Chronic idiopathic constipation: pathophysiology and treatment

Ipidacrine in combination therapy regimens of functional constipation

AIM

Analysis of the treatment response rates of different therapy regimens of functional constipation, including Ipidacrine, a cholinesterase inhibitor, based on assessment of adaptation and compensatory mechanisms in the therapy forecast.

MATERIALS AND METHODS

77 functional slow-transit constipation patients were examined after therapy regimens of functional constipation, the mean age is 44.30±14.58 y.o.

RESULTS

The treatment response rates of different therapies with Ipidacrine depends on the patient's initial adaptation and compensatory mechanisms (ACM index); certain aspects allowing to predict the expected result depending on the current mental state were identified; the severity of the state of functional constipation, ACM index and MMPI test psychometric indicators are correlated; adaptation and compensatory mechanisms of functional constipation patients were found to be reduced; the prognosis of the treatment response rates and, accordingly, the choice of the therapy regimen depend on the patient's adaptation potential (index).

CONCLUSION

Therapy regimens for functional constipation patients should be selected on the basis of the original ACM index, behavioral pattern, degree of compliance and the patient's age.

Uncovering the Mechanisms of Chinese Herbal Medicine (MaZiRenWan) for Functional Constipation by Focused Network Pharmacology Approach

MaZiRenWan (MZRW, also known as Hemp Seed Pill) is a Chinese Herbal Medicine which has been demonstrated to safely and effectively alleviate functional constipation (FC) in a randomized, placebo-controlled clinical study with 120 subjects. However, the underlying pharmacological actions of MZRW for FC, are still largely unknown. We systematically analyzed the bioactive compounds of MZRW and mechanism-of-action biological targets through a novel approach called “focused network pharmacology.” Among the 97 compounds identified by UPLC-QTOF-MS/MS in MZRW extract, 34 were found in rat plasma, while 10 were found in rat feces. Hierarchical clustering analysis suggest that these compounds can be classified into component groups, in which compounds are highly similar to each other and most of them are from the same herb. Emodin, amygdalin, albiflorin, honokiol, and naringin were selected as representative compounds of corresponding component groups. All of them were shown to induce spontaneous contractions of rat colonic smooth muscle in vitro. Network analysis revealed that biological targets in acetylcholine-, estrogen-, prostaglandin-, cannabinoid-, and purine signaling pathways are able to explain the prokinetic effects of representative compounds and corresponding component groups. In conclusion, MZRW active components enhance colonic motility, possibly by acting on multiple targets and pathways.

Evaluating slow-transit constipation in patients using laxatives: a better approach or do we need improved patient selection?

Slow-transit constipation is a relatively frequent subtype of constipation, often refractory to medical treatment. Clinical information is usually obtained in patients during laxative withdrawal; thus, data on the effect of laxatives on their daily symptoms are lacking. The evaluated article reports on the effects of laxatives on symptoms (stool frequency, stool form, straining at stool, pain and bloating) and on laxative use by means of a daily stool questionnaire. Most patients used laxatives on an intermittent basis, and a minority also used associated enemas. Use of laxatives yielded an almost average normal daily number of evacuations in this group, with only a minority having less than three bowel movements per week. The days in which patients used laxatives yielded significantly more frequent and loose stools compared with those without laxatives. Thus, the use of laxatives seems to influence the clinical aspects of patients with slow-transit constipation, and this should be considered when evaluating these participants.

Increase of colonic mast cells in obstructed defecation and their relationship with enteric glia

BACKGROUND

Mast cells are involved in visceral hypersensitivity and motor activity of the gastrointestinal tract. However, there is almost no information concerning mast cells in constipated patients.

AIMS

The purpose of this study was to investigate mast cells distribution in all colonic layers in controls and severely constipated patients with obstructed defecation.

METHODS

Full-thickness specimens from colons of patients undergoing surgery for obstructed defecation due to refractoriness to other therapeutic interventions (n = 11), compared to controls, were obtained and the number of mast cells (evaluated by specific monoclonal antibodies) were counted in the whole viscus and in the various colonic segments (cecum, ascending, transverse, descending, and sigmoid).

