Association between constipation and colorectal cancer: systematic review and meta-analysis of observational studies

Review article: do stimulant laxatives damage the gut? A critical analysis of current knowledge

Stimulant laxatives are well established as first- or second-line treatments for constipation and although they have a reliable therapeutic effect, alleged safety concerns still exist, particularly with long-term use. The potential harmful effects on the gastrointestinal system (including carcinogenicity) of the long-term use of diphenylmethane [bisacodyl, sodium picosulfate (SPS)] and senna stimulant laxatives were assessed in a comprehensive review of the publications identified in literature searches performed in PubMed and Embase up to and including June 2023. We identified and reviewed 43 publications of interest. While stimulant laxatives at supratherapeutic doses have been shown to cause structural alterations to surface absorptive cells in animals and humans, these effects are reversible and not considered clinically relevant. No formal long-term studies have demonstrated morphological changes in enteric neural elements or intestinal smooth muscle with bisacodyl or SPS in humans. Furthermore, there is no convincing evidence that stimulant laxatives are associated with the development of colon cancer, and in fact, chronic constipation itself has been reported to potentially increase the risk of colon cancer, therefore, the use of stimulant laxatives might reduce this risk. Many studies suggesting a possible harmful effect from laxatives were limited by their failure to consider confounding factors such as concomitant neurological disease, metabolic disorders, and age. These findings highlight the lack of evidence for the harmful effects of laxatives on the colon, and thus, the benefits of treatment with stimulant laxatives, even in the long-term, should be reconsidered for the management of patients with constipation.

The Yield of Colonoscopy in the Evaluation of Constipation: An Age-Based Analysis of Outcome

Background: Chronic constipation, a prevalent gastrointestinal complaint, exhibits rising incidence and diverse clinical implications, especially among the aging population. This study aims to assess colonoscopy performance in chronic constipation across age groups, comprehensively evaluating diagnostic yield and comparing results with average-risk controls. Methods: A retrospective analysis was conducted on 50,578 colonoscopy procedures performed over 12 years, including 5478 constipated patients. An average-risk control group (n = 4100) was included. Data extracted from electronic medical records covered demographics, operational aspects, and colonoscopy findings. The primary outcome measures included the diagnosis rate of colorectal cancer (CRC), polyp detection rate (PDR), and inflammatory bowel disease (IBD) diagnoses in constipated patients versus controls, with age-based and multivariate analyses. Results: Constipated patients exhibiting lower rates of adequate bowel preparation (92.7% vs. 85.3%; p < 0.001) and a lower cecal intubation rate. No significant variances between CRC and PDR were observed between constipated and controls, except for a potential of a slightly elevated CRC risk in constipated patients older than 80 (2.50% vs. 0% in controls; p = 0.07). Multivariate analysis demonstrated, across all age groups, that constipation did not confer an increased risk for CRC or polyp detection. Younger constipated patients exhibited a higher rate of IBD diagnoses (1.7% vs. 0.1% in controls; p < 0.001). Conclusions: Constipation did not confer an increased risk for CRC or polyps, among any age groups, except for a potential signal of elevated CRC risk in patients older than 80; additionally, it was associated with higher rates of IBD in younger patients.

Altered gut microbial profile is associated with differentially expressed fecal microRNAs in patients with functional constipation

While dysbiosis within the intestinal ecosystem has been associated with functional constipation (FC), the mechanisms underlying the interactions between FC and the microbiome remain poorly elucidated. Recent investigations suggested that host microRNAs (miRNAs) can modulate bacterial growth and influence the composition of the gut microbiome. To explore the connection between gut microbiota and fecal miRNAs in FC patients, we initially employed 16S rRNA sequencing to assess the gut microbial landscape in 30 FC patients and 30 healthy controls (HCs). The α-diversity within the FC group exhibited some alterations, and the β-diversity significantly differed, signifying distinctive variations in gut microbiota composition between FC patients and HCs. Subsequently, we identified 44 differentially expressed (DE) miRNAs in feces from FC patients and HCs. Through correlation analysis between DE miRNAs and FC-associated microbiota, we detected an interaction involving nine DE miRNAs (miR-205-5p, miR-493-5p, miR-215-5p, miR-184, miR-378c, miR-335-5p, miR-514a-3p, miR-141-3p, and miR-34c-5p) with seven bacterial genera (Oscillibacter, Escherichia.Shigella, UCG.002, Lachnospiraceae_NK4A136_group, Lachnospiraceae_UCG.010, Eubacterium_ruminantium_group and Megamonas), as evidenced by a co-occurrence network. Further, a comprehensive panel of seven diagnostic biomarkers (Oscillibacter, Escherichia.Shigella, UCG.002, miR-205-5p, miR-493-5p, miR-215-5p, and Lachnospiraceae_NK4A136_group) demonstrated robust discriminatory capacity in predicting FC status when integrated into a random forest model (AUC = 0.832, 95% CI: 65.73-98.88). Microbiomes correlating with DE miRNAs exhibited enrichment in distinct predicted metabolic categories. Moreover, miRNAs correlated with FC-associated bacteria were found to be enriched in signaling pathways linked to colonic contractility, including Axon guidance, PI3K-Akt signaling pathway, MAPK signaling pathway, and Hippo signaling pathway. Our study offers a comprehensive insight into the global relationship between microbiota and fecal miRNAs in the context of FC, presenting potential targets for further experimental validation and therapeutic interventions.

A key genetic factor governing arabinan utilization in the gut microbiome alleviates constipation

Impaired gastrointestinal motility is associated with gut dysbiosis. Probiotics, such as Bifidobacteria, can improve this bowel disorder; however, efficacy is strain-dependent. We determine that a genetic factor, the abfA cluster governing arabinan utilization, in Bifidobacterium longum impacts treatment efficacy against functional constipation (FC). In mice with FC, B. longum, but not an abfA mutant, improved gastrointestinal transit time, an affect that was dependent upon dietary arabinan. abfA genes were identified in other commensal bacteria, whose effects in ameliorating murine FC were similarly abfA-dependent. In a double-blind, randomized, placebo-controlled clinical trial, supplementation with abfA-cluster-carrying B. longum, but not an abfA-deficient strain, enriched arabinan-utilization residents, increased beneficial metabolites, and improved FC symptoms. Across human cohorts, abfA-cluster abundance can predict FC, and transplantation of abfA cluster-enriched human microbiota to FC-induced germ-free mice improved gut motility. Collectively, these findings demonstrate a role for microbial abfA cluster in ameliorating FC, establishing principles for genomics-directed probiotic therapies.

Opium use and risk of colorectal cancer: a multi-center case-referent study in Iran

BACKGROUND

Opium use has been associated with an increased risk of cancers of the lung, oesophagus, and pancreas, and it was recently classified by the International Agency for Cancer Research as carcinogenic to humans. It is not clear whether opium also increases the risk of colorectal cancer (CRC). The aim of our study was to assess the association between various metrics of opium use and the risk of CRC.

