Diagnosis and treatment of constipation: a clinical update based on the Rome IV criteria

Chronic constipation and its associated factors in patients with type-2 diabetes: A multicenter cross-sectional study

INTRODUCTION

Diabetes is one of the global public health concern and constipation is frequently seen among gastrointestinal symptoms in diabetes. Despite the fact that constipation is common, doctors and/or patients disregard it. This study aimed to determine the prevalence and contributing factors of constipation in patients with diabetes.

METHODS

Multi-center cross-sectional study was carried out and the data was analyzed using STATA 14. Binary and multilevel logistic regressions were also carried out to identify associated to factors. Factors having a p-value of less than 0.05 were deemed statistically significant in the final model.

RESULTS

206 diabetics participated in the survey. The mean age of the participants was 52.7 years (SD ± 11.9). The prevalence of constipation was 16% (95% CI: 10.97-21.07). Age (AOR = 13.56; 95% CI: 1.71, 107.21), females (AOR = 4.58; 95% CI: 1.76, 11.87), the duration of the diabetes (AOR = 3.16; 95% CI: 1.21, 8.24), and psychological distress (AOR = 12.49, 95% CI: 1.53, 101.8) were significant factors.

CONCLUSION

The magnitude of constipation was considerable, and it was linked to psychological distress, longer-lasting diabetes, being a woman, and ageing. Patients with type-2 diabetes need to receive careful treatment in order to reduce the severity of the condition and its additional complications.

Saline irrigation for reducing the recurrence of common bile duct stones after lithotripsy: a randomized controlled trial

Background

Mechanical lithotripsy produces stone fragments that are not easily detected by cholangiography and is a potential cause of recurrence of common bile duct stones (CBDS). This study aims to clarify whether 100 ml saline irrigation after mechanical lithotripsy reduces the recurrent rate of CBDS.

Methods

In this randomized controlled trial performed at the Surgical Endoscopy Center, the First Hospital of Lanzhou University between May 10, 2019, and Dec 31, 2020, patients undergoing endoscopic mechanical lithotripsy were randomly assigned to receive saline irrigation (study group) or no irrigation (control group). The saline irrigation was given 100 ml saline pulse irrigation after cholangiography showed no residual stones. Patients were followed up for at least 24 months after endoscopic stone removal to assess the recurrence of CBDS. This study was registered with ClinicalTrials.gov (NCT03937037).

Findings

During the median follow-up period of 35.6 months (interquartile range, 26.0-40.7), 43 of the 180 patients had stone recurrence (24%). The frequency of recurrence of CBD stones was 12.22% in the saline irrigation group and 35.56% in the control group, with a difference of 23.33% between the two groups (95% confidence interval [CI], 11.35%-35.32%, p < 0.001). Multivariable Cox proportional hazards analyses showed that constipation (hazard risk [HR] 2.42; 95% CI, 1.22-4.80, p = 0.012), periampullary diverticulum (PAD) (HR 3.06; 95% CI, 1.62-5.79, p < 0.001), and total to direct bilirubin ratio (HR 1.48; 95% CI, 1.21-1.81, p < 0.001) were independent risk factors for the recurrence of CBDS. Saline irrigation was the only preventive factor for the recurrence of CBDS (HR 0.22; 95% CI, 0.11-0.44, p < 0.001).

Interpretation

For patients with CBDS requiring mechanical lithotripsy, 100 ml saline irrigation effectively reduces the recurrent rate of CBDS after endoscopic stone removal.

Funding

This work was supported by National Natural Science Foundation of China (32160255); Natural Science Foundation of Gansu Province (22JR5RA898, 20JR10RA676); Science and Technology Planning Project of Chengguan District in Lanzhou (2020JSCX0043).

"Effects of abdominal massage applied with ginger and lavender oil for elderly with constipation: A randomized controlled trial"

BACKGROUND AND OBJECTIVES

Constipation, which is commonly seen in the elderly and negatively affects an individual's physical and psychological well-being, is a treatable health problem. This study was conducted as a randomized controlled experimental study to investigate the effect of abdominal massage applied with lavender and ginger oil on constipation for elderly individuals.

METHODS

The study examined a total of 40 elderly individuals who lived in a nursing home and suffered from constipation. Elderly individuals in the intervention group underwent 15 min of aromatherapy massage for 5 weekdays per week for 4 weeks. No intervention was conducted for individuals in the control group.

RESULTS

While the Bristol Stool Chart and the Constipation Severity Scale scores were similar in the intervention and control groups of elderly individuals at the first follow-up (p > 0.05), in the second and fourth week after the application, scores in the Bristol Stool Chart increased significantly and scores in the Constipation Severity Scale decreased significantly in the intervention group compared to the control group (p < 0.05).

