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Simrén M, Tack J. Combining symptoms and biomarkers: The future diagnostic approach for disorders of gut-brain interaction? Neurogastroenterol Motil 2020; 32:e14019. [PMID: 33107678 DOI: 10.1111/nmo.14019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 09/29/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Magnus Simrén
- University of Gothenburg, Gothenburg, Sweden.,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jan Tack
- University of Gothenburg, Gothenburg, Sweden.,Translational Research Center for Gastrointestinal Disorders (TARGID), Catholic University of Leuven, Leuven, Belgium.,Division of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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2
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Caetano AC, Costa D, Gonçalves R, Correia-Pinto J, Rolanda C. Does sequential balloon expulsion test improve the screening of defecation disorders? BMC Gastroenterol 2020; 20:338. [PMID: 33054847 PMCID: PMC7559767 DOI: 10.1186/s12876-020-01490-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/07/2020] [Indexed: 12/30/2022] Open
Abstract
Background A defecation disorder (DD) is a difficulty in evacuation documented by physiological exams. However, this physiological evaluation can be cumbersome, inaccessible and costly. Three “low-cost” tools to evaluate DD—a clinical DD score, the balloon expulsion test (BET) and a digital rectal examination (DRE) score were evaluated as separate or combined tests for DD screening. Methods This prospective study occurred between January 2015 and March 2019 in the Gastroenterology Department of a tertiary hospital. Besides the gold standard physiological tests, constipated patients answered the clinical DD score and were evaluated by DRE and BET [standard and variable volume (VV)]. Results From 98 constipated patients, 35 (38.9%) were diagnosed with DD according to Rome IV criteria, mainly female (n = 30, 86%) with a median age of 60 years old. The clinical DD score revealed an AUC of 0.417 (SE = 0.07, p = 0.191). The DRE score displayed an AUC of 0.56 (SE = 0.063, p = 0.301). The standard BET displayed a sensitivity of 86%, specificity of 58%, positive predictive value (PPV) of 57% and negative predictive value (NPV) of 86%. The sequential VVBET followed by standard BET improved the BET performance regarding the evaluation of DD, with a sensitivity of 86%, specificity of 67%, PPV of 63% and NPV of 87%. The sequential BET had an OR 8.942, p > 0.001, CI 3.18–25.14, revealing to be the most significant predictor for DD screening. Conclusion The sequential BET is a low cost, well-performing DD screening tool, appropriate to the Primary Care Setting.
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Affiliation(s)
- A C Caetano
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal. .,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal. .,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal.
| | - D Costa
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal
| | - R Gonçalves
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal
| | - J Correia-Pinto
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal
| | - C Rolanda
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal
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3
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L’Heureux-Bouron D, Legrain-Raspaud S, Carruthers HR, Whorwell PJ. Minor digestive symptoms and their impact in the general population: a cluster analysis approach. Therap Adv Gastroenterol 2018; 11:1756284818768814. [PMID: 29760783 PMCID: PMC5946602 DOI: 10.1177/1756284818768814] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 02/26/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The classification and treatment of patients who do not meet the criteria for a functional gastrointestinal (GI) disorder has not been well established. This study aimed to record the prevalence of minor digestive symptoms (MDSs) in the general population attempting to divide them into symptom clusters as well as trying to assess their impact and the way sufferers cope with them. METHODS Following face-to-face interviews, a web-based, self-administered questionnaire was designed to capture a range of GI sensations using 34 questions and 12 images depicting abdominal symptoms. A randomly selected sample of 1515 women and 409 men representing the general population in France was studied. Cluster analysis was used to identify groups of respondents with naturally co-occurring symptoms. Data were also collected on other factors such as exacerbating and relieving strategies. RESULTS MDSs were reported at least every 2 months in 66.5% of women and 47.7% of men. A total of 11 symptom clusters were identified: constipation-like, flatulence, abdominal pressure, abdominal swelling, acid reflux, diarrhoea-like, intestinal heaviness, intestinal pain, gurgling, burning and gastric pain. Despite being minor, these problems had a major impact on vitality and self-image as well as emotional, social and physical well-being. Respondents considered lifestyle, food and disordered function as the main factors responsible for MDSs. Physical measures and dietary modification were the most frequent strategies adopted to obtain relief. CONCLUSIONS MDSs are common and improved methods of recognition are needed so that better management strategies can be developed for individuals with these symptoms. The definition of symptom clusters may offer one way of achieving this goal.
