Constipation: evaluation and treatment of colonic and anorectal motility disorders

Targeting TRPV1 and TRPA1: A feasible strategy for natural herbal medicines to combat postoperative ileus

Under physiological or pathological conditions, transient receptor potential (TRP) channel vanilloid type 1 (TRPV1) and TRP ankyrin 1 (TRPA1) possess the ability to detect a vast array of stimuli and execute diverse functions. Interestingly, increasing works have reported that activation of TRPV1 and TRPA1 could also be beneficial for ameliorating postoperative ileus (POI). Increasing research has revealed that the gastrointestinal (GI) tract is rich in TRPV1/TRPA1, which can be stimulated by capsaicin, allicin and other compounds. This activation stimulates a variety of neurotransmitters, leading to increased intestinal motility and providing protective effects against GI injury. POI is the most common emergent complication following abdominal and pelvic surgery, and is characterized by postoperative bowel dysfunction, pain, and inflammatory responses. It is noteworthy that natural herbs are gradually gaining recognition as a potential therapeutic option for POI due to the lack of effective pharmacological interventions. Therefore, the focus of this paper is on the TRPV1/TRPA1 channel, and an analysis and summary of the processes and mechanism by which natural herbs activate TRPV1/TRPA1 to enhance GI motility and relieve pain are provided, which will lay the foundation for the development of natural herb treatments for this disease.

Altered Gut Microbic Flora and Haemorrhoids: Could They Have a Possible Relationship?

To date, the exact pathophysiology of haemorrhoids is poorly understood. The different philosophies on haemorrhoids aetiology may lead to different approaches of treatment. A pathogenic theory involving a correlation between altered anal canal microflora, local inflammation, and muscular dyssynergia is proposed through an extensive review of the literature. Since the middle of the twentieth century, three main theories exist: (1) the varicose vein theory, (2) the vascular hyperplasia theory, and (3) the concept of a sliding anal lining. These phenomena determine changes in the connective tissue (linked to inflammation), including loss of organization, muscular hypertrophy, fragmentation of the anal subepithelial muscle and the elastin component, and vascular changes, including abnormal venous dilatation and vascular thrombosis. Recent studies have reported a possible involvement of gut microbiota in gut motility alteration. Furthermore, dysbiosis seems to represent the leading cause of bowel mucosa inflammation in any intestinal district. The alteration of the gut microbioma in the anorectal district could be responsible for haemorrhoids and other anorectal disorders. A deeper knowledge of the gut microbiota in anorectal disorders lays the basis for unveiling the roles of these various gut microbiota components in anorectal disorder pathogenesis and being conductive to instructing future therapeutics. The therapeutic strategy of antibiotics, prebiotics, probiotics, and fecal microbiota transplantation will benefit the effective application of precision microbiome manipulation in anorectal disorders.

Non-drug therapies for the management of chronic constipation in adults: the CapaCiTY research programme including three RCTs

Background

Chronic constipation affects 1–2% of adults and significantly affects quality of life. Beyond the use of laxatives and other basic measures, there is uncertainty about management, including the value of specialist investigations, equipment-intensive therapies using biofeedback, transanal irrigation and surgery.

Objectives

(1) To determine whether or not standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback is more clinically effective than standardised specialist-led habit training alone, and whether or not outcomes of such specialist-led interventions are improved by stratification to habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or habit training alone based on prior knowledge of anorectal and colonic pathophysiology using standardised radiophysiological investigations; (2) to compare the impact of transanal irrigation initiated with low-volume and high-volume systems on patient disease-specific quality of life; and (3) to determine the clinical efficacy of laparoscopic ventral mesh rectopexy compared with controls at short-term follow-up.

Design

The Chronic Constipation Treatment Pathway (CapaCiTY) research programme was a programme of national recruitment with a standardised methodological framework (i.e. eligibility, baseline phenotyping and standardised outcomes) for three randomised trials: a parallel three-group trial, permitting two randomised comparisons (CapaCiTY trial 1), a parallel two-group trial (CapaCiTY trial 2) and a stepped-wedge (individual-level) three-group trial (CapaCiTY trial 3).

Setting

Specialist hospital centres across England, with a mix of urban and rural referral bases.

Participants

The main inclusion criteria were as follows: age 18–70 years, participant self-reported problematic constipation, symptom onset > 6 months before recruitment, symptoms meeting the American College of Gastroenterology’s constipation definition and constipation that failed treatment to a minimum basic standard. The main exclusion criteria were secondary constipation and previous experience of study interventions.

Interventions

CapaCiTY trial 1: group 1 – standardised specialist-led habit training alone (n = 68); group 2 – standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (n = 68); and group 3 – standardised radiophysiological investigations-guided treatment (n = 46) (allocation ratio 3 : 3 : 2, respectively). CapaCiTY trial 2: transanal irrigation initiated with low-volume (group 1, n = 30) or high-volume (group 2, n = 35) systems (allocation ratio 1 : 1). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy performed immediately (n = 9) and after 12 weeks’ (n = 10) and after 24 weeks’ (n = 9) waiting time (allocation ratio 1 : 1 : 1, respectively).

Main outcome measures

The main outcome measures were standardised outcomes for all three trials. The primary clinical outcome was mean change in Patient Assessment of Constipation Quality of Life score at the 6-month, 3-month or 24-week follow-up. The secondary clinical outcomes were a range of validated disease-specific and psychological scoring instrument scores. For cost-effectiveness, quality-adjusted life-year estimates were determined from individual participant-level cost data and EuroQol-5 Dimensions, five-level version, data. Participant experience was investigated through interviews and qualitative analysis.

Results

A total of 275 participants were recruited. Baseline phenotyping demonstrated high levels of symptom burden and psychological morbidity. CapaCiTY trial 1: all interventions (standardised specialist-led habit training alone, standardised specialist-led habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback and standardised radiophysiological investigations-guided habit training alone or habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback) led to similar reductions in the Patient Assessment of Constipation Quality of Life score (approximately –0.8 points), with no statistically significant difference between habit training alone and habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback (–0.03 points, 95% confidence interval –0.33 to 0.27 points; p = 0.8445) or between standardised radiophysiological investigations and no standardised radiophysiological investigations (0.22 points, 95% confidence interval –0.11 to 0.55 points; p = 0.1871). Secondary outcomes reflected similar levels of benefit for all interventions. There was no evidence of greater cost-effectiveness of habit training plus pelvic floor retraining using computer-assisted direct visual biofeedback or stratification by standardised radiophysiological investigations compared with habit training alone (with the probability that habit training alone is cost-effective at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year gain; p = 0.83). Participants reported mixed experiences and similar satisfaction in all groups in the qualitative interviews. CapaCiTY trial 2: at 3 months, there was a modest reduction in the Patient Assessment of Constipation Quality of Life score, from a mean of 2.4 to 2.2 points (i.e. a reduction of 0.2 points), in the low-volume transanal irrigation group compared with a larger mean reduction of 0.6 points in the high-volume transanal irrigation group (difference –0.37 points, 95% confidence interval –0.89 to 0.15 points). The majority of participants preferred high-volume transanal irrigation, with substantial crossover to high-volume transanal irrigation during follow-up. Compared with low-volume transanal irrigation, high-volume transanal irrigation had similar costs (median difference –£8, 95% confidence interval –£240 to £221) and resulted in significantly higher quality of life (0.093 quality-adjusted life-years, 95% confidence interval 0.016 to 0.175 quality-adjusted life-years). CapaCiTY trial 3: laparoscopic ventral mesh rectopexy resulted in a substantial short-term mean reduction in the Patient Assessment of Constipation Quality of Life score (–1.09 points, 95% confidence interval –1.76 to –0.41 points) and beneficial changes in all other outcomes; however, significant increases in cost (£5012, 95% confidence interval £4446 to £5322) resulted in only modest increases in quality of life (0.043 quality-adjusted life-years, 95% confidence interval –0.005 to 0.093 quality-adjusted life-years), with an incremental cost-effectiveness ratio of £115,512 per quality-adjusted life-year.