CONCLUSION

It was determined that aromatherapy massage applied to elderly individuals experiencing constipation softened stool consistency, decreased constipation severity, and reduced symptoms associated with constipation.

Probiotics, prebiotics, and synbiotics in chronic constipation: Outstanding aspects to be considered for the current evidence

This integrative aimed to evaluate the effects and the potential mechanism of action of prebiotics, probiotics, and synbiotics on constipation-associated gastrointestinal symptoms and to identify issues that still need to be answered. A literature search was performed in the PubMed database. Animal models (n = 23) and clinical trials (n = 39) were included. In animal studies, prebiotic, probiotic, and synbiotic supplementation showed a decreased colonic transit time (CTT) and an increase in the number and water content of feces. In humans, inulin is shown to be the most promising prebiotic, while B. lactis and L. casei Shirota probiotics were shown to increase defecation frequency, the latter strain being more effective in improving stool consistency and constipation symptoms. Overall, synbiotics seem to reduce CTT, increase defecation frequency, and improve stool consistency with a controversial effect on the improvement of constipation symptoms. Moreover, some aspects of probiotic use in constipation-related outcomes remain unanswered, such as the best dose, duration, time of consumption (before, during, or after meals), and matrices, as well as their effect and mechanisms on the regulation of inflammation in patients with constipation, on polymorphisms associated with constipation, and on the management of constipation via 5-HT. Thus, more high-quality randomized control trials (RCTs) evaluating these lacking aspects are necessary to provide safe conclusions about their effectiveness in managing intestinal constipation.

The effect of probiotics on functional constipation in adults: A randomized, double-blind controlled trial

BACKGROUND

Two formulations were developed in the form of an oral sachet containing probiotics, and their efficacy and safety were evaluated in adults with functional constipation.

METHODS

One formulation with Lactobacillus acidophilus, Bifidobacterium bifidum and Lactobacillus rhamnosus (3 billion Colony Forming Units - CFU); and another with Lactobacillus acidophilus, Bifidobacterium bifidum, Lactobacillus rhamnosus, Lactobacillus paracasei, Bifidobacterium longum, Bifidobacterium lactis, Lactobacillus casei, Bifidobacterium animallis (8 billion CFU). The participants were randomized in a 3-arm parallel study and one oral sachet was auto-administered once a day for 30 days.

RESULTS

Primary outcomes were improvement in increasing the frequency of weekly bowel movements and improvement in stool quality. Secondary outcomes were number of adverse events. In the first week one observed an increase in stool frequency and in the quality of stools, showing an improvement in constipation. No statistically significant differences were observed between the three treatment groups in relation to these outcomes (P ≥ .05). Only one adverse event was observed in a patient of group 2, related to abdominal pain.

CONCLUSION

The two probiotic cocktails were effective in improving the symptoms of functional constipation, by increasing both the weekly frequency of evacuation and stool quality, and were deemed safe. Clinicaltrials.gov number: NCT04437147.

Definitions, signs, and symptoms of constipation in people with severe or profound intellectual disabilities: A systematic review

Background

It is difficult to diagnose constipation for people with severe or profound intellectual disabilities. Definitions for this are ambiguous, and the symptoms and signs are often unnoticed. The aim of this study is to identify clear definitions of constipation for people with different levels of intellectual disabilities and to identify signs and symptoms.

Method

Guided by the PRISMA statement, a systematic review of the literature was conducted within electronic databases MEDLINE, Embase, CINAHL, Cochrane, and PsycINFO. Definitions, signs, and symptoms were extracted and the quality of definitions was assessed.

Results

In total, 24 studies were included. Quality of definitions ranged from poor to good quality. Standard and referenced definitions were used in ten studies, a self-composed definition was employed in eleven studies; and three studies did not refer to a source of the definition. The self-composed definitions had not been evaluated after being used for the target group, and no scientific substantiation was available. A broad range of signs and symptoms were described.

Conclusions

No substantiated definition has been ascertained for constipation for people with severe or profound intellectual disabilities. Further research will be necessary to identify which signs and symptoms are important for defining constipation in this target group.

Factors associated with response to simple behavioral intervention in primary enuresis nocturna

This 8-week longitudinal study examined predictors of response to simple behavioral intervention in primary enuresis nocturna (PEN). A total of 154 children, aged 8-18 years, diagnosed with PEN were evaluated. The results indicated that lack of constipation, milder enuresis severity, and higher bladder capacity are the primary predictors of good treatment response, and lower family dysfunction is the most robust familial predictor. Lack of constipation is the main predictor with unique variance in multiple regression. Specialists should be aware of conditions that hinder the success of simple behavioral intervention before implementing costly treatments. In treatment-refractory cases, it is important to examine each child for constipation. Family-centered approaches can be helpful if used in parallel with behavioral treatments.