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Affiliation(s)
| | | | - Helen R. Carruthers
- Education and Research Centre, Wythenshawe Hospital, Manchester, M23 9LT, UK
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4
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Parker CH, Tomlinson G, Correia A, Liu LWC. The Use of Standardized Questions in Identifying Patients with Dyssynergic Defecation. J Can Assoc Gastroenterol 2018; 1:60-66. [PMID: 31294401 PMCID: PMC6487988 DOI: 10.1093/jcag/gwy010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Dyssynergic defecation (DD) is present in approximately 30% of patients with idiopathic chronic constipation (CC). Diagnostic criteria for DD require objective testing such as anorectal manometry (ARM); yet, ARM remains a limited resource in Canada. The aim of this study is to determine the predictability of DD in patients with CC using a standardized self-reported symptom questionnaire. Method In this study, 166 consecutive English-speaking patients with CC who were referred for ARM completed a symptom questionnaire. DD was diagnosed if pelvic floor dyssynergy was demonstrated by ARM and balloon expulsion time was more than one minute. Likelihood ratios (LRs) were calculated for individual symptoms and prespecified symptom combinations. Likelihood ratios greater than five or less than 0.2 were considered significant. A recursive partitioning tree was used to find the symptoms best able to predict DD. Results No single constipation symptom was sufficient to predict a diagnosis of DD. Patients who reported sometimes feeling an urge to defecate and a prolonged straining duration of greater than five minutes were more likely to have DD (LR = 7.74). In patients who reported straining often or always and had a short straining duration of less than two minutes, the diagnosis of DD was less likely (LR = 0.04). The recursive partitioning tree analysis similarly identified a sense of urge with a prolonged straining duration as predictor for DD, as well as an incomplete evacuation as another potential predictor. Conclusion Questions regarding need to strain, duration of straining, urge to defecate, and incomplete evacuation are useful to predict the presence of DD in patients with CC. These questions will enable clinicians to make a clinical diagnosis of DD to guide treatment.
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Affiliation(s)
- Colleen H Parker
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | | | - Louis W C Liu
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University Health Network, Toronto, Ontario, Canada
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5
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Mearin F, Ciriza C, Mínguez M, Rey E, Mascort JJ, Peña E, Cañones P, Júdez J. Clinical Practice Guideline: Irritable bowel syndrome with constipation and functional constipation in the adult. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:332-63. [PMID: 27230827 DOI: 10.17235/reed.2016.4389/2016] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In this Clinical Practice Guideline we discuss the diagnostic and therapeutic approach of adult patients with constipation and abdominal complaints at the confluence of the irritable bowel syndrome spectrum and functional constipation. Both conditions are included among the functional bowel disorders, and have a significant personal, healthcare, and social impact, affecting the quality of life of the patients who suffer from them. The first one is the irritable bowel syndrome subtype, where constipation represents the predominant complaint, in association with recurrent abdominal pain, bloating, and abdominal distension. Constipation is characterized by difficulties with or low frequency of bowel movements, often accompanied by straining during defecation or a feeling of incomplete evacuation. Most cases have no underlying medical cause, and are therefore considered as a functional bowel disorder. There are many clinical and pathophysiological similarities between both disorders, and both respond similarly to commonly used drugs, their primary difference being the presence or absence of pain, albeit not in an "all or nothing" manner. Severity depends not only upon bowel symptom intensity but also upon other biopsychosocial factors (association of gastrointestinal and extraintestinal symptoms, grade of involvement, and perception and behavior variants). Functional bowel disorders are diagnosed using the Rome criteria. This Clinical Practice Guideline has been made consistent with the Rome IV criteria, which were published late in May 2016, and discuss alarm criteria, diagnostic tests, and referral criteria between Primary Care and gastroenterology settings. Furthermore, all the available treatment options (exercise, fluid ingestion, diet with soluble fiber-rich foods, fiber supplementation, other dietary components, osmotic or stimulating laxatives, probiotics, antibiotics, spasmolytics, peppermint essence, prucalopride, linaclotide, lubiprostone, biofeedback, antidepressants, psychological therapy, acupuncture, enemas, sacral root neurostimulation, surgery) are discussed, and practical recommendations are made regarding each of them.
