growing body of evidence has strongly supported the notion that nuclear factor erythroid 2-related factor 2 (NRF) signaling is one of the main antioxidant pathways to combat this oxidative burst against parasites. Given the important role of NRF2 in oxidative stress, in this review, we investigate the activation mechanism of the NRF2 antioxidant pathway in different parasitic diseases, such as malaria, leishmaniasis, trypanosomiasis, toxoplasmosis, schistosomiasis, entamoebiasis, and trichinosis.

Review document of the Spanish Association of Neurogastroenterology and Motility on the management of opioid-induced constipation

Opioid induced constipation is a rising problem due to the progressive increment in the prescription of opioids. By contrast to functional constipation, opioid-induced constipation is not a functional gut disorder, but a side effect of the use of opioids. Opioids produce constipation due to a decrease in gastrointestinal motility and a reduction in the gastrointestinal secretions. The treatment of OIC focuses on three basic pillars: optimizing opioid drug indication, preventing constipation onset, and treating it if it occurs. As with any other cause of constipation, lifestyle adjustments and laxatives should be the first-line treatment in the pharmacological management of OIC. Osmotic laxatives such as polyethylene glycol (PEG) are the agents of choice. PEG is inert and is neither fermented nor absorbed in the gastrointestinal tract. Furthermore, it has broad clinical applicability due to its favourable safety profile. If first-line treatments fail, peripheral mu receptor antagonists (PAMORA) are the drugs of choice. They reduce the peripheral effects of OIC with minimal potential to diminish analgesia or induce centrally mediated withdrawal syndrome. Different PAMORA are available in the market, both for oral and subcutaneous administration, with demonstrated efficacy for management of OIC in different clinical trials.

Functional Abdominal Cramping Pain: Expert Practical Guidance

Functional abdominal cramping pain (FACP) is a common complaint, which may present either on its own or in association with a functional gastrointestinal disorder. It is likely caused by a variety of, probably partly unknown, etiologies. Effective management of FACP can be challenging owing to the lack of usable diagnostic tools and the availability of a diverse range of treatment approaches. Practical guidance for their selection and use is limited. The objective of this article is to present a working definition of FACP based on expert consensus, and to propose practical strategies for the diagnosis and management of this condition for physicians, pharmacists, and patients. A panel of experts on functional gastrointestinal disorders was convened to participate in workshop activities aimed at defining FACP and agreeing upon a recommended sequence of diagnostic criteria and management recommendations. The key principles forming the foundation of the definition of FACP and suggested management algorithms include the primacy of cramping pain as the distinguishing symptom; the importance of recognizing and acting upon alarm signals of potential structural disease; the recognition of known causes that might be addressed through lifestyle adjustment; and the central role of antispasmodics in the treatment of FACP. The proposed algorithm is intended to assist physicians in reaching a meaningful diagnostic endpoint based on patient-reported symptoms of FACP. We also discuss how this algorithm may be adapted for use by pharmacists and patients.

Is Constipation Associated with Worse Functioning in Adult Women? A Cross-Sectional Study

OBJECTIVE

The aim of this study is to analyze the relationship between intestinal constipation and functioning in adult women living in a municipality in the interior of northeast Brazil.

MATERIALS AND METHODS

This is a cross-sectional study conducted with 195 adult women in the city of Santa Cruz-RN. Constipation was diagnosed using the Rome III criteria. Functioning was measured through WHODAS 2.0. Social conditions, habits and lifestyle were also investigated. Inferential analysis was performed using the chi-squared test and the Mann-Whitney U-test, and the effect size was determined by eta squared (η2). Multivariate analysis was performed using multiple linear regression to analyze the relationship between the WHODAS total score and constipation, being adjusted by covariates with p≤0.20 in the bivariate. A statistical significance level of p<0.05 was considered.

RESULTS

Most of the participants in this study were aged 19 to 39 years (69.7%) and had an income of up to 1 minimum monthly salary (79.5%). WHODAS scores showed that women with constipation had more disability in the cognitive (p <0.001), mobility (p <0.002), self-care (p <0.001), and participation (p <0.001) domains, as well as the total score (p <0.001). After multiple linear regression analysis, the total WHODAS score remained associated with constipation (p <0.001), in which this condition increases the score by nine points.

CONCLUSION

The results of this study show that there is a reduction in functioning associated with the presence of constipation in adult women, mainly affecting the cognition, mobility, self-care and participation domains, in addition to the total score.