METHODS

This case-referent study from seven provinces in Iran comprised 848 CRC cases and 3215 referents. Data on opium use (duration, amount, frequency) and potential confounders were collected by trained interviewers. Multivariable unconditional logistic regression models were used to measure odds ratios (OR) adjusted for age, gender, province, marital status, family history of CRC-linked cancers, consumption of red meat, fruits and vegetables, body shape, occupational physical activity, and socioeconomic status.

RESULTS

Regular opium consumption was not associated with the risk of CRC (OR 0.9, 95% confidence interval, CI: 0.7, 1.2) compared to subjects who never used opium. However, frequent opium use more than twice a day was associated with an increased risk of CRC compared to non-users of opium (OR: 2.0, 95% CI: 1.1, 3.8; p for quadratic trend 0.008).

CONCLUSION

There seems to be no overall association between opium use and CRC, but the risk of CRC might be increased among persons who use opium many times a day.

Colonoscopy in the young: An indication-based analysis of outcome

BACKGROUND

Data on colonoscopy's diagnostic yield in young adults with lower gastrointestinal symptoms are scarce. We evaluated this yield in young patients by performing an indication-based analysis of outcomes.

METHODS

We reviewed diagnostic colonoscopies performed in young adults (age <50 years) over 10 years. We created two groups of young adults (18-39 years, n = 4941) and quadragenarians (40-49 years; n = 6605), included a control group of average-risk patients referred for screening colonoscopies during the same period (50-60 years, n = 1453). We evaluated clinical indications for colonoscopies among the young and performed an indication-based analysis of patients' outcomes.

RESULTS

Chronic diarrhea and abdominal pain (42.4 and 36.2%), rectal bleeding (19.8 and 18.4%), and constipation were major indications for colonoscopy performance in quadragenarian and younger patients, respectively. Overall, diverticulosis (8.7 vs 1.3 and 3.9%; p1,2 < 0.000) and polyp detection rates (PDR) (19.6 vs 6.1 and 12.1; p1,2 < 0.000) were significantly higher in the control group, while inflammatory bowel disease (10.9 and 3.6% vs 0.1%; p1,2 < 0.000) was more prevalent in both young patients' groups. Indication-based analysis revealed that rectal bleeding was linked with increased PDR and significantly and independently associated with colorectal cancer (CRC) development (odds ratio = 10.160. p < 0.001 and 95% confidence interval = 6.201-16.647), even in the younger patients. In contrast, performing a colonoscopy for the evaluation of constipation was associated with the lowest yield.

CONCLUSION

We outlined the expected diagnostic yields of colonoscopy performed in young patients for multiple indications, showing that rectal bleeding was consistently associated with CRC and polyp detection.

Causal association between constipation and risk of colorectal cancer: a bidirectional two-sample Mendelian randomization study

Background

Colorectal cancer (CRC) is a globally significant health concern, necessitating effective preventive strategies through identifying modifiable risk factors. Constipation, characterized by infrequent bowel movements or difficulty passing stools, has been proposed as a potential CRC risk factor. However, establishing causal links between constipation and CRC remains challenging due to observational study limitations.

Methods

Mendelian randomization (MR) utilizes genetic variants as instrumental variables, capitalizing on genetically determined variation to assess causal relationships. In this dual-sample bidirectional MR study, we extracted genetic data from independent cohorts with CRC (Include colon cancer and rectal cancer) and constipation cases. Genome-wide association studies (GWAS) identified constipation and CRC-associated genetic variants used as instruments to infer causality. The bidirectional MR analysis evaluated constipation's impact on CRC risk and the possibility of reverse causation.

Results

Employing bidirectional MR, we explored the causal relationship between constipation and CRC using publicly available GWAS data. Analysis of constipation's effect on CRC identified 26 significant SNPs, all with strong instrumental validity. IVW-random effect analysis suggested a potential causal link [OR = 1.002(1.000, 1.004); P = 0.023], although alternative MR approaches were inconclusive. Investigating CRC's impact on constipation, 28 significant SNPs were identified, yet IVW analyses found no causal effect [OR = 0.137(0.007, 2.824); P = 0.198]. Other MR methods also yielded no significant causal association. We analyzed constipation separately from colon and rectal cancer using the same methodology in both directions, and no causal relationship was obtained.

Conclusion

Our bidirectional MR study suggests a potential constipation-CRC link, with mixed MR approach outcomes. Limited evidence supports constipation causing CRC. Reliable instruments, minimal heterogeneity, and robust analyses bolster these findings, enriching understanding. Future research should explore additional factors to enhance comprehension and clinical implications.

Exposure to weak opioids and risk of gastrointestinal tract cancers: A series of nested case-control studies

AIMS

There is evidence gastrointestinal (GI) motility may play a role in the development of GI cancers. Weak opioids (codeine and dihydrocodeine) decrease GI motility, but their effect on GI cancer risk has not been assessed. We aim to assess the association between weak opioids and cancers of the GI tract.

METHODS

A series of nested case-control studies was conducted using Scottish general practice records from the Primary Care Clinical Informatics Unit Research database. Oesophageal (n = 2432), gastric (n = 1443) and colorectal cancer (n = 8750) cases, diagnosed between 1999 and 2011, were identified and matched with up to five controls. Weak opioid use was identified from prescribing records. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression, adjusting for relevant comorbidities and medication use.

RESULTS

There was no association between weak opioids and colorectal cancer (adjusted OR = 0.96, CI 0.90, 1.02, P = 0.15). There was an increased risk of oesophageal (adjusted OR = 1.16, CI 1.04, 1.29, P = 0.01) and gastric cancer (adjusted OR = 1.26, CI 1.10, 1.45, P = 0.001). The associations for oesophageal cancer, but not gastric cancer, were attenuated when weak opioid users were compared with users of another analgesic (adjusted OR = 1.03 CI 0.86, 1.22, P = 0.76 and adjusted OR = 1.29 CI 1.02, 1.64, P = 0.04 respectively).

CONCLUSIONS

In this large population-based study, there was no consistent evidence of an association between weak opioids and oesophageal or colorectal cancer risk, but a small increased risk of gastric cancer. Further investigation is required to determine whether this association is causal or reflects residual confounding or confounding by indication.

Myths and misconceptions about childhood constipation

Many widely held beliefs and assumptions concerning childhood constipation continue to interfere with rational management of childhood constipation. Although many still believe that constipation is not a common disease, about 9.5% of the world's children suffer from chronic constipation. Most of these children live in non-Western countries. There are major misconceptions about the etiology of constipation as a significant proportion of clinicians still believe that constipation is caused by some form an organic pathology, whereas in reality, the majority have functional constipation. Contrary to a commonly held belief that children outgrow constipation without long-term problems, there is evidence that constipation leads to significant bowel and psychological consequences and has a major impact on the quality of life which detrimentally affects future health and education. Finally, ineffective management strategies such as increasing fiber and water in the diet, and short duration of treatment owing to the fear that long-term laxative treatment leads to colonic dysfunction, interfere with effective therapeutic strategies.   Conclusions: It is apparent that myths and misconception often lead to wrong assumptions regarding the distribution of the disease, its etiology, pathophysiology, and management leading to ordering incorrect investigations and ineffective therapeutic strategies while spending large sums of public funds unnecessarily. Poorly treated constipation leads to deleterious psychological consequences predisposing children to develop significant psychological damage and bowel dysfunctions. This review aims to challenge these myths about various elements of constipation by exploring the existing literature and encouraging clinicians to have a fresh look at old concepts that could interfere with the well-being of children with constipation. What is Known: • Childhood constipation is a growing problem in the world leading to significant suffering and high healthcare expenditure • Myths and misconceptions lead to poor management strategies causing psychological and bowel damage What is New: • Organic, systemic, and bowel disorders leading to constipation are uncommon, and in the majority, it arises due to deliberate fecal withholding and most investigations ordered by clinicians are not very helpful in the management • Most non-pharmacological interventions are not effective in the day-to-day management of childhood constipation. The use of laxatives is considered to be the first-line management strategy.

