Clinical practice guidelines for the management of constipation in adults. Part 1: Definition, aetiology and clinical manifestations

Exploration of the complex origins of primary constipation

Constipation is a common gastrointestinal disorder characterized by infrequent bowel movements and difficulty in passing stools. It can significantly affect an individual's quality of life and overall well-being. Understanding the causes of constipation is important for its effective management and treatment. In this paper, we have reviewed the primary causes of constipation or functional constipation. Primary constipation is a bowel disorder associated with colonic or anorectal sensorimotor or neuromuscular dysfunction. As per the literature, it is multifactorial and involves factors such as decreased interstitial cells of Cajal, altered colonic motility, enteric nervous system dysfunction, intestinal flora disturbances, and psychological influences. Clinical symptoms include difficulty in defecation, decreased frequency of defecation, or a feeling of incomplete evacuation. A comprehensive evaluation and management of constipation require an interdisciplinary approach incorporating dietary modifications, lifestyle changes, pharmacotherapy, and psychological interventions. Further research is imperative to explain the intricate mechanisms underlying constipation and develop targeted therapies for improved patient outcomes.

Nutritional Management of Oncological Symptoms: A Comprehensive Review

Throughout their experience of illness and during the course of treatment, a substantial proportion of cancer patients are prone to develop nutritional and/or metabolic disturbances. Additionally, cancer patients often encounter long-term side effects from therapies, which may lead to impaired digestion, nutrient absorption or bowel motility. Therefore, the preservation and maintenance of an optimal and balanced nutritional status are pivotal to achieving a better prognosis, increasing the tolerance and adherence to cancer therapies and improving the overall quality of life. In this context, personalized nutritional programs are essential for addressing conditions predisposing to weight loss, feeding difficulties, digestion problems and intestinal irregularity, with the goal of promoting adequate nutrient absorption and minimizing the detrimental effects of treatment regimens. The focus of this research is to examine the most common clinical conditions and metabolic changes that cancer patients may experience, including stomatitis, xerostomia, diarrhea, nausea, vomiting, dysphagia, sub-occlusion, dysgeusia, dysosmia, anorexia, and cachexia. Furthermore, we present a pragmatic example of a multidisciplinary workflow that incorporates customized recipes tailored to individual clinical scenarios, all while maintaining the hedonic value of the meals.

Daily consumption of galactooligosaccharide gummies ameliorates constipation symptoms, gut dysbiosis, degree of depression and quality of life among sedentary university teaching staff: A double-blind randomized placebo control clinical trial

BACKGROUND

Functional constipation affects approximately 10% of the Indian population and may reduce the quality of life (QOL) and increase gut dysbiosis. PURPOSE OF STUDY: The study aimed at assessing the impact of galactooligosaccharide (GOS) gummy supplementation on gut health, depression status and QOL of constipated subjects.

METHODS

A double-blind placebo control clinical trial (CTRI/2021/10/037474) was conducted on sedentary constipated adults (n = 35), who were split into an experimental group (n = 17) and a control group (n = 18), supplemented with 10 g GOS and sugar gummies, respectively, for 30 days. Relative abundance of fecal gut microbes, including Bifidobacterium, Lactobacillus, Clostridium and Bacteroides and phyla Bacteroidetes and Firmicutes using real-time polymerase chain reaction and short-chain fatty acids, was analyzed pre and post supplementation. Constipation profile was studied using Rome IV criteria and the Bristol stool chart. Depression status was studied using the Becks Depression Inventory. The QOL was assessed using patient assessment of constipation.

RESULTS

GOS gummy supplementation increased Bifidobacterium and Lactobacillus by 1230% and 322%, respectively, (p < 0.001; p < 0.01) with reduced Clostridium by 63%, phylum Firmicutes by 73% and Bacteroidetes by 85% (p < 0.01). The GOS-supplemented group demonstrated a higher F/B ratio (4.2) indicating improved gut health (p < 0.01) with reduced gut dysbiosis and constipation severity. GOS gummies enhanced acetic acid and butyric acid levels compared to the control group (p < 0.01; p < 0.001). Post supplementation, there was 40% reduction in depression (p < 0.01) and 22% improvement in QOL (p < 0.05).

CONCLUSIONS

This research validates the predicted beneficial benefits of short-term GOS consumption on constipation profile, gut microflora, depression status and quality of life of constipated subjects.