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Affiliation(s)
| | - Constanza Ciriza
- Aparato Digestivo, Hospital Universitario Doce de Octubre, España
| | | | - Enrique Rey
- Aparato Digestivo, Hospital Clínico San Carlos, España
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6
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Mearin F, Ciriza C, Mínguez M, Rey E, Mascort JJ, Peña E, Cañones P, Júdez J. [Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]. Aten Primaria 2017; 49:42-55. [PMID: 28027792 PMCID: PMC6875955 DOI: 10.1016/j.aprim.2016.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 11/01/2016] [Indexed: 12/15/2022] Open
Abstract
In this Clinical practice guide, an analysis is made of the diagnosis and treatment of adult patients with constipation and abdominal discomfort, under the spectrum of irritable bowel syndrome and functional constipation. These have an important personal, health and social impact, affecting the quality of life of these patients. In irritable bowel syndrome with a predominance of constipation, this is the predominant change in bowel movements, with recurrent abdominal pain, bloating and frequent abdominal distension. Constipation is characterised by infrequent or difficulty in bowel movements, associated with excessive straining during bowel movement or sensation of incomplete evacuation. There is often no underling cause, with an intestinal functional disorder being considered. They have many clinical and pathophysiological similarities, with a similar response of the constipation to common drugs. The fundamental difference is the presence or absence of pain, but not in a way evaluable way; "all or nothing". The severity depends on the intensity of bowel symptoms and other factors, a combination of gastrointestinal and extra-intestinal symptoms, level of involvement, forms of perception, and behaviour. The Rome criteria diagnose functional bowel disorders. This guide is adapted to the Rome criteria IV (May 2016) and in this first part an analysis is made of the alarm criteria, diagnostic tests, and the criteria for referral between Primary Care and Digestive Disease specialists. In the second part, a review will be made of the therapeutic alternatives available (exercise, diet, drug therapies, neurostimulation of sacral roots, or surgery), making practical recommendations for each one of them.
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Affiliation(s)
- F Mearin
- Coordinación de la guía de práctica clínica (GPC), Comité Roma de Trastornos Funcionales Intestinales, Asociación Española de Gastroenterología (AEG), Centro Médico Teknon, Barcelona, España
| | - C Ciriza
- Grupo de Trastornos Funcionales, Sociedad Española de Patología Digestiva (SEPD), Hospital Universitario Doce de Octubre, Madrid, España
| | - M Mínguez
- AEG y SEPD, Hospital Clínico Universitario, Universitat de Valencia, Valencia, España
| | - E Rey
- SEPD Hospital Clínico Universitario San Carlos, Madrid, España
| | - J J Mascort
- Secretaría Científica, Sociedad Española de Medicina de Familia y Comunitaria (semFYC), España.
| | - E Peña
- Coordinación de Digestivo, Sociedad Española de Médicos de Atención Primaria (SEMERGEN), España
| | - P Cañones
- Coordinación de Digestivo, Sociedad Española de Médicos Generales y de Familia (SEMG), España
| | - J Júdez
- Departamento de Gestión del Conocimiento, SEPD, España
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7
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Mearin F, Ciriza C, Mínguez M, Rey E, Mascort JJ, Peña E, Cañones P, Júdez J. [Clinical practice guidelines: Irritable bowel syndrome with constipation and functional constipation in adults: Concept, diagnosis, and healthcare continuity. (Part 1 of 2)]. Semergen 2016; 43:43-56. [PMID: 27810257 DOI: 10.1016/j.semerg.2016.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/13/2016] [Accepted: 06/14/2016] [Indexed: 12/19/2022]
Abstract
In this Clinical practice guide, an analysis is made of the diagnosis and treatment of adult patients with constipation and abdominal discomfort, under the spectrum of irritable bowel syndrome and functional constipation. These have an important personal, health and social impact, affecting the quality of life of these patients. In irritable bowel syndrome with a predominance of constipation, this is the predominant change in bowel movements, with recurrent abdominal pain, bloating and frequent abdominal distension. Constipation is characterised by infrequent or difficulty in bowel movements, associated with excessive straining during bowel movement or sensation of incomplete evacuation. There is often no underling cause, with an intestinal functional disorder being considered. They have many clinical and pathophysiological similarities, with a similar response of the constipation to common drugs. The fundamental difference is the presence or absence of pain, but not in a way evaluable way; "all or nothing". The severity depends on the intensity of bowel symptoms and other factors, a combination of gastrointestinal and extra-intestinal symptoms, level of involvement, forms of perception, and behaviour. The Rome criteria diagnose functional bowel disorders. This guide is adapted to the Rome criteria IV (May 2016) and in this first part an analysis is made of the alarm criteria, diagnostic tests, and the criteria for referral between Primary Care and Digestive Disease specialists. In the second part, a review will be made of the therapeutic alternatives available (exercise, diet, drug therapies, neurostimulation of sacral roots, or surgery), making practical recommendations for each one of them.