Association of abnormal bowel health with major chronic diseases and risk of mortality

PURPOSE

We aimed to explore the association of chronic constipation and diarrhea with major chronic diseases including cancer, cardiovascular disease (CVD), and diabetes, as well as with mortality risk. In addition, we characterized the interrelationship of inflammation with abnormal bowel health, major chronic diseases, and mortality.

METHODS

Demographic characteristics, physical and laboratory examinations were collected from the National Health and Nutrition Examination Survey (NHANES) database 2005-2010. Chronic constipation or diarrhea was diagnosed by the shape and frequency of defecation. The number of samples used for the cancer, CVD, diabetes, and mortality analyses were 11,217, 11,168, 11,555, and 14,316, respectively. Logistic regression was used to analyze the association among abnormal bowel health, major chronic diseases, dietary inflammatory index (DII), and C-reactive protein (CRP). A Cox proportional hazard regression was performed to assess risk of all-cause mortality, and the Fine and Gray models were subsequently employed to calculate the cancer and CVD mortality risks.

RESULTS

There were statistically positive associations of chronic diarrhea or constipation with breast and colon cancer, CVD, risks of all-cause mortality, and CVD mortality. Particularly in participants younger than 60, in addition to the positive correlations of chronic diarrhea with three major chronic diseases and all-cause mortality risk, chronic constipation also contributed to an elevated risk of CVD mortality. With respect to inflammation markers, an increased DII or CRP level was significantly associated with a higher prevalence of abnormal bowel health and major chronic diseases, and a higher mortality risk.

CONCLUSIONS

Participants with abnormal bowel health were more likely linked to breast cancer, colon cancer, CVD, and risks of all-cause and CVD mortality. Moreover, inflammation may have a potential role in associations among abnormal bowel health, major chronic diseases and mortality. However, these findings need to be confirmed by further prospective studies.

Case report: Melanosis coli combined with colon cancer, causality or coincidence?

The habitual use of laxative containing anthraquinone glycosides is considered to be the main cause of melanosis coli (MC). In the past, most scholars considered MC to be a benign and reversible disease. However, new evidence has emerged that MC may increase the risk of colon cancer. Here, we report a case of a 48-year-old woman diagnosed with MC and colon cancer. Through a literature review of previous basic and clinical studies, we summarize existing evidence that reveals the possible association between MC and colon cancer. Although this case cannot establish causality between MC and colon cancer, a high level of clinical vigilance for occurrence of colon cancer in patients with MC should be maintained.

Chronic Constipation as a Risk Factor for Colorectal Cancer: Results From a Nationwide, Case-Control Study

BACKGROUND & AIMS

Prolonged colon transit times may increase the contact time between potential carcinogens in the stool and the colonic mucosa. Nonetheless, previous studies have yielded conflicting results connecting chronic constipation with the risk of colorectal cancer (CRC). We examined the association between chronic constipation and later CRC.

METHODS

In this nationwide case-control study, we identified 41,299 CRC cases by colorectal biopsy in Sweden between July 2007 and December 2016 and matched them to 203,181 age- and sex-matched controls from the general population. We compared odds of earlier chronic constipation (defined as ≥2 laxative prescriptions in the Prescribed Drug Register with ≥6 months between the first and last prescription) between CRC cases and controls using logistic regression. In separate analyses, we compared odds of earlier constipation between CRC cases and sibling comparators, but also examined earlier risk of having an inpatient/outpatient specialty diagnosis of chronic constipation before CRC.

RESULTS

Overall, 3943 patients with CRC met our criteria for chronic constipation before CRC. The crude proportion of chronic constipation in CRC patients was 9.5% compared with 8.8% in controls. After multivariable adjustment, there was a modest association between chronic constipation and later CRC (odds ratio [OR], 1.10; 95% CI, 1.06-1.14) that vanished using sibling comparators to control for residual confounding (OR, 1.04; 95% CI, 0.97-1.13). In a sensitivity analysis of 126,650 CRC patients diagnosed from 1989 to 2016, we found no association with earlier chronic constipation diagnosed in inpatient/outpatient specialty clinics (OR, 0.88; 95% CI, 0.75-1.04).

CONCLUSIONS

In a nationwide case-control study, chronic constipation was not associated with later CRC.

Colorectal Cancer Epidemiology: Recent Trends and Impact on Outcomes

Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer related deaths in the world with an estimated number of 1.8 million new cases and about 881,000 deaths worldwide in 2018. The epidemiology of CRC varies significantly between different regions in the world as well as between different age, gender and racial groups. Multiple factors are involved in this variation, including risk factor exposure, demographic variations in addition to genetic susceptibility and genetic mutations and their effect on the prognosis and treatment response. In this mini-review, we discuss the recent epidemiological trend including the incidence and mortality of colorectal cancer worldwide and the factors affecting these trends.

A Case-Based Approach to Constipation in Primary Care

Primary care physicians frequently evaluate patients with constipation. The history is crucial in uncovering warning symptoms and signs that warrant colonoscopy. Particular elements in the history and rectal examination also can provide clues regarding the underlying etiology. Regardless of etiology, lifestyle modifications, fiber, and laxatives are first-line therapies. Patients who fail first-line therapies can be offered second-line treatments and/or referred for testing of defecatory function. In those with severely refractory symptoms, referrals to a gastroenterologist and a surgeon should be considered.

Patient-reported and doctor-reported symptoms when faecal immunochemical tests are requested in primary care in the diagnosis of colorectal cancer and inflammatory bowel disease: a prospective study

BACKGROUND

Rectal bleeding and a change in bowel habits are considered to be alarm symptoms for colorectal cancer and they are also common symptoms for inflammatory bowel disease. However, most patients with these symptoms do not have any of these diseases. Faecal immunochemical tests (FITs) for haemoglobin are used as triage tests in Sweden and other countries but little is known about the symptoms patients have when FITs are requested.

OBJECTIVE

Firstly, to determine patients' symptoms when FITs are used as triage tests in primary care and whether doctors record the symptoms that patients report, and secondly to evaluate the association between symptoms, FIT results and possible prediction of colorectal cancer or inflammatory bowel disease.

METHODS AND MATERIALS

This prospective study included 364 consecutive patients for whom primary care doctors requested a FIT. Questionnaires including gastrointestinal symptoms were completed by patients and doctors.