Alteration of the faecal microbiota composition in patients with constipation: evidence of American Gut Project

There is limited information is known about the composition difference of the gut microbiota in patients with constipation and healthy controls. Here, the faecal 16S rRNA fastq sequence data of microbiota from the publicly available American Gut Project (AGP) were analysed. The tendency score matching (PSM) method was used to match in a 1:1 manner to control for confounding factors age, gender, body mass index (BMI), and country. A total of 524 participants including 262 patients with constipation and 262 healthy controls were included in this analysis. The richness and evenness of the gut microbiota in the constipation group were significantly lower than those in the control group. The dominant genera in the constipation group include Escherichia_Shigella, Pseudomonas, and Citrobacter. The dominant genera in the control group include Faecalibacterium, Prevotella, Roseburia, Clostridium_XlVa, and Blautia. The abundance of three butyrate production-related pathways were significantly higher in the constipation group than in the control groups. There was no significant difference in the diversity and gut microbiota composition in patients with constipation at different ages. In conclusion, patients with constipation showed gut microbiota and butyrate metabolism dysbiosis. This dysbiosis might provide a reference for the diagnosis and clinical therapy of diseases.

A national cross-sectional survey of constipation in patients attending cancer centres in Ireland

Background: The prevalence of constipation in patients with cancer is estimated at 50-90%. It is often associated with pain, anorexia, nausea and vomiting and impacts negatively on quality of life. Despite its common occurrence, it is often poorly recognised and treated by healthcare professionals. Methods: A national cross-sectional survey was conducted in Ireland to describe constipation prevalence and severity in patients attending cancer centres and to evaluate management efficacy.  In-patients or patients attending day oncology wards in any of the country's eight designated cancer centres were eligible to participate. Participants were shown the Bristol Stool Chart  and answered questions regarding stool appearance and sensation of  incomplete defecation; they completed the Constipation Assessment Scale. Data on pain character and intensity, opioid use, and prescribed and over-the-counter laxative use were collected. Data were summarised using descriptive statistics. Significance of variations for continuous data were determined using t-tests. Conditional ordered logistic regression was undertaken to determine factors associated with constipation. Results: The dataset comprised 491 patients. 24.8% had been reviewed by specialist palliative care; 14.5% by the anaesthetic pain team. In total, 42.2% of respondents were taking step 2 or step 3 opioids. Constipation prevalence was 67.6%; 19.4% of patients had Constipation Assessment Scale scores indicating severe constipation. A total of 46% of the respondents were not taking any laxatives. Of those who were taking laxatives, 54.8%  reported constipation symptoms. While opioid use was strongly associated with participants reporting higher scores, this association was not seen in those patients receiving specialist palliative care. Conclusions: Constipation remains a clinical problem in Irish cancer centres. Despite increased opioid use, patients receiving specialist palliative care were more likely to take laxatives and reported less constipation. Specialist palliative care practice should be studied in order to identify what are the transferable 'ingredients' of effective constipation management.

Effective Communication Strategies and Tools for Improving Treatment Outcomes in Patients With Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation

Patients with chronic idiopathic constipation and irritable bowel syndrome with constipation experience an array of gastrointestinal symptoms. Given the subjective nature of these disorders, patient self-reporting is critical to diagnosis and monitoring response to therapy. Unfortunately, many patients are reluctant to discuss bowel symptoms with their healthcare providers. Differences in sex, health literacy, and age can influence symptom reporting. Negative patient-physician relationships and dissatisfaction with care lead patients to seek alternative treatments, switch healthcare providers, or discontinue care. Thus, adopting a patient-centered communication style can help create a shared understanding of patients' symptoms, achieve accurate symptom reporting, expedite diagnosis, and facilitate appropriate treatment plans. Currently, there are multiple symptom and quality-of-life scales available to assist healthcare providers in this endeavor. These scales also allow for the monitoring of constipation-related symptoms and symptom severity. When using patient self-assessments to measure treatment responses, scale selection may depend on the number of symptoms being assessed, the duration and frequency of assessments, and patients' comprehension and language skills.

Dyssynergic Defecation and Other Evacuation Disorders

Constipated patients are frequently referred to gastroenterologists for symptoms refractory to lifestyle modifications and laxatives. Dyssynergic defecation, the dyscoordination of rectoanal, abdominal, and pelvic floor muscles to facilitate defecation, is a major cause of refractory primary constipation. Understanding of the diagnosis, evaluation, and management of dyssynergic defecation and other evacuation disorders will allow providers to effectively manage these patients. This review focuses on the definition, pathophysiology, evaluation, and treatment of dyssynergic defecation and other evacuation disorders. Emerging treatments for these disorders include home biofeedback therapy for dyssynergic defecation and translumbosacral neuromodulation therapy for levator ani syndrome.

Review article: diagnosis, management and patient perspectives of the spectrum of constipation disorders

BACKGROUND

Chronic constipation is a common, heterogeneous disorder with multiple symptoms and pathophysiological mechanisms. Patients are often referred to a gastroenterology provider after laxatives fail. However, there is limited knowledge of the spectrum and management of constipation disorders.