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Affiliation(s)
- F Mearin
- Coordinación de la guía de práctica clínica (GPC), Comité Roma de Trastornos Funcionales Intestinales, Asociación Española de Gastroenterología (AEG), Centro Médico Teknon, Barcelona, España
| | - C Ciriza
- Grupo de Trastornos Funcionales, Sociedad Española de Patología Digestiva (SEPD), Hospital Universitario Doce de Octubre, Madrid, España
| | - M Mínguez
- AEG y SEPD, Hospital Clínico Universitario, Universitat de Valencia, Valencia, España
| | - E Rey
- SEPD Hospital Clínico Universitario San Carlos, Madrid, España
| | - J J Mascort
- Secretaría Científica, Sociedad Española de Medicina de Familia y Comunitaria (semFYC), España
| | - E Peña
- Coordinación de Digestivo, Sociedad Española de Médicos de Atención Primaria (SEMERGEN), España.
| | - P Cañones
- Coordinación de Digestivo, Sociedad Española de Médicos Generales y de Familia (SEMG), España
| | - J Júdez
- Departamento de Gestión del Conocimiento, SEPD, España
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- Sociedad Española de Patología Digestiva (SEPD), Sociedad Española de Medicina de Familia y Comunitaria (semFYC), Sociedad Española de Médicos de Atención Primaria (SEMERGEN), Sociedad Española de Médicos Generales y de Familia (SEMG)
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8
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Caetano AC, Santa-Cruz A, Rolanda C. Digital Rectal Examination and Balloon Expulsion Test in the Study of Defecatory Disorders: Are They Suitable as Screening or Excluding Tests? Can J Gastroenterol Hepatol 2016; 2016:8654314. [PMID: 27847802 PMCID: PMC5101368 DOI: 10.1155/2016/8654314] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 09/22/2016] [Indexed: 01/29/2023] Open
Abstract
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.
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Affiliation(s)
- Ana C. Caetano
- Department of Gastroenterology, Braga Hospital, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, Braga, Portugal
| | - André Santa-Cruz
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, Braga, Portugal
- Department of Internal Medicine, Braga Hospital, Braga, Portugal
| | - Carla Rolanda
- Department of Gastroenterology, Braga Hospital, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, Braga, Portugal
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9
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Bouchoucha M, Devroede G, Bon C, Mary F, Bejou B, Benamouzig R. Difficult defecation in constipated patients and its relationship to colonic disorders. Int J Colorectal Dis 2016; 31:685-91. [PMID: 26861636 DOI: 10.1007/s00384-016-2528-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND The importance in constipated subjects of having difficult defecation is poorly known. According to the Rome III criteria, constipated patients are classified as having either irritable bowel syndrome with constipation or functional constipation, depending on the presence and characteristics of abdominal pain. But, the Rome III criteria also identify another group of patients, labeled as suffering from functional anorectal disorders. Within this group, two complaints are akin to being constipated, but not labeled so: having dyssynergic defecation or inadequate defecation. OBJECTIVE The aim of this study was to search for an association between difficult defecation and colonic transit abnormalities in constipated patients and, thus, shed some light on the definition of constipation according to the Rome III criteria. PATIENTS Four hundred four consecutive patients (81% female), aged 44.9 ± 16.6 years, with a BMI of 25.5 ± 6.4 kg/m(2) (mean ± SD), suffering from chronic constipation were included in the present study. After filling out a standard Rome III questionnaire, patients were classified as suffering from an irritable bowel syndrome with constipation or functional constipation. In addition, they were classified as complaining of difficult defecation or not. Patients completed the Bristol Stool Form Scale as well as visual analogue scales for constipation, bloating, and abdominal pain. The colonic transit time was measured using radiopaque markers and analyzed according to three sites: the right colon, the left colon, and the rectosigmoid area. RESULTS Difficult defecation is more frequent in patients with irritable bowel syndrome with constipation (84%) than in patients with functional constipation (68%). It is associated with an increase in constipation and abdominal pain scores on Likert scales, and a longer oroanal transit time, due to a delay in the left part of the colon. CONCLUSIONS This study demonstrates that difficult defecation is part of a more generalized colorectal dysfunction in both irritable bowel syndrome and in functional constipation patients with an overlap of symptomatology. It also demonstrates the relative inadequacy of the Rome III criteria to describe the relationship between constipation and difficult defecation.