Conclusions

Excluding poor recruitment and underpowering of clinical effectiveness analyses, several themes emerge: (1) all interventions studied have beneficial effects on symptoms and disease-specific quality of life in the short term; (2) a simpler, cheaper approach to nurse-led behavioural interventions appears to be at least as clinically effective as and more cost-effective than more complex and invasive approaches (including prior investigation); (3) high-volume transanal irrigation is preferred by participants and has better clinical effectiveness than low-volume transanal irrigation systems; and (4) laparoscopic ventral mesh rectopexy in highly selected participants confers a very significant short-term reduction in symptoms, with low levels of harm but little effect on general quality of life.

Limitations

All three trials significantly under-recruited [CapaCiTY trial 1, n = 182 (target 394); CapaCiTY trial 2, n = 65 (target 300); and CapaCiTY trial 3, n = 28 (target 114)]. The numbers analysed were further limited by loss before primary outcome.

Trial registration

Current Controlled Trials ISRCTN11791740, ISRCTN11093872 and ISRCTN11747152.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.

In vivo models to evaluate ingestible devices: Present status and current trends

Evaluation of orally ingestible devices is critical to optimize their performance early in development. Using animals as a pre-clinical tool can provide useful information on functionality, yet it is important to recognize that animal gastrointestinal physiology, pathophysiology and anatomy can differ to that in humans and that the most suitable species needs to be selected to inform the evaluation. There has been a move towards in vitro and in silico models rather than animal models in line with the 3Rs (Replacement, Reduction and Refinement) as well as the better control and reproducibility associated with these systems. However, there are still instances where animal models provide the greatest understanding. This paper provides an overview of key aspects of human gastrointestinal anatomy and physiology and compares parameters to those reported in animal species. The value of each species can be determined based upon the parameter of interest from the ingested device when considering the use of pre-clinical animal testing.

A Novel Noninvasive Method for Quantitative Detection of Colonic Dysmotility Using Real-Time Ultrasonography

INTRODUCTION

Colonic motility disorders are a frequent clinical problem caused by various drugs and diseases. However, the etiology of colonic dysmotility is often unclear due to the lack of in vivo methods, including rapid dynamic assessment.

OBJECTIVES

The aim of this study was to establish a novel quantitative method to objectively assess colonic motility using ultrasonography.

METHODS

We applied echocardiographic speckle tracking-based strain imaging to analyze murine colonic motility. A trace line was placed on the boundary between the proximal wall of the colon and the inner cavity to analyze colonic wall displacement and strain rate. Locomotion activities of the colonic wall were used to quantify colonic motility via ultrasonography.

RESULTS

We found that ultrasonography can quantitatively detect a decrease in colonic motility induced by loperamide, an antidiarrheal drug. These quantitative data were consistent with the imaging findings of colonic peristalsis and colon transit time. Additionally, ultrasonography also revealed changes in colonic motility over short intervals. Furthermore, we have shown that ultrasonography can quantitatively and noninvasively detect colonic dysmotility and hypervascularity of the colonic wall in colitis mice.

CONCLUSIONS

These findings suggest that ultrasonography is a useful in vivo method for objectively monitoring changes in colonic motility caused by drugs and diseases.

Elachi Lemon (Citrus limon) Peel and Pulp: Antioxidant, Antimicrobial, Anticoagulant Activities, Bioactive Compounds, Minerals, and Heavy Metals

Background:

According to a number of previous studies, citrus fruits are rich in phytochemicals, minerals and bioactive compounds.

Objective:

The aim of this study was to investigate the antioxidant, antimicrobial and anticoagulant activities, phytonutrients, bioactive compounds, mineral and heavy metals in the peel and pulp of Elachi lemon (Citrus limon).

Methods:

Phytochemical screening was performed to estimate the total polyphenol, flavonoid, tannin, reducing sugar, total protein and vitamin C contents. High performance liquid chromatography was performed to determine the concentrations of phenolics and ascorbic acid. Antioxidant activities were evaluated by measuring 2,2-diphenyl-1-picrylhydrazyl (DPPH) free radical scavenging activity, reducing power assay and ferric reducing antioxidant power (FRAP) assay. Antibacterial activity was evaluated by the disc diffusion method and minimum inhibitory concentration (MIC). Besides estimating heavy metals and minerals, activated partial thromboplastin time (aPTT) and prothrombin time (PT) were observed for detecting anticoagulant activity.

Results:

In the case of antioxidant and antimicrobial activities, the pulp was found to be richer. Both the peel and pulp showed similar anticoagulant activities. Among the phytonutrients, protein content was richer in the peel than in the pulp. Catechin, rutin, tannic, gallic and vanillic acids were detected in the peel, whereas in pulp quercetin, tannic and gallic acids were found. Pb, Cr, Cd were present in a negligible amount whereas, Co, Cu and Fe were high in both the peel and the pulp.

Conclusion:

This study exhibits that both the peel and the pulp of Citrus limon are a rich source of antioxidant, antimicrobial, anticoagulant, minerals and various bioactive compounds with nutritional values.

Current Overview on Clinical Management of Chronic Constipation

Constipation is one of the major gastrointestinal disorders diagnosed in clinical practice in Western countries. Almost 20% of population suffer from this disorder, which means constipation is a substantial utilization of healthcare. Pathophysiology of constipation is complex and multifactorial, where aspects like disturbance in colonic transit, genetic predisposition, lifestyle habits, psychological distress, and many others need to be taken into consideration. Diagnosis of constipation is troublesome and requires thorough accurate examination. A nonpharmacological approach, education of the patient about the importance of lifestyle changes like diet and sport activity state, are the first line of therapy. In case of ineffective treatment, pharmacological treatments such as laxatives, secretagogues, serotonergic agonists, and many other medications should be induced. If pharmacologic treatment fails, the definitive solution for constipation might be surgical approach. Commonness of this disorder, costs of medical care and decrease in quality life cause constipation is a serious issue for many specialists. The aim of this review is to present current knowledge of chronic constipation and management of this disorder.

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment

INTRODUCTION

The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus).

RESULTS

A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user-friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines.

CONCLUSION

A consensus-based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

Imaging and clinical assessment of functional defecatory disorders with emphasis on defecography

Functional defecation disorders (FDD) encompass causes of constipation associated with anorectal dysfunction, which include dyssynergia or inadequate defecatory propulsion. FDD are frequently encountered in clinical practice and may affect up to 33-50% of patients with chronic constipation. The etiology of FDD is unclear, however, it has been defined as an acquired, but subliminal behavioral disorder. Pathophysiologic mechanisms may include discoordination of rectoanal muscles, paradoxical contraction or insufficient relaxation of puborectalis and/or anal sphincter during defecation, and sluggish colonic transit. A combination of comprehensive clinical assessment, digital rectal examination and a battery of physiologic tests are needed to make an accurate diagnosis of FDD. Defecography may play a crucial role in the evaluation of FDD, especially when a balloon expulsion test (BET) and/or anorectal manometry (ARM) are equivocal or demonstrate contradictory results. In this review, we provide a thorough overview of the epidemiology, pathophysiology, diagnostic criteria, clinical and imaging evaluation, and treatment options for FDD, with an emphasis on available diagnostic imaging tools such as defecography and conventional fluoroscopic methods.