RESULTS

Concordance between symptoms reported from patients and doctors was low. Rectal bleeding was recorded by 43.5% of patients versus 25.6% of doctors, FITs were negative in 58.3 and 52.7% of these cases respectively. The positive predictive value (PPV) of rectal bleeding recorded by patients for colorectal cancer or inflammatory bowel disease was 9.9% (95% confidence interval [CI] 5.2-14.7); for rectal bleeding combined with a FIT the PPV was 22.6% (95% CI 12.2-33.0) and the negative predictive value (NPV) was 98.9% (95% CI 96.7-100). For patient-recorded change in bowel habits the PPV was 6.1% (95% CI 2.4-9.8); for change in bowel habits combined with a FIT the PPV was 18.2% (95% CI 9.1-30.9) and the NPV 100% (95% CI 90.3-100).

CONCLUSIONS

Doctors should be aware that, during consultations, they do not record all symptoms experienced by patients. FITs requested in primary care, when found positive, may potentially be of help in prioritising referrals, also when patients present with rectal bleeding or change in bowel habits.

Abnormal bowel movement frequency increases the risk of rectal cancer: evidence from cohort studies with one million people

Previous studies from case-control studies failed to draw reliable conclusions regarding the relationship between bowel movement frequency and the risk of colorectal cancer. To further examine this relationship, we collect the data from cohort studies that make a more accurate estimation. Several online data were searched from inception to February 29, 2020. Ten cohort studies involving 1,038,598 individuals were included in our study. The pooled results indicated that a bowel movement of less than once per day was not associated with the risk of colorectal cancer (relative risk (RR)= 1.00, 95% confidence interval (CI): 0.87-1.16, P = 0.950) compared with that of once per day. Compared with a bowel movement frequency of once per day, a bowel movement of more than once per day was also not related to elevated risk of colorectal cancer (RR = 1.04, 95% CI: 0.91-1.19, P = 0.570). The subgroup analyses indicated a low or high bowel movement frequency did not increase the risk of colon cancer (RR = 0.91, 95% CI: 0.80-1.03, P = 0.130). However, an increased frequency of bowel movements increased the risk of rectal cancer (RR = 1.34, 95% CI: 1.19-1.52, P < 0.001). The sensitivity analysis still supports the results. No significant publication bias existed. The data from cohort indicated that less bowel movement frequency was not associated with the risk of colorectal cancer. The frequency of bowel movement affects the risk of rectal cancer.

An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation

Introduction: Chronic constipation is highly prevalent, affecting between 10% and 15% of the population. The Rome IV criteria categorizes disorders of chronic constipation into four subtypes: (a) functional constipation, (b) irritable bowel syndrome with constipation, (c) opioid-induced constipation, and (d) functional defecation disorders, including inadequate defecatory propulsion and dyssynergic defecation. The initial management approach for these disorders is similar, focusing on diet, lifestyle and the use of standard over-the-counter laxatives. If unsuccessful, further therapy is tailored according to subtype.Areas covered: This review covers the definition, epidemiology, diagnostic criteria, investigations and management of the Rome IV disorders of chronic constipation.Expert opinion: By adopting a logical step-wise approach toward the diagnosis of chronic constipation and its individual subtypes, clinicians have the opportunity to tailor therapy accordingly and improve symptoms, quality of life, and patient satisfaction.

Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management

Chronic idiopathic constipation (CIC) is one of the most common gastrointestinal disorders, with a global prevalence of 14%. It is commoner in women and its prevalence increases with age. There are three subtypes of CIC: dyssynergic defaecation, slow transit constipation and normal transit constipation, which is the most common subtype. Clinical assessment of the patient with constipation requires careful history taking, in order to identify any red flag symptoms that would necessitate further investigation with colonoscopy to exclude colorectal malignancy. Screening for hypercalcaemia, hypothyroidism and coeliac disease with appropriate blood tests should be considered. A digital rectal examination should be performed to assess for evidence of dyssynergic defaecation. If this is suspected, further investigation with high resolution anorectal manometry should be undertaken. Anorectal biofeedback can be offered to patients with dyssynergic defaecation as a means of correcting the associated impairment of pelvic floor, abdominal wall and rectal functioning. Lifestyle modifications, such as increasing dietary fibre, are the first step in managing other causes of CIC. If patients do not respond to these simple changes, then treatment with osmotic and stimulant laxatives should be trialled. Patients not responding to traditional laxatives should be offered treatment with prosecretory agents such as lubiprostone, linaclotide and plecanatide, or the 5-HT4 receptor agonist prucalopride, where available. If there is no response to pharmacological treatment, surgical intervention can be considered, but it is only suitable for a carefully selected subset of patients with proven slow transit constipation.

Risk of cancer in patients with constipation

Background: It remains unclear whether constipation is associated with cancer. We evaluated the risk of malignancies in patients with constipation requiring hospitalization. Methods: Using Danish medical registries, we calculated cumulative incidences and standardized incidence ratios (SIRs) for cancer. SIRs were computed as the observed number of gastrointestinal (GI) cancers and selected non-GI cancers in patients with constipation compared with the expected number based on national incidence rates by sex, age, and calendar year (1978-2013). Results: We identified 1,75,901 patients with constipation (59% females, median age 54 years). The cumulative incidences of GI cancers and non-GI cancers after 15 years of follow-up were 2.5% and 2.6%, respectively. During the first year of follow-up, the SIR for any GI cancer was 5.0 (95% confidence interval (CI): 4.8-5.3), driven by colon and pancreas cancers and higher for younger age groups. Beyond 1 year of follow-up, the risk declined to near unity for colorectal cancer. The risk of other GI cancers (including cancers of the esophagus, stomach, small intestine, liver, and pancreas) remained moderately increased (overall SIR =1.3, 95% CI: 1.2-1.4). Except for ovarian cancer (SIR =7.3, 95% CI: 6.3-8.4), the risk of non-GI cancers was only slightly increased during the first year of follow-up and declined to unity thereafter. Conclusions: Patients with constipation had increased short-term risk of a diagnosis of GI cancer. Beyond 1 year of follow-up, a moderately elevated risk persisted only for GI cancers other than colorectal cancer. The risk of non-GI cancers was elevated only during the first year of follow-up, particularly for ovarian cancer.

Intake of Lutein and Zeaxanthin as a Possible Factor Influencing Gastrointestinal Symptoms in Caucasian Individuals with Ulcerative Colitis in Remission Phase

The vitamin A deficiencies are commonly observed in the case of ulcerative colitis individuals. The decreased antioxidant defence may influence the intestine, inducing higher susceptibility to oxidative damage of tissues and altering the symptoms and course of disease. Intestinal symptoms, ranging from diarrhea to constipation, occur more commonly in remission ulcerative colitis individuals than in general population. The aim of the study was to analyze the association between retinoid intake and gastrointestinal symptoms in Caucasian individuals in the remission phase of ulcerative colitis. Reitnoid (total vitamin A, retinol, β-carotene, α-carotene, β-cryptoxanthin, lycopene, as well as lutein and zeaxanthin) intakes were analyzed on the basis of three-day dietary records. Gastrointestinal symptoms (daily number of bowel movements, and the presence of painful tenesmus, flatulence, and constipation) were self-reported. The study was conducted in a group of 56 ulcerative colitis remission individuals, stratified by the gastrointestinal symptoms. One in every seven individuals reported recurring constipation. Higher intake of lutein and zeaxanthin (median 1386.2 µg, 289.0–13221.3 µg vs. median 639.0 µg, 432.7–1309.0 µg) may lower the incidence of constipation (p = 0.013). The intake of retinoids other than lutein and zeaxanthin was not associated with the incidence of constipation or other gastrointestinal symptoms.