RESULTS

Compared to controls, constipated patients had significantly higher numbers of mast cells, both as an overall number and in single colonic segments. This increase was especially evident in the mucosa and submucosa. Mast cells were homogeneously represented in the various segment of the large bowel, in both controls and patients. Degranulated mast cells were found to be close to enteric glial cells and glial filaments.

CONCLUSIONS

Colonic mast cells are increased in obstructed defecation patients. This might represent a vicariating mechanism to the impaired colonic propulsive activity of these patients.

Beyond hematoxylin and eosin: the importance of immunohistochemical techniques for evaluating surgically resected constipated patients

Chronic constipation requiring surgical ablation for intractability is often a frustrating condition from the pathologist's point of view. In fact, limiting the histological examination to only hematoxylin-eosin staining usually yields only the information that there are no abnormalities. By employing some simple and widely available immunohistochemical methods, discussed in this review, it is possible to gather data that may help in explaining the pathophysiological basis of constipation in these patients.

Prucalopride: the evidence for its use in the treatment of chronic constipation

Introduction:

Chronic constipation is a common condition that is difficult to treat. Existing options for the treatment of patients with different subgroups of constipation are limited. A new efficacious and safe drug is needed to limit the frequently observed adverse effects induced by laxatives, to improve general wellbeing and quality of life, and to provide an alternative for enemas or even resectional surgery in patients in whom stimulant laxatives cause disabling adverse effects or fail to increase bowel movement frequency.

Aims:

The purpose of this article is to assess the current evidence supporting the use of the selective and high affinity serotonin-4 (5-HT₄) receptor agonist prucalopride in the management of chronic constipation.

Evidence review:

There are now convincing data from phase II and multicenter phase III randomized, double-blind, placebo-controlled trials that prucalopride treatment results in a clinically meaningful increase in the number of spontaneous complete bowel movements, a reduction of perceived severity of symptoms and improved disease-related quality of life in a significant proportion of patients. There is a rapid onset of the effect and the improvement is maintained for at least 12 weeks.

Prucalopride in a dose of up to 4 mg per day appeared generally well tolerated and devoid of serious cardiac events. Adverse events, most frequently headache and nausea, are usually mild or moderate and occur mainly during the first days of treatment. Prucalopride should be used with prudence and with careful assessment of the benefit-risk ratio until more clinical and electrophysiologic data become available, because relatively few patients have been exposed to the drug for long periods of time.

Place in therapy:

Prucalopride 1–2 mg once daily may be given to patients suffering from chronic constipation for whom laxatives do not provide adequate relief of their symptoms. Patients with severe constipation and slow transit, who frequently develop tolerance to stimulant laxatives, are also eligible for prucalopride treatment.

Physical therapy combined with a laxative fruit drink for treatment of chagasic megacolon

CONTEXT

The treatment of Chagas' disease colopathy is limited to clinical management in the initial of the process, and for patients for whom surgery is not indicated or is not possible, anti-constipation diets are used, along with judicious administration of laxatives and enemas.

OBJECTIVE

To evaluate over time the effects of physical-therapy interventions combined with daily ingestion of a laxative fruit drink in the treatment of chagasic megacolon.

METHOD

In a quantitative, prospective, and comparative study, 12 patients of both sexes and with a mean age of 67 ± 12 years were clinically evaluated to receive 12 sessions of physical therapy twice a week, along with fruit drink, and were evaluated for intestinal constipation before and after treatment.

RESULTS

A significant difference (P<0.0022) was observed in the constipation scores before and after 6 weeks of intervention in 91.7% of the patients, and in 72.7% after 12 months, with reduction of laxative medications, softer stools, and increased number of bowel movements. With respect to gender, age, and whether or not the patient had received surgical treatment, there was no significant difference (P>0.05).

CONCLUSION

The proposed protocol is easy to implement, safe, non-invasive, and low-cost, with the potential to be deployed in health care by providing benefits independent of gender, age, or whether the participant has undergone surgery, improving the condition of patients with chagasic megacolon.

Lactulose versus Polyethylene Glycol for Chronic Constipation

BACKGROUND

Constipation is a common clinical problem. Lactulose and Polyethylene Glycol (PEG) are both commonly used osmotic laxatives that have been shown to be effective and safe treatments for chronic constipation. However, there is no definitive data as to which provides the best treatment.