Effect of Physical Activity on the Association Between Dietary Fiber and Constipation: Evidence From the National Health and Nutrition Examination Survey 2005-2010

Background/Aims

The effect of physical activity on the relationship between dietary fiber intake and constipation has not been comprehensively studied. This study aims to explore the impact of physical activity.

Methods

Data were obtained from 3 cycles of the National Health and Nutrition Examination Survey (NHANES) 2005-2010 and included a total of 13 941 participants aged ≥ 20 years. Multiple logistic regression analysis was used to investigate the independent association between dietary fiber and constipation. Interaction analysis was also performed to analyze the relationship between dietary fiber and constipation in different physical activity groups.

Results

Among non-active participants, dietary fiber intake did not associate with stool consistency (OR, 1.02; 95% CI, 0.98-1.05; P = 0.407). For physically active participants, 1-gram unit increase in dietary fiber intake reduced the risk of stool consistency by 3% (OR, 0.97; 95% CI, 0.94-0.99; P = 0.020). Moreover, the relationship between dietary fiber intake and stool consistency was significantly different for groups with different levels of physical activity (P interaction = 0.044). However, dietary fiber intake was not related to stool frequency among non-active participants (OR, 0.99; 95% CI, 0.94-1.05; P = 0.767) nor physically active participants (OR, 1.01; 95% CI, 0.97-1.04; P = 0.751).

Conclusions

Increasing dietary fiber intake was associated with stool consistency-related constipation among physically active participants, but not among non-active participants. However, increasing dietary fiber intake is not significantly associated with stool frequency in different physical activity groups.

Laparoscopic-assisted colectomy with Duhamel procedure for idiopathic megacolon in adults: a retrospective study

BACKGROUND

Idiopathic megacolon (IMC) is an uncommon disease in adults. To date, only a few laparoscopic experiences and functional outcomes of IMC have been reported. This study was to retrospectively analyse our 12 year surgical experience and functional outcomes in adult patients with IMC.

METHODS

A 12-year retrospective study from October 2006 to November 2018 was performed for patients with IMC who underwent surgical interventions. Patients who underwent laparoscopic-assisted colectomy and Duhamel procedure with ileorectal or colorectal anastomosis were collected. Clinical data of surgery and functional outcomes were analysed.

RESULTS

A total of 13 patients who underwent surgical interventions were included in the study. Seven patients underwent laparoscopic total colectomy with ileorectal anastomosis (Duhamel procedure), one patient underwent laparoscopic total colectomy with end ileostomy because of acute intestinal obstruction, while five other patients underwent laparoscopic segmental colectomy with colorectal anastomosis (Duhamel procedure). The mean operative time was 181.6 min (range 150-246). The mean estimated blood loss was 75.6 ml (range 40-200). The mean postoperative hospital stay was 8.2 days (range 6-13). There was no conversion to an open procedure and no surgical mortality. Postoperative diarrhoea was the most prominent complaint during the early period after total colectomy. All patients showed adaptation to the defaecation frequency 3-6 months postoperatively, and had a good quality of life in long-term follow-up.

CONCLUSION

Laparoscopic-assisted colectomy with Duhamel procedure is a safe and efficient technique for IMC in adults. The scope of colon resection and the type of anastomosis should be individually selected.

Chronic Constipation in the Elderly Patient: Updates in Evaluation and Management

Chronic constipation (CC) is a common disorder in the elderly population globally and is associated with comorbidities and negative implications on the quality of life. Constipation prevalence varies in different studies, primarily owing to the nonuniformity of the diagnostic criteria. However, 15%-30% of individuals aged >60 years are diagnosed with CC. Primary care physicians are the main healthcare providers that manage constipation in elderly patients in parallel with increased population aging and increased prevalence of constipation. Physical inactivity, polypharmacy, chronic medical conditions, rectal hyposensitivity, and defecatory disorders all play a role in the pathogenesis of CC in elderly patients. Detailed anamnesis, particularly history related to chronic medication use, with digital rectal examination may assist in identifying constipation causes. Additionally, blood tests and colonoscopy may identify organic causes of CC. Physiologic tests (i.e., anorectal manometry, colonic transit time with radiopaque markers, and defecography) can evaluate the physiologic function of the colon, rectum, and anus. However, generally, there are several causes of constipation in older patients, and an individualized approach is recommended. Treatment of chronic idiopathic constipation is empiric, based on the stepwise approach. Lifestyle advice, adjustment of chronic medications, and prescription of laxatives are the first steps of management. Several laxatives are available, and the treatment is evolving in the last decade. Biofeedback is an effective therapy especially for defecatory disorders. This review aimed to summarize the most updated knowledge for primary care physicians in the approach and management of CC in elderly patients.

European society of neurogastroenterology and motility guidelines on functional constipation in adults

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.

Clinical Features of Severely Constipated Children: Comparison of Infrequent Bowel Movement and Fecal Soiling Groups

PURPOSE

To compare the clinical features, diagnostic findings, and medications of children with infrequent bowel movements or fecal soiling.

METHODS

This study enrolled 333 children (189 male; age range, 1 month to 18 years) diagnosed with functional constipation by Rome III or IV criteria. We classified them into 3 groups (infrequent bowel movement without fecal soiling [G3-a], infrequent bowel movement with fecal soiling [G3-b], and fecal soiling only [G3-c]) and into 2 subgroups of fecal soiling (G2-b) or not (G2-a). Retrospective data on clinical characteristics, colon transit time (CTT) test results, and medications were collected. The Wilcoxon rank-sum test, Kruskal-Wallis test, Chi-square test, and Fisher's exact test were used for the statistical analysis.

RESULTS

The median age (months) and interquartile range (IQR) was 33 (45) in G3-a, 54 (40) in G3-b, and 73 (48) in G3-c (p<0.0001). G3-c had the latest onset (median, 18; IQR, 18; p=0.0219) and longest symptom duration (24 [24], p=0.0148). PEG 4000 was used in 60.6% (G3-a), 96.8% (G3-b), and 83.2% (G3-c) of patients (p<0.0001). The median age (months) and IQR were 33.0 (45.0) in G2-a and 63.5 (52.5) in G2-b (p<0.0001). G2-b had later onset (median, 12; IQR, 19.5; p=0.0062) and longer symptom duration than G2-a (24 [12], p=0.0070). PEG 4000 was used in 60.6% (G2-a) and 88.3% (G2-b) of children (p<0.0001). No statistically significant intergroup differences were seen in maintenance laxative dose, CTT, or CTT type.

CONCLUSION

Infrequent bowel movement and fecal soiling represent the advanced stage of chronic functional constipation.

Evaluation of the Efficacy of Probiotics (MCP® BCMC® Strains) Treating Constipation in Elderly Patients with Multiple Chronic Co-Morbidities: A Randomized Control Trial

OBJECTIVES

To evaluate the impact of a microbial cell preparation (MCP®) (Hexbio®; comprising MCP® BCMC® strains) on stool frequency, consistency, and constipation-related symptoms in elderly patients with multiple chronic medical conditions.

DESIGN

Randomised control trial.