Successful Helicobacter pylori eradication therapy improves symptoms of chronic constipation

BACKGROUNDS AND AIMS

Constipation is one of the most common gastrointestinal functional disorders. Recently, the gut microbiota has been implicated in the development of constipation. Helicobacter pylori infection is considered to be a possible factor influencing the gut microbiota profile. Here, we investigated the effect of H. pylori eradication therapy on symptoms of chronic constipation.

METHODS

We recruited 166 H pylori-positive patients who underwent eradication therapy after endoscopy. We evaluated the severity of symptoms of chronic constipation before eradication therapy and 2 months post-therapy using two questionnaires, the Gastrointestinal Symptom Rating Scale (GSRS) and the Izumo scale. In addition, we evaluated association with constipation and H. pylori infection in patients with constipation-related symptoms in not only all patients, but also patients with the constipation-related symptoms in relation to eradication outcome, the severity of constipation-related symptoms, and the severity of endoscopic gastric mucosal atrophy.

RESULTS

Mean GSRS scores were 5.10 ± 2.67 in all patients and 6.15 ± 2.91 in constipation patients which were significantly lower than that before eradication (5.78 ± 3.27, P < 0.01 and 8.19 ± 3.09, P < 0.01, respectively). Constipation-related scores of the GSRS questionnaire in the successful eradication group were significantly improved after eradication from 5.63 ± 3.06 in all patients and 8.00 ± 2.85 in constipation patients to 5.11 ± 2.71 (P = 0.02) and 6.16 ± 2.96 (P < 0.01), while scores in the failed eradication group before and after eradication were similar. Constipation-related scores in patients with mild gastric atrophy (Kimura-Takemoto classification, C-I to O-I) were significantly decreased after eradication, but were not decreased in patients with severe atrophy (O-II and O-III).

CONCLUSIONS

Successful eradication therapy for H. pylori infection may confer additional benefits in H. pylori-positive patients with symptoms of chronic constipation, especially in patients with mild gastric atrophy.

Koreans’ Awareness and Preventive Behaviors Regarding Colorectal Cancer Screening

Background:

Koreans in the Republic of Korea had high incidence and mortality rates of colorectal cancer (CRC), late stage of CRC diagnosis, and low CRC screening. The purpose of this study was to gain a more thorough understanding of CRC awareness, preventive behaviors, and preferred strategies to improve CRC screening behaviors among Koreans.

Methods:

Individual interviews with 33 Koreans aged 50 and older were conducted using semi-structured, open-ended questions. All interview data were recorded and analyzed using direct content analysis.

Results:

To prevent CRC, all participants focused on primary prevention including healthy lifestyle more than secondary prevention such as screening. Motivators of CRC screening were (a) symptoms, (b) being scared by acquaintances with CRC, (c) being healthy for the family, (d) others’ recommendations, and (f) annual fecal occult blood test (FOBT) in the National Cancer Screening Program. Barriers to CRC screening were (a) no symptom, (b) discomfort on test procedure, (c) lack of knowledge, (d) low perceived risk of developing CRC, (e) mistrust in CRC screening tests or health care providers, (f) fear of CRC diagnosis, (g) embarrassment, and (h) colonoscopy was a follow-up test in the National Cancer Screening Program. Participants suggested preferred strategies using various information delivery methods.

Conclusions:

This study suggests that we should provide accurate knowledge, emphasize importance of secondary prevention, enhance motivators and decrease barriers, and use multilevel approach incorporating preferred strategies to improve CRC screening behaviors among Koreans.

Colonic stasis and chronic constipation: Demystifying proposed risk factors for colon polyp formation in a spinal cord injury veteran population

BACKGROUND AND AIMS

Patients with spinal cord injury (SCI) suffer significant morbidity from neurogenic bowel. Chronic constipation has long-been a proposed risk factor for polyp development. We performed a retrospective cohort study in veterans with SCI to assess polyp presence in the setting of colonic stasis.

METHODS

All consecutive patients at the James A. Haley Veterans Affairs Hospital with SCI and neurogenic bowel who completed screening colonoscopy between January 1, 2004 to June 30, 2013 were included. Colonoscopies were excluded if they were aborted, not completed to the cecum, of less than adequate preparation, or if polypectomy was precluded. Patient data included level, duration, and completeness of SCI. Polyp data included number, location, and histology.

RESULTS

325 patients ultimately met inclusion criteria. Most were male (96%). The average age at screening colonoscopy was 62.8 years. The majority of patients had injury to the cervical spine (41.5%). Colon polyps were detected in 130 patients (40%). Adenomatous change was seen in 95 (73%) of these patients. The adenoma detection rate (ADR) across all patients was 29.2%. Polyp presence and ADR demonstrated no statistically significant correlation with level, degree, or duration of SCI. Only patient age at time of screening colonoscopy had a significant correlation with polyp and adenoma presence (P<0.05).

CONCLUSIONS

SCI had no statistically significant correlation with polyp or adenoma presence. The ADR in our veteran SCI population with chronic constipation is comparable with that reported in the general population.

The Mexican consensus on chronic constipation

INTRODUCTION

Significant advances have been made in the knowledge and understanding of the epidemiology, pathophysiology, diagnosis, and treatment of chronic constipation, since the publication of the 2011 guidelines on chronic constipation diagnosis and treatment in Mexico from the Asociación Mexicana de Gastroenterología.

AIMS

To present a consensus review of the current state of knowledge about chronic constipation, providing updated information and integrating the new scientific evidence.

METHODS

Three general coordinators reviewed the literature published within the time frame of January 2011 and January 2017. From that information, 62 initial statements were formulated and then sent to 12 national experts for their revision. The statements were voted upon, using the Delphi system in 3 voting rounds (2 electronic and one face-to-face). The statements were classified through the GRADE system and those that reached agreement >75% were included in the consensus.

RESULTS AND CONCLUSIONS

The present consensus is made up of 42 final statements that provide updated knowledge, supplementing the information that had not been included in the previous guidelines. The strength of recommendation and quality (level) of evidence were established for each statement. The current definitions of chronic constipation, functional constipation, and opioid-induced constipation are given, and diagnostic strategies based on the available diagnostic methods are described. The consensus treatment recommendations were established from evidence on the roles of diet and exercise, fiber, laxatives, new drugs (such as prucalopride, lubiprostone, linaclotide, plecanatide), biofeedback therapy, and surgery.

Stercoral perforation proximal to the stapled anastomosis after low anterior resection with an intraluminal device

Stercoral perforation of the colon is a rare phenomenon and a potential life-threatening condition requiring acute intervention. A little more than 200 cases have been described to date. The mechanism is not completely understood. In this short communication, we present three patients with a colon perforation proximal to the anastomosis, similar to a stercoral perforation, following colorectal cancer resection with application of an intraluminal device, the C-seal.