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Affiliation(s)
- Michel Bouchoucha
- Université Paris V René Descartes, 15, rue de l'École de Médecine, 75270, Paris Cedex 06, France. .,Service de Gastroentérologie, Hôpital Avicenne, 125, rue de Stalingrad, 93009, Bobigny Cedex, France.
| | - Ghislain Devroede
- Département de Chirurgie, Faculté de Médecine, Université de Sherbrooke, Sherbrooke, Quebec, Canada.,CHUS-Hôtel-Dieu, 580 rue Bowen Sud, Sherbrooke, Quebec, J1G2EB, Canada
| | - Cyriaque Bon
- Service de Gastroentérologie, Hôpital Avicenne, 125, rue de Stalingrad, 93009, Bobigny Cedex, France
| | - Florence Mary
- Service de Gastroentérologie, Hôpital Avicenne, 125, rue de Stalingrad, 93009, Bobigny Cedex, France
| | - Baktiar Bejou
- Service de Gastroentérologie, Hôpital Avicenne, 125, rue de Stalingrad, 93009, Bobigny Cedex, France
| | - Robert Benamouzig
- Service de Gastroentérologie, Hôpital Avicenne, 125, rue de Stalingrad, 93009, Bobigny Cedex, France
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10
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Gabriele S, Sacco R, Altieri L, Neri C, Urbani A, Bravaccio C, Riccio MP, Iovene MR, Bombace F, De Magistris L, Persico AM. Slow intestinal transit contributes to elevate urinary p-cresol level in Italian autistic children. Autism Res 2015; 9:752-9. [PMID: 26437875 DOI: 10.1002/aur.1571] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 01/15/2023]
Abstract
The uremic toxin p-cresol (4-methylphenol) is either of environmental origin or can be synthetized from tyrosine by cresol-producing bacteria present in the gut lumen. Elevated p-cresol amounts have been previously found in the urines of Italian and French autism spectrum disorder (ASD) children up until 8 years of age, and may be associated with autism severity or with the intensity of abnormal behaviors. This study aims to investigate the mechanism producing elevated urinary p-cresol in ASD. Urinary p-cresol levels were thus measured by High Performance Liquid Chromatography in a sample of 53 Italian ASD children assessed for (a) presence of Clostridium spp. strains in the gut by means of an in vitro fecal stool test and of Clostridium difficile-derived toxin A/B in the feces, (b) intestinal permeability using the lactulose/mannitol (LA/MA) test, (c) frequent use of antibiotics due to recurrent infections during the first 2 years of postnatal life, and (d) stool habits with the Bristol Stool Form Scale. Chronic constipation was the only variable significantly associated with total urinary p-cresol concentration (P < 0.05). No association was found with presence of Clostridium spp. in the gut flora (P = 0.92), augmented intestinal permeability (P = 0.18), or frequent use of antibiotics in early infancy (P = 0.47). No ASD child was found to carry C. difficile in the gut or to release toxin A/B in the feces. In conclusion, urinary p-cresol levels are elevated in young ASD children with increased intestinal transit time and chronic constipation. Autism Res 2016, 9: 752-759. © 2015 International Society for Autism Research, Wiley Periodicals, Inc.