OBJECTIVES

To identify and review all relevant data in order to determine whether Lactulose or Polyethylene Glycol is more effective at treating chronic constipation and faecal impaction.

SEARCH STRATEGY

We searched the MEDLINE, EMBASE and CINAHL databases, and the Cochrane Central Register of Controlled Trials for all randomised controlled trials (RCTs) comparing the use of lactulose and polyethylene glycol in the management of faecal impaction and chronic constipation.

SELECTION CRITERIA

Studies were included if they were randomised controlled trials which compared lactulose with polyethylene glycol in the management of chronic constipation.

DATA COLLECTION AND ANALYSIS

Data on study methods, participants, interventions used and outcomes measured was extracted from each study. Data was entered into the Cochrane Review Manager software (RevMan 5.0) and analysed using Cochrane MetaView.

MAIN RESULTS

In the present meta-analysis, we considered for the first time all ten randomised controlled trials so far performed. The findings of our work indicate that Polyethylene glycol is better than lactulose in outcomes of stool frequency per week, form of stool, relief of abdominal pain and the need for additional products. On subgroup analysis, this is seen in both adults and children, except for relief of abdominal pain.

AUTHORS' CONCLUSIONS

Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation.

Constipation and obstructed defecation

Difficulties with bowel function are common and may be due to several causes including slow colonic transit and obstructed defecation. The anatomical and pathophysiological changes associated with these conditions are varying, often incompletely understood, and in many cases have limited treatment outcomes. Patients present with variable complaints and have previously tried a plethora of over-the-counter medications in an effort to relieve their symptoms. Physicians need an organized approach to manage these patients optimally. Improvements over the past few years in our understanding of the complex process of defecation, along with the increasing use of radiological and anorectal physiology studies, have led to improved treatment results.

Function and dysfunction of the colon and anorectum in adults: working team report of the Swedish Motility Group (SMoG)

Symptoms of fecal incontinence and constipation are common in the general population. These can, however, be unreliably reported and are poorly discriminatory for underlying pathophysiology. Furthermore, both symptoms may coexist. In the elderly, fecal impaction always must be excluded. For patients with constipation, colon transit studies, anorectal manometry and defecography may help to identify patients with slow-transit constipation and/or pelvic floor dysfunction. The best documented medical treatments for constipation are the macrogols, lactulose and isphagula. Evolving drugs include lubiprostone, which enhances colonic secretion by activating chloride channels. Surgery is restricted for a highly selected group of patients with severe slow-transit constipation and for those with large rectoceles that demonstrably cause rectal evacuatory impairment. For patients with fecal incontinence that does not resolve on antidiarrheal treatment, functional and structural evaluation with anorectal manometry and endoanal ultrasound or magnetic resonance (MR) of the anal canal may help to guide management. Sacral nerve stimulation is a rapidly evolving alternative when other treatments such as biofeedback and direct sphincter repair have failed. Advances in understanding the pathophysiology as a guide to treatment of patients with constipation and fecal incontinence is a continuing important goal for translational research. The content of this article is a summary of presentations given by the authors at the Fourth Meeting of the Swedish Motility Group, held in Gothenburg in April 2007.

Practical performance of defecography for the evaluation of constipation and incontinence

By opacifying the sigmoid, rectum, and vagina with different barium consistencies and using fluoroscopy to evaluate the mechanics of defecation in a physiologic setting, a wide range of pathologies associated with constipation and incontinence can be diagnosed. This review article discusses the primary indications for fluoroscopic defecography, techniques, common diagnoses, and challenges faced in clinical practice.

Clinical pharmacology of lubiprostone, a chloride channel activator in defecation disorders

BACKGROUND

Lubiprostone, a prostaglandin E1 derivative, was approved in January 2006 for the treatment of chronic idiopathic constipation (CIC) in adults and in April 2008 for the treatment of irritable bowel syndrome with constipation (IBS-C) in adult women.

OBJECTIVE

To review the pharmacology, efficacy and safety of lubiprostone and recommend its place in therapy for CIC and IBS-C.

METHODS

We conducted a literature search using PubMed/Medline (1966-April 2008) using the keywords lubiprostone, chronic constipation, and irritable bowel syndrome. Data provided by the manufacturer and the FDA were also reviewed.