Chronic constipation

Chronic constipation is a prevalent condition that severely impacts the quality of life of those affected. Several types of primary chronic constipation, which show substantial overlap, have been described, including normal-transit constipation, rectal evacuation disorders and slow-transit constipation. Diagnosis of primary chronic constipation involves a multistep process initiated by the exclusion of 'alarm' features (for example, unintentional weight loss or rectal bleeding) that might indicate organic diseases (such as polyps or tumours) and a therapeutic trial with first-line treatments such as dietary changes, lifestyle modifications and over-the-counter laxatives. If symptoms do not improve, investigations to diagnose rectal evacuation disorders and slow-transit constipation are performed, such as digital rectal examination, anorectal structure and function testing (including the balloon expulsion test, anorectal manometry or defecography) or colonic transit tests (such as the radiopaque marker test, wireless motility capsule test, scintigraphy or colonic manometry). The mainstays of treatment are diet and lifestyle interventions, pharmacological therapy and, rarely, surgery. This Primer provides an introduction to the epidemiology, pathophysiological mechanisms, diagnosis, management and quality of life associated with the commonly encountered clinical problem of chronic constipation in adults unrelated to opioid abuse.

A Diet Low in Fermentable Oligo-, Di-, and Monosaccharides and Polyols Improves Quality of Life and Reduces Activity Impairment in Patients With Irritable Bowel Syndrome and Diarrhea

BACKGROUND & AIMS

We investigated the effects of a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) vs traditional dietary recommendations on health-related quality of life (QOL), anxiety and depression, work productivity, and sleep quality in patients with irritable bowel syndrome and diarrhea (IBS-D).

METHODS

We conducted a prospective, single-center, single-blind trial of 92 adult patients with IBS-D (65 women; median age, 42.6 years) randomly assigned to groups placed on a diet low in FODMAPs or a modified diet recommended by the National Institute for Health and Care Excellence (mNICE) for 4 weeks. IBS-associated QOL (IBS-QOL), psychosocial distress (based on the Hospital Anxiety and Depression Scale), work productivity (based on the Work Productivity and Activity Impairment), and sleep quality were assessed before and after diet periods.

RESULTS

Eighty-four patients completed the study (45 in the low-FODMAP group and 39 in the mNICE group). At 4 weeks, patients on the diet low in FODMAPs had a larger mean increase in IBS-QOL score than did patients on the mNICE diet (15.0 vs 5.0; 95% CI, -17.4 to -4.3). A significantly higher proportion of patients in the low-FODMAP diet group had a meaningful clinical response, based on IBS-QOL score, than in the mNICE group (52% vs 21%; 95% CI, -0.52 to -0.08). Anxiety scores decreased in the low-FODMAP diet group compared with the mNICE group (95% CI, 0.46-2.80). Activity impairment was significantly reduced with the low-FODMAP diet (-22.89) compared with the mNICE diet (-9.44; 95% CI, 2.72-24.20).

CONCLUSIONS

In a randomized, controlled trial, a diet low in FODMAPs led to significantly greater improvements in health-related QOL, anxiety, and activity impairment compared with a diet based on traditional recommendations for patients with IBS-D. ClinicalTrials.gov, number NCT01624610.

Colon cancer presenting as pseudo-obstruction during pregnancy - A case report

The incidence of colorectal cancer in pregnancy is between 0.002 and 0.008%. Diagnosis is often delayed as symptoms of colorectal cancer can mimic as common complaints of pregnancy. We present the case of a 29-year-old with a history of chronic constipation who presented in the second trimester with abdominal pain, inability to tolerate anything orally and no bowel movement in more than three weeks. Non-contrast MRI at presentation failed to show an obstructing mass. Patient was treated conservatively for presumed pseudo-obstruction secondary to worsening constipation from chronic ondansetron use and pregnancy. After four days without clinical improvement, she had a colonoscopy that revealed a completely obstructing sigmoid mass, which biopsies confirmed was a primary colorectal adenocarcinoma. The patient underwent a total abdominal colectomy. She was referred to medical oncology and began adjuvant chemotherapy consisting of 5-fluorouracil, leucovorin and oxaloplatin four weeks post-operatively.

The role of colonoscopy and CT colonography in patients presenting with symptoms of constipation

OBJECTIVE

There is controversy whether constipation as a primary presenting complaint is an indication for diagnostic colonoscopy. CT colonography (CTC) is a less invasive and more acceptable alternative. We compared the completion and sensitivity of colonoscopy with CTC in patients who presented with the primary symptom of constipation.

METHODS

A retrospective study was conducted which examined the first 100 colonoscopies and 100 CTCs carried out for the primary symptom of constipation from June 2012 to December 2013. The primary outcome measure was failure rate of the investigations. Secondary outcomes included reasons for failure and comparison of cost effectiveness between the two modalities.

RESULTS

A total of 200 patients were included in this study. Of these, the first consecutive 100 colonoscopies and 100 CTCs were included. One colonic cancer was detected in each of the CTC and the colonoscopy arm, respectively. 37 (37%) attempted colonoscopies were incomplete examinations. The most common reasons were discomfort (51.4%) and poor bowel preparation (27%). There was no failure of CTC. For 100 patients, CTC as a primary investigation was a more cost-effective investigation (p ≤ 0.01) costing £55,016 as compared with colonoscopy costing £73,666.

CONCLUSION

There is an unacceptably high failure rate of colonoscopy in patients who presented with the primary symptom of constipation. Hence, we propose that CTC may be an acceptable first-line investigation with a further colonoscopy/flexible sigmoidoscopy if lesions are detected. Advances in knowledge: First study to examine the use of CTC in patients with constipation.

Comparison of Segmental Colon Transit Time With Total Energy Expenditure in Psychiatry Unit Patients

Physical activity is associated with a reduced risk of colorectal cancer. We examined the colon transit time (CTT) according to the total energy expenditure (TEE) in psychiatry unit patients. The study participants included 67 adults, with a mean age of 49.8 years. The participants used an accelerometer for 7 days to measure their 1-week TEE. They took a capsule containing 20 radio-opaque markers for 3 days. On the 4th day and 7th day, a supine abdominal radiography was performed. According to the TEE of all study participants, the upper 30%, middle 30%, and lower 40% were classified into groups according to high (H), moderate (M), and low (L) physical activity. The mean total CTT was 52.0 hours. The segmental CTT for the right, left, and recto-sigmoid colon were 15.3 hours, 19.2 hours, and 17.4 hours. Total CTT in the H group was significantly shorter than that in the L group (p = .010). A comparison of the segmental CTT between the L, M, and H groups showed that the right CTT (p = .010) of the H group was significantly shorter than that of the M group. The left CTT of the M group (p = .028) and H group (p = .004) was significantly shorter than that of the L group. The recto-sigmoid CTT (p = .016) of the M group was significantly shorter than that of the L group. The study showed that moderate and high TEE was assisted with reduced CTT.