SETTING

Medical outpatient and medical/surgical in-patient unit in single tertiary center.

PARTICIPANT

Patients aged ≥ 60 years who experience constipation and have multiple chronic medical conditions.

METHODS

Participants with constipation were blindly randomized into either a treatment (MCP® BCMC® strains) or a placebo group. The treatment was administered twice daily.

MEASUREMENT

Gastrointestinal symptoms and stool habits were assessed over a week during the intervention via the use of a questionnaire and stool diary.

RESULTS

Stool frequency was seen to be higher and the improvement in stool consistency was more significant in the treatment group than in the placebo group (p =<0.001). A significant improvement in symptoms was demonstrated in patients who received MCP® BCMC® strains,specifically with respect to straining (p = < 0.001) and a sensation of incomplete evacuation (p = < 0.001). reduction in anorectal blockage symptoms and the need for manual stool evacuation was also demonstrated, but this finding was not statistically significant. Significant adverse events were not observed.

CONCLUSIONS

An improvement in stool frequency and consistency was reported in elderly patients with chronic medical conditions following the administration of MCP® BCMC® strains.

Normal colonic transit time predicts the outcome of colonic manometry in patients with chronic constipation-an exploratory study

PURPOSE

Colonic manometry (CM) can be of additive value in the diagnostic workup of colonic motility in chronic constipated patients. However, it is claimed that colonic motor disturbances occur in normal-transit constipation (NTC) and slow-transit (STC) constipation, as measured using a radio-opaque marker study, and therefore, the relationship between colonic motor disturbances on CM and colonic transit time (CTT) remains unclear. Our aim was to compare results from colonic marker study with the outcome of CM in patients with treatment-refractory chronic constipation (CC).

METHOD

Eighty-seven CC patients and 12 healthy volunteers, undergoing both a CTT study and a 24-h CM in a Dutch tertiary referral center, were included. CTT was measured using radio-opaque markers (X-ray at day 4 after ingestion of 20 markers at day 0). CM was performed using a catheter with 6 solid-state pressure sensors, endoscopically clipped to the mucosa in the right colon. CM was defined as normal when at least three high-amplitude propagating contractions (HAPCs), i.e., propagating waves with amplitude ≥ 80 mmHg over at least three sensors, were identified.

RESULTS

In total, 70 patients showed STC on CTT, of which 21 (30%) showed normal CM. All 17 NTC patients and healthy volunteers showed normal CM. The negative predictive value of CTT for normal CM was 100%.

CONCLUSION

Colonic manometry should be considered in therapy-refractory STC patients in order to further delineate colonic motility. However, in this exploratory study, for patients presenting with NTC on a radio-opaque marker study, colonic manometry does not appear to have added value.

Efficacy of Polydextrose Supplementation on Colonic Transit Time, Bowel Movements, and Gastrointestinal Symptoms in Adults: A Double-Blind, Randomized, Placebo-Controlled Trial

The addition of fiber is one of the most important dietary means to relieve constipation through lifestyle modification. Polydextrose (PDX) has been reported in several studies to increase fecal bulk, soften stools, and increase the number of defecations. However, there are few studies on the effect of PDX on colonic transit time (CTT). Therefore, the aim of this study was to demonstrate the effect of PDX on CTT and other aspects of gastrointestinal function during two weeks (Day 1 to Day 14), preceded by a 2-week run-in period (Day -14 to Day -1). A total of 192 adults who were diagnosed with functional constipation per Rome III criteria were recruited for the study. Participants were randomized equally into 4 groups (12 g, 8 g, or 4 g of PDX or placebo per day). The primary endpoint was CTT, assessed using radio-opaque markers and abdominal X-rays on Day 0, the baseline; and Day 15, the end of the intervention. Secondary outcomes that were measured using inventories were the patient assessment of constipation symptoms and quality of life, bowel function index, relief of constipation, bowel movement frequency (BMF), stool consistency, degree of straining, and proportion of bowel movements. Ancillary parameters and harms were also evaluated. The recruited population was not sufficiently constipated (e.g., baseline values for CTT and BMF of 42 h and 8.7 BMF/week, respectively). Despite this limitation, our results demonstrated an increased number of bowel movements when supplemented with PDX at a dosage of 12 g per day for 2 weeks. This dosage also consistently improved the secondary outcomes that were measured using inventories at Day 15, compared with the baseline. No serious or significant adverse events were reported during the study.

Effective of education on quality of life and constipation severity in patients with primary constipation

OBJECTIVE

This study was conducted to examine the effect of education on quality of life and constipation severity in patients with primary constipation.

METHODS

This randomised controlled study was conducted with 80 patients who applied at the gastroenterology outpatient clinic of a university hospital. In the study, the Constipation Questionnaire, Constipation Quality-of-Life Questionnaire (PAC-QOL), and Constipation Severity Instrument (CSI) were used.

RESULTS

It was that found after 4 weeks of education, the total PAC-QOL mean score decreased to 60.85 ± 5.65 and total CSI mean score decreased to 20.17 ± 4.05 in the intervention group (p < 0.001). No change was observed in the patients in the control group (p > 0.05). After 4 weeks, a statistical difference was found between the two groups in PAC-QOL mean score and CSI mean score (p < 0.05).

CONCLUSION

It was determined that the education given to individuals with primary constipation decreased the constipation severity and increased the quality of life.

PRACTICE IMPLICATIONS

Constipation education will make a contribution to the active use of follow-up forms by nurses in the clinic for the diagnosis of constipation, individual assessment of each patient, and their active role in constipation management.

Profile of plecanatide in the treatment of chronic idiopathic constipation: design, development, and place in therapy

Constipation is a multifactorial disorder that can cause significant psychological distress to patients and economic burden on the health care system. Many patients are not satisfied with their current established treatment, highlighting the need for new and improved therapeutic options. Guanylate cyclase-C (GC-C)/cyclic guanosine monophosphate agonists have emerged as a safe and efficacious class of drugs for the treatment of chronic idiopathic constipation (CIC). Plecanatide, a second-in-class, US FDA-approved, synthetic GC-C agonist, has recently been approved in the US for the treatment of irritable bowel syndrome with constipation at doses of 3 and 6 mg and CIC at the 3 mg dosage. In this study, we summarize the design of this novel 16-amino acid uroguanylin analog, drug development through Phase I, II, and III clinical studies, and its role in the treatment of CIC.

New Metrics in High-Resolution and High-Definition Anorectal Manometry

PURPOSE OF REVIEW

To review recently published diagnostic methods that use high-resolution (HR-) or high-definition- (HD-) anorectal manometry (ARM) techniques.

RECENT FINDINGS

The integrated pressurized volume (IPV) is a new measure based on spatiotemporal plots obtained from HR-ARM. The IPV may be clinically useful for improving the prediction of abnormal balloon expulsion test in patients with constipation and for discriminating patients with anorectal disorders from asymptomatic controls. Combination of IPV parameters was superior to conventional manometric parameters in predicting the responsiveness to biofeedback therapy. Moreover, several novel parameters including the HR-ARM resting integral, HR-ARM squeeze profile, and anorectal asymmetry index may each be useful as predictive factors for identifying patients with fecal incontinence. HR- and HD-ARM are increasingly performed worldwide for evaluation of anorectal function. Here, we describe new metrics whose clinical significance has not been fully established. Further standardization and validation of these metrics could provide clinically important new information and could help improve our understanding of the pathophysiology of anorectal disorders.