Eph/ephrin signalling serves a bidirectional role in lipopolysaccharide‑induced intestinal injury

A growing body of evidence has demonstrated that Eph/ephrin signalling may serve a central role in intestinal diseases. However, whether erythropoietin-producing hepatocellular (Eph)/ephrin signalling is associated with the development of post-infectious irritable bowel syndrome (PI-IBS) is still unknown. In the present study, the role of Eph/Ephrin signalling in lipopolysaccharide (LPS)-induced intestinal injury was evaluated in vivo and in vitro. LPS treatment significantly increased the levels of proinflammatory mediators [monocyte chemoattractant protein-1, tumour necrosis factor α, interleukin (IL)-1β, IL-6, intercellular adhesion molecule 1 and vascular cell adhesion molecule-1], activated the EphA2-Ephrin A1, protein kinase B (Akt)-nuclear factor (NF)-κB, Src-NF-κB and Wnt/β-catenin signalling pathways, and inhibited EphB1-Ephrin B3 signalling in colon tissues, and primary cultured enteric neuronal and glial cells. Notably, EphA2 monoclonal antibody (mAb) treatment or Ephrin B3 overexpression could partially alleviate the LPS-induced upregulation of proinflammatory mediators, and Akt-NF-κB, Src-NF-κB and Wnt/β-catenin signalling pathways. In addition, EphA2 mAb treatment could partially inhibit LPS-induced inactivation of EphB-Ephrin B3 signalling, while Ephrin B3 overexpression could abrogate LPS-induced activation of EphA2-Ephrin A1 signalling. EphB1/Ephrin B3 signalling may antagonise the EphA2/Ephrin A1-dependent pathway following LPS treatment. The results associated with the EphA2 signaling pathway, indicated that Eph/ephrin signalling may serve a bidirectional role in LPS-induced intestinal injury. Eph/ephrin signalling may be a novel therapeutic target for LPS-induced intestinal injury and potentially PI-IBS.

A Novel EphA2 Inhibitor Exerts Beneficial Effects in PI-IBS in Vivo and in Vitro Models via Nrf2 and NF-κB Signaling Pathways

Though the detailed pathological mechanism of post-infectious irritable bowel syndrome (PI-IBS) remains unclear, accumulating evidence indicates that oxidative stress and inflammation are implicated in the process of PI-IBS. Oxidative stress and inflammation are regulated by Nrf2 and NF-κB signaling pathways, respectively. EphA2, a member of Eph receptor family, promotes oxidative stress and inflammatory responses via regulation of Nrf2 and NF-κB signaling pathways in various types of human diseases. Understanding the mechanisms by which EphA2 regulate oxidative stress and inflammation in PI-IBS is important for the development of new strategies to treat PI-IBS. However, the effects of ALW-II-41-27, a novel EphA2 inhibitor on PI-IBS and the underlying molecular mechanisms have never been studied. In the present study, we showed that ALW-II-41-27 decreased gastrointestinal motility and abdominal withdrawal reflex (AWR) scores, markedly reduced the levels of oxidative stress markers [4-hydroxy-2-nonenal (4-HNE), protein carbonyl, and 8-hydroxy-2-de-axyguanine (8-OHdG)] and proinflammatory cytokines (TNF-α, IL-6, IL-17, and ICAM-1), and remarkably increased the level of anti-inflammatory cytokine (IL-10) in serum and colon of Trichinella spiralis-infected mice. Moreover, ALW-II-41-27 was effective in suppressing oxidative stress and inflammation in LPS-treated NCM460 colonic cells. Treatment of ALW-II-41-27 reversed the activation of NF-κB and inactivation of Nrf2 in LPS-treated NCM460 cells. Importantly, these protective effects of ALW-II-41-27 were partially inhibited by EphA2 KO and abolished by EphA2 overexpression. In conclusion, EphA2 may represent a promising therapeutic target for patients with PI-IBS and ALW-II-41-27 might function as a novel therapeutic agent for PI-IBS.

[Irritable bowel syndrome with constipation and functional constipation in adults: Treatment (Part 2 of 2)]

In this Clinical practice guide we examine the diagnostic and therapeutic management of adult patients with constipation and abdominal discomfort, at the confluence of the spectrum of irritable bowel syndrome and functional constipation. Both fall within the framework of functional intestinal disorders and have major personal, health and social impact, altering the quality of life of the patients affected. The former is a subtype of irritable bowel syndrome in which constipation and altered bowel habit predominate, often along with recurring abdominal pain, bloating and abdominal distension. Constipation is characterised by infrequent or hard-to-pass bowel movements, often accompanied by straining during defecation or the sensation of incomplete evacuation. There is no underlying organic cause in the majority of cases; it being considered a functional bowel disorder. There are many clinical and pathophysiological similarities between the two conditions, the constipation responds in a similar way to commonly used drugs, the fundamental difference being the presence or absence of pain, but not in an "all or nothing" way. The severity of these disorders depends not only on the intensity of the intestinal symptoms but also on other biopsychosocial factors: association of gastrointestinal and extraintestinal symptoms, degree of involvement, forms of perception and behaviour. Functional bowel disorders are diagnosed using the Rome criteria. This Clinical practice guide adapts to the Rome IV criteria published at the end of May 2016. The first part (96, 97, 98) examined the conceptual and pathophysiological aspects, alarm criteria, diagnostic test and referral criteria between Primary Care and Gastroenterology. This second part reviews all the available treatment alternatives (exercise, fluid ingestion, diet with soluble fibre-rich foods, fibre supplements, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antdepressants, psychological treatment, acupuncture, enemas, sacral root neurostimulation and surgery), and practical recommendations are made for each.