Poor predictive value of lower gastrointestinal alarm features in the diagnosis of colorectal cancer in 1981 patients in secondary care

BACKGROUND

Clinicians are advised to refer patients with lower gastrointestinal (GI) alarm features for urgent colonoscopy to exclude colorectal cancer (CRC). However, the utility of alarm features is debated.

AIM

To assess whether performance of alarm features is improved by using a symptom frequency threshold to trigger referral, or by combining them into composite variables, including minimum age thresholds, as recommended by the National Institute for Health and Care Excellence (NICE).

METHODS

We collected data prospectively from 1981 consecutive adults with lower GI symptoms. Assessors were blinded to symptom status. The reference standard to define CRC was histopathological confirmation of adenocarcinoma in biopsy specimens from a malignant-looking colorectal lesion. Controls were patients without CRC. Sensitivity, specificity, positive predictive values (PPVs) and negative predictive values were calculated for individual alarm features, as well as combinations of these.

RESULTS

In identifying 47 (2.4%) patients with CRC, individual alarm features had sensitivities ranging from 11.1% (family history of CRC) to 66.0% (loose stools), and specificities from 30.5% (loose stools) to 75.6% (family history of CRC). Using higher symptom frequency thresholds improved specificity, but to the detriment of sensitivity. NICE referral criteria also had higher specificities and lower sensitivity, with PPVs above 4.8%. More than 80% of those with CRC met at least one of the NICE referral criteria.

CONCLUSIONS

Using higher symptom frequency thresholds for alarm features improved specificity, but sensitivity was low. NICE referral criteria had PPVs above 4.8%, but sensitivities ranged from 2.2% to 32.6%, meaning many cancers would be missed.

Bowel movement frequency, oxidative stress and disease prevention

The significance of diet for disease prevention has long been recognised. Dietary recommendations have therefore been integrated in health promotion messages. Gastrointestinal functioning is essential for the digestion of nutrients. Oxidative stress has been observed in patients with constipation, as well as in those with colorectal cancer, cardiovascular disease and other chronic illnesses associated with constipation. The coexistence of colorectal neoplasia and coronary artery disease has been incriminated for exposure to common risk factors associated with increased oxidative stress. It was recently demonstrated that bowel movement frequency is inversely associated with cardiovascular mortality. The aim of the present study was to review the relevant literature in light of these findings. It was concluded that suboptimal functioning of the large bowel may contribute to oxidative stress and, therefore, to increased mortality. Bowel movement frequency may represent a simple quantifiable indicator of adequate colonic function and it is dependent on diet, exercise and other lifestyle factors, but also on individual characteristics, including colonic microbiota. Future health promotion actions may improve the prevention of a number of diseases by advocating lifestyle personalisation for assuring optimal intestinal functioning.

The associations between objective numeracy and colorectal cancer screening knowledge, attitudes and defensive processing in a deprived community sample

We examined associations between numeracy and sociocognitive factors associated with colorectal cancer screening uptake (n = 964). Nearly half (45.7%) of the respondents incorrectly answered a numeracy question (low numeracy). Low numeracy respondents were less knowledgeable about colorectal cancer (p < .001), less positive towards screening (emotional, p < .001 and practical, p = .001) and less likely to intend to participate in screening (p = .001). They also reported greater defensive processing of cancer information (p = .001). Sociocognitive factors fully mediated the relationship between numeracy and screening intention. Addressing numeracy issues may reduce inequalities in CRC screening participation, but communication strategies could be limited by the tendency process cancer information defensively.

Irritable Bowel Syndrome and Female Patients

Irritable bowel syndrome is probably the most common functional gastrointestinal disorder and is characterized by abdominal pain along with altered bowel function. It is a disorder of female predominance. This article focuses on how being female influences the pathophysiology, diagnosis, management, and treatment of this common disorder and discusses the evidence and important controversies related to these areas.

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

Clinical practice guidelines for the management of constipation in adults aim to generate recommendations on the optimal approach to chronic constipation in the primary care and specialized outpatient setting. Their main objective is to provide healthcare professionals who care for patients with chronic constipation with a tool that allows them to make the best decisions about the prevention, diagnosis and treatment of this condition. They are intended for family physicians, primary care and specialist nurses, gastroenterologists and other health professionals involved in the treatment of these patients, as well as patients themselves. The guidelines have been developed in response to the high prevalence of chronic constipation, its impact on patient quality of life and recent advances in pharmacological management. The Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) system has been used to classify the scientific evidence and strengthen the recommendations.

Cissus sicyoides: Pharmacological Mechanisms Involved in the Anti-Inflammatory and Antidiarrheal Activities

The objective of this study was to evaluate the pharmacological mechanisms involved in anti-inflammatory and antidiarrheal actions of hydroalcoholic extract obtained from the leaves of Cissus sicyoides (HECS). The anti-inflammatory effect was evaluated by oral administration of HECS against acute model of edema induced by xylene, and the mechanisms of action were analysed by involvement of arachidonic acid (AA) and prostaglandin E₂ (PGE₂). The antidiarrheal effect of HECS was observed and we analyzed the motility and accumulation of intestinal fluid. We also analyzed the antidiarrheal mechanisms of action of HECS by evaluating the role of the opioid receptor, α₂ adrenergic receptor, muscarinic receptor, nitric oxide (NO) and PGE₂. The oral administration of HECS inhibited the edema induced by xylene and AA and was also able to significantly decrease the levels of PGE₂. The extract also exhibited significant anti-diarrheal activity by reducing motility and intestinal fluid accumulation. This extract significantly reduced intestinal transit stimulated by muscarinic agonist and intestinal secretion induced by PGE₂. Our data demonstrate that the mechanism of action involved in the anti-inflammatory effect of HECS is related to PGE₂. The antidiarrheal effect of this extract may be mediated by inhibition of contraction by acting on the intestinal smooth muscle and/or intestinal transit.

Carbon dioxide insufflation or warm-water infusion for unsedated colonoscopy: A randomized controlled trial in patients with chronic constipation in China

AIMS

The effect of carbon dioxide (CO2) insufflation and warm-water infusion during colonoscopy on patients with chronic constipation remains unknown. We evaluated CO 2 insufflation and warm-water irrigation versus air insufflation in unsedated patients with chronic constipation in China.

PATIENTS AND METHODS

This randomized, single-center, controlled trial enrolled 287 consecutive patients, from January 2014 to January 2015, who underwent colonoscopy for chronic constipation. Patients were randomized to CO2 insufflation, warm-water irrigation and air insufflation colonoscopy insertion phase groups. Pain scores were assessed by the visual analog scale (VAS). The primary outcome was real-time maximum insertion pain, recorded by an unblinded nurse assistant. At discharge, the recalled maximum insertion pain was recorded. Meanwhile, patients were requested to select the VAS at 0, 10, 30, and 60 min after the procedure. In addition, cecal intubation and withdrawal time, total procedure time, and adjunct measures were recorded.