A high-resolution anorectal manometry parameter based on integrated pressurized volume: A study based on 204 male patients with constipation and 26 controls

BACKGROUND

Conventional anorectal manometric parameters based on linear waves cannot properly predict balloon expulsion (BE) time. We aimed to determine the correlation between integrated pressurized volume (IPV) parameters during simulated evacuation (SE) and BE time in healthy individuals and constipated patients and to assess the correlation between each parameter and symptoms.

METHODS

A total of 230 male participants (including 26 healthy volunteers and 204 chronically constipated patients) underwent high-resolution anorectal manometry (HRAM) and BE tests. The IPV was calculated by multiplying the amplitude, distance, and time from the HRAM profile. Receiver operating characteristic curve (ROC) analysis and partial least square regression (PLSR) were performed.

KEY RESULTS

ROC analysis indicated that the IPV ratio between the upper 1 cm and lower 4 cm of the anal canal was more effective for predicting BE time (area under the curve [AUC]: 0.74, 95% confidence interval [CI]: 0.67-0.80, P < .01) than the conventional anorectal parameters, including defecation index and rectoanal gradient (AUC: 0.60, 95% CI: 0.52-0.67, P = .01). PLSR analysis of a linear combination of IPV parameters yielded an AUC of 0.79. Moreover, the IPV ratio showed a greater clinical correlation with patient symptoms than conventional parameters.

CONCLUSIONS AND INFERENCES

The IPV parameters and the combination of IPV parameters via PLSR were more significantly correlated with BE time than the conventional parameters. Thus, this study presents a useful diagnostic tool for the evaluation of pathophysiologic abnormalities in dyssynergic defecation using IPV and BE time.

Constipation in patients with myofascial pain syndrome as important aspect for clinical and nutritional treatment: A case-control study

ABSTRACT Objective To identify the occurrence of constipation in patients with myofascial pain syndrome and to correlate these disorders with the clinical and nutritional variables. Methods This report describes a case-control study performed with 98 adults of both sexs, including 49 patients and 49 individuals without pain. The intensity of the reported pain was evaluated using the Pain Visual Analog Scale, which provided a simple and efficient measurement of pain intensity consisting of a 10cm horizontal line with the ends marked “absence of pain” and “worst possible pain”. The occurrence of constipation was evaluated using the Rome III criteria. A multivariate linear regression was proposed to investigate risk factors between the frequency of bowel movements per week and independent variables this study. Results The mean ages of the patients and controls were 45.9 (7.6) years and 41.2 (12.2) years, respectively. The intensity of the reported pain showed a mean of 7.3 (1.6) points. The likelihood of exhibiting constipation was 4.5 times higher in the patients than in the controls (p=0.001). The number of stools per week was negatively correlated with the intensity of the reported pain (r=-0.613, p<0.001). The use of benzodiazepines was negatively correlated with the frequency of bowel movements per week, while the use of muscle relaxants appeared to increase the frequency of defecation when combined with the use of benzodiazepines and adjusted for the intake of fiber, water and sexs (p=0.037). Conclusion Constipation was a frequent nosological entity in this patient population and the persistence of a change in intestinal motility showed a significant correlation with the pain intensity and low water intake. The reduction of the number of stools per week seems to be associated with the use of benzodiazepines.

Minimally invasive wireless motility capsule to study canine gastrointestinal motility and pH

The aim of this study was to describe the feasibility of using a gastrointestinal tract wireless motility capsule (WMC) that measured intraluminal pressure, pH and transit time through the gastrointestinal tract, in dogs in their home environment. Forty-four adult healthy dogs, eating a standard diet, were prospectively enrolled. The WMC was well tolerated by all dogs and provided data from the different sections of the gastrointestinal tract. Median gastric emptying time was 20h (range, 6.3-119h), demonstrating a large range. The gastric pressure pattern and pH depended on the phase of food consumption. The small bowel transit time was 3.1h (range, 1.6-5.4h) with average contraction pressures of 6.5mmHg (range, 1.1-21.4mmHg) and pH 7.8 (range, 7-8.9). The large bowel transit time was 21h (range, 1-69h) with average contractions pressures of 0.9mmHg (range, 0.3-2.7mmHg) and pH 6.4 (range, 5.3-8.2). There was considerable individual variation in motility patterns and transit times between dogs. No difference was observed between the sexes. No relationships between any transit time, bowel pH or pressure pattern and bodyweights were identified. The WMC likely represents movement of a large non-digestible particle rather than normal ingesta. Due to its large size, the WMC should not be use in smaller dogs. The WMC is a promising minimally invasive tool to assess GIT solid phase transit times, pressures and pH. However, further studies are necessary due to the current limitations observed.

Intractable Constipation in the Elderly

OPINION STATEMENT

Chronic constipation is a common gastrointestinal disorder disproportionately affecting the elderly. Immobility, polypharmacy, and physiologic changes contribute to its increased prevalence in this population. Unidentified and undertreated constipation leads to a significant negative impact on quality of life and an increase in healthcare spending. Careful physical examination and exploration of the clinical history can unmask primary and secondary forms of constipation, guiding diagnostic and therapeutic considerations. Non-pharmacologic treatment options include bowel training and biofeedback as well as the addition of fiber. Laxatives are safe and can be used long term; thus, they remain the mainstay of therapy. Newer agents with specific physiologic targets have proven to be effective in adults with chronic constipation, but data is lacking for safety profile in the elderly. Consideration for surgery in medically refractory cases should be entertained, while use of neuromodulation is not ready for prime time. This is a review of the currently available treatment options for chronic constipation in adults and specifically tailored towards the elderly.

Gastrointestinal Motility, Part 2: Small-Bowel and Colon Transit

Because of the difficulty often encountered in deciding whether a patient's symptoms originate in the upper or lower gastrointestinal tract, gastrointestinal transit scintigraphy is a uniquely suited noninvasive, quantitative, and physiologic method of determining whether there is a motility disorder affecting the stomach, small bowel, or colon. Small-bowel and colon transit studies can be performed alone or together with gastric emptying studies after oral administration of an appropriately radiolabeled meal. It is hoped that newly published standards for performing these studies and the anticipated arrival of new Current Procedural Terminology codes in the United States for small-bowel and colon transit studies will increase their availability and use.

Gastrointestinal Dysmotility in the Elderly

The number of persons 60 years and older has increased 3-fold between 1950 and 2000. Aging alone does not greatly impact the gastrointestinal (GI) tract. Digestive dysfunction, including esophageal reflux, achalasia, dysphagia, dyspepsia, delayed gastric emptying, constipation, fecal incontinence, and fecal impaction, is a result of the highly prevalent comorbid conditions and the medications with which those conditions are treated. A multidisciplinary approach with the expertise of a geriatrician, gastroenterologist, neurologist, speech pathologist, and physical therapist ensures a comprehensive functional and neurological assessment of the older patient. Radiographic and endoscopic evaluation may be warranted in the evaluation of the symptomatic older patient with consideration given to the risks and benefits of the test being used. Treatment of the digestive dysfunction is aimed at improving health-related quality of life if cure cannot be achieved. Promotion of healthy aging, treatment of comorbid conditions, and avoidance of polypharmacy may prevent some of these digestive disorders. The age-related changes in GI motility, clinical presentation of GI dysmotility, and therapeutic principles in the symptomatic older patient are reviewed here.

Digital Rectal Examination and Balloon Expulsion Test in the Study of Defecatory Disorders: Are They Suitable as Screening or Excluding Tests?