CONCLUSION

Available literature for lubiprostone is mostly available in abstract data making it difficult to evaluate the clinical evidence. Although this medication shows promise, more information is needed to determine its place in therapy.

Assessing interstitial cells of Cajal in slow transit constipation using CD117 is a useful diagnostic test

Slow transit constipation (STC) is a colonic motility disorder that is characterized by measurably delayed movement of stools through the colon. The pathophysiology of STC is unclear and both the interstitial cells of Cajal (ICC) and cells of the enteric nervous system are believed to play an important role. The aim of this study was to compare the number and distribution of ICC and cells of the enteric nervous system in patients with a control group by means of immunohistochemistry. Formalin-fixed paraffin-embedded colonic sections were obtained from 15 patients, aged between 23 and 52 (mean age=37 y), who underwent colectomy for STC. Forty-five cases of normal colon from age and sex-matched nonobstructive colorectal cancer patients were selected as controls. By using c-kit (CD117) and PGP 9.5 immunohistochemical studies, ICC and enteric neurofilaments were demonstrated, respectively. The number of cells were counted under 40 x high-power field (HPF) in 3 layers of the colonic muscularis propria, that is, the inner circular muscle layer, the myenteric plexus, and the outer longitudinal muscle layer in both test and control groups. The mean number of ICC and enteric neurofilaments were significantly reduced in all 3 layers of the muscularis propria from STC patients compared with controls. This reduction was most significant in the inner circular muscle layer (P<0.0001). A cutoff value of 7 ICC per HPF in the inner circular muscle layer can be used as a further confirmation to the clinical diagnosis of STC in resected specimens.

Lubiprostone: a chloride channel activator for treatment of chronic constipation

OBJECTIVE

To review lubiprostone's pharmacology, pharmacokinetics, efficacy, and safety in the treatment of chronic constipation.

DATA SOURCES

A literature search was conducted using PubMed/MEDLINE (1966-January 2007), IngentaConnect, and International Pharmaceutical Abstracts (1977-January 2007). Key words used included lubiprostone, Amitiza, and chronic constipation.

STUDY SELECTION AND DATA EXTRACTION

All articles identified from the data sources that were published in English were evaluated.

DATA SYNTHESIS

Lubiprostone is a chloride channel activator approved by the Food and Drug Administration for the treatment of chronic constipation. A randomized, double-blind, parallel-group, placebo-controlled study evaluating the effect of lubiprostone on gastric function showed slowed gastric emptying and increased small bowel and colonic transit time. Peak plasma concentration was shown to be around 1.14 hours, with a majority of the drug excreted in the urine within 48 hours. Phase III trials have noted that most patients with chronic constipation have a spontaneous bowel movement within 24 hours after taking lubiprostone. The most common adverse events in these trials were nausea, diarrhea, abdominal pain, and headache. Lubiprostone use has not been studied in the pediatric population.

CONCLUSIONS

Lubiprostone may be a reasonable alternative for use in patients who either fail or are intolerant of standard therapy for chronic constipation. Head-to-head comparison studies with conventional therapy are needed to contrast clinical efficacy and safety of this medication.

Managing a patient's constipation with physical therapy

BACKGROUND AND PURPOSE

Constipation is a prevalent condition in the United States, with typical treatment consisting of diet modification, stool softeners, and laxatives. These interventions, however, are not always effective. The purpose of this case report is to describe the use of abdominal massage in physical therapist management for a patient with constipation.

CASE DESCRIPTION

An 85-year-old woman with constipation was referred for physical therapy following unsuccessful treatment with stool softeners. The patient was instructed in bowel management as well as a daily, 10-minute home abdominal massage program.

OUTCOMES

Upon re-examination, the patient reported a return of normal bowel frequency and function without the need to strain or use digital evacuation.

DISCUSSION

Physical therapy incorporating abdominal massage appeared to be helpful in resolving this patient's constipation. Unlike medical management of constipation, no known side effects have been identified with abdominal massage.