AIM

To discuss the latest understanding of the spectrum of constipation disorders, tools for identifying a pathophysiologic-based diagnosis in the specialist setting, treatment options and the patient's perspective of constipation.

METHODS

Literature searches were conducted using PubMed for constipation diagnostic criteria, diagnostic tools and approved treatments. The authors provided insight from their own practices.

RESULTS

Clinical assessment, stool diaries and Rome IV diagnostic criteria can facilitate diagnosis, evaluate severity and distinguish between IBS with constipation, chronic idiopathic constipation and dyssynergic defecation. Novel smartphone applications can help track constipation symptoms. Rectal examinations, anorectal manometry and balloon expulsion, assessments of neuromuscular function with colonic transit time and colonic manometry can provide mechanistic understanding of underlying pathophysiology. Treatments include lifestyle and diet changes, biofeedback therapy and pharmacological agents. Several classes of laxatives, as well as prokinetic and prosecretory agents, are available; here we describe their mechanisms of action, efficacy and side effects.

CONCLUSIONS

Constipation includes multiple overlapping subtypes identifiable using detailed history, current diagnostic tools and smartphone applications. Recognition of individual subtype(s) could pave the way for optimal, evidence-based treatments by a gastroenterology provider.

The effect of green kiwifruit on gas transit and tolerance in healthy humans

BACKGROUND

Green kiwifruit is a fiber-rich fruit that has been shown effective for treatment of constipation. However, fermentation of fibers by colonic bacteria may worsen commonly associated gas-related abdominal symptoms.

AIM

To determine the effect of green kiwifruit on transit and tolerance to intestinal gas in humans.

METHODS

In 11 healthy individuals, two gas challenge tests were performed (a) after 2 weeks on a low-flatulogenic diet and daily intake of 2 green kiwifruits and (b) after 2 weeks on a similar diet without intake of kiwifruits. The gas challenge test consisted in continuous infusion of a mixture of gases into the jejunum at 12 mL/min for 2 hours while measuring rectal gas evacuation, abdominal symptoms, and abdominal distension. During the 2 weeks prior to each gas challenge test (on-kiwifruit and off-kiwifruit), the number and consistency of stools, and abdominal symptoms were registered.

KEY RESULTS

Intake of kiwifruits was associated with more bowel movements per day (1.8 ± 0.1 vs 1.5 ± 0.1 off-kiwifruit; P = .001) and somewhat looser stools (Bristol score 3.3 ± 0.2 vs 2.8 ± 0.1 off-kiwifruit; P = .072) without relevant abdominal symptoms. Gas infusion produced similar gas evacuation (1238 ± 254 mL and 1172 ± 290 mL; P = .4355), perception of symptoms (score 1.2 ± 0.2 and 1.3 ± 0.3; P = .2367), and abdominal distension (17 ± 7 mm and 17 ± 6 mm; P = .4704) while on-kiwifruit or off-kiwifruit.

CONCLUSIONS AND INFERENCES

In healthy subjects, green kiwifruit increases stool frequency without relevant effects on intestinal gas transit and tolerance. If confirmed in patients, these fruits may provide a natural and well-tolerated treatment alternative for constipation.

Comparisons between Manual Lymph Drainage, Abdominal Massage, and Electrical Stimulation on Functional Constipation Outcomes: A Randomized, Controlled Trial

BACKGROUND

Evidence supports abdominal massage (AM) or electrical stimulation (ES) as effective in treating functional constipation (FC). Manual lymph drainage (MLD) may also be beneficial, however, it was not previously investigated or compared to ES and AM.

METHODS

Sixteen college-aged males and 36 females were recruited. Participants were randomly assigned to MLD, AM or ES. Heart rate variability (HRV) measures for total power (TP), high frequency (HF), low frequency and LF/HF ratio assessed ANS outcomes. state-trait anxiety inventory (STAI) and stress response inventory (SRI) assessed psychological factors and bowel movement frequency (BMF) and duration (BMD) were recorded daily.

RESULTS

MLD significantly improved all ANS measures (p≤0.01); AM significantly improved LF, HF and LF/HF ratios (p = 0.04); and ES significantly improved LF (p = 0.1). STAI measures improved, but not significantly in all groups. SRI improved significantly from MLD (p < 0.01), AM (p = 0.04) and ES (p < 0.01), but changes were not significant between groups. BMD improved significantly in all groups (p≤ 0.02). BMF improved significantly only following MLD and AM (p < 0.1), but differences between groups were not significant (p = 0.39).

CONCLUSIONS

MLD significantly reduced FC symptoms and MLD had greater improvements than AM or ES.