Dietary inflammatory index and its relationship with gut microbiota in individuals with intestinal constipation: a cross-sectional study

OBJECTIVE

To determine whether there is an association between the inflammatory potential of the diet, measured by the dietary inflammatory index (DII®), and the composition of intestinal microbiota in adults with functional constipation (FC).

METHODS

A cross-sectional study was carried out with 68 adults with FC. Energy-adjusted DII (E-DII) was calculated from data obtained from food surveys, serum inflammation markers were measured and the composition of the intestinal microbiota was evaluated using the 16S rRNA gene sequencing method. Participants were assigned into two groups: anti-inflammatory diet (AD: E-DII < 0) and pro-inflammatory diet (PD: E-DII ≥ 0). Associations of E-DII scores with microbial diversity and composition were examined using differences between the E-DII groups and linear and hierarchical regression.

RESULTS

E- DII was inversely correlated with relative abundance of Hungatella spp. and Bacteroides fragilis and positively correlated with Bacteroides thetaiotaomicron and Bacteroides caccae (p < 0.05). B. fragilis was positively correlated with IL-10. The AD group had higher relative abundances for the genus Blautia and Hungatella, lower abundances of Bacteroides thetaiotamicron and Bacteroides spp. (p < 0.05), as well as higher frequency of evacuation (p = 0.02) and lower use of laxatives (p = 0.05). The AD group showed a reduction in the abundance of Desulfovibrio spp. and Butyrivibrio, Butyrivibrio crossotus, Bacteroides clarus, Bacteroides coprophilus and Bacteroides intestinalis (all p < 0.05). The greater abundance of Bacteroides clarus increased the individual's chance of performing a manual evacuation maneuver.

CONCLUSION

Therefore, the results of this study demonstrated that the inflammatory potential of the diet is associated with the gut microbiota in individuals with FC.

The effect of probiotics on functional constipation in adults: Double-blind, randomized, placebo-controlled study

BACKGROUND

: Evacuation disorders are common in industrialized countries, affecting an average of 15% to 20% of the healthy adult population. Probiotic therapy can reduce functional constipation and increase both the number of weekly bowel movements and quality of stools. Based on the hypothesis that a combination of more strains may provide better results for constipation and facilitate adherence to treatment, this study will evaluate the efficacy and safety of a combination of different strains of Lactobacillus sp. and Bifidobacterium sp. in functional constipation.

METHODS

: A single-centre trial of adults aged 20 to 80 years with intestinal constipation will be conducted at a Gastroenterology Clinic in Sorocaba, State of São Paulo, Brazil. Participants will be allocated into 3 groups receiving: 1. mixture of 3 probiotics: [Lactobacillus acidophilus, Bifidobacterium bifidum, and Lactobacillus rhamnosus (3 × 10⁹ CFU)]; 2. mixture of 8 probiotics [Lactobacillus acidophilus, Bifidobacterium bifidum, Lactobacillus rhamnosus, Lactobacillus paracasei, Bifidobacterium longum, Bifidobacterium lactis, Lactobacillus defensis, Bifidobacterium animallis (8 × 10⁹ CFU)]; or 3. placebo, for 4 weeks. The outcomes of interest will be change in frequency of weekly bowel movements, change in stool quality according to the 4–6 Bristol scale, number of volunteer withdrawal, number of adverse events and number of serious adverse effect.

DISCUSSION:

The probiotic products are expected to induce beneficial changes in the intestinal microbiota, thereby increasing intestinal frequency to over 3 times a week and improving stool quality. The results can guide patients and healthcare practitioners and help in decision-making in the treatment of functional constipation.

TRIAL REGISTRATION AND REGISTRY NAME:

ClinicalTrials.gov Identifier: NCT04437147: The Effect of Probiotics on Functional Constipation in Adults: Study protocol for Double blind, Randomized, Placebo controlled Study

PROTOCOL VERSION:

Version 01 August 30, 2020.

Socio-demographic and intestinal elimination profile in women treated at a health service

Objective: To investigate the profile of intestinal eliminations in women. Method: Cross-sectional study conducted with 41 women seen at a women’s health center in the state of Piauí in Brazil. For data collection, a form was used containing the sociodemographic data and questionnaires that assessed the data on the intestinal elimination pattern with questions based on the Rome IV criteria and the Bristol scale. Results: Of the 41 participants, 56.1% reported consuming one to two servings of fruits or vegetables per day and 51.2% consumed more than two liters of water per day. Regarding the patterns of intestinal elimination, 39% had feces in the Bristol 3 category. As for the Rome IV criteria, 21 (51.2%) women were considered constipated and the frequency of evacuation was statistically significant with the presence of constipation. Conclusion: There was a significant number of women with constipation. There was a need to develop actions that help to cope with the problem and improve the quality of life of this population.