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Affiliation(s)
- Stefano Gabriele
- Unit of Child and Adolescent NeuroPsychiatry, University Campus Bio-Medico, Rome, Italy.,Laboratory of Molecular Psychiatry and Neurogenetics, University Campus Bio-Medico, Rome, Italy
| | - Roberto Sacco
- Unit of Child and Adolescent NeuroPsychiatry, University Campus Bio-Medico, Rome, Italy.,Laboratory of Molecular Psychiatry and Neurogenetics, University Campus Bio-Medico, Rome, Italy
| | - Laura Altieri
- Unit of Child and Adolescent NeuroPsychiatry, University Campus Bio-Medico, Rome, Italy.,Laboratory of Molecular Psychiatry and Neurogenetics, University Campus Bio-Medico, Rome, Italy
| | - Cristina Neri
- Department of Internal Medicine, University Tor Vergata, Rome, Italy.,Department of Experimental Neurosciences, I.R.C.C.S. "Fondazione S. Lucia", Rome, Italy
| | - Andrea Urbani
- Department of Internal Medicine, University Tor Vergata, Rome, Italy.,Department of Experimental Neurosciences, I.R.C.C.S. "Fondazione S. Lucia", Rome, Italy
| | - Carmela Bravaccio
- Department of Translational Medical Science, University "Federico II", Naples, Italy
| | - Maria Pia Riccio
- Department of Physical and Mental Health and Preventive Medicine, Second University of Naples, Naples, Italy
| | | | - Francesca Bombace
- Department of Experimental Medicine, Second University of Naples, Italy
| | - Laura De Magistris
- Department of Internal and Experimental Medicine Magrassi-Lanzara, Second University of Naples, Italy
| | - Antonio M Persico
- Unit of Child and Adolescent NeuroPsychiatry, University Campus Bio-Medico, Rome, Italy.,Laboratory of Molecular Psychiatry and Neurogenetics, University Campus Bio-Medico, Rome, Italy.,Mafalda Luce Center for Pervasive Developmental Disorders, Milan, Italy
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11
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Dinning PG, Hunt L, Lubowski DZ, Kalantar JS, Cook IJ, Jones MP. The impact of laxative use upon symptoms in patients with proven slow transit constipation. BMC Gastroenterol 2011; 11:121. [PMID: 22073923 PMCID: PMC3226636 DOI: 10.1186/1471-230x-11-121] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 11/10/2011] [Indexed: 12/30/2022] Open
Abstract
Background Constipation severity is often defined by symptoms including feelings of complete evacuation, straining, stool frequency and consistency. These descriptors are mostly obtained in the absence of laxative use. For many constipated patients laxative usage is ubiquitous and long standing. Our aim was to determine the impact of laxative use upon the stereotypic constipation descriptors. Methods Patients with confirmed slow transit constipation completed 3-week stool diaries, detailing stool frequency and form, straining, laxative use and pain and bloating scores. Each diary day was classified as being under laxative affect (laxative affected days) or not (laxative unaffected days). Unconditional logistic regression was used to assess the affects of laxatives on constipation symptoms. Results Ninety four patients with scintigraphically confirmed slow transit constipation were enrolled in the study. These patients reported a stool frequency of 5.6 ± 4.3 bowel motions/week, only 21 patients reported <3 bowel motions/week. Similarly, 21 patients reported a predominant hard stool at defecation. The majority (90%) of patients reported regular straining. A regular feeling of complete evacuation was reported in just 7 patients. Daily pain and/or bloating were reported by 92% of patients. When compared with laxative unaffected days, on the laxative affected days patients had a higher stool frequency (OR 2.23; P <0.001) and were more likely to report loose stools (OR 1.64; P <0.009). Laxatives did not increase the number of bowel actions associated with a feeling of complete evacuation. Laxative use had no affect upon straining, pain or bloating scores Conclusions The reporting of frequent and loose stools with abdominal pain and/or bloating is common in patients with slow transit constipation. While laxative use is a significant contributor to altering stool frequency and form, laxatives have no apparent affect on pain or bloating or upon a patients feeling of complete evacuation. These factors need to be taken into account when using constipation symptoms to define this population.