Background. Rome III criteria add physiological criteria to symptom-based criteria of chronic constipation (CC) for the diagnosis of defecatory disorders (DD). However, a gold-standard test is still lacking and physiological examination is expensive and time-consuming. Aim. Evaluate the usefulness of two low-cost tests-digital rectal examination (DRE) and balloon expulsion test (BET)-as screening or excluding tests of DD. Methods. We performed a systematic search in PUBMED and MEDLINE. We selected studies where constipated patients were evaluated by DRE or BET. Heterogeneity was assessed and random effect models were used to calculate the sensitivity, specificity, and negative predictive value (NPV) of the DRE and the BET. Results. Thirteen studies evaluating BET and four studies evaluating DRE (2329 patients) were selected. High heterogeneity (I2 > 80%) among studies was demonstrated. The studies evaluating the BET showed a sensitivity and specificity of 67% and 80%, respectively. Regarding the DRE, a sensitivity of 80% and specificity of 84% were calculated. NPV of 72% for the BET and NPV of 64% for the DRE were estimated. The sensitivity and specificity were similar when we restrict the analysis to studies using Rome criteria to define CC. The BET seems to perform better when a cut-off time of 2 minutes is used and when it is compared with a combination of physiological tests. Considering the DRE, strict criteria seem to improve the sensitivity but not the specificity of the test. Conclusion. Neither of the low-cost tests seems suitable for screening or excluding DD.

Guidelines for the Diagnosis and Treatment of Chronic Functional Constipation in Korea, 2015 Revised Edition

The Korean Society of Neurogastroenterology and Motility first published guidelines for chronic constipation in 2005 and was updated in 2011. Although the guidelines were updated using evidence-based process, they lacked multidisciplinary participation and did not include a diagnostic approach for chronic constipation. This article includes guidelines for diagnosis and treatment of chronic constipation to realistically fit the situation in Korea and to be applicable to clinical practice. The guideline development was based upon the adaptation method because research evidence was limited in Korea, and an organized multidisciplinary group carried out systematical literature review and series of evidence-based evaluations. Six guidelines were selected using the Appraisal of Guidelines for Research & Evaluation (AGREE) II process. A total 37 recommendations were adopted, including 4 concerning the definition and risk factors of chronic constipation, 8 regarding diagnoses, and 25 regarding treatments. The guidelines are intended to help primary physicians and general health professionals in clinical practice in Korea, to provide the principles of medical treatment to medical students, residents, and other healthcare professionals, and to help patients for choosing medical services based on the information. These guidelines will be updated and revised periodically to reflect new diagnostic and therapeutic methods.

Diagnosis and management of chronic constipation in adults

Constipation is a heterogeneous, polysymptomatic, multifactorial disease. Acute or transient constipation can be due to changes in diet, travel or stress, and secondary constipation can result from drug treatment, neurological or metabolic conditions or, rarely, colon cancer. A diagnosis of primary chronic constipation is made after exclusion of secondary causes of constipation and encompasses several overlapping subtypes. Slow-transit constipation is characterized by prolonged colonic transit in the absence of pelvic floor dysfunction. This subtype of constipation can be identified using either the radio-opaque marker test or wireless motility capsule test, and is best treated with laxatives such as polyethylene glycol or newer agents such as linaclotide or lubiprostone. If unsuccessful, subspecialist referral should be considered. Dyssynergic defecation results from impaired coordination of rectoanal and pelvic floor muscles, and causes difficulty with defecation. The condition can be identified using anorectal manometry and balloon expulsion tests and is best managed with biofeedback therapy. Opioid-induced constipation is an emerging entity, and several drugs including naloxegol, methylnaltrexone and lubiprostone are approved for its treatment. In this Review, we provide an overview of the burden and pathophysiology of chronic constipation, as well as a detailed discussion of the available diagnostic tools and treatment options.

Measurement of Gastrointestinal and Colonic Motor Functions in Humans and Animals

Accurately measuring the complex motor behaviors of the gastrointestinal tract has tremendous value for the understanding, diagnosis and treatment of digestive diseases. This review synthesizes the literature regarding current tests that are used in both humans and animals. There remains further opportunity to enhance such tests, especially when such tests are able to provide value in both the preclinical and the clinical settings.

Evolving paradigms in the treatment of opioid-induced bowel dysfunction

In recent years prescription of opioids has increased significantly. Although effective in pain management, bothersome gastrointestinal adverse effects are experienced by a substantial proportion of opioid-treated patients. This can lead to difficulties with therapy and subsequently inadequate pain relief. Collectively referred to as opioid-induced bowel dysfunction, these adverse effects are the result of binding of exogenous opioids to opioid receptors in the gastrointestinal tract. This leads to disturbance of three important gastrointestinal functions: motility, coordination of sphincter function and secretion. In the clinic this manifests in a wide range of symptoms such as reflux, bloating, abdominal cramping, hard, dry stools, and incomplete evacuation, although the most known adverse effect is opioid-induced constipation. Traditional treatment with laxatives is often insufficient, but in recent years a number of novel pharmacological approaches have been introduced. In this review the pathophysiology, symptomatology and prevalence of opioid-induced bowel dysfunction is presented along with the benefits and caveats of a suggested consensus definition for opioid-induced constipation. Finally, traditional treatment is appraised and compared with the latest pharmacological developments. In conclusion, opioid antagonists restricted to the periphery show promising results, but use of different definitions and outcome measures complicate comparison. However, an international working group has recently suggested a consensus definition for opioid-induced constipation and relevant outcome measures have also been proposed. If investigators within this field adapt the suggested consensus and include symptoms related to dysfunction of the upper gut, it will ease comparison and be a step forward in future research.

Chronic constipation in the elderly: a primer for the gastroenterologist

Constipation is a frequently reported bowel symptom in the elderly with considerable impact on quality of life and health expenses. Disease-related morbidity and even mortality have been reported in the affected frail elderly. Although constipation is not a physiologic consequence of normal aging, decreased mobility, medications, underlying diseases, and rectal sensory-motor dysfunction may all contribute to its increased prevalence in older adults. In the elderly there is usually more than one etiologic mechanism, requiring a multifactorial treatment approach. The majority of patients would respond to diet and lifestyle modifications reinforced by bowel training measures. In those not responding to conservative treatment, the approach needs to be tailored addressing all comorbid conditions. In the adult population, the management of constipation continues to evolve as well as the understanding of its complex etiology. However, the constipated elderly have been left behind while gastroenterology consultations for this common conditions are at a rise for the worldwide age increment. Aim of this review is to provide an update on epidemiology, quality of life burden, etiology, diagnosis, current approaches and limitations in the management of constipation in the older ones to ease the gastroenterologists’ clinic workload.

Defecating Disorders: A Common Cause of Constipation in Women

Defecating disorders are a common and complex problem. There are a range of anatomical and functional bowel abnormalities that can lead to this condition. Treatment is difficult and needs a multidisciplinary approach. First line treatment for defecating disorders is conservative. For those that fail conservative treatment, some may respond to surgical therapy but with variable results. The aim of this review is to offer an overview of defecating disorders as well as provide an algorithm on how to diagnose and treat them with the help of a multidisciplinary and multimodal approach.