Perfil sociodemográfico e de eliminações intestinais em mulheres atendidas em um serviço de saúde

Objetivo: Investigar o perfil de eliminações intestinais em mulheres. Método: Estudo transversal, realizado com 41 mulheres atendidas em um centro de saúde da mulher no estado do Piauí no Brasil. Para coleta de dados foi utilizado um formulário contendo os dados sociodemográficos e questionários que avaliaram os dados do padrão de eliminação intestinal com perguntas fundamentadas nos critérios de Roma IV e escala de Bristol. Resultados: Das 41 participantes, 56,1% relataram consumir de uma a duas porções de frutas ou verduras por dia e 51,2% consumiam mais de dois litros de água por dia. Com relação aos padrões de eliminação intestinal, 39% apresentavam fezes na categoria Bristol 3. Quanto aos critérios de Roma IV, 21 (51,2%) mulheres foram consideradas constipadas e a frequência de evacuação teve significância estatística com a presença de constipação. Conclusão: Houve um número expressivo de mulheres com constipação intestinal. Observou-se a necessidade de desenvolver ações que auxiliem no enfrentamento do problema e melhore a qualidade de vida dessa população.

A Brief Review of Nutraceutical Ingredients in Gastrointestinal Disorders: Evidence and Suggestions

The dietary effect on gut health has long been recognized through the empirical practice of soothing gastric discomfort with certain types of food, and recently the correlation between specific diets with lower incidences of several gastrointestinal diseases has been revealed. Ingredients from those considered beneficial foods have been isolated and studied, and some of them have already been put into the supplement market. In this review, we focus on latest studies of these food-derived ingredients for their proposed preventive and therapeutic roles in gastrointestinal disorders, with the attempt of drawing evidence-based suggestions on consuming these products.

IS THE PHYSICIAN EXPERTISE IN DIGITAL RECTAL EXAMINATION OF VALUE IN DETECTING ANAL TONE IN COMPARISON TO ANORECTAL MANOMETRY?

BACKGROUND

Digital rectal examination (DRE) is part of the physical examination, is also essential for the colorectal surgeon evaluation. A good DRE offers precious information related to the patient's complaints, which will help in decision making. It is simple, quick and minimally invasive. In many centers around the world, the DRE is still the only method to evaluate the anal sphincter prior to patient's management. On the other hand, anorectal manometry (ARM) is the main method for objective functional evaluation of anal sphincter pressures. The discrepancy of DRE depending on the examiner to determine sphincter tonus in comparison to ARM motivated this study.

OBJECTIVE

To compare the DRE performed by proficient and non-experienced examiners to sphincter pressure parameters obtained at ARM, depending on examiners expertise.

METHODS

Thirty-six consecutive patients with complaints of fecal incontinence or chronic constipation, from the anorectal physiology clinic of the University of São Paulo School of Medicine, were prospectively included. Each patient underwent ARM and DRE performed by two senior colorectal surgeons and one junior colorectal surgeon prior to the ARM. Patient's history was blinded for the examiner's knowledge, also the impressions of each examiner were blinded from the others. For the DRE rest and squeeze pressures were classified by an objective scale (DRE scoring system) that was compared to the parameters of the ARM for the analysis. The results obtained at the ARM were compared to the DRE performed by the seniors and the junior colorectal surgeons.

STATISTICAL ANALYSIS

Descriptive analysis was performed for all parameters. For the rest and squeeze pressures the Gamma index was used for the comparison between the DRE and ARM, which varied from 0 to 1. The closer to 1 the better was the agreement.

RESULTS

The mean age was 48 years old and 55.5% of patients were female. The agreement of rest anal pressures between the ARM and the DRE performed by the senior proficient examiners was 0.7 (CI 95%; 0.32-1.0), while for the junior non-experienced examiner was 0.52 (CI 95%; 0.09-0.96). The agreement of squeeze pressures was 0.96 (CI 95%; 0.87-1.0) for the seniors and 0.52 (CI 95%; 0.16-0.89) for the junior examiner.

CONCLUSION

More experienced colorectal surgeons used to DRE had a more significant agreement with the ARM, thereafter would have more appropriate therapeutic management to patients with sphincter functional problems. ARM, therefore, persists as an important exam to objectively evaluate the sphincter complex, justifying its utility in the clinical practice.