Review article: The role of serotonergic agents in the treatment of patients with primary chronic constipation

Chronic constipation is a highly prevalent disorder that is associated with significant direct and indirect costs and has substantial impact on patient quality of life. It is more common among women and non-white populations and is evenly distributed across adult age groups. Constipation is a heterogeneous disorder associated with multiple symptoms and aetiologies. Recent research has increased our understanding of the pathogenesis of this disorder and the central role of the neurotransmitter serotonin in mediating gastrointestinal motility, secretion and sensation. Abnormal serotonin signalling and reuptake appear to play central roles in the symptoms of a subset of patients with chronic constipation. This observation provides a rationale for the use of targeted serotonergic agents for the treatment of chronic constipation. As the role of serotonin in gastrointestinal function is further elucidated and additional candidate drugs are developed, it is likely that serotonergic agents will afford additional treatment options for patients with chronic constipation. This article provides a concise review of the evidence supporting a role for serotonin in the pathogenesis of chronic constipation and a summary of the currently available evidence supporting the use of serotonergic agents for this disorder.

Treatment options for primary constipation

Patients suffering from primary constipation often show symptom improvement with increased intake of fiber. Bulk laxatives are a core component of treatment if dietary fiber is unsuccessful in alleviating symptoms. Although there are a number of commercial laxative preparations available, only polyethylene glycol (PEG), an osmotic laxative, should be used on a daily basis. For the elderly, saline laxatives may be used on a regular basis, provided there are no cardiac or renal comorbid contraindications. Tegaserod, a 5-HT(4) partial receptor agonist, is approved for the treatment of constipation in female patients. The appropriate role of biofeedback remains to be determined. Surgery should be reserved for patients with slow transit constipation refractory to medical therapy. Patients being considered for surgery should be evaluated at institutions with substantial expertise in the investigation and management of this population.

Chronic idiopathic slow transit constipation: pathophysiology and management

OBJECTIVE

Patients with idiopathic slow-transit constipation comprise a small proportion of the total population complaining of constipation. The purpose of this review is to present an update of pathophysiology of this disorder and its application in clinical management.

METHODS

Medline was used to search English language articles published up to the end of September 2002 on the subject of slow-transit constipation.

RESULTS AND CONCLUSIONS

Patients with idiopathic slow-transit constipation can be divided into 2 subgroups: 1. patients with normal proximal gastrointestinal motility and with onset of constipation in connection with childbirth or pelvic surgery. This subgroup may benefit from consideration of surgical treatment; 2. patients who have a dysfunctional enteric nervous/neuroendocrine system and exhibit colonic dysmotility as part of a generalised gastrointestinal dysmotility. Surgical approach in this subgroup seems to be unhelpful and medical treatment appears to be a better approach.

Psychological state and quality of life in patients having behavioral treatment (biofeedback) for intractable constipation

OBJECTIVE

Behavioral techniques, including biofeedback, improve symptoms in a majority of patients with intractable idiopathic constipation. However, it is unknown whether there is also improvement in patients' psychological well-being and quality of life (QOL). It is also unknown whether psychological or QOL factors can be used to predict the response to treatment. We aimed to assess these factors prospectively.

METHODS

Thirty-one consecutive patients (median age 36 yr) receiving biofeedback retraining for idiopathic constipation were studied. A bowel symptom record, the General Health Questionnaire-28 (GHQ-28) (n = 31) and Hospital Anxiety and Depression Scale (n = 20), both psychological measures, and the Short Form-36 (SF-36) (n = 22), a generic QOL measure, were recorded before and after treatment.

RESULTS

Twenty-two of the patients felt subjectively symptomatically improved. When considering all patients, treatment resulted in decreased depression (p < 0.05), anxiety (p < 0.05), and somatic symptoms (p < 0.01) (psychological measures: GHQ-28), and improved general health (p < 0.05) and vitality (p < 0.05) (QOL measures: SF-36). Patients who improved symptomatically showed significantly higher scores on the GHQ-28 and SF-36, in contrast to the unchanged scores in patients who did not symptomatically improve. Pretreatment GHQ-28 did not predict who would benefit from treatment, but patients in whom pain, emotional problems, or low vitality interfered with daily living (SF-36 pain subscales) were significantly (p < 0.05) less likely to respond to treatment.

CONCLUSIONS

The symptomatic improvement produced by biofeedback in constipated patients is associated with improved psychological state and QOL. Some of the psychological morbidity in these patients is reversible. QOL parameters may be useful for predicting a likely response to treatment.