Clinical potential of naloxegol in the management of opioid-induced bowel dysfunction

Opioid-induced bowel dysfunction (OIBD) is a burdensome condition which limits the therapeutic benefit of analgesia. It affects the entire gastrointestinal tract, predominantly by activating opioid receptors in the enteric nervous system, resulting in a wide range of symptoms, such as reflux, bloating, abdominal cramping, hard, dry stools, and incomplete evacuation. The majority of studies evaluating OIBD focus on constipation experienced in approximately 60% of patients. Nevertheless, other presentations of OIBD seem to be equally frequent. Furthermore, laxative treatment is often insufficient, which in many patients results in decreased quality of life and discontinuation of opioid treatment. Novel mechanism-based pharmacological approaches targeting the gastrointestinal opioid receptors have been marketed recently and even more are in the pipeline. One strategy is prolonged release formulation of the opioid antagonist naloxone (which has limited systemic absorption) and oxycodone in a combined tablet. Another approach is peripherally acting, μ-opioid receptor antagonists (PAMORAs) that selectively target μ-opioid receptors in the gastrointestinal tract. However, in Europe the only PAMORA approved for OIBD is the subcutaneously administered methylnaltrexone. Alvimopan is an oral PAMORA, but only approved in the US for postoperative ileus in hospitalized patients. Finally, naloxegol is a novel, oral PAMORA expected to be approved soon. In this review, the prevalence and pathophysiology of OIBD is presented. As PAMORAs seem to be a promising approach, their potential effect is reviewed with special focus on naloxegol's pharmacological properties, data on safety, efficacy, and patient-focused perspectives. In conclusion, as naloxegol is administered orally once daily, has proven efficacious compared to placebo, has an acceptable safety profile, and can be used as add-on to existing pain treatment, it is a welcoming addition to the targeted treatment possibilities for OIBD.

A nation-wide study of prevalence and risk factors for fecal impaction in nursing homes

Background

There are no existing studies that provide data regarding the epidemiology of, and risk factors for, fecal impaction, either in the general population or in any sub-group of people.

Objective

Estimate the prevalence of and factors associated with fecal impaction on a representative sample of the institutionalized elderly population.

Design

Two-phase study. Phase 1: pilot study validating the methodology in which all residents of a single nursing home participated. Phase 2: national multi-center cross-sectional study.

Setting

34 randomly selected nursing homes.

Measurements

The presence of fecal impaction and associated factors were evaluated using three different tools: data collected from medical records; a self-completion questionnaire filled out by the subjects or a proxy; and a rectal examination.

Subjects

Older subjects living in nursing homes.

Results

The prevalence of chronic constipation was 70.7% (95%CI: 67.3–74.1%), of which 95.9% of patients were properly diagnosed and 43.1% were properly controlled. The prevalence of FI according to patient history was 47.3% (43.6–51.0%) and 6.6% (4.7–8.5%) according to rectal examination. Controlled constipation (OR: 9.8 [5.2–18.4]) and uncontrolled constipation (OR: 37.21 [19.7–70.1]), the number of medications (OR: 1.2 [1.1–1.3]), reduced functional capacity (OR: 0.98 [0.97–0.99]) and the occasional use of NSAIDs were independent risk factors for fecal impaction.

Conclusions

Constipation affects more than 70% of people living in nursing homes. Although it is properly diagnosed in more than 95% of cases, the disease is only controlled in less than 50%. Constipation, especially when not controlled, is the most significant risk factor leading to fecal impaction, which is prevalent in almost 50% of this population.

[Bristol Stool Chart: Prospective and monocentric study of "stools introspection" in healthy subjects]

The Bristol Stool Chart (BSC) allows patients to identify their stool form using seven different images with accompanying written descriptors. Stool form was found to correlate better than stool frequency with whole-gut transit as measured by a radio-opaque marker study. This score is widely used in order to verify the presence of a constipation and to evaluate the therapeutic impact of various treatments.

GOAL OF THE STUDY

In our clinical practice, we was strongly surprised by the facility and the great precision of the patients to report their stool form, meaning that they usually and daily verify these stools. We wanted to precise the goals of a such attitude.

MATERIAL AND METHODS

Two questionnaires were proposed to healthy and voluntary subjects. Q1 was supposedly presented in order to verify the sensibility of a French version of BSC in a healthy population. Thus, Q1 precised the difficulties or not to understand pictures and written descriptors, asked about exhaustive analysis by means of BSC of stool form and bowel condition. All subjects with history of ano-rectal disorders or specific treatment for bowel dysfunction were excluded. After Q1 fulfilled, Q2 was proposed to the subjects. Q2 was designed to precise the goals of the patient when he look at his stool and the frequency of such an investigation. Finally a specific question concerning the subject opinion about this behavior in terms of bothersome, shame, or metaphysic interrogation.

RESULTS

Eighty-five healthy subjects were recruited (42 female and 43 male). Mean age was 37.2 (sd = 15.7). Mean score of BCS was 2.07 (sd =1.05) (2.07 for female and 1.81 for male, P = 0.22). Number of categories of stool form was only 1 in 40%, 2 categories in 31%, 3 in 19%, 4 in 10%. Presence of a constipation defined by category 1 or 2 was found in 17% (23% in F, 12% in M, P = 0.075). Precision of BSC was noted as excellent in 68%, moderated in 18% and poor in 14%. BSC was considered as easy to use in 75%. Frequency of inspection of feces was systematic for 37%, 1/2 in 20%, 1/3 in 13%, 1 to 4 per month in 30%. The goal of inspection was "routine" in 54%, and devoted to track down any pathological condition ("self examination") in 46%. Eighty percent of the subjects considered having no shame or specific reticence and only 17% of them, had some interrogations concerning the real rational of such an inspection.

CONCLUSION

BSC is a useful tool widely used in routine practice, helping to the diagnosis of constipation and the control of the different therapeutic strategies. There is no psychological barriers or metaphysics inconveniences for its use. But it seems legitimate to understand the hidden reasons of such a behavior with unconscious purposes reflecting the intimal nature of the humans.

LEVEL OF EVIDENCE

3.

How to perform and interpret balloon expulsion test

The balloon expulsion test is a simple and useful method for investigating a defecatory disorder assessing the subject's ability to evacuate a simulated stool. However, there is no standard methodology and varying interpretations have been reported. This review discusses the techniques, interpretation and clinical utility of the balloon expulsion test.

Prevalence and Effectiveness of Laxative Use Among Elderly Residents in a Regional Hospital Affiliated Nursing Home in Hsinchu County

Background:

Long-term care residents are susceptible to constipation and one-half to three quarter of older nursing home residents receive laxatives regularly.

Objectives:

The purpose of this study was to evaluate the factors related to abnormal bowel function and explore the effectiveness of laxative treatment among the elderly residents of a nursing home.

Patients and Methods:

A total of 110 residents older than 65 years old was enrolled in this study. The following variables were gathered: age, gender, body mass index (BMI), length of stay, daily fluid intake, type of food, functional level, cognitive ability, physical therapy status, somatic and psychiatric diseases, number of medications, and medication use. The use and dosage of laxatives were recorded by means of Anatomical Therapeutic Chemical (ATC) classification system. Normal bowel function was defined as defecation frequency from three defecations per day to three defecations per week and stool consistency score of three to five on Bristol Stool Form Scale. A comparison between groups with normal and abnormal bowel function was drawn.

Results:

Low BMI, increased fluid intake, liquid food intake, poor functional level, poor cognition, and a history of stroke were significantly associated with altered bowel function (P < 0.05). The most frequently used laxatives were glycerol, senna glycoside, and magnesium oxide. There were significant differences in laxative regimens between residents with normal and altered bowel function; those with altered bowel function tended to take more laxatives than those with normal bowel function.