Defecation function and quality of life in patients with slow-transit constipation after colectomy

BACKGROUND

Although total or subtotal colectomy for slow-transit constipation (STC) has been proven to be a definite treatment, the associated defecation function and quality of life (QOL) are rarely studied.

AIM

To evaluate the effectiveness of surgery for STC regarding defecation function and QOL.

METHODS

From March 2013 to September 2017, 30 patients undergoing surgery for STC in our department were analyzed. Preoperative, intra-operative, and postoperative 3-mo, 6-mo, 1-year, and 2-year follow-up details were recorded. Defecation function was assessed by bowel movements, abdominal pain, bloating, straining, laxative, enema use, diarrhea, and the Wexner constipation and incontinence scales. QOL was evaluated using the gastrointestinal QOL index and the 36-item short form survey.

RESULTS

The majority of patients (93.1%, 27/29) stated that they benefited from the operation at the 2-year follow-up. At each time point of the follow-up, the number of bowel movements per week significantly increased compared with that of the preoperative conditions (P < 0.05). Similarly, compared with the preoperative values, a marked decline was observed in bloating, straining, laxative, and enema use at each time point of the follow-up (P < 0.05). Postoperative diarrhea could be controlled effectively and notably improved at the 2-year follow-up. The Wexner incontinence scores at 6-mo, 1-year, and 2-year were notably lower than those at the 3-mo follow-up (P < 0.05). Compared with those of the preoperative findings, the Wexner constipation scores significantly decreased following surgery (P < 0.05). Thus, it was reasonable to find that the gastrointestinal QOL index scores clearly increase (P < 0.05) and that the 36-item short form survey results displayed considerable improvements in six spheres (role physical, role emotional, physical pain, vitality, mental health, and general health) following surgery.

CONCLUSION

Total or subtotal colectomy for STC is not only effective in alleviating constipation-related symptoms but also in enhancing patients’ QOL.

Sacral nerve stimulation for constipation: long-term outcomes

BACKGROUND

There has been some controversy regarding the efficacy of sacral nerve stimulation (SNS) for the treatment of chronic constipation, due to less positive outcomes and concerns about cost-effectiveness in the long term. The aim of the present study was to evaluate the long-term outcomes of SNS in patients with chronic constipation.

METHODS

A retrospective study was conducted on patients who had SNS for chronic constipation in 2008-2017 at our institution. Clinical factors, profile of constipation, physiology studies, and patient satisfaction with SNS therapy were investigated during a follow-up period up to 10 years after the implantation.

RESULTS

Twenty-nine patients [86% female, median age 49 years (range 17-86)] were tested for SNS, and 24 received implants after a positive test phase [median 47 days (range 21-56 days)]. There were 27 bilateral and 2 unilateral implants, in S3 or S4 depending on best response. Mean follow-up was 59 months. Efficacy was considered as a score > 5 (on a scale of 1-10) in general symptom improvement. Nine (37.9%) implanted patients had a satisfaction score > 5. In 6 cases (25%), patient satisfaction was higher than 9. Due to the small sample size, there were no statistically significant variables considered as predictors of response.

CONCLUSIONS

Our results agree with current studies which describe around a 30% response of SNS for refractory constipation. However, there is a small group of patients highly satisfied with SNS therapy. More studies are needed to better understand this profile and optimize outcomes.

Chinese herbal medicine for postpartum constipation: a protocol of systematic review and meta-analysis

INTRODUCTION

Constipation is one of the most common gastrointestinal symptoms in postpartum mothers. The choice of treatments for postpartum constipation remains a challenging clinical problem. Chinese herbal medicine has become increasingly popular as an alternative therapy for constipation. This systematic review aims to evaluate the efficacy and safety of Chinese herbal medicine for postpartum constipation.

METHODS AND ANALYSIS

We will search PubMed (1946 to present), EMBASE (1974 to present), Cochrane Central Register of Controlled Trials (all years), Web of Science (1900 to present), Chinese Biomedical Literatures Database (1978 to present), China National Knowledge Infrastructure (1979 to present) and WANFANG data (1998 to present) to identify any eligible study. No restriction will be put on the language, publication date or status of the study. The primary outcome will be the spontaneous bowel movement. Secondary outcomes will be stool consistency, quality of life, transit time, relief of constipation symptoms and adverse events. We will perform the meta-analysis when more than one trial examines the same intervention and outcomes with comparable methods in similar populations. If the heterogeneity is not significant statistically (p>0.10 or I2<50%), the fixed-effect model will be built to estimate the overall intervention effects. Otherwise, the random-effect model will be used to provide more conservative results.

ETHICS AND DISSEMINATION

No ethical issues are foreseen because no primary data will be collected. The results will be published in a peer-reviewed scientific journal.

PROSPERO REGISTRATION NUMBER

CRD42018093741.