Constipation

Most patients with chronic constipation respond to dietary measures, fiber supplements, or laxatives. For those who do not, diagnostic tests of colonic and anorectal function help to select appropriate treatments. Therapeutic options, pharmacologic agents, and surgery, the last resort, are discussed in this article.

A randomized, placebo-controlled, multicenter study of the safety and efficacy of a new polyethylene glycol laxative

OBJECTIVE

This study was designed to determine the efficacy and safety of a new laxative, Braintree polyethylene glycol (PEG) laxative (Miralax, Braintree Laboratories, Braintree, MA).

METHODS

This investigation was designed as a placebo-controlled, blinded, randomized, multicenter parallel trial. Study subjects were constipated but otherwise healthy outpatients who had < or =2 stools during a 7-day qualification period. Braintree PEG laxative 17 g or dextrose placebo p.o. in 8 oz of water for a 14-day treatment period. A diary recorded each bowel movement and subjective symptoms of stool consistency, ease of passage, cramps, and flatus. CBC, blood chemistries and urinalysis were performed before and after the treatment period.

RESULTS

There were 151 randomized subjects, 131 female and 20 male. An increase in bowel movement frequency was observed with the PEG laxative as compared to placebo (p<0.001), with the greatest difference in efficacy in wk 2 of treatment (p<0.001). By wk 2 of treatment, on average, placebo subjects had 2.7 bowel movements/wk and PEG-treated study subjects had 4.5 movements/wk (p<0.01), or more than one bowel movement every 2 days. Investigator (p<0.005) and patient (p<0.001) subjective assessment of perception of treatment effectiveness, and patient evaluations of stool consistency and passage showed significant improvement in the active treatment group (p<0.001). There were no significant differences in laboratory changes or adverse experiences recorded between groups.

CONCLUSION

Braintree PEG laxative is safe and effective in the short term for the treatment of constipation.

Colonic motility in man: features in normal subjects and in patients with chronic idiopathic constipation

The human colon is still a relatively unknown viscus, especially concerning its motor activity. However, in recent years, techniques have been perfected that allow a better understanding of colonic motility, especially through prolonged recording periods. In this way, it has been demonstrated that the viscus contracts according to a circadian trend, is responsive to physiological stimuli (meals, sleep), and features high amplitude, propulsive contractions that are part of the complex dynamic of the defecatory process. These physiological properties and their alterations in patients with chronic idiopathic constipation are reviewed in this article.

The effect of dietary fiber on bowel function following radical hysterectomy: a randomized trial

OBJECTIVE

To assess the effect of high-fiber dietary instruction in relieving chronic constipation, a known and accepted complication of radical hysterectomy (RH).

METHODS

Thirty-five women with a diagnosis of cervical cancer who were scheduled for RH were randomized into groups that followed either a high-fiber diet plan or their usual diet. Data were gathered using a validated subjective bowel function questionnaire (SBFQ); a typical day's intake form and food frequency tool; and a diary used to record food, medication, bowel, and exercise information. Patients were evaluated at 1, 4, and 7 months after surgery.

RESULTS

Postoperatively, the dietary fiber intake was significantly higher for the treatment (T) group (22.9 g) than the control (C) group (12.4 g) (P = 0.007). With regard to intergroup comparisons, there were few differences at the first follow-up. By the second visit, the T group reported taking medications to achieve regularity less often (P = 0.0269), straining less often (P = 0.0210), having pain with bowel movement (BM) less often (P = 0.0116), and having crampy abdominal pain less often (P = 0.123) than the C group. Four significant positive changes occurred in the T group, whereas only one occurred in the C group. With regard to intragroup comparison, the significant changes in bowel function in the T group were generally positive, whereas all of the C group's significant changes were negative. According to summary questions on the SBFQ, the T group reported a significant change in the frequency of BM (P = 0.0096); however, the C group reported no significant changes. Analysis of bowel function records showed clearer differences. The T group took less time to defecate (P < 0. 001) but had more BMs accompanied by gas (P < 0.001). The C group had significantly more BMs with cramps (P < 0.001), straining (P < 0. 001), and retention (P < 0.001) and significantly more BMs, which were hard (P < 0.001). Two C patients dropped out of the study because of severe bowel dysfunction despite maximum medication.

CONCLUSION

Dietary management seems to be an inexpensive effective therapeutic intervention for addressing bowel dysfunction associated with RH.