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Affiliation(s)
- Phil G Dinning
- Department of Human Physiology, School of Medicine, Flinders University, Adelaide, SA 5042, Australia.
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Dinning PG, Jones M, Hunt L, Fuentealba SE, Kalanter J, King DW, Lubowski DZ, Talley NJ, Cook IJ. Factor analysis identifies subgroups of constipation. World J Gastroenterol 2011; 17:1468-74. [PMID: 21472106 PMCID: PMC3070021 DOI: 10.3748/wjg.v17.i11.1468] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 01/13/2011] [Accepted: 01/20/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine whether distinct symptom groupings exist in a constipated population and whether such grouping might correlate with quantifiable pathophysiological measures of colonic dysfunction.
METHODS: One hundred and ninety-one patients presenting to a Gastroenterology clinic with constipation and 32 constipated patients responding to a newspaper advertisement completed a 53-item, wide-ranging self-report questionnaire. One hundred of these patients had colonic transit measured scintigraphically. Factor analysis determined whether constipation-related symptoms grouped into distinct aspects of symptomatology. Cluster analysis was used to determine whether individual patients naturally group into distinct subtypes.
RESULTS: Cluster analysis yielded a 4 cluster solution with the presence or absence of pain and laxative unresponsiveness providing the main descriptors. Amongst all clusters there was a considerable proportion of patients with demonstrable delayed colon transit, irritable bowel syndrome positive criteria and regular stool frequency. The majority of patients with these characteristics also reported regular laxative use.
CONCLUSION: Factor analysis identified four constipation subgroups, based on severity and laxative unresponsiveness, in a constipated population. However, clear stratification into clinically identifiable groups remains imprecise.
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Cook IJ, Talley NJ, Benninga MA, Rao SS, Scott SM. Chronic constipation: overview and challenges. Neurogastroenterol Motil 2009; 21 Suppl 2:1-8. [PMID: 19824933 DOI: 10.1111/j.1365-2982.2009.01399.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite its high prevalence and cost implications, our understanding of the pathophysiology of constipation remains primitive, and available therapies have limited efficacy. The purpose of this supplement is to address critically the reasons for the current lack of understanding and to propose avenues of future research to address these deficiencies.
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Affiliation(s)
- I J Cook
- University of New South Wales, Department of Gastroenterology, St George Hospital, Sydney, NSW, Australia.
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Cowlam S, Khan U, Mackie A, Varma JS, Yiannankou Y. Validity of segmental transit studies used in routine clinical practice, to characterize defaecatory disorder in patients with functional constipation. Colorectal Dis 2008; 10:818-22. [PMID: 18462230 DOI: 10.1111/j.1463-1318.2008.01566.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Segmental colonic transit can be determined by performing regional counts of radio-opaque markers on an abdominal radiograph. It has been claimed that the pattern of markers can be used to characterize the type of constipation, with a concentration of markers seen in the rectosigmoid region in patients with defaecatory disorders. The aim of our study was to examine this hypothesis in a cohort of patients with functional constipation. METHOD Consecutive patients presenting to a specialist constipation clinic and satisfying inclusion criteria were studied. All patients had the following assessments: radio-opaque marker study performed according to a standard protocol; proforma-based symptom assessment using Likert scoring; and radioisotope defaecating proctogram. Transit study data included total transit time, rectosigmoid transit time and geometric mean of markers. Symptom scores were recorded for straining, incomplete evacuation and digitation, together with a cumulative symptom score. Evidence of outlet obstruction from the proctogram included four previously described parameters. RESULTS A total of 108 patients with functional constipation according to the Rome criteria with a median age of 41 years were studied. Neither rectosigmoid transit time nor the geometric centre of markers could differentiate patients with a functional defaecatory disorder (FDD). There was no correlation between the pattern of marker distribution and any of the parameters denoting outlet obstruction. CONCLUSION Our data do not support the hypothesis that assessment of segmental transit, using standard methods applicable to routine clinical practice can determine the type of constipation. In particular, patients exhibiting evidence of FDD are no more likely to have recto-sigmoid retention of markers than those without.
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Affiliation(s)
- S Cowlam
- University Hospital of North Durham, Durham, UK
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