Conclusions:

This study suggested that treatment of constipation in the nursing home was unsatisfactory. To improve treatment outcomes in those susceptible to altered bowel function, a coordinated approach with involvement of physicians, nursing staff, and other professionals including dieticians and pharmacists seems necessary.

Constipation in older adults

Constipation is a common complaint in the general population, particularly among older adults. Patients present with infrequent bowel movements or difficulty passing stools. Management of this uncomfortable condition involves diet, fluid intake, and medications.

Biofeedback therapy combined with traditional chinese medicine prescription improves the symptoms, surface myoelectricity, and anal canal pressure of the patients with spleen deficiency constipation

In order to observe the clinical therapeutic effects of Yiqi Kaimi Prescription and biofeedback therapy on treating constipation with deficiency of spleen qi, the 30 cases in the control group were given oral administration of Yiqi Kaimi Prescription, in combination with anus-lifting exercise; the 30 cases in the treatment group were given biofeedback therapy on the basis of the afore mentioned methods for the control group. The TCM symptom scores and anorectal pressures before and after treatment were observed and evaluated. There were significant differences in TCM symptom scores, anorectal pressure, and clinical recovery rate before and after treatment. In the treatment group, the total recovery rate was 86.66%, while in the control group it was 50%; there were significant differences between the two groups (P < 0.01). Yiqi Kaimi Prescription coupled with biofeedback therapy is clinically effective for treating constipation with deficiency of spleen qi, and thus this method is applicable for functional constipation with deficiency of spleen qi.

Changes in the innervation of the mouse internal anal sphincter during aging

BACKGROUND

The innervation of the mouse internal anal sphincter (IAS) has been little studied, and how it changes during aging has not previously been investigated. The aim of this study was therefore to characterize the distribution and density of subtypes of nerve fibers in the IAS and underlying mucosa in 3-, 12- to 13-, 18- and 24- to 25-month-old male C57BL/6 mice.

METHODS

Nerve fibers were immunolabeled with antibodies against protein gene product 9.5 (PGP9.5), neuronal nitric oxide synthase (nNOS), vasoactive intestinal polypeptide (VIP), substance P (SP), calcitonin gene-related peptide (CGRP), and calretinin (CR). Immunoreactivity in nerve fibers in the circular muscle and mucosa was quantified using Image J software.

KEY RESULTS

In young adult (3 month) mice, nNOS-immunoreactive (IR) nerve fibers were densely distributed in the circular muscle, but relatively few in the mucosa; VIP-IR nerve fibers were abundant in the circular muscle and common in the mucosa; SP-IR nerve fibers were common in circular muscle and mucosa; CGRP- and CR-IR nerve fibers were dense in mucosa and sparse in circular muscle. The density of PGP9.5 immunoreactivity (IRY) was not significantly reduced with age, but a significant reduction in nNOS-IRY and SP-IRY with age was found in the IAS circular muscle. Neuronal nitric oxide synthase-, VIP-, and SP-IRY in the anal mucosa were significantly reduced with age. CGRP-IRY in both circular muscle and mucosa was increased in 18-month-old animals.

CONCLUSIONS & INFERENCES

The density of immunoreactivity of markers for some types of IAS nerve fibers decreases during aging, which may contribute to age-related ano-rectal dysfunction.

Clinical utility of colonic manometry in slow transit constipation

BACKGROUND

The clinical significance of colorectal sensorimotor evaluation in patients with slow transit constipation (STC) is unclear. We investigated whether colonic manometric evaluation is useful for characterizing colonic sensorimotor dysfunction and for guiding therapy in STC.

METHODS

24-h ambulatory colonic manometry was performed in 80 patients (70 females) with STC by placing a six sensor solid-state probe, along with assessment of colonic sensation with barostat. Anorectal manometry was also performed. Manometrically, patients were categorized as having colonic neuropathy or myopathy based on gastrocolonic response, waking response and high amplitude propagated contractions (HAPC); and based on colonic sensation, as colonic hyposensitivity or hypersensitivity. Clinical response to pharmacological, biofeedback, and surgical treatment was assessed at 1 year and correlated with manometric findings.

KEY RESULTS

Forty seven (59%) patients who had abnormal colonic manometry, with features suggestive of neuropathy (26%), and myopathy (33%); 41% had normal colonic manometry. Patients who had abnormal colonic sensation were 74% and 61% had overlapping dyssynergic defecation. Patients with neuropathy were more likely to have colonic hyposensitivity. Sixty-four percent of patients with colonic myopathy or normal manometry improved with medical/biofeedback therapy when compared to 15% with colonic neuropathy (P < 0.01). Selected patients with colonic neuropathy had excellent response to surgery, but many developed bacterial overgrowth.

CONCLUSIONS & INFERENCES

Colonic manometry demonstrates significant colonic sensorimotor dysfunction in STC patients and reveals considerable pathophysiological heterogeneity. It can be useful for characterizing the underlying pathophysiology and for guiding clinical management in STC, especially surgery.

Fiber and functional gastrointestinal disorders

Despite years of advising patients to alter their dietary and supplementary fiber intake, the evidence surrounding the use of fiber for functional bowel disease is limited. This paper outlines the organization of fiber types and highlights the importance of assessing the fermentation characteristics of each fiber type when choosing a suitable strategy for patients. Fiber undergoes partial or total fermentation in the distal small bowel and colon leading to the production of short-chain fatty acids and gas, thereby affecting gastrointestinal function and sensation. When fiber is recommended for functional bowel disease, use of a soluble supplement such as ispaghula/psyllium is best supported by the available evidence. Even when used judiciously, fiber can exacerbate abdominal distension, flatulence, constipation, and diarrhea.

Evaluation of constipation

The evaluation of the chronically constipated patient is multifaceted and challenging. Many clinicians define constipation according to the latest Rome III diagnostic criteria for functional gastrointestinal disorders. Female sex, older age, low fiber diet, a sedentary life style, malnutrition, polypharmacy, and a lower socioeconomic status have all been identified as risk factors for functional constipation. In elderly patients, it is important to rule out a colonic malignancy as the cause of constipation. The initial evaluation of the constipated patient includes a detailed history to elicit symptoms distinguishing slow transit constipation from obstructive defecation. Slow transit and obstructive defecation are the two major subtypes of functional constipation. In addition, the clinician should identify any secondary causes of constipation. The office examination of the constipated patient includes an abdominal, perineal, and a rectal exam. Many patients improve with lifestyle modification. When dietary interventions and lifestyle modifications fail, many diagnostic studies are available to further evaluate the constipated patient. Sitzmark transit study, nuclear scintigraphic defecography, electromyography, anorectal manometry, balloon expulsion test, paradoxical puborectalis contraction, cinedefecography, and dynamic magnetic resonance imaging defecography have all been used to diagnose the underlying causes of functional constipation.

Use of complementary and alternative medicine to treat constipation in the elderly

Many modalities of complementary and alternative medicine, such as probiotic bacteria, traditional herbal medicines, biofeedback and massage, have been used to treat constipation in older adults. Virtually all studies in the published literature have been plagued with methodological problems, such as lack of blinding. Chinese herbal medications have been the most frequent subject of studies in controlled trials, but have suffered from methodological insufficiencies, and few have been published in publications other than Chinese language journals. Several therapies, such as yogurt containing probiotic bacteria and massage, are relatively easy to use by the patient, and are likely to cause few adverse reactions. Therefore, complementary and alternative therapies might show the greatest promise for being adopted as adjunctive therapies to conventional treatment.