RESULTS

A total of 287 patients were randomized. The correlation between real-time and recalled maximum insertion pain ((Pearson coefficient r = 0.929; P < 0.0001) confirmed internal validation of the primary outcome. The mean real-time maximum pain scores during insertion 2.9 ± 2.1 for CO2, 2.7 ± 1.9 for water achieved a significantly lower pain score compared with air (5.7 ± 2.5) group (air vs CO2 P < 0.001; air vs water P < 0.001). However, no significant pain score differences were found between the patients in the CO2 and water groups (CO2 vs water, P = 0.0535). P values in painless colonoscopy and only discomfort colonoscopy (pain 1-2) were, respectively, 6 (6.4%) and 8 (8.5%) for air; 17 (17.7%) and 29 (30.2%) for CO2; 16 (16.5%) and 31 (31.9%) for water. At 0, 10, 30, and 60 min postprocedure, pain scores showed in the CO2 and water groups had significantly reduced than in air group. Insertion time was significantly different between air (10.6 ± 2.5) and CO2 ( 7.2 ± 1.4) (air vs CO2 P < 0.001), air and water (6.9 ± 1.3) (air vs water P < 0.001). However, CO2 and was not significantly different in cecum-intubated time (CO2 vs water, P = 0.404). CO2 and water group in extubation time were significantly different, respectively, CO2 (7.9 ± 1.1) and water (8.0 ± 1.1) (CO2 vs water, P = 0.707). CO2 or water group required less implementation of adjunct measures and more willingness to repeat the procedure.

CONCLUSIONS

Compared with air, the CO2 or water-aided method reduced real-time maximum pain and cecum-intubated time for chronic constipated patients in unsedated colonoscopy. The CO2 insufflation or warm-water irrigation may be a simple and inexpensive way to reduce discomfort in unsedated patients with constipation. This study demonstrated an advantage of using CO2 insufflation and warm-water irrigation during colonoscopy in unsedated constipated patients in China.

Irritable bowel syndrome and chronic constipation: Fact and fiction

Irritable bowel syndrome (IBS) and functional constipation (FC) are the most common functional gastrointestinal disorders. According to the Rome III Criteria these two disorders should be theoretically separated mainly by the presence of abdominal pain or discomfort relieved by defecation (typical of IBS) and they should be mutually exclusive. However, many gastroenterologists have serious doubts as regards a clear separation. Both IBS-C and FC, often associated with many other functional digestive and non digestive disorders, are responsible for a low quality of life. The impact of the media on patients’ perception of these topics is sometimes disruptive, often suggesting a distorted view of pathophysiology, diagnosis and therapy. These messages frequently overlap with previous subjective opinions and are further processed on the basis of the different culture and the previous experience of the constipated patients, often producing odd, useless or even dangerous behaviors. The aim of this review was to analyze the most common patients’ beliefs about IBS-C and CC, helping physicians to understand where they should focus their attention when communicating with patients, detecting false opinions and misconceptions and correcting them on the basis of scientific evidence.

Prevalence of functional gastrointestinal disorders among consecutive new patient referrals to a gastroenterology clinic

OBJECTIVE

Functional gastrointestinal disorders (FGIDs) are common in the community. Many patients will consult a physician in primary care, but the burden that these diseases represent to secondary care has not been studied for many years. We therefore examined this subject.

DESIGN

Unselected consecutive new adult patient referrals were recruited during a 3-year period from January 2010 until December 2012. Medical records were reviewed retrospectively and the following data were recorded: age and sex of the patient, symptoms reported or signs noted at the first consultation, all investigations requested and ultimate diagnosis after investigation to the level deemed appropriate by the consulting physician.

SETTING

A luminal gastroenterology clinic at a teaching hospital.

RESULTS

There were a total of 613 new patient referrals (mean age 54.2 years, 357 (58.2%) female). In total, 214 (34.9%) patients were diagnosed as having an FGID. Among the 214 patients diagnosed with an FGID, 65.9% were female, compared with 54.1% without an FGID (p=0.005). Mean age of those with an FGID was 47.9 years, compared with 57.5 years among those without (p<0.001). The total number of symptoms reported was significantly higher among patients with an FGID, but the total number of investigations did not differ.

CONCLUSIONS

More than one-third of new patient referrals to a luminal gastroenterology clinic were diagnosed with an FGID. These conditions form a large part of the workload in secondary care gastroenterology, and primary care commissioning needs to reflect this.

Risk of developing colorectal cancer and benign colorectal neoplasm in patients with chronic constipation

BACKGROUND

Chronic constipation (CC) is a highly prevalent health problem, potentially associated with increased risk of colorectal cancer (CRCancer).

AIM

To investigate the association between CC, its severity, and CRCancer by estimating the relative risk of developing CRCancer and benign colorectal neoplasm (BCN) among severity-stratified patients with and without CC.

METHODS

Chronic constipation patients from a large retrospective US claims database were matched 1:3 with CC-free controls by demographic characteristics. CRCancer and BCN prevalence were measured over 1 year. In pre-index CRCancer- and BCN-free patients, incidence rate ratios (IRRs) of new CRCancer and BCN were calculated. Multivariate regression models adjusted for comorbidities and family history. CC patients' disease severity was rated based on CC-related resource use. IRRs for new CRCancer and BCN were estimated for CC severity groups and controls.

RESULTS

Chronic constipation (N = 28,854) and CC-free (N = 86,562) patients had mean age 61.9 years; 66.7% were female. One-year CRCancer prevalence was 2.7% and 1.7%, and BCN prevalence was 24.8% and 11.9% for CC and CC-free patients, respectively. Adjusted IRRs between CC and CC-free patients were 1.59 [95% confidence interval (CI): 1.43-1.78] and 2.60 [95% CI: 1.51-2.70] for CRCancer and BCN, respectively. Patients with severe and very severe CC had significantly greater incidence of CRCancer and BCN. At ≥ 2 and ≥ 5 years of observation, CRCancer and BCN incidence remained consistently and significantly higher for CC patients.

CONCLUSIONS

Patients with chronic constipation are associated with significantly higher prevalence and incidence of colorectal cancer and benign colorectal neoplasm than matched chronic constipation-free patients. These risks increase with the severity of chronic constipation.

Prediction rule for estimating advanced colorectal neoplasm risk in average-risk populations in southern Jiangsu Province

OBJECTIVE

The aim of this study was to establish the risk scoring system towards the advanced colorectal neoplasm (CN) risk in the average-risk populations in the southern Jiangsu Province, and to evaluate the screening efficacy.

METHODS

Totally 905 cases of the average-risk populations who received the colonoscopy were selected as the objective. The multivariate logistic regression analysis method was used to establish the scoring system towards the occurrence risk of the advanced tumor, and its screening efficacy was evaluated through the prediction consistency, distinguishing ability and screening accuracy.

RESULTS

The scoring system consisted of five variables, namely age, gender, coronary heart disease, egg intake and stool frequency. The results revealed that it had good prediction consistency (P=0.205) and distinguishing ability [the area under the receiver operating characteristic (ROC) curve was 0.75, with 95% confidence interval (95% CI) of 0.69-0.82]. Thus, 2.5 points was set as the screening cutoff value, and its sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were 93.8%, 47.6%, 50.1%, 9.1%, 99.3%, 1.79 and 0.13, respectively.

CONCLUSIONS

The established scoring system had good screening efficacy, and can be used as the screening tool applying to the CN screening within the average-risk populations in the southern Jiangsu Province.